While monitoring a client receiving a newly prescribed intravenous cephalosporin, the nurse observes sudden-onset audible stridor, diffuse urticaria, and a precipitous drop in blood pressure to 78/46 mm Hg. Arrange the following nursing interventions in the correct order of priority.
- 1Stop the intravenous cephalosporin infusion.
- 2Maintain the airway and apply high-flow oxygen.
- 3Administer intramuscular epinephrine into the anterolateral thigh.
- 4Bolus 0.9% sodium chloride through the existing intravenous line.
- 5Administer intravenous diphenhydramine and methylprednisolone.
Cevap
The correct sequence for managing acute anaphylaxis is to first stop the offending medication, secure the airway and provide oxygen, administer intramuscular epinephrine, initiate volume expansion with intravenous fluids, and finally administer adjunctive medications like antihistamines and corticosteroids.
In any acute hypersensitivity reaction, the standard of care dictates removing the offending trigger first. Once stopped, the nurse must follow the ABC prioritization framework. Stridor represents an immediate threat to the airway, making oxygenation the next priority. This is followed immediately by epinephrine to treat the systemic physiological collapse. Fluids are then pushed to treat the profound distributive shock. Finally, secondary medications (antihistamines and steroids) are given to manage ongoing inflammation.
Adım Adım Çözüm
Anahtar Kavram
Management of Anaphylactic Shock