Allergic Reaction Anaphylaxis

Allergic Reaction: Anaphylaxis

Clinical Findings

Neuro: Anxiety, restlessness. Resp: Dyspnea, bronchospasm, wheezing, stridor, swelling of tongue or throat, respiratory arrest. CV: Hypotension, localized or systemic edema, CV collapse. Skin: Rash, itching, hives, cool, pale, cyanosis, diaphoresis.

Nursing Interventions

■ If Pt is in respiratory distress or exhibiting signs of inadequate perfusion (e.g., decreased LOC; hypotension; cool, moist skin), call code/ notify physician and RT STAT. Note: Follow hospital protocol when calling code. ■ Remove source of allergy (e.g., discontinue suspect medication, blood transfusion, latex gloves, etc.). ■ Administer supplemental oxygen titrated to SpO2 >90% and be prepared to ventilate Pt manually using BVM if needed. ■ Obtain IV access if ordered and titrate to SBP >90 mm Hg. ■ If Pt is receiving blood transfusion, assess Pt for possible blood transfusion reaction. If transfusion reaction evident or suspected, discontinue blood, hang normal saline, and (after crisis) return unused blood product to blood bank for analysis. ■ Administer STAT medication if ordered: epinephrine 1:1,000 0.3–0.5 mg SC; diphenhydramine 25–50 mg IV or IM. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering a STAT 12-lead ECG, labs (CBC, electrolytes, and coagulation studies) chest x-ray, additional pharmacologic therapy (e.g., bronchodilators, corticosteroids, vasopressors), and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.