ANAPHYLACTIC SHOCK

Also known as distributive shock, or vasogenic shock is a life-threatening allergic reaction that is
caused by a systemic antigen-antibody immune response to a foreign substance (antigen)
introduced into the body. 

Brief Pathophysiology: It is characterized by a smooth muscle contraction, massive vasodilation and

increased capillary permeability triggered by a release of histamine. It occurs within seconds to
minutes after contact with an antigenic substances and progresses rapidly to respiratory distress,
vascular collapse, systemic shock, and possibly death if emergency treatment is not initiated.
Causative agents include severe reactions to a sensitive substance such as a drug, vaccine, food (e.g.,
eggs, milk, peanuts, shellfish), insect venom, dyes or contrast media, or blood products.

Ineffective Breathing Pattern

Nursing Diagnosis

 Ineffective Breathing Pattern

May be related to

 Bronchospasm.
 Bronchoconstriction.
 Facial angioedema.
 Laryngeal oedema.
Possibly evidenced by

 Chest tightness/shortness of breath

 Cyanosis.
 Coughing.
 Dyspnea.
 Hoarseness.
 Respiratory distress.
 Stridor.
 Tachypnoea.
 Use of accessory muscles.
 Wheezing.

Goal: patient will maintain an effective breathing pattern, as evidenced by relaxed breathing at normal
rate and depth and absence of adventitious breath sounds.
 Nursing Interventions
Assess the respiratory rate, rhythm, and depth,
and note for changes such as:
 Coughing.
 Dyspnea.
 Increased shortness of breath.
 Stridor.
 Tachypnea.
 Use of accessory muscles.
 Wheezing.
Auscultate breath sounds.
Assess the patient’s anxiety level.
Assess the patient for the sensation of a narrowed
airway.
Observe for changes in colour of the skin, tongue,
and mucosa.
Assess the presence of angioedema.
Monitor oxygen saturation and arterial blood
gasses.
Maintain a calm, assured manner. Assure the
patient and significant others of close, continuous
monitoring that will ensure prompt intervention.
Provide assurance and alleviate anxiety by staying
with the patient during acute distress.
Instruct the patient to breathe slowly and deeply.
Position the patient upright.
Administer IV fluids as ordered.
Administer oxygen as prescribed.
Rationale
Histamine is the primary mediator of anaphylactic shock. It
causes smooth muscle contraction in the bronchi as a result of
the stimulation of histamine receptors (H1). As the
anaphylactic reaction progresses, the patient develops
dyspnea, wheezing, and increased pulmonary secretions.
Vascular to interstitial fluid shifts to contribute to respiratory
distress through swelling in the upper airways.
By auscultation, wheezing can be heard over the entire chest.
But when the bronchial constriction worsens, there will be
decreased audible wheezing and respiratory distress will
heighten. Therefore it is also important to auscultate for
decreasing air movement.
Life-threatening situations such as respiratory distress and
shock can produce elevated levels of anxiety within the
patient.
Systemic antigen-antibody immune response can result in
severe bronchial airway narrowing, edema, and obstruction.
As airway gets narrow, patient demonstrates increase
respiratory effort.
Bluish discoloration of these body parts is considered a
medical emergency.
Angioedema is characterized by the swelling of the skin, lips,
tongue, hands, eyelids and feet.
Pulse oximetry is used to monitor oxygen saturation. It should
be kept at least 90% or higher.
The staff’s anxiety may be easily perceived by the patient.
The patient’s feeling of stability increases in a calm, non-
threatening environment. The presence of a trusted person can
help the patient feel less threatened.
Air hunger can produce an extremely anxious state that leads
to rapid and shallow respirations.
Focus breathing may help calm the patient, and the increase
tidal volume facilitates improved gas exchange.
This position provides oxygenation by promoting maximum
chest expansion and is the position of choice during
respiratory distress.
Hypotension caused by vasodilation and distributive shock
responds to fluid resuscitation.
Oxygen increase arterial saturation. Oxygen saturation that is
less than 90% results to tissue hypoxia, acidosis,

Administer medications as ordered:
 Bronchodilators-Salbutamol nebs
 Corticosteroids-Hydrocortisone
 Adrenalin/Epinephrine.
 H1-receptor blockers/antihistamines
Berotec nebs/inhaler.
Maintain a patent airway. Anticipate an
emergency intubation or tracheostomy if stridor
occurs.
Discharge: 
 Provide information about emergency
medications and plans that should be
considered should the situation
reoccur.
 Assist the patient and/or family in
identifying factors that precipitate
and/or exacerbate similar crises.
dysrhythmias, and changes in the level of consciousness.
These medications reduce bronchospasm and help open the
airways in the lungs by relaxing smooth muscle around the
airways.
Steroids stabilize the cell membrane and decrease cellular
permeability, vasomotor response, and inflammation.
Epinephrine is the cornerstone of anaphylaxis management. It
is fast-acting and relaxes pulmonary vessels to improve air
exchange and stabilizes cellular permeability.
These medications block the action of histamine and decrease
cellular oedema.
Respiratory distress may progress rapidly. If laryngeal
oedema is present, endotracheal intubation will be required to
maintain a patient airway.
Adequate preparation decreases risks.
Knowledge can facilitate prompt intervention.