Anaphylaxis: Nursing process (ADPIE)

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Jocelyn Williams is a 18-year-old female client with a history of severe peanut allergy who is brought to the emergency department, or ED, via paramedics after accidentally eating a cookie that contained peanuts.

After a few bites she felt a tingling sensation in her mouth and lips and her tongue started to swell. She could not find her EpiPen, so her roommate called 911.

Upon arrival to the ED, the paramedic reports that Jocelyn’s face was flushed and swollen at the time of their arrival; she had generalized hives, tachypnea, and labored respirations.

Her initial vital signs were tympanic temperature 98.7 F or 37 C, heart rate 126 beats per minute, respiratory rate 32 breaths per minute with audible wheezing, blood pressure 96/60, and SpO2 87% on room air.

They administered one dose of epinephrine IM per protocol, and placed her on a non-rebreather mask at 10L/min.

Anaphylaxis is a severe allergic reaction that affects multiple organ systems and can be life-threatening.

Now, allergic reactions typically happen when the immune system overreacts and starts targeting harmless antigens that don’t cause any problems for most people.

These include antigens found in certain foods like peanuts, eggs, and shellfish, as well as venom from insect bites or bee stings.

Other antigens include certain medications, such as antibiotics like penicillin, as well as NSAIDs, or streptokinase, which is used as a thrombolytic therapy.

In addition, some clients can develop allergic reactions when exposed to latex or radiocontrast agents used for imaging techniques like a CT scan or MRI.


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