JALAPIT, MARRY RUTH P.

3BSN-C
Allergy
It is the result of your immune system's response to a substance. Immune responses can be
mild, from coughing and a runny nose, to a life-threatening reaction knows as anaphylaxis. A
person becomes allergic when their body develops antigens against a substance.

NURSING CARE PLAN

ASSESSMENT NURSING GOAL INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS OUTCOME N
SUBJECTIVE Ineffective Breathing The client INDEPENDENT The client
DATA: Pattern related to will maintain : - Life-threatening maintained an
Client report Bronchospasm an effective -Assess the events, such as effective
feeling and Bronchoconstriction breathing client’s anxiety respiratory distress breathing
concerns. Facial angioedema pattern, as level and shock, might pattern, as
OBJECTIVE Laryngeal edema evidenced by cause the client to evidenced by
DATA: As evidenced by relaxed become anxious. relaxed
 Vital signs  Chest breathing at -Observe for - Bluish discoloration breathing at a
 Laboratory tightness. a normal rate changes in of these body parts normal rate
result  Cyanosis. and depth color of the is considered a and depth and
 Physical  Coughing. and absence skin, tongue, medical emergency. absence of
assessment  Dyspnea. of and mucosa adventitious
 Hoarseness. adventitious breath sounds.
 Respiratory breath -Monitor oxygen - Pulse oximetry is
distress. sounds. saturation and used to monitor
 Stridor. arterial blood oxygen saturation. It
 Tachypnea. gasses should be kept at
 Use of least 90% or higher.
accessory
muscles. -Instruct the - The increased tidal
 Wheezing. client to breathe volume promotes
slowly and improved gas
deeply exchange, and focus
breathing may help
to calm the client.
DEPENDENT:
-Administer IV - Hypotension caused
fluids as by vasodilation and
ordered distributive shock
responds to fluid
resuscitation.
- Administer - Oxygen saturation
oxygen as that is less than 90%
prescribed results to tissue
hypoxia, acidosis,
dysrhythmias, and
changes in the level
of consciousness.