ANAPHYLAXIS EMERGENCY CARE - STANDARDIZED NURSING PROCEDURES

Effective Date: 
Wed, 09/01/2010
Reviewed: 
Sat, 08/27/2011
Revised: 
Fri, 02/03/2017

This procedure gives the RN the delegated authority to initiate appropriate care of the patient presenting with an anaphylactic reaction. Anaphylactic reactions are rare but life threatening. The timely use of Epinephrine, Benadryl and oxygen is critical to appropriate care of the patient.
Procedure
RN assesses patient and notes evidence of anaphylaxis. Percentages noted in parenthesis indicate likelihood of having this symptom as an indicator of impending anaphylaxis.
Evidence of developing anaphylaxis includes:

  • Skin Changes such as flushing, diffuse or local erythema, angioedema, urticaria, itching, especially around eyes, mouth, lips, tongue, genitals, palms and soles (80 to 90%).
  • Dyspnea, cough, wheeze, chest tightness, or difficulty speaking (70%).
  • GI symptoms (45%)
  • Hypotension (defined as a systolic pressure <90)
  • Agitation, lightheadedness, sense of doom, syncope.

RN initiates emergency response system using the overhead paging system (4-4) to announce “Code Blue” and patient location. RN directs another staff person to call 911 for emergency transportation/EMT support.

If stable, patient is Transferred to Same Day Care. Lay patient down, elevate legs. Otherwise, RN sends for anaphylaxis tray.

RN assesses airway, breathing, and circulation including O2 saturation and blood pressure.
RN initiates supportive measures as indicated including:

  • Epinephrine Auto-injector, 1:1000m 0.3 ml IM for hypoxia, hypotension, angioedema, rapidly developing skin reactions.
  • Benadryl, 50mg, IM once.
  • Oxygen at 8 to 10 L/min by mask or 4 to 6 L/min via nasal cannula for O2 saturation less than 90% or if a second dose of epinephrine is required.

RN starts IV with Normal Saline at a wide open rate for patients with systolic blood pressure less than 90 and monitors blood pressure and O2 saturation every 5-10 minutes during use of this infusion rate.

If vital signs after initial 10 minutes are not improved, repeat dose of Epinephrine Auto-injector 1:1000, 0.3 ml IM.

For wheezing and respiratory distress, Albuterol via nebulizer, one ampule may be given and repeated every 15 minutes.

Upon arrival of clinician or EMTP, RN gives pertinent history, including presentation, vital signs at onset and currently, and any treatments given prior to arrival of clinician. Upon arrival, clinician and/or EMTP assumes patient care responsibility. RN receives on-going orders for care from the UCSC provider on the scene.

Experience, Training and/or Education

  • Current CA RN license
  • Completion of UCSC orientation specific to Anaphylactic Reaction.
  • Ability to rapidly recognize abnormal vital signs, dyspnea, patient distress.

Evaluation of Competence
Initial Competency

  • Demonstrates knowledge of the location and contents of the Anaphylaxis Tray and their appropriate use.
  • Demonstrates knowledge of signs and symptoms of allergic reaction and anaphylaxis.

On-going Competency

  • Chart reviews of this procedure occur as part of the on-going Quality Assurance program of the UCSC Student Health Center.
  • Incident report generates quality assurance audit.

Scope of Supervision
No direct supervision necessary to initiate this procedure.
Criteria for Provider Consultation & Referral
This procedure allows the RN to respond to a medical emergency while awaiting the arrival of a clinician or the EMTP who will assume patient care.
Documentation

  • RN documents according to the standards delineated in the UCSC Student Health Center Policies on Documentation of Care and Responding to Medical Emergencies.
  • Documentation should include the time of presentation, time of call for help (overhead and 911), vital signs at presentation and at least every 10 minutes during emergency, time of O2 administration, medication administration (including dose, site, and response to medications) and, finally, time and patient condition at transfer of care from RN to clinician or EMTP.
  • RN completes an Incident Report for the incident.