What are the 5 Cardinal signs of inflammation?
Warmth, Redness, Swelling, Pain, Decreased function
First and most important thing to do when anaphylaxis is suspected and what steps do you take to achieve this?
ESTABLISH AIRWAY
remove trigger, call a rapid, apply o2, prepare to administer epi
S/S of stage 1
flu-like symptoms and bulls eye rash
(1 of 3)
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.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)
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.
What are the 4 classes of allergies/hypersensitivities?
1. rapid hypersensitivity or atopic allergy
2. cytotoxic reactions3. immune complex reactions
4. delayed hypersensitivity
3 things you can do to prevent anaphylaxis?
avoid allergens, wear medical alert bracelet, carry epi pen
Two prevention methods of lyme disease
(2 of 3)
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
Contact the Rapid Response Team
D
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.
What is Type 1 hypersensitivity or atopic allergy described as?
Basic allergens and anaphylaxis
S/S of anaphylaxis
weakness, impending doom, respiratory symptoms, hypo-tension, diaphoresis.
(3 of 3)
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
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.
a reaction from a previous trigger that occurs hours to days after exposure
Life threatening type 1 hypersensitivity reaction, rapid, systemic, can be fatal, angioedema
Anaphylaxis
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.”
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.
What is type 2 hypersensitivity described as?
auto antibodies attacking the bodies cells with foreign protein attached to them
Chronic, progressive autoimmune disorder caused by excessive inflammation and overactive immunity leading to organ failure and death.
Lupus
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
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.
Severe type 1 hypersensitivity reaction that involves blood vessels and all layers of the skin, mucous membranes, and subcutaneous tissues in the affected area.
angiodema
What are some triggers to lupus?
infection, drugs, hormones, exposure to antibidy
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
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.
What is type 3 hypersensitivity described as?
Excess antigens causing immune complexes to form in the blood. (most autoimmune disorders are caused by this type of reaction)
Signs and symptoms of lupus
butterfly rash, discoid rash, photosenesitivity, chronic lesions, non erosive arthritis, serosal membrane inflammation, neurologic, hematologic, and immunity problems.