Nursing care plan for Anaphylactic Shockwith a primary nursing diagnosis of Ineffective airway clearance related to laryngeal edema

and bronchospasm.Anaphylactic shock, or anaphylaxis, is an immediate, life-threatening allergic reactionthat is caused by a systemic antigen-antibody immune response to a foreign substance (antigen) introduced into the body. The term was first coined in 1902 when a second dose of a vaccination caused the death of an animal; the animals death was described as the opposite of prophylaxis, and was therefore called anaphylaxis, which means without protection. In the United States, experts estimate that from 20,000 to 50,000 people have anaphylactic shock each year; fatalities are infrequent but as many as 1000 people may die in the United States each year. Anaphylactic shock is caused by a type I, immunoglobulin Emediated hypersensitivity reaction. The antigen combines with immunoglobulin E (IgE) on the surface of the mast cells, and precipitates a release of histamine and other chemical mediators such as serotonin and slowreacting substance of anaphylaxis (SRS-A). The resulting increased capillary permeability, smooth muscle contraction, and vasodilation account for the cardiovascular collapse. More than one organ system must be involved to be considered anaphylaxis, and those organs are most commonly the heart, lungs, skin, and gastrointestinal systems. Bronchoconstriction, bronchospasm, and relative hypovolemia result in impaired airway, breathing, and circulation; death may follow if anaphylaxis is not promptly reversed. Although a delayed reaction may occur 24 hours after the exposure to an antigen, most reactions occur within minutes after exposure, and a recurrence of symptoms may occur after 4 to 8 hours. The most common causes of death from anaphylaxis are airway obstruction and hypotension.

Causes of Anaphylactic Shock: Anaphylactic shockcan result from a variety of causes, but it most commonly occurs in response to food, medications, and insect bites. Severe reactions to penicillin occur with a frequency of 1 to 5 patients per 10,000 courses of medication, and deaths from penicillin occur in 1 case per 50,000 to 100,000 courses of medication. Insect stings cause 25 to 50 deaths per year in the United States. Other common sources are iodine-based contrast materials and medications that have been derived from biological protein sources. These medications can include those derived from horse sera, vaccines, enzymes, and hormones. Foods such as fish, eggs, peanuts, milk products, and chocolate can cause allergic reactions and anaphylaxis. Nursing care plan assessment and intervention: Obtain information about any recent food intake, medication ingestion, outdoor activities and exposure to insects, or knownallergies. Symptoms usually begin within 5 to 30 minutes, and the earlier the signs and symptoms begin, the more severe the reaction. Often the signs and symptoms begin with skin and respiratory involvement and include Ask the members about a family history of drug allergies or a history of previous reactions. Note any hives, which appear as well-defined areas of redness with raised borders and blanched centers. Generalized symptoms include flushing, tingling, and angioedema around the mouth, tongue, eyes, and hands. Wheezing, stridor, loss of the voice, and difficulty breathing indicate laryngeal edema and bronchospasm and may indicate the need for

emergency intubation. Auscultate the patients blood pressure with a high suspicion for hypotension. Auscultate the patients heart to identify cardiac dysrhythmias, which may precipitate vascular collapse. Palpate the patients extremities for signs of cardiovascular compromise, such as weak peripheral pulses and delayed capillary refill. The patient who is experiencing an anaphylactic reaction is often panicky and fearful. Although alert, the patient may express a feeling of helplessness, loss of control, and impending doom. In addition, the family, parents, or significant others are apt to be fearful and severely anxious. Nursing care plan treatment plan and intervention: The plan of care depends on the severity of the reaction. Discontinue the administration of any possible allergen immediately. Consider applying a tourniquet to the extremity with the antigen source; this procedure can retard antigen exposure to the systemic circulation but the tourniquet needs to be released every 5 minutes, and it should not be left in place longer than 30 minutes. Complete an assessment of the patients airway to ensure patency and adequate breathing. If the patient has airway compromise, endotracheal intubation and mechanical ventilation with oxygenation may be necessary. More severe or prolonged cases of anaphylactic shock are aggressively treated with the establishment of IV access and infusion of normal saline or lactated Ringers as well as supplemental oxygen therapy. The patient may require urinary catheterization to monitor urinary output during periods of instability. The most important priority for nurses is to ensure adequacy of the airway, breathing, and circulation. Keep intubation equipment available for immediate use. Insert an oral or nasal airway if the patient is at risk for airway occlusion but has adequate breathing. Use an oral airway for unresponsive patients and a nasal airway for patients who are responsive. If endotracheal intubation is necessary, secure the tube firmly and suction the patient as needed to maintain the airway. If the patient has a compromised circulation that does not respond to pharmacologic intervention, begin cardiopulmonary resuscitation with chest compressions. Teach the patient and family how to prevent future allergic reactions. Explain the nature of the allergy, the signs and symptoms to expect, and measures to perform if the patient is exposed to the allergen. Teach the patient that if shortness of breath, difficulty swallowing, or the formation of the lump in the throat occurs, she or he should go to an emergency

department immediately. If the allergen is a medication, make sure the patient and family understand that they must avoid the various sources of the medication in both prescription drugs and available overthe- counter preparations for the rest of their lives. Encourage the patient to notify all healthcare providers of the allergy prior to treatment. Nursing care plan discharge guidelines: Provide a complete explanation of all allergic responses and how to avoid future reactions. If the patient has a reaction to a food or medication, instruct the patient and family about the substance itself and all potential sources. If the patient has a food allergy, you may need to include a dietitian in the patient teaching. Encourage the patient to carry an anaphylaxis kit with epinephrine. Teach the patient to administer subcutaneous epinephrine in case of emergencies. Encourage the patient to wear an identification bracelet at all times that specifies the allergy.

Cardiogenic shock is the inability to meet the metabolic needs due to severely impaired contractility of either ventricle. That leads to decreased tissue perfusion and a shock like state. Risk factor includes prior myocardial infarction, advanced age, female, diabetes, or anterior wall myocardial infarction. The most common cause of cardiogenic shock are acute Myocardial infarction, ventricular septal defect, acute mitral regurgitation, cardiac tamponade,aortic dissection, massive pulmonary infarct, and severe dysrhythmias. Signs and Symptoms

Pale, cool and clammy skin Pulmonary congestion and hypoxemia worsen as the ventricles fail to eject adequate volume and the blood backs up into the lung.

Tissue hypoperfusion continues because the oxygen does not meet the metabolic needs. Physical Examination Appearance Restlessness progressing to unresponsiveness Chest pain Dysrhythmias

Vital signs HR: >100 beats/min BP: <80 mm Hg RR: > 20 breaths/min

Neurologic Agitation Restlessness progressing to unresponsiveness, and changes in level of consciousness. Cardiovascular Weak thready pulses Rhythm may be irregular

Pulmonary Orthopnea Crackles Cough with increased secretions. Acute Care Patient Management Nursing Diagnosis: Impaired gas exchange related to increased left ventricular diastolic pressure (LVEDP) and pulmonary edema associated with severe left ventricular (LV) dysfunction. Outcome Criteria

Patient alert and oriented Pao2 80 to 100 mm Hg pH 7.35 to 7.45 Paco2 35 to 45 mm Hg O2 sat ?95 % RR 12 to 20 breaths/min, eupnea

Lungs clear to auscultation Nursing Interventions Patient Monitoring Continuously monitor oxygenation status with pulse oximetry. Monitor for desaturation in response to nursing intervention. Monitor ECG for dysrhythmias caused by hypoxemia, electrolyte imbalances, or ventricular dysfunction.

1. 2. 3.

4. Monitor fluid volume status. Patient Assessment

1. 2.

Obtain HR, RR, and BP every 15 minutes to evaluate the patients response to therapy and detect cardiopulmonary deterioration. Assess the patients respiratory status. The use of accessory muscles and inability to speak suggest worsening

pulmonary congestion. 3. Assess for excess fluid volume, which can further compromise myocardial function. Diagnostic Assessment 1. Review ABGs for decreasing trend in Pao2 (hypoxemia) or pH (acidosis). These conditions can adversely affect myocardial contractility. 2. Review serial chest radiographs to evaluate the patients progress or a worsening lung condition. Patient Management 1. 2. 3. 4. 5. Provide supplemental oxygen as ordered. If the patient develops respiratory distress, be prepared for intubation and mechanical ventilation. Administer low-dose morphine sulfate as ordered to reduce preload in an attempt to decrease pulmonary congestion. Minimize oxygen demand by maintaining bed rest and decreasing anxiety, fever, and pain. Position the patient for maximum chest excursion and comfort. Administer diuretics and /or vasodilators as ordered to reduce circulating volume and decrease preload.

Cardiogenic shock occurs when cardiac output is insufficient to meet the metabolic demands of the body, resulting in inadequate tissue perfusion. There are four stages ofCardiogenic shock: initial, compensatory, progressive, and refractory. During the initial stage, there is diminished cardiac output without any clinical symptoms. In the compensatory stage, the baroreceptors respond to the decreased cardiac output by stimulating the sympathetic nervous system to release catecholamines to improve myocardial contractility and vasoconstriction, leading to increased venous return and arterial blood pressure. Impaired renal perfusion activates the renin-angiotensin system, whose end-product, angiotensin II, causes sodium and water retention as well as vasoconstriction. The progressive stage follows the compensatory stage if there is no intervention or if the intervention fails to reverse the inadequate tissue perfusion. Compensatory mechanisms, aimed at improving cardiac output and tissue perfusion, place an increased demand on an already compromised myocardium. As tissue perfusion remains inadequate, the cells begin anaerobic metabolism, leading to metabolic acidosis and fluid leakage out of the capillaries and into the interstitial spaces. A decrease in circulating volume and an increase in blood viscosity may cause clotting in the capillaries and tissue death.

As the body releases fibrinolytic agents to break down the clots, disseminated intravascular coagulation (DIC) may ensue. Lactic acidosis causes depression of the myocardium and a decrease in the vascular responsiveness to catecholamines, further reducing cardiac output. Blood pools and stagnates in the capillaries, and the continued increase in hydrostatic

pressure causes fluid to leak into the interstitium. Severe cerebral ischemia causes depression of the vasomotor center and loss of sympathetic stimulation, resulting in blood pooling in the periphery, a decrease in preload, and further reduction in cardiac output. If there is no effective intervention at this point, the shock will progress to the refractory stage, when the chance of survival is extremely limited. Most experts acknowledge that Cardiogenic shock is often unresponsive to treatment and has a mortality rate ranging from 50% to 80%. The most common cause of Cardiogenic shock is acute myocardial infarction (MI) resulting in a loss of more than 40% of the functional myocardium. Cardiogenic shockoccurs with 10% to 20% of all hospital admissions for acute MI and carries an 80% mortality rate. Other causes include papillary muscle rupture, left ventricular free wall rupture, acute ventricular septal defect, severe congestive heart failure, end-stage cardiomyopathy, severe valvular dysfunction, acute cardiac tamponade, cardiac contusion, massive pulmonary embolus, or overdose of drugs such as beta blockers or calcium channel blockers. Nursing care plan assessment and physical examination The patient is likely to have a history of symptoms of an acute MI, including crushing, viselike chest pain or heaviness that radiates to the arms, neck, or jaw, lasting more than 20 minutes and unrelieved by nitroglycerin and rest. Other MI symptoms include shortness of breath, nausea, anxiety, and a sense of impending doom. The patient may also have a history of symptoms of any of the other etiologies mentioned above. During the initial stage of shock, there are no clinical findings unless the cardiac output can be measured. When the patient has entered the compensatory stage, symptoms may include an altered level of consciousness; sinus tachycardia; the presence of an S3 or S4 gallop rhythm; jugular venous distension; hypotension; rapid, deep respirations; pulmonary crackles; venous oxygen saturation (SvO2) less than 60%; cyanosis; urine output less than 20 mL/hr; decreased urinary sodium; increased urinary osmolarity; peripheral edema; hyperglycemia; hypernatremia; cold, clammy skin; and decreased bowel sounds. As the patient enters the progressive stage, the symptoms become more pronounced and resistant to treatment. The patient becomes mentally unresponsive; hypotension becomes worse, requiring high doses of positive inotropic agents; metabolic and respiratory acidosis become apparent; oliguria or anuria and anasarca may ensue; and symptoms of DIC may be present. When the shock reaches the refractory stage, multisystem organ failure is apparent, with the

above symptoms unresponsive to treatment. The patient in Cardiogenic shock is in a life-threatening situation. The chances for survival are small, and the patient may experience a sense of impending doom. The impaired tissue perfusion may lead to anxiety and fear. The patient and his or her family or significant other may be in crisis. Both the patient and the family may be experiencing grief in response to the potential loss of life. Nursing care plan primary nursing diagnosis: Altered tissue perfusion (peripheral, cerebral, renal, and cardiopulmonary) related to inadequate cardiac output. Nursing care plan intervention and treatment The primary goal in treating Cardiogenic shock is improvement in tissue perfusion and oxygenation. To limit the infarct size and treat the dyspnea, pulmonary congestion, hypoxemia, and acidosis, the physician is likely to prescribe oxygen. If a previously normocapnic patients PaCO2 decreases below 50 mm Hg, then the patient may require endotracheal intubation and mechanical ventilation. Although the patient needs an adequate blood pressure, afterload may also need to be decreased, which may be accomplished with the intra-aortic balloon pump (IABP). A left ventricular assist device (LVAD) may be used to replace the function of the patients heart for several days to provide total rest for the heart. An LVAD diverts blood from the left atrium or left ventricle by means of a pressure gradient and moves it to the external pump, after which the blood is returned to the aorta during diastole. An LVAD can reduce the patients right ventricular contraction. Monitor the patients central venous pressure carefully. Limiting myocardial oxygen consumption is a primary concern. Decreasing oxygen demand may limit ischemia, injury, and infarction. Restrict the patients activity, and maintain the patient on bedrest. Address the patients anxiety by explaining all procedures. Permit the family or significant others to remain with the patient as long as their presence does not cause added stress. Maintaining a calm and peaceful environment provides reassurance and reduces anxiety, which, in turn, will reduce myocardial oxygen consumption. Restricted activity could lead to impaired skin integrity, necessitating frequent assessment and care of the skin. Adequate protein and calories are essential for the prevention or healing of impaired skin integrity and should be provided by oral, enteral, or parenteral means. Nursing care plan discharge and home health care guidelines

Teach the patient how to reduce controllable risk factors for heart disease. If the physician has referred the patient to a cardiac rehabilitation program, encourage attendance. Be sure the patient understands the medication prescribed. Teach the patient to restrict fluids to 2 to 2.5 L per day, or as prescribed by the physician, and observe sodium restrictions. The patient should report a weight gain of greater than 4 pounds in 2 days to the physician. Finally, teach the patient to monitor for increasing shortness of breath and edema and to report either of those signs or symptoms to the physician. If the patient experiences acute shortness of breath, she or he should call 911 or go to the emergency department immediately.

A. General information 1. 2. 3. 4. Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working. Hypovolemic shock reduces CO and causes inadequate tissue perfusion from loss of circulating blood volume. Inadequate tissue perfusion resulting from markedly reduced circulating volume.

Surgical patients are at high risk because of blood loss intraoperatively and trauma from the manipulation of body tissue. B. Causes Hemorrhage Burns Dehydration

1. 2. 3.

4. Trauma C. Assessment findings 1. 2. 3. 4. 5. 6. 7. 8. Systolic blood pressure less than 90 mm Hg or 30 mm Hg less than baseline values Rapid weak pulse Dyspnea Tachypnea Cool, clammy skin Pallor Extreme thirst Irritability

9. Urine output less than 30mL/hr D. Diagnostic test findings 1. 2. 3. Chest X-ray: pulmonary lesions and areas of atelectasis ABG measurements: respiratory alkalosis progressing to combined respiratory and metabolic acidosis; hypoxemia Serum chemistries: increased BUN, alkaline phosphatase, creatinine, lactate, and potassium levels; decreased

HCO3, and albumin levels 4. CBC: increased hematocrit (HCT) levels E. Patient care management goal: restore the circulating blood volume 1. 2. 3. 4. 5. 6. 7. Assess and document continuous ECG rhythm; vital signs; mental status; heart, lung, and bowel sounds; urine output; and any signs and symptoms indicating changes in these parameters Administer fluids (lactated Ringers solution or normal saline solution) to correct fluid deficit Obtain ABG measurements and monitor for hypoxemia and acid-base imbalance; monitor SaO2 with a pulse oximeter If a pulmonary artery catheter is in place, assess the patients fluid volume and document CVP, PAP, PAWP, CO, and SVR as ordered Weigh the patient daily, at the same time and on the same scale with patient wearing the same amount of clothing, to evaluate fluid balance Administer oxygen at a flow rate based on the patients clinical condition to relieve ischemia If gas exchange is inadequate, prepare the patient and equipment for intubation