If symptoms persist or escalate after initial therapy
Hydrocortisone 100 mg IV push over 1 minute, then
Repeat Diphenhydramine 50 mg IV push over 2 minutes, and
Cetirizine 10 mg PO (if not already given).
Note: Some chemo/biotherapy agents advise avoiding corticosteroids; however, steroids should still be given in severe allergic reactions.
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Step 3D — Severe / Suspected Anaphylaxis
Immediate Emergency Management
STOP infusion.
O₂ 2 L/min via nasal cannula if SpO₂ ≤ 92%.
Normal saline 150 mL/hour IV.
Administer sequentially:
Epinephrine (1 mg/mL) 0.5 mg IM — anterolateral mid-thigh preferred (deltoid if thigh not possible).
Diphenhydramine 50 mg IV push over 2 minutes (if not given within last 30 minutes).
Hydrocortisone 100 mg IV push over 1 minute.
Monitor vitals every 5 minutes and continuous SpO₂; activate emergency response.
Administer epinephrine IM regardless of platelet count when anaphylaxis is suspected.
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Step 4 — Disposition & Documentation
Provider Evaluation & Paperwork
Responding Provider/emergency team evaluates for re-challenge, rate change, premed changes, or discontinuation.
Reassess need for IV fluids and supportive care.
Document: use HSR/Allergy orders, record as Observed ADR, include timing, symptoms, vitals, medications (dose/route/time), and response.
Quick Reference (Doses & Interventions)
Medication / Support
Typical Nurse Action
Diphenhydramine
50 mg IV push over 2 minutes (see premed timing logic)
Cetirizine
10 mg PO
Acetaminophen
1,000 mg PO x 1 dose
Hydrocortisone
100 mg IV push over 1 minute
Epinephrine (1 mg/mL)
0.5 mg IM (anterolateral thigh preferred)
Oxygen
2 L/min via NC if SpO₂ ≤ 92%
Fluids
Normal saline 150 mL/hour IV
Monitoring
Vitals every 5 minutes; continuous SpO₂
⚠️ Not intended for pregnant patients. Follow obstetric-specific anaphylaxis pathways when applicable.
Flip Flashcards
Case Quiz
🧪12 questions
🧭Practice mode (instant feedback)
🎯Score: 0 / 0
How it works: Read each case, choose the best nursing action(s) per the Adult HSR/Allergic Reaction Management algorithm. Some questions are multi‑select.
Quick reference
First steps for any suspected HSR: Stop infusion, vitals q5 min, notify provider/activate response.
Hives/itching: Diphenhydramine 50 mg IV push over 2 min. If diphenhydramine was given within 30 min, still give 50 mg IV and add cetirizine 10 mg PO. Reassess in 5 min. If no improvement: hydrocortisone 100 mg IV push over 1 min; repeat diphenhydramine; ensure cetirizine given.
Fever/chills/rigors: Acetaminophen 1,000 mg PO x1 unless given within 4 h or patient is SCT—then get provider guidance before dosing.
Severe signs (hypotension, wheeze/SOB, angioedema): Epinephrine (1 mg/mL) 0.5 mg IM (anterolateral mid‑thigh) → Diphenhydramine 50 mg IV → Hydrocortisone 100 mg IV; O₂ 2 L/min NC if SpO₂ ≤92%; NS 150 mL/h; vitals q5; continuous SpO₂.