Primary Nursing Diagnosis

Ineffective airway clearance related to laryngeal edema and bronchospasm

OUTCOMES. Respiratory status: Gas exchange and ventilation; Safety status: Physical injury

INTERVENTIONS. Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistance


The plan of care depends on the severity of the reaction. Discontinue the administration of any possible allergen immediately. Consider applying a tourniquet to the extremity with the antigen source; this procedure can retard antigen exposure to the systemic circulation but the tourniquet needs to be released every 5 minutes, and it should not be left in place longer than 30 minutes. Complete an assessment of the patient's airway to ensure patency and adequate breathing. If the patient has airway compromise, endotracheal intubation and mechanical ventilation with oxygenation may be necessary. More severe or prolonged cases of anaphylactic shock are aggressively treated with the establishment of IV access and infusion of normal saline or lactated Ringer's as well as supplemental oxygen therapy. The patient may require urinary catheteriza-tion to monitor urinary output during periods of instability.

Pharmacologic Highlights

Medication or

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