What is the primary action the nurse should take when a patient presents with symptoms of anaphylaxis, such as wheezing and throat tightness?

A) Administer intramuscular epinephrine

C) Encourage deep breathing exercises

D) Start an intravenous line for fluid administration

What is the priority action for a nurse when a patient exhibits signs of anaphylaxis, such as wheezing and throat tightness?

B) Administer intramuscular epinephrine

A) Administer oral antihistamines

B) Administer intramuscular epinephrine

C) Apply a cold compress to the rash

D) Encourage the patient to drink fluids

What is the primary action of intramuscular epinephrine in the management of anaphylaxis?

B) Constricts blood vessels and relaxes airway muscles

D) Neutralizes allergens in the bloodstream

What is the most appropriate initial action for a nurse when a patient begins to show signs of anaphylaxis?

B) Ensure the patient's airway is patent

C) Start an intravenous fluid line

Which of the following vital sign measurements indicates stability in the patient's condition during the initial assessment in the step-down unit?

B) Blood pressure of 110/70 mmHg

C) Respiratory rate of 24 breaths per minute

D) Oxygen saturation of 88% on room air

Which of the following is the most appropriate nursing action to ensure the patient's safety after discharge?

B) Educate the patient on the use of an epinephrine auto-injector and ensure they understand when to use it.

A) Instruct the patient to take the antihistamine only if symptoms recur.

B) Educate the patient on the use of an epinephrine auto-injector and ensure they understand when to use it.

C) Advise the patient to avoid all foods until they see an allergist.

D) Recommend the patient take over-the-counter pain medication for any discomfort.

A patient reports experiencing mild dizziness when standing up after starting an antihistamine medication. Which intervention should the nurse prioritize to prevent falls?

B) Instruct the patient to change positions slowly.

A) Encourage the patient to perform vigorous exercise.

B) Instruct the patient to change positions slowly.

C) Advise the patient to increase salt intake.

D) Suggest the patient limit fluid intake.

A patient who is being monitored for side effects of antihistamine medication reports dizziness when standing. Which initial nursing intervention is most appropriate to address this symptom?

C) Advise the patient to change positions slowly

A) Increase the patient's fluid intake

B) Encourage the patient to perform leg exercises

C) Advise the patient to change positions slowly

D) Administer additional antihistamine medication

A patient reports mild itching and minimal erythema on her forearms following an allergic reaction. What is the most appropriate initial nursing action?

C) Closely monitor the patient for any progression of symptoms

A) Administer an additional dose of antihistamine

B) Apply a topical corticosteroid to the affected area

C) Closely monitor the patient for any progression of symptoms

D) Discontinue all current medications to prevent further reactions

A patient who recently experienced an allergic reaction is being discharged with a prescription for an antihistamine. What is the primary action of antihistamines in managing allergic reactions?

A) They block the release of histamine from mast cells.

B) They prevent the production of allergens in the body.

C) They reduce inflammation by constricting blood vessels.

D) They increase the immune response to allergens.

Anaphylactic Shock - Nursing Case Study

Pathophysiology

• Primary mechanism: Anaphylactic shock occurs when the immune system overreacts to an allergen, causing a massive release of histamine and other chemicals from mast cells and basophils. This leads to widespread vasodilation and increased vascular permeability, resulting in a sudden drop in blood pressure (hypotension).

• Secondary mechanism: The released histamine and other mediators also cause constriction of the smooth muscles in the airways, leading to bronchoconstriction. This can cause difficulty breathing and reduced oxygen delivery to vital organs.

• Key complication: The combination of low blood pressure and impaired breathing can lead to inadequate blood flow and oxygen to organs, potentially resulting in organ dysfunction or failure if not treated promptly.

Patient Profile

Demographics:

28-year-old female, teacher

History:

• Key past medical history: Mild seasonal allergies

• Current medications: Oral contraceptive pills

• Allergies: Peanuts

Current Presentation:

• Chief complaint: Sudden onset of rash and difficulty breathing after eating a cookie

• Key symptoms: Rash, mild wheezing, throat tightness

• Vital signs: Blood pressure 110/70 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F

Section 1

Initial Assessment Findings:

Upon further assessment in the emergency department, the patient exhibits mild wheezing and erythematous rash covering her arms and torso. She reports a sensation of throat tightness but is able to speak in full sentences, indicating that her airway is patent but compromised. Auscultation of the lungs reveals bilateral wheezing, particularly in the upper lung fields, suggesting bronchoconstriction due to the allergic reaction. Her heart rate has increased slightly to 94 bpm, but her blood pressure remains stable at 110/70 mmHg. Oxygen saturation is at 94% on room air, slightly decreased from normal levels, indicating a mild hypoxemia likely secondary to the bronchoconstriction.

The nursing staff initiates the standard anaphylaxis protocol, administering intramuscular epinephrine and supplemental oxygen via nasal cannula at 2 liters per minute to alleviate respiratory distress and support oxygenation. The patient remains alert and oriented, and reassessment shows a slight improvement in her breathing and a reduction in her wheezing within minutes of the intervention. Her rash begins to fade, and her throat tightness lessens, suggesting a positive response to the epinephrine.

These findings and interventions reflect an early stage of anaphylactic shock with minor complications, where timely recognition and treatment have prevented the progression to more severe symptoms. The nursing team continues to monitor the patient closely for any changes in her condition, ready to escalate care if necessary. Further assessment and observation will determine the next steps in her management, ensuring that she remains stable and safe.

Section 2

Response to Interventions:

Following the administration of intramuscular epinephrine and supplemental oxygen, the patient's condition continues to improve. Her oxygen saturation rises to 97% with the nasal cannula, indicating enhanced oxygenation and effective relief of bronchoconstriction. The erythematous rash on her arms and torso has further diminished, now appearing as faint pink patches. Her heart rate stabilizes at 88 bpm, and her blood pressure remains within normal limits at 112/72 mmHg. The patient continues to report decreased throat tightness and is now able to take deep breaths with minimal discomfort. The wheezing has significantly reduced, with only slight expiratory wheezing heard upon auscultation, primarily in the upper lung fields.

The nursing team maintains vigilant monitoring, ensuring the patient's airway remains patent and her vital signs stable. A repeat assessment of her respiratory status confirms steady improvement, with no signs of reoccurrence of severe symptoms. The team reviews the patient's medical history and medication allergies to identify potential triggers for the allergic reaction, emphasizing the importance of prevention in future care. Educational materials are provided to the patient and her family, outlining signs of anaphylaxis and the necessity of carrying an epinephrine auto-injector for emergency use.

As the patient continues to stabilize, the healthcare team discusses transitioning her to a step-down unit for extended observation. The plan includes ongoing monitoring of her respiratory status, skin condition, and overall response to treatment. This transition marks a positive step in her recovery, allowing for continued care in a less acute setting while ensuring readiness to address any potential late-phase anaphylactic reactions. The focus remains on optimizing her recovery and preparing her for safe discharge with appropriate follow-up care.

Section 3

As the patient is transferred to the step-down unit, the nursing team conducts a thorough initial assessment to ensure her continued stability. Her vital signs remain stable with a heart rate of 85 bpm, blood pressure at 110/70 mmHg, and respiratory rate of 16 breaths per minute. Oxygen saturation holds steady at 98% on room air, demonstrating successful weaning from supplemental oxygen. Upon a detailed skin examination, the erythematous rash has almost completely resolved, with only faint remnants visible. Lung auscultation reveals minimal expiratory wheezing, now localized to the right upper lobe, indicating ongoing improvement in her respiratory status.

To further evaluate the patient’s recovery, a complete blood count (CBC) and serum tryptase level are ordered to assess any lingering systemic effects of the allergic reaction. The CBC results show a slight elevation in eosinophils at 6% (normal range 1-4%), which is consistent with a resolving allergic response. The serum tryptase level has normalized compared to the initial elevated level, confirming a reduction in mast cell activity and supporting the overall positive trend in the patient’s condition.

With these reassuring findings, the healthcare team collaborates to refine the care plan. The focus now shifts to ensuring patient education regarding anaphylaxis management and the importance of allergist follow-up to identify specific allergens. A discharge plan is being developed, emphasizing adherence to the prescribed antihistamine regimen and the critical need for an epinephrine auto-injector. The nursing team remains attentive to any subtle changes, prepared to intervene promptly should any delayed allergic symptoms arise. This comprehensive approach ensures a smooth transition towards discharge and empowers the patient with the knowledge to prevent future anaphylactic episodes.

Section 4

As the day progresses, the nursing team observes the patient closely, continuously monitoring her vital signs and overall condition. The patient's vital signs remain stable, with her heart rate maintaining at 84 bpm, blood pressure at 112/72 mmHg, and respiratory rate of 16 breaths per minute. Oxygen saturation continues to be optimal at 98% on room air, reinforcing the successful weaning off supplemental oxygen. The patient reports feeling much better and expresses relief at the improvement in her symptoms.

During a routine check, the patient mentions a mild headache and slight dizziness when standing up. The nursing team conducts an orthostatic blood pressure check to assess for any postural changes, revealing a minor drop in blood pressure to 100/68 mmHg upon standing. This finding suggests a potential side effect of the antihistamine medication, which can occasionally cause mild orthostatic hypotension. The team advises the patient to change positions slowly, particularly when moving from lying to standing, to mitigate these symptoms.

In light of these observations, the nursing team adjusts the care plan to include education on managing side effects of her medication. They emphasize adequate hydration and careful monitoring of symptoms like dizziness, which could affect her balance and increase the risk of falls. This proactive approach ensures the patient's safety while reinforcing her understanding of medication management, preparing her for a confident transition to home care. The next steps in her discharge plan continue to focus on comprehensive education and empowerment, ensuring she feels supported as she resumes her daily activities.

Section 5

As the nursing team continues to support the patient, they notice a slight change in her condition later in the afternoon. Although her vital signs remain stable with a heart rate of 86 bpm, blood pressure at 110/70 mmHg, and respiratory rate of 17 breaths per minute, she reports a mild itching sensation on her arms and legs. The team promptly assesses for any visible signs of hives or rash but finds only minimal erythema on her forearms. Recognizing this as a potential residual effect of her allergic reaction, they decide to monitor her closely for any progression.

In response to these new symptoms, the nursing team evaluates her recent blood work, focusing on the complete blood count (CBC) and inflammatory markers. Her CBC shows a slight elevation in eosinophils, consistent with an allergic reaction, but other values, including white blood cell count, remain within normal ranges. The team educates the patient on the importance of continuing her prescribed antihistamine regimen to manage these symptoms. They also reinforce the significance of avoiding known allergens and maintaining a symptom diary to track any changes.

With these interventions, the patient's symptoms remain under control, and she expresses confidence in managing her condition at home. The team finalizes her discharge plan, ensuring she has all necessary prescriptions and education materials. They schedule a follow-up appointment with her primary care provider to reassess her condition and adjust her management plan if needed. This comprehensive approach ensures a seamless transition from hospital care to home, prioritizing her safety and well-being.