Symptoms are associated with hypersensitivity and anaphylaxi

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• Skin:
  • Hives (urticaria): Itchy, raised red welts.
  • Itching (pruritus).
  • Redness (erythema) or flushing.
  • Swelling (angioedema), often around the eyes, lips, face, or hands.
• Respiratory:
  • Nasal congestion (runny nose).
  • Sneezing.
  • Itchy or watery eyes.
  • Mild wheezing or coughing.
• Gastrointestinal:
  • Nausea.
  • Mild abdominal pain or cramps.
  • Diarrhea.
• Other:
  • Headache.
  • Feeling "off" or uneasy.

Anaphylaxis (Severe Systemic Hypersensitivity Reaction): Anaphylaxis is characterized by the rapid onset of severe symptoms involving two or more body systems, often progressing quickly and potentially leading to death if not treated promptly.

• Skin/Mucosal (often the first to appear, but can be absent in severe cases):
  • Generalized hives, intense itching, flushing.
  • Angioedema: Rapid and significant swelling of the face, lips, tongue, or throat, which can be life-threatening if it compromises the airway.
• Respiratory (can be life-threatening):
  • Dyspnea (difficulty breathing): Shortness of breath, gasping.
  • Wheezing: Due to bronchospasm (narrowing of airways).
  • Stridor: A high-pitched, harsh sound during inspiration, indicating upper airway obstruction (e.g., from laryngeal edema/swelling of the vocal cords).
  • Coughing, hoarse voice.
  • Feeling of throat tightness or "lump in the throat."
  • Cyanosis (bluish discoloration) due to lack of oxygen.
• Cardiovascular (can be life-threatening):
  • Hypotension (low blood pressure): Dizziness, lightheadedness, feeling faint, collapse, loss of consciousness. This occurs due to widespread vasodilation and fluid leakage from blood vessels.
  • Tachycardia (rapid heart rate): The heart tries to compensate for low blood pressure.
  • Weak or absent pulse.
  • Cardiac arrest.
• Gastrointestinal:
  • Severe abdominal cramping and pain.
  • Nausea, vomiting, diarrhea.
• Neurological:
  • Feeling of "impending doom" (a profound sense of dread).
  • Anxiety.
  • Confusion.
  • Loss of consciousness, seizures.

 

How the Nurse Differentiates Hypersensitivity from Other Conditions/Issues:

  Differentiating anaphylaxis from other conditions is crucial for timely intervention. The nurse will rely on a combination of factors:

1. Rapid Onset and Progression:
   • Key Differentiator: Anaphylaxis typically develops within minutes (or up to a few hours) of exposure to an allergen. The symptoms often worsen rapidly and involve multiple body systems. Other conditions may have a slower onset or affect only one system.
2. Exposure to a Known or Suspected Allergen:
   • Key Question: Has the patient been exposed to anything new? (e.g., new medication, food, insect sting, contrast dye, latex). This is a strong indicator.
3. Involvement of Multiple Body Systems:
   • Key Differentiator: While a mild allergic reaction might just cause hives, anaphylaxis involves at least two systems (e.g., skin rash and difficulty breathing, or GI symptoms and hypotension).
4. Specific Life-Threatening Signs:
   • Key Differentiator: The presence of airway compromise (stridor, severe wheezing, throat swelling) or circulatory compromise (hypotension, dizziness, collapse) is highly indicative of anaphylaxis and differentiates it from a mild reaction or other issues.
5. Absence of Other Explanations:
   • The nurse will consider and rule out other conditions that might mimic anaphylaxis, such as:
     • Asthma exacerbation: Primarily respiratory, typically without widespread skin symptoms or severe hypotension.
     • Vasovagal syncope (fainting): Often sudden, transient loss of consciousness, but usually preceded by pallor, sweating, and bradycardia (slow heart rate), without respiratory distress, hives, or angioedema.
     • Panic attack: Can cause dyspnea, tachycardia, and anxiety, but usually not associated with hives, angioedema, or severe hypotension.
     • Septic shock: Also causes hypotension and tachycardia, but typically has a slower onset, often with fever and a clear source of infection, and lacks the rapid onset of skin/airway symptoms.
     • Acute myocardial infarction (heart attack): Chest pain and shortness of breath, but usually with specific ECG changes and cardiac enzyme elevation, no generalized skin rash.
     • Choking/Foreign Body Airway Obstruction: Presents with sudden inability to breathe or speak, but typically without generalized allergic symptoms.

 

Steps to Take if the Nurse Suspects Anaphylaxis:

  Anaphylaxis is a medical emergency requiring immediate action. The nurse should follow these critical steps, prioritizing ABCs (Airway, Breathing, Circulation):

1. Call for Help/Activate Emergency Response (e.g., Code Blue/Rapid Response Team):
   • Immediately alert other healthcare professionals and activate the facility's emergency protocol. Do not delay.
2. Remove the Allergen (if possible):
   • If an IV infusion is the suspected cause, stop the infusion immediately.
   • If a bee sting, carefully remove the stinger (without squeezing the venom sac).
   • If a food, instruct the patient to stop eating.
3. Assess ABCs and Vital Signs:
   • Airway: Check for stridor, hoarseness, throat swelling, difficulty swallowing. Is the airway patent?
   • Breathing: Assess respiratory rate, effort, presence of wheezing, crackles, or diminished breath sounds. Check oxygen saturation.
   • Circulation: Check pulse rate and quality, blood pressure, capillary refill, and skin color/temperature.
   • Consciousness/Responsiveness: Assess level of consciousness.
   • Obtain a full set of vital signs.
4. Administer Epinephrine (Adrenaline) IMMEDIATELY:
   • This is the first-line and most crucial treatment for anaphylaxis. There are no absolute contraindications in an anaphylactic emergency.
   • Route: Intramuscular (IM) into the mid-anterolateral thigh is the preferred route for rapid absorption.
   • Dose (Adults): 0.3 mg to 0.5 mg of 1:1000 solution. If an auto-injector (e.g., EpiPen) is available, use it.
   • Repeat: May be repeated every 5-15 minutes if symptoms do not improve or worsen, as directed by protocol or physician order.
5. Position the Patient:
   • Lay the patient flat: If hypotensive, elevate the legs to promote venous return to the heart.
   • If unconscious or pregnant: Place in the recovery (left lateral) position.
   • If experiencing severe respiratory distress: Allow them to sit up if that eases breathing, but monitor for worsening hypotension. Avoid sudden changes in posture.
6. Administer Oxygen:
   • Provide high-flow oxygen (e.g., 10-15 L/min via non-rebreather mask) to support oxygenation, especially if there's respiratory distress or hypoxemia.
7. Establish IV Access and Administer IV Fluids:
   • Insert one or two large-bore IV catheters.
   • Administer rapid intravenous fluid boluses (e.g., 0.9% normal saline) to treat hypotension and restore intravascular volume.
8. Administer Adjunct Medications (after Epinephrine):
   • H1 Antihistamines: (e.g., diphenhydramine IV) to help with skin symptoms (itching, hives) and angioedema, but do not reverse airway or cardiovascular collapse.
   • H2 Antihistamines: (e.g., ranitidine or famotidine IV) can be used in conjunction with H1 blockers.
   • Corticosteroids: (e.g., methylprednisolone IV or hydrocortisone IV) to prevent prolonged or biphasic reactions (recurrence of symptoms hours after the initial reaction). They have a delayed onset of action and are not first-line for acute symptoms.
   • Beta-agonists (e.g., nebulized albuterol): For bronchospasm/wheezing that persists after epinephrine.
9. Continuous Monitoring:
   • Continuously monitor vital signs (BP, HR, RR, SpO2).
   • Cardiac monitoring for arrhythmias.
   • Respiratory assessment (breath sounds, work of breathing).
   • Level of consciousness.
   • Urine output.
10. Documentation:
    • Document all interventions, patient's response, and vital signs meticulously.
11. Patient Education and Referral:
    • Once stabilized, educate the patient about their allergen, avoidance strategies, and the proper use of an epinephrine auto-injector.
    • Referral to an allergist/immunologist for further evaluation and management plan is crucial.
    • Advise the patient to carry two epinephrine auto-injectors at all times.

The nurse's rapid recognition and immediate administration of epinephrine are critical in preventing the severe morbidity and mortality associated with anaphylaxis.

Sample Answer

          Hypersensitivity reactions are an exaggerated or inappropriate immune response to an allergen (a substance that is usually harmless). Anaphylaxis is the most severe and life-threatening form of an acute generalized hypersensitivity reaction. Here's a breakdown of the symptoms, differentiation, and nursing steps:  

Symptoms Associated with Hypersensitivity and Anaphylaxis:

  Hypersensitivity (General Allergic Reaction - often Type I, but can be other types): Symptoms of general hypersensitivity can range from mild to moderate and typically involve one or two body systems. They usually develop within minutes to a few hours of exposure.

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