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Allergic Rhinitis

Allergic Rhinitis.Ray kept on rubbing at his nose for 2 days now. This was noticed by his mother, who then asked if Ray is feeling okay. Ray complained that his nose feels stuffy, and he keeps on sneezing. Ray’s mother brought him to his pediatrician and after several tests, Ray was found out to have allergic rhinitis.

Description


Although allergic rhinitis (AR) is a common disease, the impact on daily life cannot be underestimated.
  • Allergic rhinitis in children is most often caused by sensitization to animal dander, house dust, pollens, and molds.
  • Pollen allergy seldom appears before 4 or 5 years of age.
  • Sensitization to outdoor allergens can occur in allergic rhinitis in children older than 2 years; however, sensitization to outdoor allergens is more common in children older than 4-6 years.

Pathophysiology


Understanding the function of the nose is important in order to understand allergic rhinitis (AR).
  • The purpose of the nose is to filter, humidify, and regulate the temperature of inspired air; this is accomplished on a large surface area spread over 3 turbinates in each nostril.
  • A triad of physical elements (ie, a thin layer of mucus, cilia, and vibrissae [hairs] that trap particles in the air) accomplishes temperature regulation.
  • The amount of blood flow to each nostril regulates the size of the turbinates and affects airflow resistance.
  • The nature of the filtered particles can affect the nose.
  • Irritants (eg, cigarette smoke, cold air) cause short-term rhinitis; however, allergens cause a cascade of events that can lead to more significant, prolonged inflammatory reactions.
  • In short, rhinitis results from a local defense mechanism in the nasal airways that attempts to prevent irritants and allergens from entering the lungs.

Statistics and Incidences


Allergic rhinitis (AR) has no race predilection; however, individuals from nonwhite backgrounds seek out medical attention less often than whites.
  • AR has no sex predilection.
  • Clinically significant sensitization to indoor allergens may occur in children younger than 2 years.
  • AR-like symptoms (runny nose, blocked nose, or sneezing apart from a cold) may begin as early as age 18 months.
  • In a report from the Pollution and Asthma Risk: an Infant Study (PARIS), 9.1% of the 1859 toddlers in the study cohort reported allergic rhinitis-like symptoms at age 18 months.

Causes


AR is caused by an immunoglobulin E (IgE)–mediated reaction to various allergens in the nasal mucosa.
  • Allergens. The most common allergens include dust mites, pet danders, cockroaches, molds, and pollens.

Clinical Manifestations


Symptoms of rhinitis consist of:
  • Rhinorrhea. This condition is commonly called “runny nose”.
  • Nasal congestion. The child may complain of stuffiness in the nose.
  • Postnasal drainage. This occurs when excessive mucus is produced by the nasal mucosa.
  • Repetitive sneezing. Sneezing repeatedly is a sign that there is irritation.
  • Itchiness. There is itching of the palate, ears, nose, or eyes.
  • Allergic salute. The allergic salute is when the child pushes his or her nose upward and backward to relieve itching and open the air passages in the nose.

Assessment and Diagnostic Findings


No studies are needed in allergic rhinitis (AR) if the patient has a straightforward history. When the history is confusing, various studies are helpful, including the following:
  • Skin-prick testing. This test is highly sensitive and specific for aeroallergens; however, a false positive reaction can occur without corresponding clinical features, especially when skin mast cells are easily activated by pressure or other physical stimuli.
  • Serum allergen-specific IgE testing. The main limitations are that patients may be sensitive on a molecular level before IgE response is clinically seen on standard skin testing; this may lead to positive results on laboratory tests that are not triggering clinical symptoms.
  • Nasal smear. Eosinophils usually indicate allergy.
  • CBC count with differential. A CBC count may reveal an increased number of eosinophils; an eosinophil count within the reference range does not exclude AR; however, an elevated eosinophil count is suggestive of the diagnosis.

Medical Management


Treatment of allergic rhinitis (AR) can be divided into 3 categories: avoidance of allergens or environmental controls, medications, and allergen-specific immunotherapy (sublingual or allergy shots).
  • Environment control. Use of environmental controls is not adequately explored in most patients; for many patients, the removal of the trigger can have a dramatic effect; difficulty arises when the trigger needs to be identified and eliminated; eliminating the trigger may be simple if removal of a feather pillow or blanket is involved; however, it can be very difficult if a family pet needs to be removed.

Pharmacologic Management

Many groups of medications are used for allergic rhinitis (AR), including antihistamines, corticosteroids, decongestants, saline, sodium cromolyn, and leukotriene receptor antagonists.
  • 2nd generation antihistamines. Antihistamines are classified in several ways, including sedating and nonsedating, newer and older, and first- and second-generation antihistamines (most widely accepted classification); first-generation antihistamines are primarily over-the-counter OTC) and are included in many combination products for cough, colds, and allergies.
  • Intranasal antihistamines. These agents are an alternative to oral antihistamines to treat allergic rhinitis; currently, azelastine and olopatadine are the only agents available in the United States.
  • Intranasal corticosteroids. This class of medications is most effective; intranasal corticosteroids are potent anti-inflammatory agents shown to decrease allergic rhinitis symptoms in more than 90% of patients.
  • Intranasal antihistamine and corticosteroids. Combination products are emerging on the market for patients who require an intranasal antihistamine and corticosteroids.
  • Intranasal decongestants. Decongestants are effective for short-term symptom control; they decrease nasal discharge and congestion and are available without a prescription.
  • Leukotriene receptor agonists. Montelukast has been approved as monotherapy for allergic rhinitis; it has been shown to be most effective in patients in whom significant congestion is a primary complaint.
  • Allergen immunotherapy. Immunotherapy with daily sublingual (SL) tablets may be able to replace weekly injections in some individuals, depending on the offending allergens; depending on the particular SL tablet, therapy must be initiated at least 3-4 months before the allergen season that is being treated.
  • Intranasal mast cell stabilizers. These are effective therapy for AR in approximately 70-80% of patients; they produce mast cell stabilization and antiallergic effects by inhibiting mast cell degranulation.

Nursing Management


Nursing management of the child with allergic rhinitis includes:

Nursing Assessment

Assessment of the child include:
  • History. Nurses should try to identify seasonal variations, provocative elements in the environment, and the timing of events that lead to symptoms; for example, if the patient only has issues during the week, this may lead to investigating the environment of the child’s classroom or daycare for allergens like pets or molds.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:
  • Ineffective airway clearance related to obstruction or presence of thickened secretions.
  • Disturbed sleep pattern related to obstruction of the nose.
  • Self-concept disturbance related to the condition.
  • Anxiety related to lack of knowledge about the disease and medical action procedure.

Nursing Care Planning and Goals

The major goals for a child with allergic rhinitis are:
  • Child will no longer breathe through the mouth.
  • Airway will be back to normal, especially the nose.
  • Child will sleep 6-8 hours a day.
  • Child and parents will describe the level of anxiety and coping patterns.
  • Child and parents will know and understand about the disease and treatment.

Nursing Interventions

Nursing interventions for the child include:
  • Identification of the allergen. Identification and elimination is easiest for dust mite allergens; pollen is more difficult to avoid because daily activities must be altered to do so; an easy intervention is to keep the windows closed, which is easily accomplished in air-conditioned homes and must be done throughout the year.
  • Use of nasal sprays. Teach the patient and parents on how to use nasal sprays by blowing the nose first then administering the medication.
  • Encourage thorough cleaning of the house. Encourage a routine cleaning of the house, furniture, and equipment which may house dust and other pollens.
  • Encourage medication compliance. Administer pharmacologic treatment as ordered by the physician.

Evaluation

Goals are met as evidenced by:
  • Child no longer breathes through the mouth.
  • Airway is back to normal, especially the nose.
  • Child sleeps 6-8 hours a day.
  • Child and parents describe the level of anxiety and coping patterns.
  • Child and parents know and understand about the disease and treatment.

Documentation Guidelines

Documentation in a child with allergic rhinitis includes the following:
  • Environmental assessment.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Long-term care.
  • Modifications to the plan of care.
  • Attainment or progress toward desired outcomes.

Practice Quiz: Allergic Rhinitis


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1. For Mikael who is diagnosed of having allergic rhinitis, which nursing intervention is the most appropriate? A. Encouraging the client to use nasal saline sprays. B. Discouraging nose blowing before administering nasal medication. C. Advising use of bronchodilator regularly, even if having no symptoms. D. Instructing the client to carry epinephrine with him at all times. 1. Answer: A. Encouraging the client to use nasal saline sprays.
  • Option A: For the client with allergic rhinitis, saline nasal sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants.
  • Option B: To achieve maximum relief, the client should blow the nose before administering any medication into the nasal cavity.
  • Option C: The client diagnosed with asthma, not allergic rhinitis, may use bronchodilators.
  • Option D: Carrying epinephrine would be appropriate for the client with an allergy to insect stings or certain foods such as shellfish.
2. Which intervention should Nurse John Joe discuss with Elena who has an allergic disorder and is requesting information for allergy symptom control? (Select all that apply.) A. Instructing the client to refrain from using air conditioning or humidifiers in the house. B. Instructing the client to use curtains instead of pull shades over windows. C. Instructing the client to cover the mattress with a hypoallergenic cover. D. Instructing the client to wear a mask when cleaning. E. Instructing the client to avoid using sprays, powders, and perfumes. F. Instructing the client to change detergents frequently. 2. Answer: C, D, E.
  • Option C: Using hypoallergenic covers and cosmetics will help reduce the chance of an allergic attack.
  • Option D: Wearing mask while cleaning will help decrease the amount of dust entering the lungs.
  • Option E: Avoiding sprays, powders, and perfumes will help decrease the chance of an allergic attack.
  • Options A, B, and F: The client should use air conditioning and humidifiers; drapes, curtains, blinds, and carpets should be removed; the client should not change detergents or soaps.
3. For Aubrey Anne who has allergies, which client statement indicates that the nurse’s teaching about her condition has be successful? A. “I don’t need to wear any type of mask when I’m cleaning my house.” B. “I should stay in the house when there’s a low pollen count outside.” C. “I should avoid any types of spray, powders, and perfumes.” D. “I can wear any type of clothing that I want to as long as I wash it first.” 3. Answer: C. “I should avoid any types of spray, powders, and perfumes.”
  • Option C: The goal of teaching a client with allergies focuses on avoidance of the offending agent, and other triggers.
  • Options A and B: The client also should wear a mask when cleaning the house or working in the yard and stay inside when the pollen counts are high, not low.
  • Option D: Any fabrics that cause itching should be avoided.
4. After the first injection of an immunotherapy program, the nurse notices a large, red wheal on the client’s arm, coughing, and expiratory wheezing. Which intervention should the nurse implement first? A. Notifying the health care provider immediately. B. Administering I.M. epinephrine per protocol. C. Beginning oxygen by way of nasal cannula. D. Starting an I.V. line for medication administration. 4. Answer: B. Administering I.M. epinephrine per protocol.
  • Option B: Immediately on noticing the client’s sign and symptoms, the nurse would determine that the client is experiencing anaphylaxis to the injection; the first action is to give 0.2 to 0.5 ml of 1:1,000 epinephrine I.M.
  • Options A, C, and D: Notifying the health care provider, beginning oxygen administration, and starting an I.V. line follow after the initial injection of epinephrine is administered.
5. Which condition would Nurse Jade suspect when a client complains of a runny nose, itching and burning eyes, and sneezing since visiting a friend who had a cat in the home? A. Anaphylaxis. B. Bronchitis. C. Allergic rhinitis. D. Asthma. 5. Answer: C. Allergic rhinitis.
  • Option C: The client most likely is suffering from allergic rhinitis, an allergic reaction to inhaled airborne allergens; in this case, the friend’s cat triggered the client’s symptoms.
  • Option A: Anaphylaxis is an acute, life-threatening allergic reaction marked by rapidly progressive urticaria and respiratory distress.
  • Options B and D: Bronchitis and asthma produce symptoms in the lower respiratory tract, such as expiratory wheezing and chest tightness.

See Also


Related topics to this study guide:

Further Reading


Recommended resources and books for pediatric nursing:
  1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)
  2. Pediatric Nursing Made Incredibly Easy
  3. Wong's Essentials of Pediatric Nursing
  4. Pediatric Nursing: The Critical Components of Nursing Care

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