Concept Map
* Risk Factors:
pre-existing respiratory disease (eg.,
asthma, pneumonia)
cardiovascular disease
Other risk factors include:
increasing age
mastocytosis patients
(Regateiro et al., 2020)
a family history of anaphylaxis
allergies or asthma
a previous anaphylactic reaction
(Biggers, 2019)
* Etiology:
Common cause of Anaphylaxis for Mr. K.B. is his prescribed antibiotic of Ceftriaxone
1 gram IV q 12 hours. According to El Hussein & Osuji (2020), the most common causes
of anaphylaxis include antibiotic medications, certain foods (eg., peanuts, tree nuts,
shellfish, fish, milk, eggs, soy or wheat), insect stings (eg., bees, hornets, or ants), latex
(eg., medical and non-medical products containing latex) or from other
pharmaceutical/biologic agents (eg., animal serums). But for Mr. K.B. case, the etiology of
his anaphylaxis reaction is due to administration of his antibiotic that is used to treat for
his Pneumonia.
* Specific pathophysiology for Mr. K.B.:
Anaphylaxis is caused by the interaction of a foreign antigen (eg., food or medications)
with specific immunoglobulin IgE antibodies that can be found on the surface membrane
of mast cells and peripheral blood basophils (El Hussein & Osuji, 2020). Then it follows
with the abrupt release of histamine and other bioactive mediators that causes activation
of platelets, eosinophils and neutrophils. The sudden release of pro-inflammatory
mediators causes vascular permeability changes such as flushing, urticaria, angioedema,
hypotension and bronchoconstriction that signalize an anaphylaxis reaction. (El Hussein &
Osuji, 2020).
* Sign & Symptoms:
Respiratory: Coughing, Dyspnea, Tachypnea, Wheezing,
Hoarseness, Stridor, Sensation of narrowed airway
Cardiovascular: Tachycardia, Dysrhythmias
Skin: Urticaria, Pruritus, Erythema
Neurological: Feeling like there is an impending doom.
(Lewis et al., 2019)
Symptoms vary from appearing flush, skin warmth to touch,
rash, itchiness, feeling anxious, cough and wheezing to severe
systemic reactions such as bronchospasm, laryngeal edema,
dyspnea, cyanosis and hypotension (“Medical Scenario 1:
Kenneth Bronson”, n.d.).
* Medical Management
(Pharmacological/Surgical)
Pharmacological includes Epinephrine,
Diphenhydramine, Albuterol nebulizer,
Ranitide, Methylprednisolone.
Assessment/Intervention Epinephrine:
Assess lung sounds and monitor vital
signs such as respiration rate, pulse,
BP before administration and during
the peak of the medication.
Observe for paradoxical
bronchospasm or wheezing. If the
condition worsens, withhold
medication and notify the physician
right away.
(see below for continuation)
Respiratory failure from severe
bronchospasm or laryngeal edema can
cause hypoxia which results to brain
damage/injury if not treated right away
Anaphylactic shock can block airways and
prevent a person from breathing. It can stop
the heart due to the decrease in blood
pressure that prevents the heart from
receiving enough oxygen to sustain other
organs. Therefore, brain damage, kidney
failure, cardiogenic shock, respiratory failure,
arrhythmias, heart attack and death can
occur if not treated promptly.
(Biggers, 2019)
* Nursing Management/Care:
Ineffective Airway Clearance related to bronchospasm and laryngeal
edema.
Diagnosis of Mr. K.B.:
Anaphylaxis
*Assessment Findings:
Subjective Data:
27-year-old male admitted to Medical
Unit with right lower lobe pneumonia.
Symptoms: complain of cough, chest
tightness, difficulty breathing.
Pain scale score 2/10
Patient states that he has no known
allergies on admission. Newly
discovered allergy to Ceftriaxone
Tobacco smoker "2 packs a day for the
past 10 years".
States has no medical problems
During anaphylaxis reaction to antibiotic:
"I feel like my throat is swelling, I cant
breathe" , "I feel kind of lightheaded".
Objective Data: (see next page)
*Potential Complications:
Auscultate breath sounds q 1-4 hours
Monitor respiratory patterns including rate, depth and effort
Monitor blood gas values and pulse oxygen saturation levels as
available. O2 sat less than 90% or partial pressure of O2 of <80
mm Hg indicates significant oxygenation problems.
Position patient in an upright position.
Administer bronchodilators (eg., Albuterol) as ordered.
Administer oxygen as ordered. (Ackley et al., 2017)
*Labs/Diagnostic Tests:
ECG
Cardiac Monitoring
(“Medical Scenario 1: Kenneth Bronson”, n.d.).
Laboratory tests: Clinical diagnosis of
anaphylaxis can be sometimes be supported
by serum tryptase, plasma histamine and
future tests such as mature beta-tryptase
Serum tryptase: ideally blood sample must be
obtained from 15 minutes to 3 hrs after the
onset of symptoms.
Plasma histamine
And future tests such as laboratory test for
mature beta-tryptase - a better marker of mast
cell activation than total serum trytase.
However, this is not widely available.
(Chapman & Lalkhen, 2016)
* Teaching:
Goal of teaching is to prevent measures to
decrease risk of repeat episodes of
Anaphylaxis
Nurse must educate Mr. K.B. about
the medication that induces his
anaphylaxis reaction. The patient
must be instructed about the antigen
that should be avoided which was
Ceftriaxone.
The nurse educates Mr. K.B. and his
family in the use of epinephrine and
has the patient and family
demonstrate the correct
administration of the medication.
(El Hussein & Osuji, 2020).
* Medical Management (continuation):
The onset of action is usually 3-5 minutes and intramuscular administration into the anterolateral thigh is
the preferred route. This should be administered promptly at the onset of bronchospasm (Pflipsen & Colon,
2020).
Epinephrine autoinjectors are advantageous because of quick use to administer and this decreases dosing
errors (Pflipsen & Colon, 2020).
The most common adverse effects include agitation, anxiety, tremulousness, headache, dizziness, pallor
and palpitations (Pflipsen & Colon, 2020).
Assessment/Intervention Diphenhydramine medication:
May cause drowsiness. Avoid other activities requiring alertness until response to drug is known.
Assess for urticaria and for patency of the airway. (David Plus, 2015)
Assessment/Intervention Albuterol medication:
Assess lung sounds and vital signs before administration and during peak of medication.
Observe for wheezing. If the condition worsens, withhold medication and notify MD.
For nebulizer, compressed air or oxygen flow should be around 6-10 L/min; a single treatment of 3ml lasts
about 10 minutes. (David Plus, 2015)
Assessment/Intervention Ranitide/Methylprednisolone medication:
Histamine H1 and H2 antagonists and corticosteroids are not an effective first-line treatment for
anaphylaxis. It is only recommended that these medications used only as an addition to epinephrine.
Antihistamines have onset of action of 1-2 hours. They improve cutaneous erythema and decrease
itchiness but they have not shown to reverse upper airway obstruction. The onset of corticosteroids is
approximately 6 hours and they have little to no effect on initial signs and symptoms of anaphylaxis. It is
used for the reduction of biphasic reactions (recurrent anaphylaxis reaction) and decreases the length
of hospital stay (Pflipsen & Colon, 2020).
* Nursing Management/Care
(continuation):
*Assessment Findings
(continuation):
Objective Data:
During medical unit admission:
BP=137/82 mmHg, O2
sat=95% room air, HR= 96,
T=39.1, RR = 17 bpm. There is
normal skin turgor, sweating,
skin is warm. Liver is not
enlarged.
Chest xray revealed right lower
lobe pneumonia.
After administration of
antibiotic: Respiratory:
Dyspnea, Laryngeal edema,
Airway obstruction, Increased
respiratory
effort. Integumentary: Urticarial
rashes on chest. Vital signs:
HR=150 bpm strong and
regular, BP= 144/80 mm
Hg,RR=34 bpm, O2 sat = 89%
via albuterol nebulizer 6 L/min
oxygen, T=39.1
Nurse initial action is to assess the
patient’s sign and symptoms of
anaphylaxis. Assess the airway,
breathing pattern and vital signs.
Nurse must stopped infusion of the
antibiotic when an anaphylactic
reaction had developed. Nurse
observed K.B. for level of
consciousness, cardiac rhythm,
increasing edema and respiratory
distress. Nurse to notify physician
right away and follow MD orders such
as administration of emergency
medications (eg., epinephrine,
diphenhydramine, histamine
blockers, etc.), fluid and oxygen
administration.
Education: Since K.B. has recovered
from anaphylaxis, he needs an
explanation of what occurred and
instruction about avoiding future
exposure to antigens and how to
administer emergency medications to
treat his anaphylaxis.
(El Hussein & Osuji, 2020).
REFERENCES:
Ackley, B. J., Ladwig, G.B., & Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
Biggers, A. (2019, March 22). Anaphylactic Shock: What You Need to Know. Healthline. https://www.healthline.com/health/anaphylactic-shock
Chapman, J., & Lalkhen, A. (2016). Anaphylaxis. Anaesthesia and Intensive Care Medicine, 18(1), 16–21. https://doi.org/10.1016/j.mpaic.2016.10.008
David Plus. (2015). Albuterol. https://davisplus.fadavis.com/3976/meddeck/pdf/albuterol.pdf
David Plus. (2015). Diphenhydramine. https://davisplus.fadavis.com/3976/meddeck/pdf/diphenhydramine.pdf
El Hussein, M., & Osuji, J. (2020). Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing (4th ed.). Lippincott Williams & Wilkins.
Lewis, S. L., Bucher, L., MacLean Heitkemper, M., Harding, M. M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S. (Eds.). (2019). Medical-Surgical
Nursing in Canada: Assessment and Management of Clinical Problems (4th ed.). Elsevier Canada.
Medical Scenario 1: Kenneth Bronson. (n.d.). The point: Vsim for Nursing. https://thepoint.lww.com/Book/Show/446600?
focus=vs#/CoursePointContent/Show/b4489068-e2aa-4ef7-becf-37ea013d7e7b?forceView=False&viewMode=Student&productAssetId=c7c81e79b0cd-4128-865b-375a0103c8c4&behavior=Display&ts=1601413561439
Pflipsen, M. C., & Colon, K. M. V. (2020, September 15). Anaphylaxis: Recognition and Management. American Family Physician, 102(6), 355-362.
https://link.gale.com/apps/doc/A636080244/AONE?u=ko_acd_can&sid=AONE&xid=2822e657
Regateiro, F. S., Marques M. L., & Gomes E. R. (2020, May 12). Drug-Induced Anaphylaxis: An Update on Epidemiology and Risk Factors. International
Archives of Allergy and Immunology, 181(7), 481-487. https://doi.org/10.1159/000507445
* Teaching (continuation):
Patient measures:
Mr. K.B. must be educated on the sign and
symptoms of anaphylaxis reactions such as
shortness of breath/trouble breathing, rash,
itchiness, or upper airway obstruction from
swelling of the tongue, larynx.
Maintain a current and appropriately dosed
epinephrine auto-injector near where the patient
spends most of his time. Mr. K.B. must take it
when travelling and keep a placebo trainer for
education.
Mr. K.B. with medication-induced anaphylaxis
must strongly avoid the offending medication and
those with known cross reactivity.
Educate Mr. K.B. on the importance of wearing a
medical alert bracelet to prevent the
administration of the offending drug.
(Pflipsen & Colon, 2020)