Kaye went on a picnic with her friends at the beach. Everyone brought food and shared them for lunch. Moments after biting off a chunk of sandwich, Kaye went dizzy and complained of severe shortness of breath. IT turned out that the sandwich is a peanut butter and jelly ensemble, and Kaye is allergic to peanuts. She was immediately rushed to the emergency department and was diagnosed with anaphylactic shock. Show
What is Anaphylactic Shock?Anaphylactic shock occurs rapidly and is life-threatening.
PathophysiologyAnaphylaxis occurs in an individual after reexposure to an antigen to which that person has produced a specific IgE antibody.
Statistics and IncidencesAnaphylaxis occurs worldwide and in different ages.
CausesAllergy symptoms aren’t usually life-threatening, but a severe allergic reaction can lead to anaphylaxis.
Clinical ManifestationsAn anaphylactic reaction produces the following symptoms:
PreventionBecause anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it can often be prevented.
ComplicationsThe complications of anaphylactic shock include:
Assessment and Diagnostic FindingsBecause anaphylaxis is primarily a clinical diagnosis, laboratory studies are not usually required and are rarely helpful.
Medical ManagementTreatment of anaphylactic shock include:
Pharmacologic TherapyMedications used for a patient at risk or under anaphylactic shock are:
Nursing ManagementThe nurse has an important role in preventing anaphylactic shock. Nursing AssessmentCommunication is an essential part of assessment.
Nursing DiagnosisBased on the assessment data, the nursing diagnoses appropriate for the patient are:
Nursing Care Planning and GoalsMain Article: 4 Anaphylactic Shock Nursing Care Plans The major goals for a patient with anaphylactic shock are:
Nursing InterventionsNursing interventions for the patient are:
EvaluationExpected patient outcomes include:
Discharge and Home Care GuidelinesUpon discharge, the patient and family need to learn about the following:
Documentation GuidelinesThe focus of documentation include:
Practice Quiz: Anaphylactic ShockHere are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions. 1. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it. 1. Answer: A. Removing the stinger by scraping it.
2. Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first? A.
Administering oxygen 2. Answer: A. Administering oxygen
3. Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next? A. Administer beta-adrenergic blockers. 3. Answer: B. Administer bronchodilators.
4. Anaphylactic shock is associated with which type of hypersensitivity? A. Type I hypersensitivity. 4. Answer: A. Type I hypersensitivity.
5. What are some conditions that may precipitate anaphylactic shock? A. Insects. 5. Answer: D. All of the above.
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[sc name=”Affiliate_MedicalSurgical”] What is the most important precaution you should take to prevent an anaphylactic reaction?The best way to prevent anaphylaxis is to stay away from substances that cause this severe reaction. Also: Wear a medical alert necklace or bracelet to indicate you have an allergy to specific drugs or other substances. Keep an emergency kit with prescribed medications available at all times.
What should a nurse do during anaphylactic shock?Nursing interventions for the patient are:. Monitor client's airway. Assess the client for the sensation of a narrowed airway.. Monitor the oxygenation status. Monitor oxygen saturation and arterial blood gas values.. Focus breathing. ... . Positioning. ... . Activity. ... . Hemodynamic parameters. ... . Monitor urine output.. Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?Epinephrine — Epinephrine is the first and most important treatment for anaphylaxis, and it should be administered as soon as anaphylaxis is recognized to prevent the progression to life-threatening symptoms as described in the rapid overviews of the emergency management of anaphylaxis in adults (table 1) and children ...
What is your main priority when dealing with someone in anaphylactic shock?What to do. If someone has symptoms of anaphylaxis: use an adrenaline auto-injector if the person has one – but make sure you know how to use it correctly first. call 999 for an ambulance immediately (even if they start to feel better) – mention that you think the person has anaphylaxis.
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