00217 Risk Of Allergic Reaction

Domain 11: security/protection
Class 5: defensive processes
Diagnostic Code: 00217
Nanda label: allergic reaction risk
Diagnostic focus: allergic reaction
Approved 2010 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of allergic reaction is defined as: susceptible to suffering an immune response or exaggerated reaction to substances, which can compromise health.

Risk factors

  • Exposure to allergens
  • Exposure to environmental allergens
  • Exposure to toxic chemicals
  • Inappropriate knowledge about the avoidance of relevant allergens
  • Lack of attention to potential exposure to allergens

Risk population

  • People with a history of food allergy
  • People with a history of allergy to insect bites
  • People with repeated exposure to allergenic environmental substances

Suggestions of use

  • It is important to keep in mind that all the risk factors listed are environmental, and that their presence does not usually produce allergic reactions in most people. Therefore, a risk of allergic response cannot be diagnosed to a particular patient simply because he was exposed, for example, to cosmetics or seafood.
  • In this case, all people are at risk of suffering an allergic response. The only specific risk factor for an individual, identified by NANDA-I, is the repeated exposure to substances of the environment.
  • Only allergic response risk should be diagnosed if there is any reason to suspect that a patient presents a higher risk to certain allergens. If this diagnosis is used, allergen should be specified if this is practical (for example, risk of allergic response due to exposure to peanuts or penicillin).

NOC Results

  • Noc results have not yet been formally associated with this diagnosis, although the following could be useful:
  • Allergic response: Located: Severity of the hypersensitive immune response located before an environmental (exogenous) antigen determined
  • Allergic response: systemic: severity of the systemic hypersensitive immune reaction to a specific environmental antigen (exogenous)

Evaluation objectives and criteria

  • • It will not experience an allergic response, given the absence of an allergic response: systemic or localized
  • • Does not present allergic response: located, as the following indicators show (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Pain in the sinuses
    • Headache
    • Itching, redness or erythema, located
  • • Does not present allergic response: systemic, evidenced by the following indicators (specify 1-5: severe, substantial, moderate, light or none):
  • • Sibilations, rales or dyspnea at rest
  • • Tachycardia, blood hypotension or arrhythmias
  • • Urticaria
  • • Petechies
  • • Nausea, vomiting or diarrhea
  • • Anaphylactic shock
  • Other examples

    The patient will be able to:

    • • Identify and avoid environmental allergens that affect it
    • • Do not present localized or systemic allergic responses (for example, cutaneous, respiratory, cardiac, gastrointestinal, musculoskeletal)

    NIC Interventions

    • NIC interventions have not yet been formally associated with this diagnosis, although the following could be useful:
    • Medication administration: preparation, administration and evaluation of the effectiveness of prescribed and non -prescribed drugs
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Tissue integrity: skin and mucous membranes: intact structure and normal physiological function of the skin and mucous membranes
    • Allergy Management: Identification, treatment and prevention of allergic responses to food, medicines, insect bites, contrast material, blood or other substances
    • Management of the environment: manipulation of the patient’s environment to achieve therapeutic benefit, sensory reference and psychological well -being
    • Respiratory monitoring: Patient data collection and analysis to ensure the permeability of the respiratory tract and an appropriate gas exchange
    • Surveillance: Collection, interpretation and synthesis of patient data, continuous and with an end, to make clinical decisions

    Nursing Activities

    • Nursing activities for allergic response risk are concentrated in helping the patient identify allergens or allergen sources to which it is sensitive or could show sensitivity; Assess the signs and symptoms of known allergies, as well as support the patient to avoid known allergens, as required.

    Valuations

    • • Identify source (s) of allergens to which the patient is (or could be) exposed, both at work and at home
    • • Evaluate the knowledge of the patient and his family about the sources of allergens to which the patient shows sensitivity
    • • Evaluate knowledge about awareness and allergic reactions
    • • Monitor the appearance of an asthmatic response (wheezing, dyspnea, etc.)

    Patient and family education

    • • Inform about awareness and allergic reactions, as required
    • • Counting self -medication if allergic reactions are suspected
    • • If the allergies are, or could be serious, teach to use an epinephrine injector