Nursing Diagnosis for Anaphylactic Shock : Impaired Gas Exchange
Anaphylactic shock is a hypersensitivity response mediated by immunoglobulin E (hypersensitivity type I) is characterized by cardiac output and arterial pressure decreased great. This is caused by the presence of an antigen-antibody reaction which arises as soon as a sensitive antigen into the circulation. Anaphylactic shock is a clinical manifestation of anaphylaxis which is a distributive shock, characterized by the presence of significant hypotension due to sudden vasodilation of the blood vessels and accompanied the collapse of blood circulation which can lead to death. Anaphylactic shock is a case of gravity, but too narrow to describe anaphylaxis as a whole, because of severe anaphylaxis can occur in the absence of hypotension, as the main symptoms of anaphylaxis with airway obstruction.
Clinical manifestations of anaphylaxis vary widely. In the clinic, there are 3 types of anaphylactic reaction, namely the rapid reaction which occurs several minutes to 1 hour after exposure to the allergen; moderate reaction occurs between 1 and 24 hours after exposure to the allergen; and slow reactions occurred more than 24 hours after exposure to the allergen.
Symptoms may begin with a new prodormal symptoms become severe, but sometimes directly heavy. Based on the degree of the complaint, anaphylaxis is also divided into mild, moderate, and severe. Mild often with symptoms of peripheral tingling, warm sensation, tightness in the mouth, and throat. Can also occur nasal congestion, periorbital swelling, pruritus, sneezing, and watery eyes. Onset of symptoms started within the first 2 hours after exposure. Degrees were able to cover all the mild symptoms plus bronchospasm and airway or laryngeal edema with dyspnea, cough and wheezing. Facial redness, warm, anxiety, and itching are also common. Onset of symptoms similar to a mild reaction. The degree of weight have a very sudden onset with signs and symptoms are the same as those mentioned above with the rapid progress towards bronkospame, laryngeal edema, severe dyspnea, and cyanosis. Can be accompanied by symptoms of dysphagia, abdominal cramps, vomiting, diarrhea, and convulsions. Cardiac arrest and coma are rare. Death can result from respiratory failure, ventricular arrhythmias or irreversible shock.
Symptoms can occur immediately after exposure to the antigen and can occur in one or more target organs, such as cardiovascular, respiratory, gastrointestinal, skin, eyes, central nervous system and urinary system, and other systems. Complaints are often found in the initial phase is fear, burning in the mouth, itching of the eyes and skin, heat and tingling in the limbs, shortness, hoarseness, nausea, dizziness, fatigue and abdominal pain.
In the respiratory system occur hyperventilation, decreased pulmonary blood flow, decreased oxygen saturation, increased pulmonary pressure, respiratory failure, and a decrease in tidal volume. Upper respiratory tract can be impaired if the tongue or oropharynx involved causing stridor. Hoarse voice could even no sound at all if edema continues to deteriorate. Complete airway obstruction is the most frequent cause of death in anaphylaxis. Wheezing breath sounds occur when the lower respiratory tract is interrupted due to bronchospasm or mucosal edema. In addition, a cough, nasal congestion, and sneezing.
Nursing Care Plan for Anaphylactic Shock
Nursing Diagnosis : Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.
Goal: expected gas exchange problems handled
with expected outcomes: no shortness of breath, adequate ventilation, no symptoms of respiratory distress.
Nursing Interventions:
Anaphylactic shock is a hypersensitivity response mediated by immunoglobulin E (hypersensitivity type I) is characterized by cardiac output and arterial pressure decreased great. This is caused by the presence of an antigen-antibody reaction which arises as soon as a sensitive antigen into the circulation. Anaphylactic shock is a clinical manifestation of anaphylaxis which is a distributive shock, characterized by the presence of significant hypotension due to sudden vasodilation of the blood vessels and accompanied the collapse of blood circulation which can lead to death. Anaphylactic shock is a case of gravity, but too narrow to describe anaphylaxis as a whole, because of severe anaphylaxis can occur in the absence of hypotension, as the main symptoms of anaphylaxis with airway obstruction.
Clinical manifestations of anaphylaxis vary widely. In the clinic, there are 3 types of anaphylactic reaction, namely the rapid reaction which occurs several minutes to 1 hour after exposure to the allergen; moderate reaction occurs between 1 and 24 hours after exposure to the allergen; and slow reactions occurred more than 24 hours after exposure to the allergen.
Symptoms may begin with a new prodormal symptoms become severe, but sometimes directly heavy. Based on the degree of the complaint, anaphylaxis is also divided into mild, moderate, and severe. Mild often with symptoms of peripheral tingling, warm sensation, tightness in the mouth, and throat. Can also occur nasal congestion, periorbital swelling, pruritus, sneezing, and watery eyes. Onset of symptoms started within the first 2 hours after exposure. Degrees were able to cover all the mild symptoms plus bronchospasm and airway or laryngeal edema with dyspnea, cough and wheezing. Facial redness, warm, anxiety, and itching are also common. Onset of symptoms similar to a mild reaction. The degree of weight have a very sudden onset with signs and symptoms are the same as those mentioned above with the rapid progress towards bronkospame, laryngeal edema, severe dyspnea, and cyanosis. Can be accompanied by symptoms of dysphagia, abdominal cramps, vomiting, diarrhea, and convulsions. Cardiac arrest and coma are rare. Death can result from respiratory failure, ventricular arrhythmias or irreversible shock.
Symptoms can occur immediately after exposure to the antigen and can occur in one or more target organs, such as cardiovascular, respiratory, gastrointestinal, skin, eyes, central nervous system and urinary system, and other systems. Complaints are often found in the initial phase is fear, burning in the mouth, itching of the eyes and skin, heat and tingling in the limbs, shortness, hoarseness, nausea, dizziness, fatigue and abdominal pain.
In the respiratory system occur hyperventilation, decreased pulmonary blood flow, decreased oxygen saturation, increased pulmonary pressure, respiratory failure, and a decrease in tidal volume. Upper respiratory tract can be impaired if the tongue or oropharynx involved causing stridor. Hoarse voice could even no sound at all if edema continues to deteriorate. Complete airway obstruction is the most frequent cause of death in anaphylaxis. Wheezing breath sounds occur when the lower respiratory tract is interrupted due to bronchospasm or mucosal edema. In addition, a cough, nasal congestion, and sneezing.
Nursing Care Plan for Anaphylactic Shock
Nursing Diagnosis : Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.
Goal: expected gas exchange problems handled
with expected outcomes: no shortness of breath, adequate ventilation, no symptoms of respiratory distress.
Nursing Interventions:
- Assess frequency, depth and ease breathing.
- Maintain patency of the airway to give the position, exploitation, and the use of tools.
- Assess the level of consciousness / mental changes.
- Collaboration give oxygen therapy correctly, according to the condition of clients.
- Collaboration give medicines.
- Increased respiratory effort may indicate the degree of hypoxemia and useful in the evaluation of the degree of respiratory distress.
- Because airway obstruction may affect ventilation and impairs gas exchange.
- Therefore, systemic hypoxemia can be demonstrated first by the restless and sensitive excitatory later by progressive mental decline.
- The aim of oxygen therapy is to maintain PaO 2 above 60 mm Hg, oxygen is supplied with appropriate delivery methods tolerance client.
- Used to prevent allergic reactions / inhibit histamine release, lose weight and spasm of the airway, respiratory inflammation and dyspnea.
