- Decreased Cardiac Output related to decreased preload due to leak of histamine causing blood vessels to leak fluid into the tissues as evidenced by Tachycardia and Hypotension
- Deficient Knowledge related to insufficient knowledge about anaphylaxis and lack of information about emergency management of anaphylaxis as evidenced by verbalization of concerns and Questions about anaphylaxis
- Impaired Spontaneous Ventilation related to Narrowing of the airways and Bronchospasm as evidenced by Dyspnoea, Hypoxia and Cough
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Expressions related to restlessness Objective Data: -Tachycardia -Palpitations -Hypotension -Anxiety -Restlessness | Decreased Cardiac Output related to decreased preload due to leak of histamine causing blood vessels to leak fluid into the tissues as evidenced by Tachycardia and Hypotension | Patient will maintain pulse rate and blood pressure within therapeutic limits. Patient will be able to verbalize relief from anxiety and restlessness. Patient will be able to manifest a calm and well-rested appearance. | 1. Check for IV access. Ensure patent IV access for blood sampling, medication, and IV administration. 2. Immediately discontinue a suspected IV medication or infusion. Colloid solutions are a known cause of anaphylaxis and are not advised for its treatment. Medications such as penicillin, aspirin, non-steroidal anti-inflammatory drugs, blood products, and anaesthesia can also cause anaphylaxis. 3. Administer IV fluids. Fluid resuscitation is a central intervention for hypotension. Isotonic crystalloid bolus is recommended. 4. Administer vasopressors. If additional doses of epinephrine are needed, but the patient is experiencing side effects, vasopressors may be given for hypotensive shock. 5. Prepare the emergency or crash cart at the bedside. If first-line medications are not successful and the patient codes, additional life-saving interventions will be required. A crash cart should be at the bedside with all equipment available. | Patient maintained pulse rate and blood pressure within therapeutic limits. Patient verbalized relief from anxiety and restlessness. Patient manifested a calm and well-rested appearance. |
| Subjective Data: -Verbalizes poor understanding -Seeks additional information -Denial of a need to learn Objective Data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment | Deficient Knowledge related to insufficient knowledge about anaphylaxis and lack of information about emergency management of anaphylaxis as evidenced by verbalization of concerns and Questions about anaphylaxis | Patient will be able to verbalize an understanding of anaphylaxis and its signs and symptoms. Patient will verbalize two strategies to prevent anaphylaxis. Patient will not experience a recurrence of anaphylaxis. | 1. Develop the care plan with the patient. Patient involvement includes the patient in decision-making. A lifetime commitment to avoiding triggers and compliance with desensitization procedures are necessary for fulfilling long-term goals. 2. Consider the patient’s learning factors in health teaching. Adapt the teaching plan to the patient’s education level, attitude, strengths, and obstacles in learning anaphylaxis. Consider teaching methods for young or school-age children. Anaphylaxis can be prevented once the patient knows how to avoid and manage it. 3. Encourage inquiries. Patients’ inquiries should be welcomed. Encourage queries by acting in a friendly, open manner. Anxiety is common in patients with anaphylaxis, and clarification can ease worry. 4. Reinforce positive comments. When the patient’s health objectives are attained and complications are avoided, show appreciation for their efforts and adherence to their care plan. 5. Ask the patient to list the preventive measures of anaphylaxis. The best method to prevent anaphylaxis is to avoid it. By letting the patient enumerate the precautions they can take to prevent anaphylaxis, the nurse can assess for effective learning. 6. Refer to an allergist. An allergist can detect and create avoidance strategies appropriate for the patient’s age, activities, career, interests, living arrangements, and access to healthcare. 7. Encourage wearing a medical alert bracelet. Patients should be informed of the value of wearing a medical alert bracelet or identification in the event of an emergency. | Patient verbalized an understanding of anaphylaxis and its signs and symptoms. Patient verbalized two strategies to prevent anaphylaxis. Patient experienced a recurrence of anaphylaxis. |
| Subjective Data: Patient verbalizes difficulty in breathing Objective Data: -Dyspnoea -Hypoxia -Cough -Tachycardia -Cyanosis -Restlessness | Impaired Spontaneous Ventilation Related to Narrowing of the airways and Bronchospasm as evidenced by Dyspnoea, Hypoxia and Cough | Patient will demonstrate respiratory rate and oxygen saturation within normal limits. Patient will demonstrate clear lung sounds upon auscultation. | 1. Ensure patency of the airway. Suction any secretions if present to encourage spontaneous ventilation and prevent complications like aspiration. Anaphylaxis releases inflammatory mediators, causing increased mucus production and airway constriction. 2. Administer medications as prescribed. An infusion of epinephrine may be necessary if respiratory symptoms do not improve with IM epinephrine. Bronchodilators like albuterol are administered via nebulizer to dilate the airways and relieve wheezing and stridor. 3. Collaborate with respiratory therapy. The nurse works in collaboration with respiratory therapists to ensure ventilator, oxygen, and alarm settings are correct. 4. Obtain ABGs. Monitor arterial blood gas (ABG) results to ensure proper oxygenation and acid-base balance. | Patient demonstrated respiratory rate and oxygen saturation within normal limits. Patient demonstrated clear lung sounds upon auscultation. |