A patient presented with difficulty breathing due to anaphylaxis. The nurse assessed nasal flaring, increased respiratory rate, restlessness, cyanosis of the nail beds, and cold clammy skin. The patient was diagnosed with ineffective airway clearance secondary to anaphylaxis. The nurse placed the patient in Fowler's position, checked the airway, administered oxygen and epinephrine as needed, and monitored oxygen saturation levels. Once stable, the nurse obtained the patient's medical history and provided health teaching about avoiding allergens and carrying an emergency kit to prevent future anaphylactic reactions.
A patient presented with difficulty breathing due to anaphylaxis. The nurse assessed nasal flaring, increased respiratory rate, restlessness, cyanosis of the nail beds, and cold clammy skin. The patient was diagnosed with ineffective airway clearance secondary to anaphylaxis. The nurse placed the patient in Fowler's position, checked the airway, administered oxygen and epinephrine as needed, and monitored oxygen saturation levels. Once stable, the nurse obtained the patient's medical history and provided health teaching about avoiding allergens and carrying an emergency kit to prevent future anaphylactic reactions.
A patient presented with difficulty breathing due to anaphylaxis. The nurse assessed nasal flaring, increased respiratory rate, restlessness, cyanosis of the nail beds, and cold clammy skin. The patient was diagnosed with ineffective airway clearance secondary to anaphylaxis. The nurse placed the patient in Fowler's position, checked the airway, administered oxygen and epinephrine as needed, and monitored oxygen saturation levels. Once stable, the nurse obtained the patient's medical history and provided health teaching about avoiding allergens and carrying an emergency kit to prevent future anaphylactic reactions.
Ineffective Airway Clearance Secondary to Anaphylaxis
In 5-10 minutes, the patient will be able to breath in with ease
Assess for any previous history of anaphylaxis or allergic reaction.
Place the patient in a Fowlers position/Semi- fowlers position
Check airway clearance
Administer Oxygen as necessary
Assist in the administration of Epinephrine
Assess if the patient is responding well to the medication.
Monitor patients oxygen saturation by using a pulse oximeter
Once the patient is stable, in depth medical history is necessary.
It will provide important information of the patients past medical history, thus can give the nurse an overview on how to handle the situation.
Allows patient to improve its breathing capacity to the maximum.
Any airway obstruction should be removed.
Improves body oxygenation
Epinephrine is the primary medication for anaphylaxis.
If the patient is not responding to the first shot, the doctor might order another shot after 15min.
A 98-100% oxygen saturation is needed to make sure that the patient is getting enough oxygen in his/her body.
Know the recent activities the patient did before coming to the facility including the food that the patient ate.
Health Teaching
Educate the patient about the things they should avoid especially what caused the allergic reaction
If exposure to allergen cannot be avoided, instructed them to carry an emergency kit with medication and instruct them the proper way to medicate themselves.
Also inform them of the subtle signs of an allergic reaction like urticaria, periorbital swelling, pruritus, nasal congestion and the like.
To know when the patient had this anaphylactic reaction.
This is necessary to know what caused this allergic reaction and to prevent this from happening again in the future.
To give the patient an overview of what specific things to avoid.
This is to ensure the patient knows what to do in emergency cases.
This will prevent further progression of a life threatening scenarios like brochospsm and laryngeal edema which can cause dyspnea.
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