NANDA-NursingPlan Area 11 Safety/Defense

NANDA-00217 Risk for allergy reaction

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 “Safety/Defense”
Category 5 Defense function Process of protecting the self from the non-self

00217 Risk for allergy reaction

Nursing Diagnosis: Allergic Reaction Risk State
Definition: A condition in which an exaggerated or predisposed immune response to a wide variety of substances can compromise health.

1. What is an allergic reaction?

Allergies refer to excessive immune reactions to specific antigens. Normally, immunity is a defense system that eliminates foreign substances (non-self) from the body. Allergies are broadly classified into types I to IV (Gell and Coombs’ classification) depending on the mechanism of development.

✩ Gell and Coombs Classification of Allergic Reactions ✩

Type I reaction (immediate anaphylactic type)

・Antibodies: IgE
・Mediator cytokines: histamine, leukotrienes
・A mediator is a transmitter
・Antigens: house dust, mites, pollen, fungi, drugs, bees, food
・Skin reaction: Immediate type 15 to 20 minutes
・Representative diseases: Anaphylactic shock (*1), allergic rhinitis, conjunctivitis, bronchial asthma, urticaria

Type II reaction (cytotoxic type, cytolytic type)

・Antibodies: IgG, IgM IgG binds to its own cells, and leukocytes that recognize it destroy its own cells
・Mediator cytokine: Complement system
・Antigen: exogenous antigen, autoantigen
・Representative diseases: hemolytic anemia due to incompatible blood transfusion, autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenic purpura (ITP), drug-induced hemolytic anemia, granulocytopenia, thrombocytopenia, Goodpasture’s syndrome , hepatitis B, hepatitis C, penicillin allergy (penicillin is of biological origin)

Type III reaction (immune complex type)

・Antibodies: IgG, IgM Create immune complexes in which antigens, antibodies, and complements bind to each other
・Mediator cytokines: complement system, lysosomal enzymes
・Antigen: foreign antigen, self antigen (denatured IgG, DNA)
・Skin reaction: Late-onset erythema and edema maximal at 3-8 hours
・Representative diseases: SLE, rheumatism, glomerulonephritis

Type IV reaction (delayed cell-mediated immunity)

・Antibodies: sensitized T cells
・Mediator cytokines: interleukins, lymphokines
・Antigens: foreign antigens (fungi, bacteria), self antigens
・Skin reaction: Late-onset erythema and induration at 24-72 hours
・Representative diseases: contact dermatitis, allergic encephalitis, atopic dermatitis, transplant rejection, tuberculous cavities, epithelioid granuloma, drug-induced pneumonia, Guillain-Barré syndrome, tuberculin reaction

★ 1 What is anaphylactic shock?

Quoted from the Japanese Society of Allergology “Anaphylaxis Guidelines”

https://anaphylaxis-guideline.jp/pdf/guideline_slide.pdf

1) Definition

(1) What is anaphylaxis? A hypersensitivity reaction in which systemic allergic symptoms are induced in multiple organs due to the intrusion of an allergen, etc., and can be life-threatening.

(2) What is anaphylactic shock? When anaphylaxis is accompanied by a drop in blood pressure or disturbance of consciousness

2. Indications for Nursing Diagnosis Risk for allergy reaction

Risk of type I reaction = exposure to allergen

・Food: kiwi, shellfish, buckwheat, wheat, soybeans, pineapple, peanuts, etc.
・Environmental allergens: house dust (dust, mold, dandruff), pollen
・Irritation to the respiratory tract of patients with bronchial asthma: dry air, cold air, etc. can be irritating.

Risk of type II reaction

・Incompatible blood transfusion
・Autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura, drug-induced hemolytic anemia, granulocytopenia, thrombocytopenia, Goodpasture syndrome, hepatitis B, hepatitis C

Risk of type III reaction

・Rheumatoid arthritis, SLE, glomerulonephritis

Risk of type IV reaction

・Contact dermatitis: metal allergy, latex allergy, lacquer
・Atopic dermatitis
・Transplant rejection

3. setting a goal

Goal setting by linkage (listed in the second half of the NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Allergic reaction: systemic (0706)
(Definition: severity of systemic hypersensitivity immune response to specific environmental (exogenous) antigens)

・Allergic reaction: local (0705)
(Definition: severity of local hypersensitivity immune response to specific environmental (exogenous) antigens)

Severity of shock: anaphylaxis (0417)
(Definition: severity of symptoms and signs suggestive of inadequate tissue perfusion resulting from vasodilatation associated with acute onset of systemic hypersensitivity reactions and increased capillary permeability)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Be aware of your own allergies and live a life that avoids allergens.
・If severe hay fever interferes with daily life, consult a doctor and receive treatment (desensitization therapy, nasal cavity mucosa ablation, etc.).
・To be able to describe allergic reactions such as rash, itching, and difficulty breathing. Also, if you see the reaction, you can consult a medical institution.
・If you have an EpiPen, you can use it at the first signs of anaphylactic shock. Caregivers and caregivers can also state directions for use and use when appropriate.

*Nurse goals include:

・Early detection of allergic reactions caused by drug administration or food to prevent aggravation.
・Support patients to understand allergens and learn lifestyle methods to avoid allergens.

4. nursing plan

1) Observation Plan 《OP》

We will draft an observation plan (OP) for each outcome of the linkage.


・Causative antigen by blood test (specific IgE antibody test: RAST)
・Exposure to allergens
・pharyngeal edema
・Facial edema
・Dyspnea at rest
・Wheezing ・Constriction sound ・Adjunct noise
・Tachycardia, hypotension, arrhythmia
・Pulmonary edema
・ Decreased level of consciousness
・ Whole body pruritus ・ Urticaria ・ Whole body desquamation
・Petechial hemorrhage/erythema
・Rise in skin temperature ・Fever ・Chills
・Nausea, vomiting, diarrhea
・Anaphylactic shock
・Taking antiallergic drugs
・Compliance with taking antiallergic drugs

・Low blood pressure ・Increased heart rate ・Arrhythmia
・Decreased urine volume
・Decreased level of consciousness ・Delirium
・Rhinitis
・Wheezing (wheezing, wheezing)
・Pharyngeal spasm ・Bronchospasm ・Dyspnea ・Decreased PaO2
・ Warm, flushed skin
・Edema of the lips, eyelids, and tongue
・Angioedema
・Edema of limbs ・Edema of genitalia
・ paresthesia
・Pruritus
・ Abdominal cramps, vomiting, diarrhea

2) Action plan 《TP》

・If any abnormalities in respiratory condition, skin condition, altered level of consciousness, or abnormal vital signs are observed during the use of a newly administered drug, discontinue use and immediately report to the doctor.
・If the victim is unconscious, call the staff and start CPR.
・According to the doctor’s instructions, cooperate while speaking, such as observation, recording, time measurement, chest compression, bag valve mask, securing peripheral veins, drug preparation and administration, DC (defibrillation) preparation, intubation preparation, blood sampling, etc. do.
・Contact your family.
・ Organize routes such as intravenous drips and gastric tubes, and manage them cleanly and safely.
・Apply an ointment to the rash if instructed to do so.
・Even if it is not an emergency, if you find persistent abdominal symptoms or skin symptoms after administration, report them to your doctor.

3) Education plan 《EP》

・If the allergen is specified, explain how to avoid the allergen in pamphlets, etc. (The Japanese Society of Allergology and the Ministry of Education, Culture, Sports, Science and Technology have pamphlets on their websites.)
Reference: Japanese Society of Allergology, see “Allergy Portal” supervised by the Ministry of Health, Labor and Welfare https://allergyportal.jp/
・Explain that de(hypo)sensitization therapy is an option for hay fever and house dust.
・Instruct the patient to call the nurse if there are any abnormal symptoms, such as difficulty breathing, feeling unwell, or fainting, when eating or administering drugs.
・According to the doctor’s instructions, explain to follow the dosage and usage of oral medicines and inhaled medicines.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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