Objectives Nursing Diagnosis Goal Interventions Implementation Evaluation

Subjective:

Nurse, nahihirapan ako
huminga. Para akong pagod
huminga, as verbalized by
the patient.

Objective:

40 bpm
Nasal flaring
Restlessness
Cold clammy skin
Slow capillary refill






Anaphylactic shock:
Ineffective breathing pattern
related to
bronchoconstriction
secondary to chemical
mediators
Patients respiratory
rate will be normal
Patient will
demonstrate free
from difficulty of
breathing
Patients capillary
refill within normal
range
Assess for history of
anaphylactic or
allergies.
R: will give the nurse
important information about
patients medical history and
thus help the nurse handle
the patient.
Place patient in
Fowlers or semi-
fowlers position.
R: allow patient to improve its
breathing capacity.
Administer oxygen as
necessary.
R: improves body
oxygenation.
Assist in giving
Epinephrine to
patient or any drugs
ordered by the
physician.
R: epinephrine is the primary
drug given for anaphylaxis.
Assess if patient is
responding to
medications given.
R: if the patient is not
responding to the drug, the
doctor might order another
shot after 15 mins.
Monitor patients
saturation using pulse
Assessed for history
of anaphylactic or
allergies.
Place patient in
Fowlers position.
Administered oxygen
as ordered.
Assisted in giving
Epinephrine to
patient or any drugs
ordered by the
physician.
Assessed if patient is
responding to
medications given.
Monitored patients
saturation using pulse
oximeter.
Reassessed patient.
Patients respiratory
rate 23 bpm
Patient demonstrated
no difficulty of
breathing.
Patient'

oximeter
R: 95-100% oxygenation is
needed to assure that patient
is getting the right amount of
oxygen in his body.
When patient is
already stable, depth
assessment may be
conducted.
R: to know that causes the
shock and/or activities the
patient did before going to
the facility.