Beruflich Dokumente
Kultur Dokumente
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.
d. Patients Profile
Name:
L.S.
Address:
Sex:
Female
Age:
48 years old
Birth date:
Place of Birth:
Iligan City
Occupation:
None
Civil status:
Married
Nationality:
Filipino
Religion:
Roman Catholic
Date of Admission:
Time of Admission:
1:30 am
Chief Complaint:
Loss of consciousness
Admitting Diagnosis:
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.
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.
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
Secure consent
NPO
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
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
Insert NGT
1-25-2015
3:20 am
BP = 160/100
1-25-2015
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 %
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
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:
Specific Indication:
Contraindication:
Side Effects/Toxic Effects:
Nursing Precaution:
signs
Before Giving the medication can cause sudden drop of vital signs.
Name of Drug:
Classification:
Mechanism of Action:
Name of Drug:
Classification:
Mechanism of Action:
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:
Name of Drug:
Classification:
Mechanism of Action:
Specific Indication:
inhibitor of plasmin.
control of hemorrhage in surgical and clinical cases, hemostatics
Contraindication:
Side Effects/Toxic Effects:
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
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
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
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 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 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
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.
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.
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
EXERCISE
TREATMENT
OUT-PATIENT
(Check-up)
DIET
before
discharge
will
help
prevent
untoward
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
/
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
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
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.
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
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.
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