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Anaphylaxis
College of Nursing
Anaphylaxis
INTRODUCTION
DEFINITION
Anaphylactic reactions produce a clinical syndrome that affects multiple organ systems.
Reactions may be categorized as mild, moderate, or severe. The time from exposure to the
antigen to onset of symptoms is a good indicator of the severity of the reaction-the faster the
onset, the more severe the reaction. The severity depends on the degree of allergy and the dose
of allergen.
Moderate systemic reactions may include flushing, warmth, anxiety and itching in
addition to any of the milder symptoms. More serious reactions include bronchospasm and
edema of the airways or larynx with dyspnea, coughing and wheezing. The onset of symptoms
is the same as for a mild reaction.
Severe systemic reactions have been an abrupt onset with the same signs and symptoms
described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema,
severe dyspnea, cyanosis and hypotension. Dysphagia, abdominal cramping, vomiting,
diarrhea and seizures can also occur. Cardiac arrest and coma may follow.
PATHOPHYSIOLOGY
NURSING INTERVENTION
Independent
Assess patient’s airway, breathing pattern and vital signs. Rationale: ABC (Airway,
Breathing, and Circulation) is the primary prioritization in this kind of episode; Checks
client for the sensation of a narrowed airway
Observe patient for signs of increasing edema and respiratory distress. Rationale: May
indicate a worsening allergic reaction.
Position the client upright. Rationale: this position provides oxygenation by promoting
maximum chest expansion
Limit activities within client’s tolerance. Rationale: For safety purposes and to avoid
further occurrences of anaphylaxis.
RUNNING HEAD: ANAPHYLAXIS
Dependent
Source: