Anaphylaxis care plan
Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur in response to a trigger such as an insect sting, medication, or food. Anaphylaxis requires immediate medical attention and can be treated with epinephrine (adrenaline).
The assessment of anaphylaxis includes a thorough history and physical examination. The individual’s history may reveal a previous episode of anaphylaxis, a family history of allergies, or a known allergy to a particular trigger.
Physical examination findings in anaphylaxis can vary depending on the severity of the reaction. Vital signs may be normal or may reveal tachycardia, hypotension, or respiratory distress. The skin may be flushed, pruritic, or erythematous. Angioedema may also be present.
The nursing diagnoses for an individual with anaphylaxis include:
- -Airway obstruction related to bronchospasm and edema
- -Cardiac dysfunction related to myocardial dysrhythmias
- -Fluid volume deficit related to third-spacing of fluids and increased insensible losses
- -Anxiety related to the threat to personal safety
- -Imbalanced nutrition: Less than body requirements related to anaphylactic reaction and nausea/vomiting
The outcomes for an individual with anaphylaxis include:
- -maintain patent airway
- -maintain hemodynamic stability
- -maintain fluid volume
- -reduce anxiety
- -attain/maintain nutrition
The interventions for an individual with anaphylaxis include:
- -epinephrine administration
- -airway management
- -fluid resuscitation
- -monitoring vital signs
- -supportive care
The rationales for the interventions in anaphylaxis care include:
- -Epinephrine is the first-line treatment for anaphylaxis and should be administered immediately.
- -Airway management may be necessary in severe cases of anaphylaxis.
- -Fluid resuscitation is necessary in individuals who are hypotensive or have significant third-spacing of fluids.
- -Monitoring vital signs is necessary to assess the individual’s response to treatment and to identify any complications.
- -Supportive care is important in all cases of anaphylaxis.
The evaluation of anaphylaxis care includes monitoring the individual’s response to treatment and assessing for any complications.
Anaphylaxis is a potentially life-threatening emergency that requires prompt treatment and nursing care.