Anaphylaxis is an atopic reaction that dramatic and widely spread. It is commonly signed by urticaria and sudden and progressive respiratory distress. Anaphylaxis reaction can be dangerous and deathly because it will accelerate vascular collapse, so that the patient becomes systemic shock. To do right anaphylaxis nursing care will help the patient’s recovery.

Anaphylaxis Etiology

To do anaphylaxis nursing care, what you have to do is to know the etiology of the anaphylaxis. What is the main causes of anaphylaxis shock? That needs to be assessed before anaphylaxis nursing care action. Here are some:

  • Systemic exposure of medicine that makes allergic reaction
  • Other sensitive substances:
    • Allergen extract
    • Chemical Diagnostic substance like natrium dehydrocolat and radiography contrast media
    • Foods like beans, berry, sea foods, and egg
    • Enzyme like L-asparginase enzyme
    • Hormone
    • Insecticide for hornet, yellow jacket, ant, mosquitoes, and spiders. Reading recommendation: Fire Ant Anaphylaxis
    • Local anesthesia
    • Penicillin and other antibiotics
    • Polysaccharide
    • Serums
    • Addiction to food with sulfate ingredients
    • Sulfonamides
    • Vaccine

RELATED Foods That Cause Anaphylaxis Can be Vary, Avoid it and Still Safe

Anaphylaxis Sign and Symptoms

Then assess the patient’s sign and symptoms. What sign and symptoms that are come up? Head to to assessment is recomended. Some of those signs and symptoms are;

  • Angioedema
  • Cardiac arrhythmia
  • Diarrhea
  • Dyspnea
  • Anxiety
  • Sore throat
  • Hypotension
  • Nasal mucosa congestion and edema
  • Nasal pruritus
  • Nausea
  • Rhinorrhea
  • Abdominal cramp
  • Shock
  • Shallow respiration
  • Sneezing
  • Stridor
  • Sudden sneezing attack
  • Sweaty
  • Incontinence of urine
  • Urticaria
  • Weakness

Diagnosis Examination

Next, to make sure the anaphylaxis is really happening, and before you are going to do anaphylaxis nursing care, diagnosis examination should be done well and got the anaphylaxis diagnosis. Anaphylaxis can be diagnosed well through cardiac and respiratory diagnosis examination or only assess the sign and symptoms that usually appear in anaphylaxis case.


Anaphylaxis nursing care should colaborate with medical treatment such as:

  1. Epinephrine injection 0,1 to 0,5 ml should administrated immediately and soak it in water for injection about 1:1000, repeat every 5 to 20 minutes.
  2. Epinephrine can be injected through intra muscular or subcutaneous if patient is still aware of the environment
  3. Cardiac Pulmonary Resuscitation (CPR) should be done if there is cardiac arrest
  4. Endotracheal intubation or tracheotomy and mechanic ventilation are done to maintain airway clearance and oxygenation.
  5. Vasopressor like norepinephrine, dopamine, or phenylephrine
  6. Difenhydrinate is prescribed for long-term medication
  7. Corticosteroid to reduce the inflammation
  8. Bronchodilator like aminophylline is administrated intravenous to control bronchospasm
  9. Blood volume improvement like normal saline or albumin to improve blood pressure


Anaphylaxis Nursing Care

You may do anaphylaxis nursing care with based on nursing diagnosis. These are the most common anaphylaxis nursing care that you can implement it.

  1. Assess the patient’s respiratory status and maintain the airway clearance. Always aware of patient that shows early sign and symptoms of larynx edema like stridor, sore throat, and dyspnea
  2. If patient anaphylaxis with heart arrest, start the CPR chain like chest compression and ventilation. The next therapy is depended on patient’s condition after
  3. Give blood volume improvement and norepinephrine and vasopressor dopamine through vein to improve blood pressure. Monitor the blood pressure, central venous pressure, and urine output as a patient’s respond guidelines.
  4. To prevent anaphylaxis ask patient to avoid allergen exposure that is already known. If patient allergic to insects for instance, the patient should bring the equipment for anaphylaxis firs aid. If patient is easy to get anaphylaxis reaction, the patient should bring medical identity that shows allergy status.
  5. Teach patient how to use anaphylaxis equipment box. If the doctor gave the anaphylaxis equipment box for patient, explain the patient that box consist of 2 injectors, epinephrine, alcohol swab, tourniquet, and antihistamine tablets.
  6. If patient must take the medicine that he / she has allergy with it, make sure the patient got desensitization by increasing antigen doses or steroid administration periodically to prevent severe reaction of anaphylaxis.

Anaphylaxis Equipment

Here is some instruction about using anaphylaxis equipment.


Take auto injector of epinephrine from the box.
Clean the injection area with alcohol swab (about 4 cm around)


Put back side of epinephrine auto injector onto injection place
Push the tool into injection place slowly. ‘Click’ sound will be heard that indicate the tool is ready to inject medicine, hold the injector in its place about 10 seconds.
Take auto injector, and put it away safely

How to pull up hornet sting

Pull up the insect that is seen. Use your nail or pinset to pull up the insect remains

Using tourniquet

If you stung in hand or leg, tie a tourniquet between the stung area with heart area. Pull the tourniquet to tight it up after 10 minutes, take off tourniquet

Antihistamine administration

Chew or swallow the antihistamine tablet (the doses of antihistamine must be right as doctors prescription)

Additional Steps

Ice compressed on stung area. Avoid to use extra energy, keep body warm, and find the nearest health facilities
If you did not recover for 10 minutes, get second injection. Follow the injecting steps above

Special instruction

Always provide the anaphylaxis box everywhere to as a precaution of emergency case.
Follow the pharmacist guideline how to store it
Periodically, check epinephrine in injection. If there are changes in it, it must replace with the new one
Aware of expired date of medicines