pt 1. care of patients with immune hypersensitivity reaction

treatment of latex allergies

-Medications are available to reduce the symptoms of latex allergy, there is no cure. -The only way to prevent a latex allergic reaction is to avoid products that contain latex.

main nursing assesment interventions for anaphylatic reactio

-Observe for changes in color 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 client and significant others of close, continuous monitoring that will ensure prompt intervention. Assess the respiratory rate, rhythm, and depth, and note for changes Auscultate breath sounds for wheezing for bronchial constriction

side effects of Bronchodilators. (albuterol) and Corticosteroids. (methylprednisolone

-bronchodilators: 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.

If you've had a severe allergic reaction to latex, you may need to carry what at all times

-carry injectable epinephrine with you at all times. If you have an anaphylactic reaction, you will need to go to the emergency room for an immediate injection of adrenaline (epinephrine).

classic s/s of anaphylaxis

-loss of consciousness, hives, swelling of tongue, inabaility to swallow, rapid swelling of throat tissues -diff breathing, nausea, diaareah, flushing of the skin, chest tighteness, wheezing, swollen eyes, abdominal pain, swollen feet, floppy feeling in limbs

what is the awareness for type IV delayed hypersensitivty

-serious reaction that can cause death, requires medical treatment and follow up with a allergen specilaist -can affect 2 or more body systems at same time -occur within a few seconds to hours after exposure to an allergen -it can reoccur up to 4 hours after tx

3a. Based on the client's history of new onset of shortness of breath and edema of the eyes and lips, what does the nurse suspect is the problem?

3a. The nurse anticipates that the client may be having an anaphylactic reaction. The client stated a peanut allergy. These have been linked to contact with latex.

3b. What questions are appropriate to ask this client?

3b. Because the client had been working prior to presenting to the ED, the nurse should inquire about use of latex gloves at work. Anaphylaxis is the most dramatic and life-threatening example of type I hypersensitivity reaction; it occurs rapidly and systemically.

The nurse has educated a client with a shellfish allergy about angioedema. Which client statement requires further nursing teaching? A."Shrimp is OK to eat because it is not a shellfish." B."I keep an epinephrine injector in my backpack." C."Angioedema includes swelling of eyes, lips, and tongue." D."When I see a new provider, I will disclose my shellfish allergy."

ANS: A •Shrimp is a shellfish, and should not be consumed by clients with shellfish allergies. This statement therefore requires further teaching by the nurse. The client should carry an epinephrine injector at all times. Symptoms of angioedema include swelling of eyes, lips, and tongue. clients should report all allergies to health care providers.

A client has been admitted to the ED with bilateral eyelid swelling and subsequent difficulty seeing. What is the priority nursing assessment? A.Airway B.Nasal cavity C.Visual disturbance D.Drugs taken consistently

ANS: A •The client likely has angioedema that has caused the swelling. This can progress very quickly to affect the airway. Interventions focus on stopping the reaction and ensuring an adequate airway. While swelling can invade the nasal cavity, the priority is on securing and maintaining the airway. The visual disturbance will likely return when eyelid swelling is decreased. Knowing the drugs the client consistently takes can be determined after the airway is secured.

5. What treatment does the nurse anticipate will be ordered by the provider? (Select all that apply.) A.Oxygen B.IV fluids C.Epinephrine D.Acetaminophen E.Diphenhydramine

ANS: A, B, C, E •If the reaction is severe, the provider may order the first-line drug epinephrine for the client. Antihistamines such as diphenhydramine are second-line drugs and are usually given for angioedema and urticaria. Acetaminophen is not indicated. IV fluids are usually started when a reaction is suspected, and the provider may order oxygen to address the client's shortness of breath.

2. The nurse asks the client about a history of any allergies. The client, who reports coming straight from work as a nursing assistant, admits to a peanut allergy, but denies eating today. Which laboratory test does the nurse anticipate the provider will order? (Select all that apply.) A.Electrolytes B.Immunoglobulin E C.CBC with differential D.Liver function tests (LFT) E.Kidney function tests (KFT)

ANS: B, C •With the CBC with differential (diff), look for increased eosinophils, which may be as high as 12% (normal = 1%). Some clients may also have a higher than normal total WBC count. Normal IgE levels are about 39 IU/mL (<100 IU/mL). This level is greatly increased with allergies.

Upon receiving a new IV medication, a client becomes short of breath with itching and hives. What is the priority nursing action? A.Assess vital signs B.Review the client's allergies C.Stop the intravenous infusion D.Administer diphenhydramine as ordered

ANS: C • •If an IV drug is suspected to be causing the anaphylaxis, stop the drug immediately but do not remove the venous access because restarting an IV is difficult when the client is severely hypotensive. Other actions can be done after the new medication infusion is stopped.

anaphylactic shock is also known as... and what is it characterized by

Anaphylactic Shock also known as distributive 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. -It is characterized by a smooth muscle contraction, massive vasodilation and increased capillary permeability triggered by a release of histamine

Assess the presence of angioedema.

Angioedema is characterized by the swelling of the skin, lips, tongue, hands, eyelids, and feet.

-Observe for changes in color of the skin, tongue, and mucosa.

Bluish discoloration of these body parts is considered a medical emergency.

Five minutes later, the client continues to experience some shortness of breath, and reports tongue swelling and anxiety. 4. What is the priority nursing intervention? A.Assess lung sounds B.Provide reassurance C.Notify the health care provider D.Contact the Rapid Response Team

D.Contact the Rapid Response Team •The client has tongue swelling, indicating angioedema. She is still short of breath and may have abnormal breath sounds such as crackles and wheezes. Respiratory failure due to swelling of the tongue and larynx may soon follow. Emergency respiratory management is critical during an anaphylactic reaction because severity increases with time. This is the time to call the Rapid Response Team so they will be on the way; all other actions can immediately follow their notification.

side effects of Epinephrine. and H1-receptor blockers/antihistamines. (Benadryl, Cimetidine)

Epinephrine is the cornerstone of anaphylaxis management. It is fast-acting and relaxes pulmonary vessels to improve air exchange and stabilizes cellular permeability. H1 receptor blocker/antihistamines: These medications block the action of histamine and decrease cellular edema.

causes of anaphylactic reaction

Insect stings, medication reaction, food allergy

Monitor oxygen saturation and arterial blood gasses.

Pulse oximetry is used to monitor oxygen saturation. It should be kept at least 90% or higher. As shock progresses, aerobic metabolism stops and lactic acidosis occurs, resulting in the increased level of carbon dioxide and decreasing pH.

side effects of epipen auto injector

Side effects include angina, tachycardia, hypertension, restlessness, nervousness, hyperglycemia

\Maintain a calm, assured manner. Assure the client and significant others of close, continuous monitoring that will ensure prompt intervention.

The staff's anxiety may be easily perceived by the client. The client's feeling of stability increases in a calm, non-threatening environment. The presence of a trusted person can help the client feel less threatened.

•For less severe reactions, your doctor may prescribe what for latex allergies

antihistamines or corticosteroids, which you can take after exposure to latex to control your reaction and help relieve discomfort

children have a higher risk for

incidence of food related anaphylaxis

Histamine is the primary mediator of

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 client develops dyspnea, wheezing, and increased pulmonary secretions. Vascular to interstitial fluid shifts to contribute to respiratory distress through swelling in the upper airways.

s/s of anaphylactic reaction

rapid onset, dyspnea, tight throat, bronchospasm, laryngeal edema, feeling s of apprehension -tingling and swelling in mouth, face, throat -itching, decreased bp, tachycardia, loss of consciousness

anaphylactic reaction

severe, often life-threatening allergic reaction

Angiodema

swelling around the face

increased risk for anaphylaxis with higher socioeconomic status, t or f?

true

Despite your best efforts to avoid latex..

you may still come into contact with it

interventions for epipen auto injection

• Use with MAOI may lead to hypertensive crisis • Patients should not use stimulants (caffeine, guarana, etc.) • Excessive use may cause bronchospasm • Assess lung sounds, pulse, BP, and other hemodynamic parameters • Monitor for chest pain• Instruct patient to use as directed • Patient should ensure adequate fluid intake to liquefy secretions • Mouth should be rinsed after inhalation• Beta blockers may negate effects • May increase blood glucose levels

action of epipen auto injector

•Action: Affects both beta1 and beta2 also has alpha agonist properties resulting in bronchodilation & increases in HR and BP. Inhibits hypersensitivity reactions.

A client comes to the ED with mild shortness of breath and a runny nose. The triage nurse notes that the client's lips and eyes are somewhat swollen. 1. What action will the nurse take at this time?

•An accurate and detailed history is important; the nurse will begin collecting this information as long as the client is not in imminent danger, although the client will likely be triaged back to the environment of care right away, given the risk of this condition progressing quickly. The client should be asked to describe the onset and duration of problems related to possible allergen exposure. Ask about work, school, and home environments and possible exposures through food, hobbies, leisure, or sports activities. The client should also be asked about the presence of allergies among close relatives because of the tendency for type I allergies to be inherited.

what is angiodema

•Angioedema is a severe type I hypersensitivity reaction that involves the blood vessels and all layers of the skin, mucous membranes, and subcutaneous tissues in the affected area •affects the Lips, face, tongue, larynx, neck

for anaphylaxis interventon, what do you need to be prepared to admisiter?

•Be prepared to administer epinephrine (1st line) • this Promotes bronchodilation and inhibits further release of immune mediators •0.2-0.5mg of a 1:1000 dilution •Can be given IM q5-15 minutes until symptoms cease

what does Anaphylaxis: Type I Hypersensitivity cause and lead to

•Blood vessel dilation •Decreased cardiac output •Bronchoconstriction •Can lead to decrease perfusion, shock, airway obstruction, circulatory collapse (shock) and death

what medications do you give for anaphylaxis•Bronchodilators. (albuterol) •Corticosteroids. (methylprednisolone •Epinephrine.

•Bronchodilators. (albuterol) •Corticosteroids. (methylprednisolone •Epinephrine. •H1-receptor blockers/antihistamines. (Benadryl, Cimetidine)

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.

what are triggers for Anaphylaxis: Type I Hypersensitivity

•Food, peanuts, insects, latex, medications shellfish, antibioitcs, insects like yellow jackets

physical assesment for anaphylaxis (recognizing the cues)

•History • •Physical assessment (Classic) •Angioedema: Lip swelling, itching in back of throat •Deep, firm swelling of face, lips, tongue neck •Difficulty speaking, hoarse, dysphagia •Nasal swelling •Rhinorrhea

what are the priority concepts for hypersensitivites/allergies

•Immunity •Inflammation

for anaphylaxis the initial symptoms may be subtle, what Is the assessment of the different systems of the body that anaphylaxis affects

•Initial symptoms may be subtle •CV: Decreased BP, tachycardia or bradycardia, diaphoresis weak rapid pulse •Resp: Cough, dyspnea, hoarse, wheezing •Skin: Urticaria, erythema, pruritus •Neuro: Feelings of apprehension, loss of consciousness, weakness, impending doom, Headache, syncope •GI: Nausea and vomiting •GU: Incontinence

anaphylactic shock occurs within..

•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. •prepare to give Vasopressors

Anaphylaxis: Type I Hypersensitivity

•Life-threatening - •Rapid, systemic. and Affects many organs-seconds after exposure-minutes-hours •Medical emergency

what is the patho of Anaphylaxis: Type I Hypersensitivity

•Mast cell activation and overwhelming biochemical immune response •Triggered by activation of immunoglobulin (Ig) E •Systemic vasodilation, laryngeal edema, increase capillary permeability, bronchospasm and cutaneous reaction

s/s of type IV delayed hypersensitivty and when does it occur

•Occurs hours to days after exposure •Edema, induration, ischemia, tissue damage at site of exposure (e.g., dermatitis)

hypersensitivies are classified as

•Overactive immunity with excessive inflammation in response to presence of an antigen to which patient has been previously exposed

plan of care for anaphylaxis

•Plan of Care: Impaired Gas Exchange, Hypovolemia, Alteration in Cardiac Output

health promotion and maintenence for anaphylaxis

•Prevention is best •Avoid known allergens •Know how to read food labels •Wear medical alert bracelet •Notify health care personnel about specific allergies •Carry anaphylaxis kit or epinephrine injector •Health records should prominently display list of specific allergens •Implement precautionary measures if drug or agent must be used despite history of allergic reaction

nursing interventions for anaphylaxis

•Remove from cause •If an IV drug is suspected as the cause, discontinue it immediately •Establish or stabilize the airway •Oxygen therapy, intubation/ventilation •Insertion of a large bore IV catheter (16 or 18 g) •Continuous ECG •Vital signs •Call RRT •Comfort and emotional support •Positioning, TCDB and increase HOB, skin care and management of itching •Surveillance for complications

EpiPen Auto-Injector

•Should be always carried and easily accessible •Can be administered through clothing •Teach clients and family members how to administer (Training devices) •Adrenergic agonist

Type IV Delayed Hypersensitivity

•T-lymphocytes (T-cells) are the activated immune system component triggering the excessive responses •Antibodies and complement are not involved •Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen.

The Degree of reaction ranges from

•Uncomfortable (itchy, watery eyes; sneezing) •Life threatening (allergic asthma, angioedema, anaphylaxis, bronchoconstriction, circulatory collapse)