Nursing care for a patient presenting an acute anaphylactic re- action

Set of activities performed by the nurse aimed at recovering the patient’s vital functions.

Objectives:

– Maintain the patient’s life support. – To provide the patient with the necessary care to resolve the acute anaphylactic reaction quickly and effectively. – Decrease the anxiety of the patient and family.

Equipment:

– Crash cart. – Sphygmomanometer. – Stethoscope.

Material:

– Non-sterile gloves. – Specific medication. – Physiological saline solution. – Necessary material for oxygen therapy. – Material necessary for Peripheral Catheter Insertion Technique. – Necessary material for Fluid Therapy Insertion. – Necessary material for aspiration. – Nursing records.

Procedure:

– Call for help and notify physician. – Suspend all ongoing therapy. – Preserve patient’s privacy. – Move crash cart with patient. – Put on disposable gloves. – Place the patient in the supine position and loosen compressive clothing. If hypotension is present, place the patient in Trendelemburg position. – Monitor vital signs. – Keep the airway permeable. – Administer sufficient oxygen therapy to reduce hypoxemia. – Maintain 1-2 thick venous lines, cannulate peripheral lines if the patient does not have them and maintain them with saline. – Administer fluids and drugs prescribed by the physician. Have adrenaline, corticoids and antihistamines ready, wait for their administration to be ordered by the physician. – If cardio-respiratory arrest occurs, start resuscitation maneuvers. – Prepare everything necessary for transfer to the ICU, if necessary. – Collect the material used and clean it. – Remove gloves. – Record in nursing documentation: start time and duration, medication administered, procedures performed, time of transfer to ICU, incidents, constants.

Observations:

After resolution of the anaphylactic reaction, it is very important to identify the causative agent. After its identification, the patient should be informed, indicating the importance of avoiding it and of always carrying medical information on anaphylactic sensitivity.