Nursing Care Plan for Anaphylaxis
Also searched as: anaphylactic reaction, severe allergic reaction
🎓 Educational example. Adapt to your patient and have your instructor review it. Not medical advice.
⚠️ Time-critical condition. Anaphylaxis can deteriorate quickly. This page is a study example, not a clinical protocol: at the bedside follow your facility's policy, escalate to the provider or rapid response team, and never delay treatment to consult a study resource.
A rapid, systemic allergic reaction in which airway swelling, bronchospasm and vasodilation can move from first symptom to life threat within minutes. Nursing care is built around one priority: recognize early, give epinephrine per protocol without delay, and support airway and circulation while the reaction is brought under control.
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Assessment
- Subjective: patient reports sudden itching, throat tightness, trouble breathing, dizziness or a feeling of impending doom, often within minutes of a food, medication, or sting exposure
- Objective: hives or flushing, swelling of lips, tongue or throat, stridor or wheeze, falling blood pressure with rising pulse, vomiting or cramping; symptoms in two or more body systems after a likely allergen
Nursing diagnoses
As evidenced by: stridor, hoarseness, tongue and lip swelling, wheeze, rising work of breathing
Risk factors: falling blood pressure, tachycardia, delayed capillary refill, dizziness on sitting up, history of biphasic reactions
Goals / expected outcomes
- The patient will maintain an open airway and adequate oxygenation throughout the reaction and observation period.
- The patient will remain hemodynamically stable, with blood pressure and pulse returning to their baseline range, through the observation window.
Nursing interventions & rationale
| Intervention | Rationale |
|---|---|
| Give intramuscular epinephrine immediately per protocol at the first recognition of anaphylaxis, before or while completing any further assessment. | Epinephrine is the only first-line treatment and outcomes worsen with every minute of delay; no other drug in the sequence substitutes for it. |
| Position supine with legs elevated unless breathing requires sitting up, give high-flow oxygen, and establish IV access for fluid boluses as ordered. | Distributive shock empties the central circulation; position and fluids defend perfusion while epinephrine works. |
| Observe for the ordered period after symptoms resolve and reassess frequently. | Biphasic reactions can return hours after the first response has settled, when everyone has relaxed. |
| Before discharge, teach allergen avoidance and epinephrine auto-injector technique with a return demonstration, and confirm a prescription and an action plan. | The next reaction will likely start outside a hospital; the auto-injector in the patient's hand is the treatment that will actually be available. |
Evaluation
- Airway remains open with normal voice and unlabored breathing
- Vital signs return to baseline and stay there through observation
- Patient demonstrates correct auto-injector use and states their avoidance and emergency plan
Sources & further reading
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Build a care plan free Preview Pro (coming soon)Anaphylaxis care plan: FAQ
What is the nursing diagnosis for Anaphylaxis?
Common nursing diagnoses include: Impaired airway patency related to laryngeal edema and bronchospasm from the systemic allergic response; Risk for decreased tissue perfusion related to widespread vasodilation and capillary leak. Choose the one your patient's assessment data supports.
What are nursing interventions for Anaphylaxis?
Key interventions: Give intramuscular epinephrine immediately per protocol at the first recognition of anaphylaxis, before or while completing any further assessment.; Position supine with legs elevated unless breathing requires sitting up, give high-flow oxygen, and establish IV access for fluid boluses as ordered.; Observe for the ordered period after symptoms resolve and reassess frequently., each paired with a rationale.
Can I use this care plan for my assignment?
Use it as a study example and starting draft. Always adapt it to your specific patient and have it reviewed by your instructor. This is an educational tool, not medical advice.
For nursing education only, NOT medical advice and not a clinical decision-making tool. Nothing here should be used to assess, diagnose, or treat any real patient. Care plans and answers are unverified study drafts to review with your instructor or a licensed clinician and adapt to the individual patient and your institution’s protocols before any use.
Last reviewed 2026-07. Educational content based on standard nursing practice; not medical advice and not affiliated with NANDA-I/NIC/NOC. Always follow your institution's protocols and your instructor's guidance.