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Summary NUR 122 -Final study guide
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NUR 122 -Final study guide /NUR 122 -Final study guide
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Final Study GuideChapter 37
Causes of Anaphylaxis
o Rapid clinical response to an immediate immunologic reaction
between a specific antigen & antibody
o Foods – peanuts, tree nuts (walnuts, pecans, cashews,
almonds), shellfish (shrimp, lobster, crab), fish, milk, eggs, soy,
wheat
o Meds – antibiotics (PENICILLIN & SULFA drugs), allopurinol,
radiocontrast agents, anesthetic (lidocaine, procaine), vaccines,
hormones (insulin, vasopressin, adrenocorticotropic hormone),
aspirin, nonsteroidal anti-inflammatory drugs
o Pharmaceutical/biologic agents – animal serum (tetanus
antitoxin, snake venom antitoxin, rabies antitoxin), antigens
used in skin testing
o Insect stings – bees, wasps, hornets, yellow jackets, ants
(including fire ants)
o Latex – medical & nonmedical products containing latex
Priority nursing assessment, interventions and evaluation of a pt. who
has had a severe allergic reaction
o Airway, breathing pattern & VS
o Signs of increasing edema & respiratory distress
, o ABC’s, RR, O2 sats, BP will be low
Education regarding epinephrine pen
o After removing EpiPen from tube, grasp the pen w/the orange tip
(injecting end) pointing downward. W/other hand remove blue
safety release cap
o Hold black tip near outer thigh, swing & jab firmly into the outer
thigh until a click is heard w/the device at 90 degrees to the
thigh (do NOT inject into buttocks)
o Hold firmly against thigh for approx. 10 secs then remove the
unit from the thigh & gently massage the injection area for 10
seconds.
o Give epi in outer aspect of the thigh, 90 degree angle,
massage after injection
Priority Care of pt who has received CT with contrast
o Shellfish allergy usually indicates contrast allergy
Type II (Cytotoxic) Hypersensitivity Response
o Occurs when the system identifies a normal constituent of the
body as foreign
o My be a result of a cross reacting antibody
o Associated w/ – myasthenia gravis, the body mistakenly
generates antibodies against normal nerve ending receptors
Goodposture syndrome – generates antibodies against lung
& renal tissue, producing lung damage & kidney injury
, o Autoimmune disorder such as RA/Blood transfusion
reaction
Chapter 32
Priority assessments and interventions when caring and administering
blood transfusion to a pt x3
o Pretransfusion assessment
Pt history – helps determine the history of previous
reactions & previous reactions
Should include the type of reaction, its
manifestations, the interventions required & any
preventive measures (if any)
Nurse assesses # of pregnancies – higher # increase risk
of reaction due to antibodies developing from exposure to
fetal circulation
Pay close attention to – cardiac, pulmonary, & vascular
diseases
o Physical assessment
Baseline VS & fluid status before transfusion
Assess respiratory system
Auscultate lungs & the use of accessory muscles
Cardiac system assessment
Careful inspection of edema, signs of HF (jugular
venous distention)
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