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Anaphylaxis Nursing Guide

This course is intended as a Quick Reference for anaphylaxis and will provide an overview as well as nursing considerations utilizing the nursing process.

The content for this course was created by Stephanie L. Whitfield, B.S.N., R.N

Anaphylaxis Etiology and Epidemiology 

Anaphylaxis is a form of an allergic reaction in which the immune system reacts to environmental substances. However, anaphylaxis, unlike other allergic reactions, can be fatal. Anaphylaxis is an immunologically mediated process (Dynamed, 2018): 

  • The immune system produces specific immunoglobulin in the lymph nodes due to exposure to an antigen Helper T cells. 
  • Antibodies (IgE) bind to membrane receptors located on mast cells and basophils. 
  • When the body comes in contact with the antigen again, the IgE antibody recognizes the antigen, causing the release of chemical mediators. 
  • IgG or IgM enters into the reaction by activating the release of complement factors such as C3a, C4a, and C5a, which cause mast cell and basophil degranulation. 
  • The release of mediators can result in bronchospasm, hypotension, dysrhythmias, and syncope. In extreme cases, it can cause complete airway obstruction, shock, and death. 

Common triggers of anaphylaxis are (Scholten, 2021): 

  • Foods 
  • Peanuts, tree nuts, and seeds 
  • Fish/shellfish 
  • Eggs 
  • Cow's milk 
  • Insect stings 
  • Medications 
  • Blood transfusions 
  • Vaccines 
  • Latex 

Risk factors include (Scholten, 2021): 

  • Personal or familial history of anaphylaxis, eczema, hay fever, or asthma 
  • Exposure to an allergen 
  • Dysfunction of the immune system 
  • Spina bifida 
  • Exposure to latex gloves or medical devices with latex 

Symptoms usually appear within minutes of coming into contact with an allergen or may occur hours later. They can be moderate or severe. Signs and symptoms of anaphylaxis include (Scholten, 2021): 

  • Itching and hives 
  • Skin redness or warmth 
  • Swelling, redness, stinging, or burning sensations of the face, mouth, eyes, or hands 
  • Dizziness, headache, "pounding" heartbeat 
  • Skin color that is pale or blue 
  • Breathing or swallowing difficulties 
  • Vomiting, nausea, cramps, diarrhea, or stomach discomfort 
  • Loss of consciousness 

Anaphylaxis ICD-10 Code: 

  • Z87.892 - Personal history of anaphylaxis

Anaphylaxis Symptoms & Diagnosis

The most important tool in identifying whether anaphylaxis occurred and the cause is to obtain a history. Anaphylaxis is defined clinically as the acute onset of a reaction involving the skin, mucosal tissue, or both AND at least one of the following (Dynamed, 2018): 

  • Breathing difficulties 
  • Suddenly low blood pressure 
  • Hypotonia, syncope, or incontinence 
  • Persistent gastrointestinal symptoms 

Additional testing can help confirm the diagnosis and possible cause, including (Dynamed, 2018): 

  • Serum tryptase 
  • Plasma histamine 
  • 24-hour urinary histamine metabolites 
  • Urinary prostaglandin D2 
  • Allergy skin tests 
  • Allergen-specific immunoglobulin E [IgE] 
  • Challenge tests 

Anaphylaxis Treatment & Management

The following medications will be administered as part of the treatment (Kliegman et. al, 2016): 

  • Epinephrine (EpiPen®) 
  • To decrease the body's allergic response 
  • Oxygen 
  • To help with breathing 
  • Antihistamines (e.g., diphenhydramine [Benadryl®], cetirizine [Zyrtec®]) and steroids (e.g., methylprednisolone [Medrol®], prednisolone [Omnipred®]) 
  • To improve breathing by reducing inflammation in the airways 
  • Beta agonist (such as albuterol [Proair HFA®]) 
  • To alleviate respiratory problems 

For long-term treatment or management of an individual with an anaphylactic reaction history, the following is recommended (Dynamed, 2018): 

  • Provide epinephrine autoinjector and education for self-administration. Educate the individual and/or caregiver on: 
  • How to identify and avoid triggers. 
  • Skills for self-injection with epinephrine autoinjector for subsequent reactions. 
  • Immunomodulatory interventions (i.e., allergy shots that contain a tiny amount of specific allergens to stimulate the immune system and cause desensitization) 

If an individual stops breathing or their heart stops beating during an anaphylactic attack, they require cardiopulmonary resuscitation (CPR). 

Anaphylaxis Nursing Care Plan

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for anaphylaxis are listed below. 

Assessment 

Because anaphylaxis is a medical emergency, it is essential first to assess and stabilize the individual’s (Dynamed, 2018): 

  • Airway 
  • Breathing 
  • Circulation 

If the individual is unstable, activate the emergency response system. 

If the individual is stable, lay the individual down and raise their legs. If indicated, administer supportive measures such as: 

  • Epinephrine (EpiPen®) 
  • Diphenhydramine (Benadryl®) 
  • Oxygen for O2 saturation less than 90% or if the second dosage of epinephrine is needed 

Provide pertinent history to the treatment team, including: 

  • Presentation of symptoms 
  • Vital signs 
  • Therapies administered 

Nursing Diagnosis/Risk For 

  • Anxiety 
  • Decreased cardiac output 
  • Impaired gas exchange 
  • Ineffective breathing pattern 
  • Fluid volume deficit 
  • Impaired skin integrity 
  • Deficient knowledge 

Anaphylaxis Interventions 

  • Monitor: 
    • Pulse oximetry 
    • Vital signs 
    • Respiratory status 
    • Degree of edema 
    • Level of consciousness 
    • Neurological status 
    • Signs and symptoms of complications 
    • Treatment response 
    • Urine output 
    • Administer medications as appropriate. 
    • Initiate IV access and maintain patency. 
    • Maintain a calm environment. 
    • Place the individual in a supine position with their legs elevated, if possible. 
    • Provide supplemental oxygen as needed. 
    • Perform CPR if necessary. 
    • Prepare for intubation if needed. 
    • Remove the source of the antigen, if possible. 
    • Educate the individual and/or caregiver regarding avoidance of allergens and how to use an EpiPen®. 

Expected Outcomes 

The individual will: 

  • Demonstrate hemodynamic stability 
  • Maintain: 
    • An open airway and adequate ventilation 
    • Fluid volume balance 
    • Skin integrity 

The individual and/or caregivers will verbalize: 

  • Decreased anxiety 
  • Understanding of an allergic reaction, prevention, and management of anaphylaxis 
  • The need to: 
    • Carry emergency intervention 
    • Inform their healthcare providers of any allergies 
    • Have a medical alert bracelet or necklace 
    • The importance of seeking emergency care 

Individual/Caregiver Education 

  • Instruct caregivers about anaphylaxis, its diagnosis, and treatment. 
  • Instruct individuals and/or caregivers on ways to reduce the risk of anaphylaxis, including: 
  • Avoid contacting triggers. 
  • Always keep an epinephrine injector on hand. 
  • Always wear a medical alert bracelet. 
  • Instruct on the use of an EpiPen®: 
    • Reinforce the need to count to 10 before removing the EpiPen needle to ensure complete expulsion of medication. 
    • Obtain emergency medical care immediately after use because effects are short- term and additional doses of epinephrine and other treatment may be required. 
    • Provide information about emergency medications. 
    • Educate the individual and/or caregiver on how to identify precipitating factors and exacerbations. 
    • Discuss referral to an allergist. 

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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2024

Course Contributor 

The content for this course was created by Stephanie L. Whitfield, B.S.N., R.N. Stephanie has over 15 years of clinical and teaching experience. Her areas of expertise are in neonatal intensive care, general pediatrics, home health, and children with medical complexities. She earned her Bachelor of Science in nursing from Chamberlain University in 2013. Her professional practice is guided by Jean Watson’s philosophy that, “Caring is the essence of nursing.” 

References 

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