Anaphylactic Shock: Stages and Assessment (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 Now, let's look at the stages and the assessment findings that you could expect.

    00:04 Now, here is our friend, the NCSBN Clinical Judgment Measurement Model.

    00:11 This is the basis and the framework of how the NCLEX exam is written.

    00:15 But also it will help you in practice.

    00:18 So we're going to put it up here on the screen.

    00:19 You've seen it before.

    00:21 But remember, Layer 0, you're just talking about client needs and client decisions.

    00:25 Layer 1, that's where we start really focusing on your clinical judgment.

    00:30 Now, the next layer talks about how we form hypothesis where we find them, and we evaluate them.

    00:36 Layer 3, that's where it gets super interesting.

    00:40 This is where the most of the content that is going to come that you're tested on, both in nursing school and on your NCLEX exam.

    00:48 So they're looking for you to recognize queues.

    00:50 Do you know how to analyze them? Put them together, prioritize a hypothesis, generate solutions, then know what to do next, to take actions and evaluate if those actions did what you wanted them to do.

    01:02 So we also have Layer 4 up there for your review.

    01:05 So you see the complete model.

    01:07 But Layer 3 is where most of the content is going to come from, for your exam questions.

    01:12 So that's where we're going to zero in.

    01:15 Let's talk about the cues and how we analyze them in someone with anaphylactic shock.

    01:20 Now, the cues in each shock state will vary a little bit just depends on where you are in the process.

    01:26 But here is the four stages we're going to use as a framework.

    01:29 The initial stage where everything is kind of okay.

    01:33 And as you move down the slide, things are really not okay.

    01:38 Remember, if a person is at the phase of shock, right, they've moved whether it's anaphylactic, neurogenic, cardiogenic, whatever it is.

    01:46 But if they're in the state where they're in shock, that means their tissues are not getting oxygen.

    01:52 This will lead to death, in many cases, if it's not treated.

    01:57 First, the person is exposed to the allergens.

    01:59 So you see her eating something that's the allergen or the trigger for this Type One hypersensitivity response, see what's starting to happen. She's looking really uncomfortable.

    02:11 Now she's find it kind of hard to breathe, and she's coughing, and it's getting more and more difficult to breathe, because this will affect the airway in circulation.

    02:20 This is not a normal allergic reaction.

    02:22 This isn't like just a little rash, or they may also develop one of those, but we're not concerned about the rash as much as we are the airway problems.

    02:32 So if someone is having a Type 1 hypersensitivity response, and is having airway difficulty, they are progressing towards anaphylactic shock.

    02:41 They see these allergens, they react with our body.

    02:44 And they produce these crazy things like histamine, right.

    02:47 So when that is released, think of it like this big explosion.

    02:52 This causes itching and vasodilation.

    02:55 We're like itching is kind of a bother, yes, but it's the vasodilation that really is problematic internally.

    03:01 So, let's Let's break that down.

    03:03 Here's an airway, right.

    03:04 So if you look at that you see normal on the left, and the one on the right is not normal.

    03:10 That's a bronchospasm.

    03:12 Think of that as your airway.

    03:13 See the normal one? How wide and open it is? Now, that's the airway wrapped around it, the darker pink bands or the smooth muscle that surrounds that tissue, and at the end, are alveoli.

    03:25 The difference between the normal one and the one on the right, which is experiencing an anaphylactic reaction, that's the one you can see why the client is going to have much more difficulty breathing.

    03:36 Why that airway is going to be irritated, and there'll be coughing.

    03:39 See, it's kind of swollen up.

    03:41 But let's talk about how vasodilation causes the airway to look like that.

    03:46 So around there, you see the vessel.

    03:49 So you've got a big one up on the side for you.

    03:51 And you can also see the tiny little circle.

    03:53 This is an airway of someone normal, healthy, not having any type of reaction.

    03:59 Now, what happens, because that vasodilation and everything swells and fluid starts to leak into that tissue.

    04:07 So this is why the airway looks so swollen in someone having an anaphylactic reaction.

    04:14 The vasodilation is part of the anaphylactic reaction to the allergen.

    04:18 Remember those things that were released, all that histamine? This is the result of those being released.

    04:25 So then the patient starts to have a whole lot of other symptoms.

    04:29 They might have dizziness, chest pain, they might be incontinent. Now that's really severe.

    04:34 But chest pain and continence swelling of the lips, and tongue, and wheezing, and stridor.

    04:42 So whenever you see a list in nursing school, we usually kind of just work through it, right? And they don't really stick.

    04:48 But I want you to slow down here and think about what's going on.

    04:53 Why is this patient having these symptoms? Why would they be describing this to you? These are cues.

    04:59 These are the things you need to be looking for, in your practice, in your regular life, and on a test question.

    05:07 Well, if everything is filling up, and I'm having a difficult time breathing, dizziness makes sense.

    05:11 You're not perfusing my brain like it needs to.

    05:14 Chest pain. Remember, shock is a lack of adequate oxygen.

    05:19 Chest pain is an indication of lack of adequate oxygen getting to my heart.

    05:24 Incontinence. Well, your brain just thinks you're gonna die.

    05:27 Everything kind of goes crazy.

    05:29 Now swelling of the lips. That said vasodilation we talked about.

    05:32 And the tongue that is really scary for a patient to go through.

    05:37 The wheezing and stridor are abnormal breath sounds that are telling you when you listen and you hear that, that the airways are swelling and vasodilating and things are leaking.

    05:48 And their airways look like that picture we just showed you.

    05:51 Remember, it's a systemic vasodilation.

    05:54 So when you have systemic vasodilation, that decreases the amount of blood that's available for the heart to pump.

    06:01 Kind of stays out here in the periphery instead of going back to the heart.

    06:05 Another reason why that patient is feeling dizzy.

    06:08 So when you see a list of symptoms, remember those are cues that as a professional nurse, you're going to be expected to recognize and put together if someone has just eaten something, you start to see these symptoms, you should be thinking, "Ah, are they having an allergic or an anaphylactic reaction?" Now these pictures, wow, these are graphic.

    06:29 The one on the left of that little baby just breaks your heart Doesn't it that that happened? That's what it looks like in a pretty extreme case.

    06:37 The arm, you also see the swelling and there's the erythema, the redness, the rash. That's a pretty big deal.

    06:43 That's an immediate response that's happened quickly after the patient was exposed to the allergen.

    06:50 So let's come at this from a nother perspective.

    06:54 There's your cells.

    06:55 We want to remind you that they're telling us we need oxygen.

    06:59 And why is that? Well, less blood is being pumped.

    07:03 That means you have less oxygen going to our tissues, which is hypoxemia.

    07:08 So we lead to hypoxemia, which means we have less blood going to our tissues.

    07:12 And that's why our cells are very sad.

    07:15 So when the tissues and the cells can't get enough oxygen, we switch from aerobic to anaerobic metabolism.

    07:24 Now, remember why that's such a big deal? Because you're going to end up with lactic acid and you have this lactic acid buildup, that becomes really problematic.

    07:33 Now, in the compensatory stage, we've got some different things that we're starting to move, and the patient is becoming worse. They're declining.

    07:40 You're going to see a difference in their stroke volume.

    07:43 It's going to go down.

    07:44 You're gonna see a difference in their cardiac output.

    07:46 It's going to go down.

    07:48 Remember, you've got that vasodilation and more blood is staying out here instead of being returned back to the heart.

    07:54 It's that systemic vasodilation that diminishes the amount of blood that's available for the heart to pump.

    08:01 That's why you have the lower stroke volume and the lower cardiac output.

    08:06 Now, why would their heart be fast? Well, we've talked about the heart, but I want to switch over to tachypnea.

    08:13 Tachy is a word that you've heard with heart rate, right.

    08:16 Tachycardia, but the patient is also going to be breathing faster.

    08:20 Remember what their airways look like? Unlike hypovolemic shock, or cardiogenic shock, In anaphylactic shock, the airways are directly impacted.

    08:29 So they're gonna be trying to breathe faster.

    08:32 But remember, the press sound said they have stridor and wheezes, this is going to be really difficult for them.

    08:38 So, yes, their heart rate is going to be up right.

    08:41 But this is a difference in anaphylaxis and the other types of shock, that airway is directly impacted.

    08:48 So your body's going to do the same thing.

    08:50 It doesn't other sets of shock, right? It's going to try and shut what blood it has available to the most important organs.

    08:57 And it sees that as the brain and the heart.

    09:00 So it's going to move blood from the periphery to the most important organs, the brain and the heart.

    09:06 That means the other organs are going to be hypoperfused.

    09:09 Let's take a look at the cues that are your vital signs.

    09:12 If a patient has progressed to anaphylactic shock, then you can expect that the blood pressure is going to be lower.

    09:19 Now you know what normal is expect something along the lines of less than 90 systolic and a mean arterial pressure of like 65.

    09:27 So keep in mind, if we're progressing to shock, that means they're showing you symptoms, cues you should be looking for, or hypotension.

    09:35 Why would their hands be pale? Remember, as the blood pressure is dropping, your body is going to shunt blood towards the brain and to the heart.

    09:45 So that's why the hands are going to feel pale because they have less blood circulating to them.

    09:50 Now, usually this is a good idea. This would make sense.

    09:53 And of course, you want to protect the brain and the heart.

    09:56 But some things happen when that volume appears to be less to the body, even as small as 15, up to 30%, you have this sympathetic nervous system response.

    10:07 So what happens when your sympathetic nervous system response gets activated, as your heart rate tries to pick up? Right, because it has just a less volume.

    10:17 It appears because of the vasodilation.

    10:20 So your heart's trying to compensate by moving what you have around faster.

    10:24 Respiratory rate, we already talked about.

    10:26 Anaphylaxis. You've got that significant straight up impact on your airways, so your respiratory rate will also be faster.

    10:34 My blood pressure is lower, my heart is beating faster.

    10:38 And my respiratory rate is higher than normal, as long as I have the energy and the strength to do that.

    10:44 Now, when we do all this with increased contractility, like the heart pumping harder and faster, what does the heart need more of? You got it. Oxygen. This is definitely problematic.

    10:57 So this is why shock is such a critical emergency that it need an immediate intervention.

    11:04 We've looked at what happens to the heart and this anaphylactic response.

    11:08 When we've got blood shunted, right? shifted to the heart and to the brain, the lungs don't get the benefit of that deal.

    11:15 Now this is a set of lungs that are not experiencing anaphylactic shock.

    11:20 Look, they're well perfused.

    11:22 But what happens in anaphylactic shock, once that blood is being prioritized to go to the brain into the heart, that means the lung is getting less.

    11:32 It's not as perfused.

    11:33 That decreased blood flow to the lungs increases the patient's need for more oxygen because you have increased dead space.

    11:42 And in that dead space, you cannot exchange CO2 and O2.

    11:46 So instead of having all of the lung tissue to work with, they have less.

    11:51 So the lung is already under distress.

    11:53 Areas are always in distress.

    11:55 Now we've got more dead space after the blood flow has been redistributed.

    11:59 You can obviously see why that would be problematic for your patients.

    12:03 Now, when we talked about the vasoconstriction with the heart, this is really what does it.

    12:08 This is the sympathetic nervous system response, you've got the RAAS.

    12:12 And at the end of that, when you have low blood pressure in the kidneys release renin and you end up at the end with Angiotensin II and Aldosterone, this is two ways that your body tries to increase the blood pressure.

    12:26 One, the potent vasoconstriction of Angiotensin II.

    12:30 And second, you have the extra fluid because at this point, Aldosterone tells your body to hang on or reabsorb sodium.

    12:39 Water follows and volume increases.

    12:42 Now, let's move to the progressive stage.

    12:45 This is where the patient's going to be anxious and confused.

    12:48 Their body is telling him we're going to die if you don't do something.

    12:52 Their CNS system is being hypoperfused.

    12:55 Now their hands are not just pale, they're cold and they're clammy, or having some weird dysrhythmias.

    13:00 Maybe even myocardial ischemia or heart attack due to lack of oxygen plus increased workload on the heart.

    13:07 That is a really bad combo.

    13:09 Their lungs may progress to the point where they're almost experiencing acute respiratory distress syndrome, at least are going to have tachypnea, they might have crackles, things are really going south here.

    13:20 That's not all. I have more bad news for you.

    13:23 Other symptoms and other systems are involved.

    13:27 When you have poor blood flow, remember is your gut, The one that blood flow gets prioritized to? No.

    13:33 So now when your gut doesn't have the blood flow that it needs, it's not going to be able to absorb the nutrients that the body needs to survive.

    13:42 This also puts them at a higher risk for ulcers or for GI bleeding.

    13:46 Because anytime you have prolonged decrease tissue perfusion, you have this normally protective mucosal barrier becomes ischemic.

    13:56 So, that was a lot of lerv. That was a lot of words, even mine don't get twisted up.

    14:02 Think about your gut. I know it's not super glamorous, but it's definitely not going to getting a lot of blood supply, the damage is going to happen when that mucosal barrier becomes ischemic.

    14:13 Another reason why you're more likely to develop ulcers and GI bleeding, that tissue becomes even more fragile.

    14:21 So that your gut, what happens to your kidneys? Well, the biggest risk is renal tubular ischemia.

    14:27 So that means the little tiny tubules and your million nephrons, is risking being damaged.

    14:34 So there are huge problems and risks for a patient in shock.

    14:38 Now, the last face. This one is the worst possible outcome.

    14:43 People's become non-reactive. The patient is unresponsive.

    14:47 They have profound hypertension. Can't raise their blood pressure, They're in respiratory failure. Their gut is ischemic.

    14:55 We've got hypothermia, because they can no longer control their temperature.

    15:00 Their hands are blue, or sciatic, and their kidneys have stopped making urine.

    15:06 They're in full anuria.

    About the Lecture

    The lecture Anaphylactic Shock: Stages and Assessment (Nursing) by Rhonda Lawes, PhD, RN is from the course Shock (Nursing).

    Included Quiz Questions

    1. Vasodilation
    2. Vasoconstriction
    3. Vasomotor delay
    4. Vasovagal response
    1. Wheezes
    2. Stridor
    3. Crackles
    4. Pleural friction rub
    5. Rhonchi
    1. Compensatory
    2. Progressive
    3. Refractory
    4. Initial
    1. Brain
    2. Heart
    3. Lungs
    4. Liver
    5. Pancreas
    1. BP: 80/55 HR: 120 RR: 26
    2. BP: 160/99 HR: 130 RR: 18
    3. BP: 99/60 HR: 50 RR: 14
    4. BP: 140/80 HR: 40 RR: 20
    1. To raise blood pressure
    2. To lower blood pressure
    3. To raise heart rate
    4. To raise respiratory rate
    5. To lower respiratory rate

    Author of lecture Anaphylactic Shock: Stages and Assessment (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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