Anaphylactic reactions

Assessment Diagnosis Planning Intervention Rationale Evaluation

S:
nahihirapan po
ako huminga,
hindi po ako
makahinga ng
maayos

O:
Nasal flaring
Increase
respiratory rate
Restlessness
Peripheral
cyanosis (nail
beds)
Cold clammy
skin (hands)


Ineffective
Airway
Clearance
Secondary to
Anaphylaxis


In 5-10
minutes, the
patient will
be able to
breath in
with ease

Assess for any
previous history
of anaphylaxis or
allergic reaction.





Place the patient
in a Fowlers
position/Semi-
fowlers position


Check airway
clearance


Administer
Oxygen as
necessary

Assist in the
administration of
Epinephrine

Assess if the
patient is
responding well
to the
medication.



Monitor patients
oxygen
saturation by
using a pulse
oximeter



Once the patient
is stable, in depth
medical history
is necessary.

It will provide
important
information of
the patients
past medical
history, thus
can give the
nurse an
overview on
how to handle
the situation.

Allows patient
to improve its
breathing
capacity to the
maximum.

Any airway
obstruction
should be
removed.

Improves body
oxygenation

Epinephrine is
the primary
medication for
anaphylaxis.

If the patient is
not responding
to the first shot,
the doctor
might order
another shot
after 15min.

A 98-100%
oxygen
saturation is
needed to make
sure that the
patient is
getting enough
oxygen in
his/her body.


Know the recent
activities the
patient did
before coming to
the facility
including the
food that the
patient ate.

Health
Teaching

Educate the
patient about the
things they
should avoid
especially what
caused the
allergic reaction

If exposure to
allergen cannot
be avoided,
instructed them
to carry an
emergency kit
with medication
and instruct them
the proper way to
medicate
themselves.

Also inform
them of the
subtle signs of an
allergic reaction
like urticaria,
periorbital
swelling,
pruritus, nasal
congestion and
the like.


To know when
the patient had
this
anaphylactic
reaction.

This is
necessary to
know what
caused this
allergic
reaction and to
prevent this
from happening
again in the
future.



To give the
patient an
overview of
what specific
things to avoid.



This is to
ensure the
patient knows
what to do in
emergency
cases.





This will
prevent further
progression of a
life threatening
scenarios like
brochospsm
and laryngeal
edema which
can cause
dyspnea.