Cagayan de Oro College-PHINMA

College of Nursing

A Case Study of

Anaphylactic Shock
Submitted to:
Mr. Arsenio S. Poral, Jr., RN, MAN (c)

Submitted by:
Carmelli Mariae H. Calugay
BSN-IV

September 1, 2015
I. INTRODUCTION

a. Overview
Anaphylaxis is an alarming emergency situation because of its rapid onset which may
lead to death within a short period of time. Despite of its fatalities, death and the
irreversible damage it caused, anaphylaxis is not always recognized thus, studies may
underestimate the incidence (Soar et al, 2008). Anaphylaxis is not a reportable disease
and the true incidence is unknown as concluded by Sheikh and colleagues (2012)due to
perplexity of its diagnosis, treatment and investigation; limited data on fatal anaphylaxis;
and non-compliance for outpatient follow-up of its victims. Time trends for anaphylaxis
fatalities are not properly presented.
Definition
Anaphylactic shock is a severe, life-threatening, generalized or systemic hypersensitivity
reaction characterized by rapidly developing critical tribulations on airway / breathing
and circulation usually associated with skin and mucosal changes, as defined by
the European Academy of Allergology and Clinical Immunology Nomeclature
Committee. It is a circulatory shock state resulting from severe allergic reaction
producing an overwhelming systemic vasodilatation and hypovolemia (Smeltzer & Bare,
2004).
Epidemiology
In the study of Soar and colleagues (2008), the American College of Allergy,Asthmaand
Immunology reported that the overall frequency of episodes of anaphylaxis lies between
30 and 950 cases per 100, 000 persons per year and a lifetime prevalence of between 50
and 2000 episodes per 100, 000 persons or 0.05-2.0%.
Death immediately occurs after the contact with the trigger if anaphylaxis is fatal, called
anaphylactic shock. From a case-series, fatal food reactions cause respiratory arrest
typically after 30-35 min; insect stings cause collapse from shock after 10-15 min; and
deaths caused by intravenous medication occur most commonly within 5 min. Death
never occurred more than 6 hours after contact with the trigger (Soar et al, 2008).

Causative Agents
Trigger factors include foods, insect venoms (sting), medications, anesthetics, natural
rubber latex and exercise (Sheikh et al, 2012); allergens such as plant pollens, dust, mold
spores and chemicals in cosmetics (Scanlon & Sanders, 2007); blood products and
contrast agents (Smeltzer & Bare, 2004).
b. Objective of the Study
The objective of this study is to be able to:
1. Acquire knowledge about the disease process.
2. Discuss thoroughly the disease process.
3. Formulate realistic and appropriate nursing care plans.
4. Identify and learn more about the treatment and modalities of the said disease
5. Apply the nursing process and appreciate its significance in nursing practice.

c. Scope and Limitation of the Study

This study covers about facts related to patients condition. It includes the nature, causes,
signs and symptoms, Pathophysiology, prognosis, treatment and the nursing interventions
appropriate for his condition. A nursing care plan is also provided which serves as a guide for the
interventions to be applied to the patient to aid in recovery and it will also serve as basis for the
evaluation of client care outcomes. Health teachings including referrals were also imparted to the
patient and the watcher to ensure his recovery during hospital stay and after discharge.
It is limited only to the case of our client. For the completion of this study, some information
was taken from significant others. The assessment and so with the interventions rendered to the
patient were also limited due to time constraint, with a total of 2 days, dated January 26 and 27 of
2015. Thus, weve supplemented our study with facts from various references.

d. Patients Profile
Name:

L.S.

Address:

Block-3, Puntod, Cagayan de Oro, Misamis Oriental

Sex:

Female

Age:

48 years old

Birth date:

March 26, 1966

Place of Birth:

Iligan City

Occupation:

None

Civil status:

Married

Nationality:

Filipino

Religion:

Roman Catholic

Date of Admission:

January 18, 2015

Time of Admission:

1:30 am

Chief Complaint:

Loss of consciousness

Admitting Diagnosis:

T/C Hemorrhagic stroke at the right fronto-temporal area;

hypertension; Intracranial hemorrhage left basal ganglia

Attending Physician:

Dr. Talabucon

e. Medical History
Upon assessment, significant others said that the client is known to be hypertensive. She
has maintenance of antihypertensive drugs. At first, she religiously takes those but later
on, she only complies whenever she felt the symptoms of hypertension.

f. Social History
The patient is reasonably sociable. According to her daughters, their mother is caring and
kind. She used to be friendly and kind to people.
g. Family History
According to the patients daughters, they have a family history of hypertension.
Therefore, it is hereditary.

h. History of Present Illness

This is the case of patient L.S., who was admitted in Polymedic Medical Plaza at
their Intensive Care Unit area last January. She was already known for being
hypertensive. She has maintenance of antihypertensive drugs like vascor and Metoprolol.
For straight three days prior to admission, she had headache, until she suddenly
lost her consciousness prior to admission.
She was brought to the hospital by her family. They were the ones assisted her on
the emergency room.
Upon her arrival at the hospital at the emergency department, she was catered
under the care of Dr. Talabucon. They just found out after checking her vital signs and
signs and symptoms that she just had a stroke (Hemorrhagic stroke).

i. Chief Complaint
The patient lost her consciousness, and was brought to the hospital because of this.

j. Diagnosis/Impression

She was then diagnosed to have hemorrhagic stroke at right fronto-temporal area; Intracranial
hemorrhage at left basal ganglia.

II. GROWTH AND DEVELOPMENT

Developmental theories of learning have to do with the additional learning tasks
individuals can accomplish as they mature mentally, emotionally, and physically.
Although this maturation actually progresses in slow, continuous fashion, it is often
described as proceeding in stages.
Many names are associated with developmental research. The following people and
their stages of development are important in the field of development theory

FREUDS PSYCHOSEXUAL THEORY

Genital Stage: 13 yrs and above
Freuds advanced a theory of personality development that centered on the effects of
the sexual pleasure drive on the individual psyche. At particular points in the
developmental process, he claimed, a single body part is particularly sensitive to sexual,
erotic stimulation.
Based on Sigmund Freuds Psychosexual Stages of development our client belongs
to the genital Stage. Characteristics of this stage are that energy of a person is directed
toward full sexual maturity and function and development of skills needed to cope with
environment as well as its demands. The patient is able to achieve independence and able
to practice decision-making. But this condition the patient needs support from family in
activities of daily living as well as decision making to his present condition.

PIAGETS COGNITIVE DEVELOPMENT THEORY

Formal Operations Phase: 11- 15 and above

In this developmental theory, our patient belongs to FORMAL-OPERATIONAL
wherein logical reasoning processes are applied to abstract ideas as well as concrete
objects. This is the time when people are most capable of forming new concepts and
shifting their thinking in order to solve problems and general concepts are related to
specific situations and alternatives are considered.

III. ANATOMY AND PHYSIOLOGY

Anatomy and Physiology
Anaphylactic shock is a multisystem failure resulted from inadequate tissue perfusion
involving function shut-down of cardiovascular system, respiratory system, urinary
system, circulatory system, nervous system, integumentary system and gastrointestinal
system. The principal reason for anaphylactic shock is the over-activity of the immune
system resulting in a systemic inability to thrive.
An allergyis a hypersensitivity to a particular foreign antigen, called an allergen. When
the immune system over-reacts to the allergen, it causes hypersensitivity producing tissue
damage. The antigen is a chemical marker that identify cells whether self or non-self
(foreign body). Antibodies, also called immune globulins (IgE) or gamma globulins,
attached to antigens to label them for destruction of foreign body (Scanlon & Sanders,
2007).
During an allergic response, the immune system produce are IgE antibodies, which bond
to mast cells. Mast cells release chemicals such as histamine and leukotrienes. These
chemicals contribute to the process of inflammation by increasing the permeability of
capillaries and venules. Tissue fluid collects and more WBCs are brought to the damaged
area. In the case of anaphylactic shock, allergy mediators flooded the body causing severe
inflammation (Scanlon & Sanders, 2007; Sheir et al, 2006).
IV. PATHOPHYSIOLOGY
a. Definition

In intracerebral hemorrhage, bleeding occurs directly into the brain

parenchyma. The usual mechanism is thought to be leakage from small
intracerebral arteries damaged by chronic hypertension. Other mechanisms
include bleeding diatheses, iatrogenic anticoagulation, cerebral amyloidosis, and
cocaine abuse.
Intracerebral hemorrhage has a predilection for certain sites in the brain,
including the thalamus, putamen, cerebellum, and brainstem. In addition to the
area of the brain injured by the hemorrhage, the surrounding brain can be
damaged by pressure produced by the mass effect of the hematoma. A general
increase in intracranial pressure may occur.

b. Precipitating and Predisposing Factors

Pathophysiological DiagramPathophysiology
Anaphylactic agents may enter the body through ingestion, inhalation, direct skin

contact/topical, sting, transfusion and injections. Antigen will identify the allergens as
non-self (foreign body). Mast cells will release chemicals and binds with antibodies IgE
leading to an inflammatory reaction. Anaphylactic shock occurs when overresponding of
allergy mediators occur, causing systemic vasodilatation and increase capillary
permeability resulting to poor tissue perfusion. Poor tissue perfusion and hypovolemia
resulted to shock (Scanlon & Sanders, 2007; Sheir et al, 2006; Smeltzer & Bare, 2004).
V. MEDICAL MANAGEMENT
A. Doctors Order
Progress
Notes
1-17-2015
12:30 pm

Doctors Order

Implication

Please admit to ICU under Dr.

Talabucon

> Admit the pt. to an appropriate

department for care; for management

Secure consent

> Agreement that the patient will

submit to the care; for legal purposes

Vital signs every hour

BP every 30 minutes

> Monitors vital signs, normal and

abnormal values

NPO

> Appropriate diet, nothing per orem

IVF: PNSS iL @ 30 gtts/min

> For fluid and electrolyte balance

BP = 180/100
HR = 116
RR = unstable
T= 38.0C
Wt.= not taken

LABS:
o Cranial CT-scan
o CBC, U/A, BUN, Na, K
o Chest x-ray, AP
o ECG
o HGT

1-17-2015
4:40 pm

> To check for possible cause of

illness/ relation to disease condition

MEDS:
1. Omeprazole 40 mg IVTT
now then OD 7am
2. Citicoline i gm IVTT now
then q8H
3. Paracetamol 300 mg IVTT
now then q4H PRN

> Pharmacologic management

Insert NGT

> For nutrition; feeding

1-25-2015
3:20 am
BP = 160/100
1-25-2015

Resume Nicadipine drip:

10mg/10ml Amp + PNSS 90ml
@ 3 cc/hr
Hold Nicardipine drip if BP
< 140 mmHg
Change EVO bottle and tubing

> Pharmacologic management;

To have target BP of 140-150 mmHg
> To prevent fluctuation of BP
> To prevent infection

2:30 pm

B. Laboratory result
Date: 1-23-15

Hemoglobin

Result
Low - 11.8 g/dL

Normal Range
12.2-16.2 g/dL

Hematocrit

Low - 36.7 %

37.7 47.9 %

White Blood Cells

High- 10.98 x
10^9/L

5.0-10.0 x
10^9/L

Segmenters

High - 74.3

0.5-0.7

Creatinine

Low 0.63

0.70 1.30

Potassium

Low - 3.25

3.50 - 5.50

CT scans (without contrast enhancements)

Sensitivity= 16%
Specificity= 96%

MRI scan
Sensitivity= 83%
Specificity= 98%

Interpretation
Decrease in
hemoglobin is a sign
hemorrhage.
Decreased hematocrit
is a sign of
hemorrhage.
Increased no. of
WBC is a sign of
infection, or
leukocytosis
Increased no. may be
a sign of infection, or
inflammation
Decreased no. may be
a sign of low muscle
mass
Decreases no. may be
a sign of
hypokalemia

C. Drug Study
Name of Drug:

Classification:
Mechanism of Action:

Citicoline (Zynerva) i gm/tab

Central Nervous System Drugs (CNS stimulants /Neurotonics)

increase dopamine receptor densities, and suggest that CDPcholine supplementation can ameliorate memory impairment

Specific Indication:
Contraindication:
Side Effects/Toxic Effects:
Nursing Precaution:

caused by environmental conditions.

CVA in acute and recovery phase.w/ symptoms and signs of
cerebral insuffiency; dizziness, headache and recent crania
trauma.
Hypersensitivity; Contraindicated in hypertonia of the
parasympathetic meclofenoxate (clophexonate).
It stimulates parasympathetic action and fleeting and discreet
hypotensor effect.
Use cautiously in patients& observe proper dosage, take vital

signs
Before Giving the medication can cause sudden drop of vital signs.

Name of Drug:

Classification:
Mechanism of Action:

Metoprolol (Metoprolol Tartate) 100mg i tab

antihypertensive, anti- anginas

Bocks stimulation of beta adrenergic receptor; doest not usually

affect beta2- adrenergic receptor sites.

Hypertension, prevention of M.I. and decreased mortality in
patients with recent M.I. management of stable angina,
Symptomatic heart failure due to ischemic hypertensive or
cardiomyopathic origin
Contraindication:
Hypersensitivity
Side Effects/Toxic Effects: Dizziness, fatigue, anxiety, drowsiness, nervousness, erectile
Dysfunction, hyperglycemia, back pain, dry mouth
Nursing Precaution:
Monitor for possible drug induced adverse reactions
Specific Indication:

Name of Drug:

Captopril (Conamid) 25mg tab i tab

Classification:
Mechanism of Action:

Angiotensin- converting enzyme ace inhibitors

It blocks the conversion of angiotensin1 to the vasoconstrictor
angiotensin2. It also prevents degradation of bradykinin and other

vasodilatory prostaglandins.
alone or with other agents in the management of hypertension.
hypersensitivity; history of angioedema with previous use of ace
Inhibitors
Side Effects/Toxic Effects:
dizziness, drowsiness, fatigue, headache, weakness, cough,
Specific Indication:
Contraindication:

Nursing Precaution:

dyspnea
Monitor for possible drug induced adverse reactions

Name of Drug:

Valsartan 20mg

Classification:
Mechanism of Action:

Angiotensin 2 receptor antagonist; Antihypertensives

blocks vasoconstrictor and aldosterone producing effects of
angiotensin 2 at receptor sites including vascular smooth muscles

and adrenal glands.

Specific Indication:
alone or with other agent in the management of hypertension
Contraindication:
Hypersensitivity
Side Effects/Toxic Effects: Headache, dizziness, anxiety, depression, fatigue, weakness
Nursing Precaution:
use cautiously in CHF patients may result oliguria, acute renal
Failure.

Name of Drug:

Classification:
Mechanism of Action:

Tranexamic acid / Hemostan 800 mg

cardiovascular drugs/ hemostatics

Tranexamic acid is a competitive inhibitor of plasminogen
activation, and at much higher concentrations, a noncompetitive

Specific Indication:

inhibitor of plasmin.
control of hemorrhage in surgical and clinical cases, hemostatics

Contraindication:
Side Effects/Toxic Effects:

for traumatic injuries.

severe renal insufficiency, patients with microscopic hematuria
GI disturbances, giddiness, hypotension, color vision

Nursing Precaution:

disturbances.
Use with caution in patients with thromboembolic disease.

NURSING ASSESSMENT
Complete Physical Assessment
Time Assessed: 3:00 P.M.
Initial Vital Signs:
Temperature: 36.3 C
Pulse Rate: 77 cpm
Respiratory Rate: 16 cpm
Blood Pressure: 160/90 mmHg
General Appearance:
The pt. is lying on bed, stuporous with an IVF of PNSS regulated @ 20cc/hr 840ml.
level infusing well @ right hand.
With Nasogastric Tube inserted.
With Foley catheter inserted.
With endotracheal tube inserted.
WithEVObottleatleftsideofhead.

Area Assessed

Techniqu
e Used

Normal
Findings

Actual
Findings

SKIN
color

Inspection

Tan

Pale

Texture
Turgor

Palpation
Palpation

Hair Distribution

Inspection

Temperature
Moisture

Palpation
Palpation

Smooth, soft
Skin snaps
back
immediately
When pinched
Evenly
distributed
Warm to touch
Dry, skin folds
are normally
moist

Smooth, soft
Skin snaps
back
immediately
When pinched
Evenly
distributed
Warm to touch
Dry, skin folds
are normally
moist

NAILS
Color of Nail bed
Texture

Inspection
Palpation

Pink and clear

Smooth

Pink and clear

Smooth

Analysis
Due to decrease
oxygen supply.
Normal
Normal

Normal
Normal
Normal

Normal
Normal

Shape

Inspection

Convex
curvature
Firm
2-3 seconds

Convex
curvature
Firm
4 sec.

Nail base
Capillary refill
time
HAIR
Color
Distribution

Inspection
Blanch test

Inspection

Black (varies)
Evenly
distributed
Neither
excessively dry
nor oily
Silky, resilient

Black (varies)
Evenly
distributed
Neither
excessively dry
nor oily
Silky, resilient

Moisture

Inspection

Texture
HEAD
Scalp symmetry

Inspection

Symmetrical

Symmetrical

Normal

Skull size
Shape

Normocephalic
Round

Normocephalic
Round

Normal
Normal

Nodules/ masses

Inspection
Inspection
and
Palpation
Palpation

Absence of
nodules and
masses

Absence of
nodules and
masses

Normal

FACE
Symmetry

Inspection

Symmetrical

Symmetrical

Normal

Facial movement

Inspection

Symmetrical

Symmetrical

Normal

Skin color

Inspection

Tan

Pale

EYES
Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Ability to blink

Inspection

Symmetrically
aligned, equal
movement
Slightly curved
upward
Smooth, tan, do
not cover pupil
as sclera, close
symmetrically
Blinks
involuntarily.

Frequency of
blinking
Ocular movement

Inspection

Position

Inspection

Size

Inspection

Symmetrically
aligned, equal
movement
Slightly curved
upward
Smooth, tan, do
not cover pupil
as sclera, close
symmetrically
Blinks
voluntarily and
bilaterally
20 blinks per
min.
Eye moves
freely
Drawn from
lateral angle
Medium

Due to decrease
oxygen supply.
Normal

Inspection
Inspection

Inspection

To speech.
Lack of eye
movement
Drawn from
lateral angle
Medium

Normal
Normal
Due to decrease
oxygen supply.
Normal
Normal
Normal
Normal

Normal
Normal

Due to damage
of Brocas area.
Due to damage
of Brocas area.
Due to damage
of Brocas area.
Normal
Normal

Texture

Palpation

Mobile, firm and

non-tender

Mobile, firm and

non-tender

Normal

Color

Inspection

Transparent
with light color

Transparent
with light color

Normal

Texture

Inspection
Inspection

Shiny and
smooth
No lesions

Normal

Presence of
lesions
APPARATUS

Shiny and
smooth
No lesions

CONJUCTIVA

Normal

Cornea
Color
Texture

Inspection
Inspection

Black
Shiny and
smooth

Black
Shiny and
smooth

Normal
Normal

PUPILS
Color
Reaction to light

Inspection
Inspection

Inspection
Inspection

Symmetry
Visual Acuity

Inspection
Inspection

Black
Pupils Equally
Round and
React to Light
Accommodation
(PERRLA)
Equal
Round and
constrict briskly
Equal in size
Cannot able to
real news print.

Normal
Normal

Size
Shape

Black
Pupils Equally
Round and
React to Light
Accommodation
(PERRLA)
Equal
Round and
constrict briskly
Equal in size
Able to real
news print

Visual Fields

Inspection

With clear
vision and can
classify objects
in periphery.

Ocular

Inspection

When looking
straight ahead,
client can see
objects in
periphery
Eyes move
freely

Eyes move
freely

Normal

Symmetrical,
smooth and tan
Reddish to
pinkish

Symmetrical,
smooth and tan
Reddish to
pinkish

Normal

Oval,
symmetrical
No discharge
Not tender

Oval,
symmetrical
No discharge
Not tender

Normal

NOSE
Symmetry, shape,
size and color
Mucosa color

Inspection
Inspection

Normal
Normal
Normal
Due to damage
of the left
hemisphere of
the brain.
Normal

Normal

NASAL SEPTUM
Nares
Inspection
Nasal discharge
Sinuses

Inspection
Inspection

Normal
Normal

MOUTH
Secretion

Inspection

(neutral in
color) without
mucus
production

With mucus
production

Due to
tracheobronchial
secretion

Lips
Color

Inspection

Pinkish to
slightly brown

Due to decrease
oxygen level

Symmetry
Texture

Palpation
Palpation

Moisture

Palpation

Symmetrical
Soft, moist,
smooth
Soft and moist

Dark and brown

and cracking
lips
Symmetrical
Crack, rough s
Dry

Due to decrease
oxygen.

HEART
Heart rate
Heart sounds

Auscultation
Auscultation

77 bpm
Clear

Normal
Normal

Resonant

Normal

Normal
Normal

Lung field
THORAX &
LUNGS
POSTERIOR
THORAX
Symmetry

Auscultation

60-100bpm
Clear, without
crackles
Resonant

Inspection

Symmetrical

Symmetrical

Normal

Respiratory rate
Spinal Alignment

Inspection
Inspection
Inspection

16 cpm
Spine vertically
align
Skin intact

Normal
Normal

Skin integrity
ANTERIOR
THORAX
Breathing pattern

12-20cpm
Spine vertically
align
Skin intact

Breathing is
with effort, and
produces
noise

Due to
orthopnea

Lung/ breath
sounds

Auscultation

Breathing is
automatic and
effortless,
regular and
even and
produces no
noise
Bronchiavesicular,
produces no
noise

Has crackles

Due to retained
secretions

Flat
Smooth
Audible; soft
gurgling sound
occur irregularly
and rages from
5-30 mins

Flat
Smooth
Audible; soft
gurgling sound
occur irregularly
and rages from
5-30 mins

Normal
Normal
Normal

ABDOMEN
Contour
Texture
Frequency and
character

Auscultation

Inspection
Palpation
Auscultation

Normal

UPPER
EXTREMITY
Skin color

Inspection

Tan

Pale

Movement

Inspection

Size (arms)
Symmetry
Hair distribution

Inspection
Inspection
Inspection

With ROM and

sensation
Equal
Symmetrical
Evenly
distributed

With no ROM
and sensation
Equal
Symmetrical
Evenly
distributed

Due to decrease
oxygen
Due to
neuromuscular
impairment
Normal
Normal
Normal

LOWER
EXTREMITY
Skin color

Inspection

Tan

Pale

Due to decrease
oxygen

Movement

Inspection

With ROM and

sensation

With no ROM
and sensation

Size (legs)
Symmetry
Hair distribution

Inspection
Inspection
Inspection

Equal
Symmetrical
Evenly
distributed

Equal
Symmetrical
Evenly
distributed

NEUROLOGICAL
Level of
consciousness

Interview

Can follow
instructions and
commands
Makes eye
contact with the
examiner
Expresses
feelings which
corresponds to
the examiner

Unconscious
Does not make
eye contact with
the examiner.
Expresses
feelings which
corresponds to
the examiner

Due to decrease
level of
consciousness
Normal

Due to
neuromuscular
impairment and
(+) weakness on
right lower
extremities.
Normal
Normal
Normal
Due to decrease
level of
consciousness.

Behavioral and
appearance

Interview

Mood

Interview

MENTAL
STATUS
Orientation

Interview

Oriented with
time

Disoriented with
time

Due to decrease
level of
consciousness

TIME
Recall recent and
remote memory

Interview

Interview

Cannot recall
events readily,
immediate
recall of remote
information
Cannot make

Due to aphasia.

Judgments and

Recall events
readily,
immediate
recall of remote
information
Can make

Due to decrease

thoughts

logical
decisions

logical
decisions

level of
consciousness

VI. NURSING MANAGEMENT

A. IDEAL NURSING CARE PLAN

Nursing Diagnosis
Altered Cerebral
Tissue Perfusion
related to
interruption of blood
flow as evidenced
by altered level of
consciousness and
changes of motor
responses

Desired Outcome

Interventions
INDEPENDENT:
The patient will be able > Monitor patients vital
to demonstrate
signs and changes in
behaviors, and
mentation.
verbalizes knowledge
condition, therapy
>Observe a close
regimen.
monitoring for any signs
of sudden chest pain,
respiratory distress and
restlessness.
>Assess visual
personality, sensory /
motor changes such as
headaches, dizziness,
and altered mental
status.
>Elevate the bed about
30 degrees and
maintain head /neck in
midline or neutral
position.

Rationale
-This is to check the
patients condition and
mental status for
further treatment to be
rendered.
-This is to ensure that
he patient is safe from
getting worse of the
condition and to be
given management in
early time
-This is to ensure that
the patients condition
is monitor and to check
for any progress in the
status.
- This is to promote
circulation and venous
drainage.

DEPENDENT:
>Administer
medications as
prescribed by the
attending physician.

-This is for the

treatment of the
present disease
condition.

Nursing Diagnosis
Impaired Physical
Mobility related to
neuromuscular
involvement,
weakness, limited
range of motion and
impaired
coordination

Desired Outcome

Interventions
INDEPENDENT:
The patient will be able >Assess degree of
to verbalize and
immobility in relation
demonstrate
behavioral responses.
willingness to
participate activities.
> Position the patient for
optimum comfort or side
turnings in every 2hours
>Monitor circulation /
nerve function in the
affected body parts
noting the temperatures
color, sensation and
movement.
>Place a side rails each
side of the bed of the
patient and encourages
the patient to do range
of motion exercises.
DEPENDENT:
> Give medications as
prescribed by the
attending physician

Rationale
-This is to check the
patients behavioral
responses and its
degree of mobility for
further treatment.
- This is to promote
ventilation and to
prevent any bedsores
of the patients back.
-This is to know the
present condition at the
affected body parts for
treatment.
- This is to protect the
patient from falling from
the bed to the floor and
ROM exercise
promotes blood
circulation of the body.
- For the treatment of
the present illness

Nursing Diagnosis
Impaired Verbal
Communication
related to motor
deficits and
generalized
weakness as
evidenced by
inability to speak
words.

Desired Outcome

Interventions
INDEPENDENT:
The patient will be able > Observe the degree of
to established method Impairment and
of communication in
Assess the style of
which needs can be
speech that the patient
expressed
shows
> Establish relationship
with the patient listening
carefully to patients
verbal / nonverbal
expressions.
>Anticipate needs until
effective
communication is
reestablished

Rationale
-Helps evaluate degree
of the impairment of
the patient and to
identify its type of
speech for further
treatment to be given.
> To have the best way
in communicating the
patient and have
his/her cooperation and
also to know the
patients needs.

> this is to make sure

that if earlier methods
are not very effective
make more of the best
>Provide environmental of it until it will be met.
stimuli as needed to
> this to reduce or
maintain contact with
lessen the patients
reality or reduce stimuli anxiety.
to lessen anxiety
DEPENDENT:
> This is for therapeutic
>Administer medication treatment of the patient
as order by the
for the present illness
attending physician
that she/ he have.

B. ACTUAL NURSING CARE PLAN

S
O
A
P
I

S
O
A
P
I

No subject cues. The patient is unable to speak due to the endotracheal tube inserted.
Restless, facial grimace, chest pain
Acute Pain related to Head Injury as evidence by facial grimace when head is touch
specifically the forehead area
Short term: At the end of 30 minutes the patient will be relieve from pain.
Long term: At the end of 8 hours the patient will be shows less stressful and relieved from
pain that he was experiencing.
1. Monitored the patient closely by taking vital signs
- This is to check the patients status to prevent any complication and to know if there
progress of the status of the patient.
2. Provided comfort measures such as back rub
- Massage and backrubs helps to relieved pain that he was experiencing
3. provided a quite and comfortable place to relieved the patient from getting irritated
4. Provide diversional activities, like encouraging expressing the feeling in other form of
communication through actions to lessen the feeling of having the pain.
5. Administered medication as ordered by the attending physician
- This is for the treatment of the present illness of the patient
At the end of 30 minutes the patient shows gestures and facial expressions that indicates no
pain.

No subject cues. The patient is unable to speak due to the endotracheal tube inserted.
Respiratory difficulties, dry mouth, weakness
Anxiety related to the situational crisis, change in physical and emotional condition.
Short term: At the end of 30 minutes the patient will be have lesser feeling of anxiety.
Long term: At the end of 8 hours the patient will be shows less stress and anxiety.
1. Monitored the patient closely by taking vital signs
- This is to check the patients status to prevent any complication and to know if there
progress of the status of the patient.
2. Provided comfort measures such as back rub
- Massage and backrubs decreases anxiety and tension
3. provided a quite and comfortable place to prevent the patient from getting irritation
4.Given oral care/ mouth care to the patient especially that its dry
- This is to prevent halitosis and make sure to prevent cracks of the lips which are very

S
O
A
P

S
O
A
P

painful.
5. Administered medication as ordered by the attending physician
- This is for the treatment of the present illness of the patient
At the end of 30 minutes the patient shows gestures and facial expressions that reflects
decrease distress.

No subject cues. The patient is unable to speak due to the endotracheal tube inserted.
Nasogastric tubing attached in the left nostrils for feeding and per orem medications
Altered facial muscle function
Impaired swallowing related to neuromuscular dysfunction as evidenced by
traumatic head injury
Short term: At the end of 72 hours the patient will be able to pass food from the mouth to the
stomach instead of using feedings through Nasogastric tubing.
Long term: At the end of 5 days the patient will be able to demonstrate feeding methods
appropriate to the individual situation.
1. Checked the oral mucosa for any abnormalities.
- this is to identify the abnormalities that can be found and basis for the care to be given
2.Positioned the bed about 30 degrees in the head part especially when giving feedings
- this is to prevent aspiration
3.Turned the patient in every 2 hours in the sides and monitored neurovital signs hourly
- This is to prevent bed sores and pressure ulcers and to check the neurological status of
the patient
4.Applied baby powder to patients back and give back tapping
- This is to maintain the patients back dry and prevent aspiration in the lungs
5. Administer medication as ordered by the attending physician
To treat the present illness
At the end of 5 days the patient was able to maintain adequate hydration and achieve the
desired body weight and good skin turgor.
. . No subject cues the patient cant able to speak due to the head injury where speech is
affected.
Difficulty in forming words/ verbalizes with difficulty
Impaired Verbal communication patterns and motor coordination related to central
nervous system alteration as evidenced by traumatic head injury
Short term: at the end of 30 minutes the patient will be able to use alternative methods of
communication effectively
Long term: at the end of 8 hours the patient will be able to use effective communication
techniques.
1. Assessed the patients condition that involves the communication status
- This is to check the patients communication status to be given
2.Used simple communication ; speak in a well modulated voice that shows concern
- This will encourage the client to have active participation and to prevent confusion
3. Encouraged to have a ROM exercises

- This will promote blood circulation to the body

4. Established rapport with the patient by listening carefully through nonverbal cues
- This will help you identify what the patient needs and feels
5. Administer medication as ordered
- This is for the treatment of the present illness
At the end of 30 minutes the patient was able to establish effective methods of
communication needs can be expressed.

VII. HEALTH TEACHINGS

MEDICATIONS

Instructed complete procurement of stocks of medicine and

take it on right time, dosage, route as prescribed. Emphasized
the importance of following proper protocol and consideration
upon taking the medicine.

EXERCISE

Encouraged to have range of motion exercises to promote

blood circulation throughout the body.
Encouraged also to have adequate balance between sleep and
daily exercise to prevent further stress that can more

TREATMENT

complicate the situation.

Instructed to follow what has been ordered by the doctor and
stressed the importance of strict compliance of all the

OUT-PATIENT
(Check-up)

medications and treatment prescribed by the physician.

With patients critical case. He should see the doctor regularly
for check-up. Doing so will help foresee probable readmission
and management. Proper compliance to every instruction
given

DIET

before

discharge

will

help

prevent

untoward

complications, and help patient live a normal life again.

Eat well-balanced diet for proper nutrition; nutritious foods
like fruits and green leafy vegetables (eg. pechay, Malunggay,
and oranges, apple, banana, etc.)
Instructed to avoid foods that are high in cholesterol, fats, and
sodium.

VIII. RECOMMENDATION
Mrs. L.S. will be referred to a doctor (internist) after discharge persistence of
chief complaints reoccurs and complicates. Schedules for follow-up visits should not be
overlooked to evaluate progress of the patients health condition after termed medical and
nursing management. She should have check up at the nearest hospital a week after
discharge as scheduled by her physician. The physician also ordered to continue on using
all the medications prescribed.

IX. CONCLUSION
I, therefore conclude, that CVA or stroke may lead to permanent brain damage or death to
individuals with sedentary lifestyle. People who consumed large amount of food high in cholesterol,
alcohol, cigarette smoking, obesity, and high blood pressure can increase the possibility of stroke.
This may also lead to heart disease and maybe worsen if we dont prevent the common factors that
cause stroke. Self-discipline is very important for us not to acquire this feared or killing disease.

X. PROGNOSIS
CRITERIA
A.) Onset of Illness
B.) Duration of Illness

GOOD PROGNOSIS
/

C.) Precipitating Factor

D.) Attitude and Willingness
toward taking medication
and treatment
E.) Family Support

POOR PROGNOSIS
/

/
/
/

On the criteria listed above, it shows only 2 out of 5 criteria falls under poor
prognosis therefore the clients prognosis is good.

XI. BIBLIOGRAPHY

Brunner and Suddarth Textbook of Medical-Surgical Nursing, 11th Edition by

Johnson pages, 1000; 1500; 2013; 2089

Pocket Guide Nursing Diagnosis with Interventions, 3rd Edition by M.

Doenges, pages,123; 423; 543; 589; 1002; 1570

Nursing 2010 Drug Handbook, 20th Anniversary Edition by Davis drug guide,
pages, 23; 58; 348; 479; 996; 998

Medical Surgical Nursing, 7th Edition by Black and Hawks ,pages,1589; 5090

Manual of Nursing Practice, 7th edition, Volume 1, Lippincott, pages 899; 900

I.

DOCUMENTATION
I wasnt able to take any pictures with the patient due to the request of the
significant others for confidentiality purposes.

Clinical Manifestations (Sheikh et al, 2012; Soar et al, 2008; Decker et al, 2008; NHTA,
1990).
Integumentary System
erythema patch, generalized, red rash
-edema (localized, anasarca)
urticaria (hives, nettle rash, weals, welts) pale, pink or red, may look like nettle stings,
different shapes and sizes, surrounded by a red flare, pruritic
angioedema swelling of deeper tissues in the eyelids, lips, mouth and throat
*Skin and mucosal changes often the first feature and present in over 80% of
anaphylactic reactions (Soar et al, 2008).
Respiratory System
pharyngeal/laryngeal edema
difficulty of breathing (dyspnea) / shortness of breath
tachypnea
hypoventilation
labored breathing using accessory muscles
abnormal retractions
prolonged expirations
difficulty of swallowing, tightness in the throat, congestion
hoarseness of voice
aphonia
stridor (upper airway)
wheeze (lower airway)
diminished lung sounds

 increase respiratory rate

respiratory arrest (late stage)
Cardiovascular system
myocardial ischemia with ECG changes
chest pain
presyncope, syncope
orthostasis
tachycardia (compensatory)
arrhythmia (late sign)
hypotension (late sign)
bradycardia (late sign)
cardiac arrest (late stage)
Nervous System
confusion, agitation, dis-oriented, loss of consciousness
dizziness, fainting
seizures
Circulatory System
cold, pale and clammy
cyanosis (late sign)
Gastrointestinal System
oral mucosal pruritus
intraoral angioedema of buccal mucosa, tongue, palate or oropharynx
nausea
emesis
dysphagia
abdominal cramps
diarrhea

Urinary System
increase GFR
increase urinary output (hypovolemia late stage)
Assessment (NHTA, 1990)
*Not all signs and symptoms are present in every case
A. History
1. previous exposure
2. previous experience to exposure
3. onset of symptoms
B. Presenting signs and symptoms
C. Glasgow coma scale (level of consciousness), general condition, vital signs
D. Assessment tools
1. cardiac monitor
2. pulse oximetry (usually low)
3. end tidal CO2 (usually high)
4. non-invasive blood pressure to monitor hypotension
5. 12-lead ECG to monitor cardiac arrest
Diagnostic Examination
The diagnosis of anaphylaxis is based largely on history and physical findings.
Laboratory procedures have proven to be not always reliable in the diagnosis.
Elevated plasma histamine is only reliable within one hour of onset. Serum or plasma
tryptase levels greater than 15ng/ml within 12 hours (ideally within 3 hours) of onset is
more widely used as a confirmatory test but usually negative in food-induced
anaphylaxis. Serial total serum or plasma tryptase measurements are more advisable that
single measurement. Proven skin tests to allergens and elevated allergen-specific IgE
levels in serum are not a reliable diagnostic of anaphylaxis, moreover these tests provides

clinical relevance in the prevention of anaphylaxis (Sheikh et al, 2012). Mast cell
tryptase is the laboratory procedure that will confirm a diagnosis of anaphylactic reaction.
Medical emergency investigations such as arterial blood gases, ECG, chest x-ray, urea
and electrolytes may also be helpful in the treatment (Soar et al, 2008).
Medical Management
Patients having an anaphylactic reaction should be treated using the Airway, Breathing,
Circulation, Disability, Exposure (ABCDE) approach (Soar et al, 2008).
Remove the trigger, if possible.
Immediate intervention for anaphylaxis is the removal of the causative agent, although it
is not always feasible. Once first sign of reaction occur, immediately stop/discontinue any
drug, infusion and/or transfusion suspected of causing the allergic reaction. Remove the
stinger after a bee sting. For food-induced anaphylaxis, force vomiting is not
recommended because of the possibility of aspiration due to esophageal edema. Do not
delay definitive treatment if removing the trigger is not possible (Soar et al, 2008; NHTA,
1990).
Positioning
Patient should be placed in a comfortable position to promote ventilation and circulation.
Patient with airway and breathing problems may assume fowlers position for maximal
breathing (for early stage), unless not contraindicated, e.g. hypovolemia and hypotension
(late stage). Lying flat with or without leg elevation or trendelenburg position is helpful
for patients with hypotension and other circulatory problems. Patient with anaphylactic
shock should not be placed on sitting and never on standing up, as these can deteriorate
patients condition leading to cardiac arrest. Victims that are breathing and unconscious
should be place on their side, recovery position. Pregnant patients should lie on their left
side to prevent caval compression (Soar et al, 2008; NHTA, 1990). In the study of Zhao
et al (2007), it was concluded that the head-down tilt posture (trendelenburg position) can
facilitate venous return from the splanchnic organs and lower extremities and is
recommended for the treatment of hypotension in anaphylactic shock.

Assist on Ventilation and Advanced Airway

Due to laryngeal edema and inflammation of the bronchial passages, endotracheal
intubation or tracheostomy may be necessary to establish an airway and promote
ventilation (Smeltzer & Bare, 2004).
Circulation
Initiating venous access is a must for fluid resuscitation and administration of
medications. Central venous line is also important in monitoring central venous pressure.
Managing Cardio-pulmonary arrest
If cardio-pulmonary arrest occurred, CPR is immediately performed. Start CPR
according to current guidelines (Soar et al, 2008; Smeltzer & Bare, 2004).
Pharmacological Management
Pharmacological treatment aims to decrease vascular permeability, restore vascular tone
and provide emergency support to basic life functions (Smeltzer & Bare, 2004; NHTA,
1990).
Oxygen
Highest concentration of oxygen is immediately administered, preferably using a mask
with an oxygen reservoir which gives 60%-100% O2 concentration. Use self-inflating
bag for patient with tracheostomy or endotracheal tube (Soar et al, 2008). Anaphylactic
shock and the other types of shock are characterized by generalized cellular hypoxia
resulted from poor tissue perfusion and decrease oxygen. The severity, irreversible
damage and mortality after shock are strongly associated with depleted oxygen level in
the brain (Cui et al, 2006).
Fluid Resuscitation

Large volumes of fluid may leak from the patients circulation during anaphylactic
reaction because of fluid shift during systemic inflammatory process and increase urinary
output resulting to hypovolemia. There will also be vasodilatation. A large volume of
fluid may be needed to treat hypovolemia and promote circulation. Fluid resuscitation
should be infused immediately. Hartmanns solution or 0.9% saline are advised for fluid
management. Be careful with the use of colloids and crystalloids as this may cause
anaphylaxis (Soar et al, 2008).
Adrenaline (Epinephrine)
Adrenaline is widely used as the first-line and main stay treatment of choice for
anaphylaxis. It is administered for the purpose of its vasoconstrictive action (Sheikh et al,
2012; Soar et al, 2008; Smeltzer & Bare, 2004; NHTA, 1990).
Antihistamine
Antihistamines are the second line of treatment. Anti-histamines may help counter
histamine-mediated bronchoconstriction and vasodilatation, thereby reducing capillary
permeability. Chlorpheniramine maleate and Diphenhydramine are the drugs of choice
for anaphylactic reaction (Soar et al, 2008; Smeltzer & Bare, 2004).
Bronchodilator
Bronchodilators can be given to reverse histamine-induced bronchospasm.
Aminophylline per IV can be given for severe cases. Nebulization is administered using
albuterol, salbutamol and ipratropium. Although intravenous magnesium is a vasodilator,
contraindicated in anaphylactic shock since it can cause hot flushes and make
hypotension worse (Soar et al, 2008; Smeltzer & Bare, 2004).
Anti-inflammatory / Immunosuppressant
Steroids management using corticosteroids may help prevent or shorten anaphylactic
reactions. This works by decreasing inflammation and reducing the activity of the
immune system (Soar et al, 2008; Smeltzer & Bare, 2004; NHTA, 1990).

Vasopressor
Vasopressors and inotropes (noradrenaline, vasopressin, metarminol and glucagon) are
used when initial resuscitation with adrenaline and fluids are not effective. Glucagon is
given for patients who are taking beta-blockers. For patients who develop severe
bradycardia after an anaphylactic reaction, atropine IV can treat this condition (Soar et al,
2008)

Anaphylaxis Algorithm

Nursing
Management
Promotive and Preventive
1. The nurse should identify the patients history on allergy, assessing patients for
allergies or previous reactions to antigens plays an important role in the prevention of
anaphylactic shock.
2. Patients and familys education to prevent further exposure to antigens and the
immediate actions to be taken.
3. Provide record keeping. When allergies are identified, it is important that the patient
keeps a record with him/her or wear an identification band.
Curative
1. Early recognition with accurate assessment and diagnosis.
2. Render immediate treatment without any delay using the ABCDE approach.
3. Knowledge and skills in the medical treatment and pharmacological management of
anaphylactic shock.
4. Expertise on IV therapy, BLS and ACLS.
Rehabilitative

1. Psychological support and support system.

2. Disability rehabilitation.
Complications
The most distressing complication of anaphylactic shock is the disability and the
irreversible damage following poor brain tissue perfusion. Respiratory complications may
occur, and patient may have tracheostomy or much worst with the support of mechanical
ventilator. Physical disability is possible, and physical rehabilitation is a must.
Autoimmune disorders following prolonged medications and renal complications may
occur after severe hypovolemia and anaphylactic shock.
Discharge Plan and Patients Education
Medications
1. Compliance with medical regimen.
2. Pharmacokinetics and pharmacodynamics of medications, including emphasis on
actions and side-effects.
3. Provide instructions and training for the patient and family on the use of adrenaline
auto-injector, administration of emergency medications and injection of anti-histamine
for patients with repeated history of anaphylactic shocks and high risk cases (Soar et
al, 2008; Smeltzer & Bare, 2004)
Environment
1. To prevent anaphylactic shock, avoid the triggers (allergens). Provide an allergen free
environment or keep away from any sources of allergy.
Treatment
1. Early recognition of allergic reaction.
2. An early call for help.
3. Immediate first aid measures.
4. Avoidance of allergens.
Health Teaching
1. Patients need to know the allergens and how to avoid it.

2. Patient and family need to recognize the early symptoms and how to manage it.
3. Importance of early detection and management.
4. Avoid contact with allergens.
Out-patient Care
1. Adherence to follow up consultation after confinement.
2. Referral to specialist.
Diet
1. Hypo-allergenic diet.
2. Eat organic foods, fruits, meats and vegetables, whenever possible.
3. Avoid anything with sugar, glucose, fructose, EDTA, MSG, flavoring, color, or other
additives or preservatives.
4. Provide a hypo-allergenic food guidelines or what foods to eat and what foods to
avoid.
Statistics shows that anaphylaxis mortality rate is low and stable, despite the increasing
prevalencebut, its irreversible damage and the life-long disability which can occur after
anaphylactic shock can never be ignored. The emergency state of anaphylactic shock
remains to be an alarming truth of disability causing financial, physical and emotional
burden. The reaction occurs without any warning and can be a frightening experience for
those at risk and for their families.
The most important requirements in the treatment of anaphylactic shock are early
detection, early diagnosis and immediate interventions without any delay of each
procedure. The aim of resuscitation is to restore and maintain the vital organ perfusion
and prevent complications of irreversible damage. Thus, the patient and family should be
aware of the condition and knowledgeable on immediate first aid measures before the
patient reach health care facilities. Health care providers such as physicians, nurses and
other anxillary health team should be knowledgeable enough with proper training and
expertise in handling emergency situations like anaphylactic shock. They should base
their decisions on both clinical situation and comprehensive advance knowledge on the
pharmacologic background and the rationale of every intervention.

TIME COUNTS TO SAVE THE PATIENT ON THE IMPENDING DOOM OF

ANAPHYLACTIC SHOCK.
References:

Spectrophotometer, Decreases Independently of Venoconstriction During Hepatic

Anaphylaxis in Perfused Rat Liver. Shock, 26(1), 6268. Decker, W.W. et al (2008).
The Etiology and Incidence of Anaphylaxis in Rochester, Minnesota: A Report from

the Rochester Epidemiology Project. Journal of Allergy and Clinical Immnunology,

122(6), 11611165.National Highway Traffic Administration (1990). Emergency
Medical Technician-Basic:
National Standard Curriculum Instructors Course Guide. United States Department of

Transportation. Scanlon, V.C. & Sanders, T. (2007). Essentials of Anatomy and

Physiology, 5th ed. Philadelphia: F.A. Davis Company, 327336. Sheikh, A. et al
(2012).
Adrenaline (Epinephrine) for the Treatment of Anaphylaxis With or Without Shock

(Review). The Cochrane Library, 4: JohnWiley & Sons, Ltd.

http://summaries.cochrane.org/CD006312/adrenaline-for-the-emergency-treatment-ofanaphylaxis Sheir, D.N. et al (2006). Holes Essentials of Human Anatomy &
Physiology, 9th ed. New York: McGraw-Hill Companies, Inc. Smeltzer, S.C. & Bare,
B.G. (2004). Brunner & Suddarths Textbook of Medical-Surgical
Nursing, 10th ed. PA: Lippincott Williams & Wilkins, 296, 311312. Soar, J. et al.
(2008). Emergency Treatment of Anaphylactic ReactionsGuidelines for Healthcare
Providers. Resuscitation, 77(2), 157169. Zhao, Z. et al (2007). Head-Down Tilt
Posture Attenuates Anaphylactic Hypotension in Mice and Rats. Journal of
Physiological Sciences, 57(5), 269274.