7 Anaphylactic Shock Nursing Care Plans

Anaphylaxis kills fast when it kills, and it does it two ways at once: the airway swells shut while the blood pressure drops out from under the patient. Minutes matter. Epinephrine is the drug that reverses it, and nothing else substitutes. Your job is to recognize it early, get epinephrine in, support airway and circulation, and watch for a biphasic return hours later.

What is Anaphylactic Shock?

Anaphylactic shock (also called distributive or vasogenic shock) is a life-threatening allergic reaction from a systemic antigen-antibody response to a foreign substance. Histamine release drives smooth muscle contraction, massive vasodilation, and increased capillary permeability. It hits within seconds to minutes of exposure and progresses rapidly to respiratory distress, vascular collapse, systemic shock, and death without emergency treatment. Triggers include drugs, vaccines, foods (eggs, milk, peanuts, shellfish), insect venom, dyes or contrast media, and blood products.

Nursing Care Plans and Management

Nursing Problem Priorities

• Ensure a clear airway.
• Monitor and assess breathing.
• Monitor and assess circulation.
• Administer epinephrine promptly.
• Provide fluid resuscitation as needed.
• Administer prescribed medications.

Nursing Assessment

Assess for respiratory compromise (chest tightness, cyanosis, coughing, dyspnea, hoarseness, respiratory distress, stridor, tachypnea, accessory muscle use, wheezing, bronchospasm) and for circulatory collapse (hypotension, shock, tachycardia, pallor, decreased CVP, decreased peripheral pulses, decreased pulmonary pressures, dizziness, oliguria, prolonged capillary refill, restlessness). Also assess for knowledge gaps: inability to identify allergens, recurrent reactions, and poor follow-through on instructions.

Related factors include bronchospasm, bronchoconstriction, facial angioedema, laryngeal edema, ventilation-perfusion imbalance, generalized vasodilation (decreased preload and afterload), and increased capillary permeability (fluid shifts).

Nursing Diagnosis

After assessment, the nurse formulates diagnoses based on the patient's condition. Clinical judgment, not the diagnostic label, drives the care plan.

Nursing Goals

• The patient maintains an effective breathing pattern, evidenced by relaxed breathing at normal rate and depth and no adventitious sounds.
• The patient demonstrates improved ventilation, evidenced by absence of shortness of breath and respiratory distress.
• The patient is hemodynamically stable, evidenced by strong peripheral pulses, HR 60 to 100 beats/min with regular rhythm, systolic BP within 20 mm Hg of baseline, urine output greater than 30 mL/hr, warm dry skin, and alert mentation.
• The patient and family verbalize understanding of allergic reactions, their prevention, and management.
• The patient and family verbalize the need to carry emergency medication, inform providers of allergies, wear medical alert identification, and seek emergency care.

Nursing Interventions and Actions

1. Promoting an Effective Breathing Pattern

Bronchospasm, laryngeal edema, and facial angioedema narrow the airway and swell the throat and face. Watch the breathing constantly; respiratory distress can progress to failure in minutes.

Assess respiratory rate, rhythm, and depth, noting coughing, dyspnea, stridor, tachypnea, wheezing, and accessory muscle use. Histamine, the primary mediator, contracts bronchial smooth muscle through H1 receptors, and fluid shifts swell the upper airway.

Auscultate breath sounds. Wheezing is heard across the chest, but as bronchial constriction worsens, audible wheezing decreases and distress climbs. Listen for falling air movement, which is the dangerous sign.

Assess anxiety and the sensation of a narrowing airway. A systemic antigen-antibody response can severely narrow and obstruct the airway, and rising respiratory effort signals it.

Watch skin, tongue, and mucosa for bluish discoloration, which is a medical emergency, and check for angioedema (swelling of skin, lips, tongue, hands, eyelids, feet).

Monitor oxygen saturation and ABGs. Keep saturation at 90% or higher. As shock progresses, aerobic metabolism stops and lactic acidosis raises carbon dioxide and drops pH.

Stay with the patient and keep a calm manner. Air hunger drives anxiety and rapid shallow breathing; a trusted presence steadies the patient.

Coach slow, deep breathing to improve tidal volume and gas exchange, and position the patient upright for maximum chest expansion.

Give IV fluids as ordered for the hypotension of distributive shock, and give oxygen as prescribed. Saturation below 90% causes tissue hypoxia, acidosis, dysrhythmias, and altered consciousness.

Maintain a patent airway and anticipate emergency intubation or tracheostomy if stridor occurs. Laryngeal edema requires endotracheal intubation to keep the airway open.

For home management, provide emergency medication and a crisis plan, and help the patient and family identify what precipitates or worsens a reaction.

2. Enhancing Gas Exchange

Bronchospasm and airway swelling impair oxygen and carbon dioxide exchange. Optimize gas exchange while treating the underlying reaction.

Note respiratory rate, depth, and effort, which gauge the degree of hypoxemia, and assess level of consciousness. Anxiety, restlessness, confusion, and headache are early signs of mild hypoxemia.

Monitor oxygen saturation and ABGs, keeping saturation at 90% or higher.

Maintain airway patency, elevate the head of the bed, and use airway adjuncts and suction as indicated. An oropharyngeal or nasopharyngeal airway maintains patency for spontaneous respiration or bag-mask ventilation.

Provide oxygen therapy to maintain PaO2 above 60 mm Hg, and limit activity to within tolerance to reduce oxygen demand.

Give corticosteroids, bronchodilators, and antihistamines as ordered to inhibit histamine release and reduce airway spasm and inflammation.

3. Managing Decreased Cardiac Output

Generalized vasodilation and increased capillary permeability drop blood pressure and cardiac output, cutting flow to vital organs.

Assess HR, BP, and peripheral pulses. Intense vasodilation produces severe hypovolemia and hypotension, and pulses weaken with falling stroke volume.

Assess the ECG for dysrhythmias, which arise from low perfusion, acidosis, or hypoxia.

Assess level of consciousness. Restlessness and anxiety are early cerebral hypoxia; confusion and memory loss come late.

Assess skin temperature and cyanosis as markers of peripheral perfusion, and monitor urine output. Oliguria signals inadequate renal perfusion.

Monitor CVP, pulmonary artery diastolic pressure, pulmonary capillary wedge pressure, and cardiac output/index. These distinguish low output from fluid deficit versus fluid overload from aggressive IV therapy. CVP estimates right ventricular preload; wedge and PA diastolic pressures reflect left-sided volume.

Position the patient with the head of the bed flat, trunk horizontal, and lower extremities elevated 20 to 30 degrees with knees straight to promote venous return.

Give volume expanders and parenteral fluids through a large-bore needle, maintaining filling pressures and cardiac output. Avoid fluid overload in older patients.

If a blood transfusion is causing the reaction, stop the infusion immediately, keep the vein open with normal saline, and notify the physician.

4. Patient Education

Patients need to recognize early signs (difficulty breathing, swelling, hives, rapid heartbeat), know their triggers, and carry epinephrine at all times.

Assess current knowledge of the condition and allergen exposure as a baseline.

Explain the risk factors (certain drugs, blood products, insect venom, food, environmental triggers) so the patient can modify exposure. If the trigger is pollen, that means showering and changing clothes after time outdoors.

Instruct the patient to wear medical alert identification so providers know the history in an emergency.

Teach the patient and family what precipitates a recurrence and how to avoid it. Re-exposure to the same antigen puts the patient at high risk again.

Teach use of insect sting kits (with a chewable antihistamine) and prefilled epinephrine syringes, including how to obtain and self-administer them.

Have the patient disclose all allergies (blood products, food, pollen, latex, medications, contrast dyes, dust mites) in the medical history.

Teach self-care for an initial attack. The EpiPen is injected into the thigh muscle. Specifically:

• For a drop in blood pressure (dizziness), lie down with feet elevated.
• For wheezing, use the prescribed inhaled bronchodilator.
• For a severe reaction, self-inject epinephrine from the kit (EpiPen).
• Minimize exposure to the trigger.
• Take an oral antihistamine (Benadryl) if swallowing is intact.
• Call 911 or have someone drive to the hospital before the attack worsens.

Refer to an allergist if allergens are hard to avoid. Skin tests identify the specific allergen, and desensitization may help.

5. Monitoring for Complications

Anaphylaxis can cause systemic complications and can return hours later as a biphasic reaction.

Assess vital signs regularly (BP, HR, respiratory rate, oxygen saturation) for instability, and monitor level of consciousness, since changes signal inadequate cerebral oxygenation.

Assess airway and breathing for increased work of breathing, wheezing, or stridor from airway edema or bronchospasm.

Evaluate skin (hives, angioedema, erythema) for progression or resolution, and watch for cardiovascular instability (hypotension, tachycardia, arrhythmias).

Assess for GI distress (nausea, vomiting, abdominal pain), which can indicate systemic involvement.

Monitor oxygen saturation continuously and watch for delayed or biphasic reactions, which can reappear hours after the initial event.

Obtain labs as ordered (CBC, coagulation profile, serum tryptase) and document all assessments and changes thoroughly.

6. Medications and Pharmacologic Support

Epinephrine is the first-line drug for anaphylaxis and reverses the systemic effects: it constricts blood vessels, relaxes airway muscles, and reduces swelling, easing bronchospasm, hypotension, and angioedema. The remaining medications are adjuncts.

• Bronchodilators. Short-acting beta-agonists such as albuterol (Ventolin) relax airway smooth muscle to relieve bronchospasm.
• Antihistamines (H1-receptor blockers). Diphenhydramine (Benadryl) or cetirizine (Zyrtec) block histamine and reduce itching, hives, and rash, used alongside epinephrine.
• Corticosteroids. Methylprednisolone (Solu-Medrol) or prednisone stabilize cell membranes, reduce airway inflammation, and help prevent delayed or biphasic reactions.
• Glucagon. Used when hypotension persists despite epinephrine and fluids; it raises heart rate and myocardial contractility to support blood pressure.
• IV fluids. Isotonic crystalloids (normal saline) restore blood volume against vasodilation and fluid shift.
• Vasopressors. Norepinephrine or dopamine support blood pressure in refractory hypotension.
• Oxygen. Delivered by nasal prongs or mask to maintain saturation.

7. Laboratory and Diagnostic Procedures

• Complete blood count (CBC): identifies abnormal cell counts or signs of infection.
• Serum tryptase: released by mast cells, it confirms the diagnosis and gauges severity. Draw serially, the first during the acute phase, then 1 to 2 hours and 24 hours later.
• Coagulation profile: PT, aPTT, and INR detect clotting abnormalities from the systemic inflammatory response.
• Arterial blood gas (ABG): assesses oxygenation, carbon dioxide, and acid-base balance.
• Electrolyte panel: sodium, potassium, chloride, and bicarbonate, affected by fluid shifts and treatment.
• Liver function tests: ALT, AST, ALP, and bilirubin detect liver involvement.
• Renal function tests: creatinine and BUN, since shock and hemodynamic instability can impair the kidneys.
• ECG: detects arrhythmias and conduction abnormalities.
• Chest X-ray: evaluates for pulmonary edema, pneumothorax, or other complications.
• Allergen-specific IgE testing: RAST or ELISA identifies the responsible allergen to guide avoidance and immunotherapy.