Nursing Care Plan for Anaphylaxis

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. It typically causes a number of symptoms including an itchy rash, throat swelling, and low blood pressure. Common causes include insect bites and stings, foods, and medications.

On a mechanistic level, anaphylaxis is caused by the release of mediators from certain types of white blood cells triggered by either immunologic or non-immunologic mechanisms. It is diagnosed on the basis of the presenting symptoms and signs. The primary treatment is injection of epinephrine, the administration of intravenous fluids, and positioning the person flat, with other measures being complementary.

Anaphylaxis typically presents many different symptoms over minutes or hours with an average onset of 5 to 30 minutes if exposure is intravenous and 2 hours for foods. The most common areas affected include: skin (80–90%), respiratory (70%), gastrointestinal (30–45%), heart and vasculature (10–45%), and central nervous system (10–15%)[5] with usually two or more being involved.

Nursing Diagnosis for Anaphylaxis

1. Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

2. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
characterized by: palpitations, skin pale, cold acral, hypotension, angioedema, arrhythmias, ECG features horizontal and inverted T waves.

3. Ineffective breathing pattern related to the swelling of the nasal mucosa wall
characterized by: shortness of breath, breath with the lips, there rhinitis.

4. Acute pain related to gastric irritation
characterized by: abdominal pain, looked grimacing while holding stomach.

5. Impaired skin integrity related to changes in circulation
characterized by: swelling and itching of the skin and the nose, there are hives, urticaria, and runny nose.

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