Anaphylaxis: Nursing process (ADPIE)

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.

Now, let’s say a person gets stung by a bee for the first time. So the first time these antigens enter the body, they get picked up and recognized by immune cells, called dendritic cells.

These then activate other immune cells, the T lymphocytes, which in turn stimulate B lymphocytes to secrete IgE antibodies into the bloodstream.

IgEs then bind to the surface of mast cells and basophils, which are immune cells that are full of granules that contain proinflammatory molecules like histamine.

Later on, if the same person gets stung by a bee again, their mast cells and basophils, which already have IgE antibodies on their surface, are able to recognize the antigens and release their proinflammatory molecules, triggering an allergic reaction.

In most cases, this would cause some localized damage, like a swelling around the sting site, but sometimes things get really serious, and there’s massive release of proinflammatory molecules into the bloodstream.

When the allergic reaction involves two or more organ systems, such as the cutaneous, respiratory, cardiovascular, and gastrointestinal systems, it’s called anaphylaxis.

Now, there are some factors that may put the client at risk of anaphylaxis, such as atopy, which means having a genetic predisposition to allergic reactions, including allergic rhinitis, asthma, and atopic dermatitis.

Other risk factors include having a personal or family history of anaphylaxis. Symptoms of anaphylaxis typically start right after exposure to the antigen, and usually peak within 30 minutes.

These include angioedema, where tissues all over the body might start to swell up, including the eyes, mouth, tongue, and throat.

Angioedema is often associated with cutaneous manifestations like urticaria, which presents with a skin rash and pruritus, as well as flushing of the skin.

Anaphylaxis can also cause respiratory symptoms like chest tightness, shortness of breath, coughing, and wheezing, as well as gastrointestinal symptoms like abdominal pain, vomiting, and diarrhea.

Now, if not promptly treated, anaphylaxis can progress to serious complications like laryngeal edema, which can cause upper airway obstruction and even respiratory arrest.

In some cases, the massive release of proinflammatory molecules can lead to widespread vasodilation, which results in severe hypotension.

If blood pressure gets so low that it can’t supply vital organs, like the heart or brain, it’s called anaphylactic shock.

Reduced blood supply to the heart could cause myocardial infarction, especially in clients who already have an underlying heart disease, while reduced blood supply to the brain can cause loss of consciousness. Finally, if not promptly treated, anaphylaxis can lead to death.

Diagnosis of anaphylaxis is typically based on history and physical examination, as well as identifying a likely exposure and trigger.

One way to identify an allergic trigger is through skin prick tests, where small drops of allergens are pricked into the skin with a tool, to see if there’s evidence of an allergic reaction, like raised, itchy, red bumps or weals. Finally, specific lab tests like histamine and IgE levels are usually elevated.

Now, anaphylaxis is a medical emergency that needs immediate treatment, starting by ensuring a patent airway.