Anaphylactic Shock

Shock, anaphylactic (Allergic reaction)

Nursing dignosis
Decrease Cardiac Output

Related to:
Severe reactions to drugs, insect bites, diagnostic agents, or food

Defining characteristics

• Hypotension
• Tachycardia
• Decreased CVP
• Decreased pulmonary pressures
• Decreased Cardiac Output
• Oliguria
• Decreased peripheral pulses

Expected Outcomes
Patient achieves adequate cardiac output as evidence by:
1. Strong peripheral pulses
2. Normal vital signs
3. Urine output >30 ml/hr
4. Warm Dry Skin
5. Responsive Mentation

Assessment
1. Assess Skin warmth
2. Assess peripheral pulses, peripheral vasoconstriction causes cool, pale, diaphoretic skin
3. Assess for restlessness and axiety (early signs of Hypoxia) leading to agitation and confusion.
4. Monitor for dysrhythmias, Cardiac dysrhythmias may occur from the low perfusion state,
acidosis or hypoxia.
5. Monitor urine output with foley catheter. Oliguria is a classic sign of inadequate renal
perfusion
6. Monitor ABG results

Nursing Interventions
1. If injected agents or insect bites are the cause of the reaction, apply tourniquet above
injection site or insect bite followed by infiltration of the site with epinephrine as ordered.
Inspect the site for stinger following an insect sting, and remove if present. Removed
tourniquet every 15 minutes and then reapply, to ensure perfusion to the distal extremity.

2. If ingested foods or drug are the cause of reaction, assist with forced emesis to delay
absorption of the drug.

3. Administer medication as ordered by the physician
*Benadryl: An antihistamine with anticholinergic and sedative side effects that is a useful
therapeutic adjuct to epinephrine after the acute episode is controlled.
*Vasopressors: Usefull to reverse vasodilation in the acute stage.
*Corticosteroids: may be usedto suppress immune and inflammatory response.
*Epinephrine: An endogenous catecholamine with both alpha and beta receptor stimulating
actions that provides rapid relief of hypersensitivity ractions.