LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS

KEY TERMS - Eosinophils are rare,

making up less than 1
• Allergen percent of the total
- substance (e.g., dust, weeds, pollen, dander) number of white blood
that causes manifestations of allergy cells occurring in the
• Allergy human body.
- inappropriate and often harmful immune - Eosinophils are actively
system response to substances that are motile and phagocytic and
normally harmless participate in
• Hypersensitivity hypersensitivity and
- abnormal heightened reaction to a stimulus of inflammatory reactions,
any kind primarily by dampening
PRIMARY MEDIATORS their destructive effects.
Histamine - Is an important chemical Platelet- - is an endogenous
that has a role in a number activating phospholipid involved in
of different bodily factor platelet activation and
processes aggregation after antigen
- Organic molecule present challenge. PAF affects a
in most animals, microbes, variety of organs and cell
and plants. types including liver,
- It contracts bowel, pancreas, heart,
gastrointestinal, uterine, and lung
and bronchial smooth - It also plays a role in shock
muscles. It dilates and and inflammation
permeates tiny blood - PAF is released and acts in
vessels, causing runny a paracrine fashion on
noses, watery eyes, and nearby cells or travels in
tissue swelling in hay fever the blood to act as an
and other allergies. endocrine mediator. It has
Trauma, infection, and been suggested that most
some medications release of the actions of PAF occur
histamine, which may help in a juxtacrine fashion
the body defend against a Prostaglandins - a group of lipids made at
hazardous environment. sites of tissue damage or
- In some allergy situations, infection that are involved
histamine causes in dealing with injury and
excessive responses with illness. They control
distressing symptoms (see processes such as
anaphylaxis). Nettles and inflammation, blood flow,
insect venoms contain the formation of blood
histamine. clots and the induction of
- Histone carboxylation labour.
produces histamine in - interesting aspect of
humans. Antihistamines prostaglandins is that
counteract it. different ones have
Eosinophil - are thought to play an different effects. Many
chemotactic important role in the times, these effects are
factor of recruitment of eosinophils exact opposites. Examples
anaphylaxis to parasitic inflammatory include:
regions. ▪ constriction or dilation
- Eosinophil, type of white of blood vessels
blood cell (leukocyte) that ▪ forming platelets into a
is characterized cluster or breaking
histologically by its ability them up
to be stained by acidic dyes ▪ opening or closing up
(e.g., eosin) and airways
functionally by its role in ▪ contracting or relaxing
mediating certain types of smooth muscle in the
allergic reactions gastrointestinal (GI)
tract

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LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS
▪ causing uterine - Serotonin plays a key role
contractions in in such body functions as
pregnancy and when mood, sleep, digestion,
not pregnant nausea, wound healing,
Basophil - preformed mediators, are bone health, blood clotting
kallikrein responsible for the and sexual desire
generation of kinins. Heparin - Heparin injection is an
Bradykinins have been anticoagulant.
implicated as the - It is used to decrease the
mediators responsible for clotting ability of the blood
cardiovascular collapse in and help prevent harmful
clinical situations where clots from forming in blood
no other manifestations of vessels.
anaphylaxis are present. - This medicine is
SECONDARY MEDIATOS sometimes called a blood
Bradykinin - is a product of kallikrein thinner, although it does
induced breakdown of not actually thin the blood.
high-molecular-weight - Heparin is used to prevent
kininogen (HMWK) in the or treat certain blood
kinin cascade. vessel, heart, and lung
- HMWK also serves as an conditions.
inducer of the conversion - Heparin is also used to
of factor seven to factor prevent blood clotting
seven A in the intrinsic during open-heart surgery,
pathway, or contact bypass surgery, kidney
activation, of the dialysis, and blood
coagulation cascade. transfusions.
- The activation of the kinin - It is used in low doses to
system-bradykinin is prevent the formation of
particularly important in blood clots in certain
blood pressure regulation patients, especially those
and in inflammatory who must have certain
reactions, through types of surgery or who
bradykinin ability to must remain in bed for a
elevate vascular long time.
permeability and to cause - Heparin may also be used
vasodilatation in some to diagnose and treat a
arteries and veins. serious blood condition
Serotonin - a chemical that carries called disseminated
messages between nerve intravascular coagulation.
cells in the brain and Leukotrienes - Leukotrienes are
throughout your body. inflammatory chemicals
- Serotonin is found in many the body releases after
parts of your body: in your coming in contact with an
digestive system, blood allergen or allergy trigger.
platelets, and throughout Leukotrienes cause
the central nervous tightening of airway
system. muscles and the
- It’s also thought to play a production of excess
role in regulating your mucus and fluid. These
mood. chemicals play a key role
- Serotonin is made from the in allergies, allergic
essential amino acid rhinitis, and asthma, also
tryptophan. This amino causing a tightening of
acid must enter your body your airways, making it
through your diet and is difficult to breathe.
commonly found in foods - Leukotriene modifiers
such as meat, dairy work by blocking the
products, eggs, and nuts. action of leukotrienes, one
cause of the inflammation

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LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS
and nasal congestion
associated with allergies.
For those with allergies
and asthma, leukotriene
modifiers help keep
bronchial tubes, airways
to your lungs, from
constricting.

DIAGNOSTIC EVALUATION

• CBC with differential (15 to 40% eosinophils

suggests moderate eosinophilia, which may be
found in patients with allergic disorders)
• Eosinophil count – nasal secretions,
conjunctival
• secretions, sputum
• Total serum Ig E levels
• Skin tests – ID injection or superficial
Application (epicutaneous) of solutions at ANAPHYLAXIS
several sites
• Provocative testing – direct administration of • Anaphylaxis is a severe allergic reaction to
the suspected allergen to the sensitive tissue venom, food, or medication. Most cases are
(e.g. conjunctiva, nasal or bronchial mucosa, caused by a bee sting or eating foods that are
GIT) known to cause allergies, such as peanuts or
• Radioallergosorbent test (RAST) – patient’s tree nuts.
serum • Risk Factors
• is exposed to a variety of suspected ▪ Foods (e.g. peanuts, shellfish, fish, eggs,
radiolabeled allergen particle complexes milk, soy, wheat)
▪ Insect stings (e.g. bees, ants)
▪ Medications (e.g. penicillin and sulfa
HYPERSENSITIVITY REACTION
antibiotics, NSAIDs)
• Hypersensitivity reactions are exaggerated or ▪ Radiocontrast agents
inappropriate immunologic responses ▪ Latex
occurring in response to an antigen or ▪ Exercise
allergen. Type I, II and III hypersensitivity ▪ Immunotherapy
reactions are known as immediate • Clinical Manifestations: Mild Systemic
hypersensitivity reactions because they occur Reactions
within 24 hours of exposure to the antigen or ▪ Peripheral tingling and sensation of
allergen. warmth
• Types of Reaction ▪ Sensation of fullness in the mouth & throat
I. Type I (Anaphylactic) ▪ Nasal congestion
- Immediate reaction (within minutes of ▪ Periorbital swelling
exposure to an antigen) ▪ Pruritus
II. Type II (Cytotoxic) ▪ Sneezing
- System mistakenly identifies a normal ▪ Tearing of the eyes
constituent of the body as foreign, leading • Moderate systemic reactions
to cell and tissue damage ▪ Any of the milder symptoms and, Flushing,
III. Type III (Immune Complex) Warmth, Anxiety, Itching
- Immune complexes are deposited in ▪ Bronchospasm
tissues or vascular endothelium, causing ▪ Edema of the airways
increased vascular permeability and tissue ▪ Dyspnea
injury ▪ Cough
▪ Wheezing
• Severe systemic reactions
▪ Progress rapidly to bronchospasm,
laryngeal edema, severe dyspnea, cyanosis
and hypotension
▪ Dysphagia, abdominal cramping,
vomiting, diarrhea, seizures

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LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS
▪ Cardiac arrest and coma
• Prevention of Anaphylaxis
▪ Avoid potential allergens
▪ Administration of epinephrine in the event
of exposure to the allergen (EpiPen Auto-
injector)
▪ Immunotherapy/desensitization
▪ Wear MedicAlert bracelet.
▪ Avoid wearing brightly colored or black
clothes, perfume and hair spray.
▪ Wear shoes at all times.
▪ Read drug labels. Discard all unused
drugs.
▪ Label drugs.
▪ Exercise in moderation. Wait at least 2
hours after eating to exercise
• Medical Management
▪ Evaluate respiratory and cardiovascular
functions
▪ CPR if needed
▪ Supplemental oxygen
▪ Epinephrine SC in the upper extremity or
thigh, may be followed by a continuous IV
infusion
▪ Antihistamines
▪ Corticosteroids
▪ Aminophylline
▪ IV PNSS, volume expanders, vasopressor
agents
▪ Observe for a “rebound” or delayed
reaction 4 to 10 hours after the initial
allergic reaction
• Nursing Management
▪ Assess ABC and VS
▪ Administer meds as prescribed
▪ Monitor IVF infusion
▪ Reduce patient’s anxiety
▪ Instruct patients to avoid allergens and
how to prevent recurrence of anaphylaxis
UTICARIA AND ANGIOEDEMA
• Urticaria (also known as Hives)
- A skin reaction that causes itchy welts.
Chronic hives are welts that last for more than
six weeks and return often over months or
years. Often, the cause of chronic hives isn't
clear.
- The welts often start as itchy patches that turn
into swollen welts that vary in size. These welts
appear and fade at random as the reaction
runs its course.
- Chronic urticaria – longer than 6 weeks
- Causes
▪ The welts that come with hives are caused
by the release of immune system
chemicals, such as histamine, into your
bloodstream. It's often not known why
chronic hives happen or why short-term
hives sometimes turn into a long-term
problem.
▪ Heat or cold
▪ Sunlight
▪ Vibration, such as caused by jogging or
using lawnmowers
▪ Pressure on the skin, as from a tight
waistband
▪ Medical conditions, such as thyroid
disease, infection, allergy and cancer
- Medications
▪ Anti-itch drugs. The standard treatment
for hives and angioedema is
antihistamines that don't make you
drowsy. These medications reduce itching,
swelling and other allergy symptoms.
They're available in nonprescription and
prescription formulations.
▪ Drugs that suppress the immune system.
If antihistamines are not effective, your
doctor might prescribe a drug that can
calm an overactive immune system.
▪ Drugs for hereditary angioedema. If you
have the type of angioedema that runs in
families, you may take medication to
relieve symptoms and keep the levels of
certain proteins in your blood at levels that
do not cause symptoms.
▪ Anti-inflammatory drugs. For severe hives
or angioedema, doctors may prescribe a
short course of an oral corticosteroid drug
— such as prednisone — to reduce
swelling, inflammation and itching.
• Angioneurotic edema (angioedema)
- Angioedema is swelling underneath the skin.
It's usually a reaction to a trigger, such as a
medicine or something you're allergic to.
- It is not normally serious, but it can be a
recurring problem for some people and can
very occasionally be life-threatening if it affects
breathing.
Causes of angioedema
▪ an allergic reaction, such as a food allergy
– this is known as allergic angioedema
▪ a medicine, such as angiotensin-
converting enzyme (ACE) inhibitors for
high blood pressure – this is known as
drug-induced angioedema
▪ a genetic fault that you inherit from your
parents – this is a rare, lifelong condition
that usually starts in childhood called
hereditary angioedema
- Treatments for angioedema
▪ The swelling will usually get better by itself
in a few days, but there are treatments that
can help it settle faster and reduce the risk
of it happening again.
▪ allergic and idiopathic angioedema are
usually treated with antihistamines or,
occasionally, steroid medicine to reduce
the swelling
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LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS
▪ drug-induced angioedema will usually
resolve if you change to a different
medicine – your doctor will advise you
about this
▪ hereditary angioedema cannot be cured,
but medicines can help prevent swelling
and quickly treat swelling when it occurs
ALLERGIC RHINITIS
• Is where your nose gets irritated by something
you're allergic to, such as pollen, causing
sneezing and other symptoms
• 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
▪ 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.
• Causes
▪ Allergens. The most common allergens
include dust mites, pet danders,
cockroaches, molds, and pollens.
• Types
a. Intermittent – symptoms present less than
4 days per week and less than 4 weeks per
year
b. Persistent
• Avoidance Therapy
▪ Use of air conditioners, air cleaners,
humidifiers, and dehumidifiers
▪ Removal of dust-catching furnishings,
carpets, and window coverings; of pets
from the home or bedroom
▪ Use of pillow and mattress covers
impermeable to dust mite
▪ Smoke-free environment
▪ High-efficiency particulate air (HEPA)
purifiers and vacuum cleaner filters
• Pharmacologic Therapy
▪ H1 receptor antagonists (H1 blockers) –
diphenhydramine (Benadryl), loratadine
(Claritin), cetirizine (Zyrtec), fexofenadine
(Allegra)
▪ Decongestants
▪ Adrenergic agents (topical, PO) –
vasoconstriction of mucosal vessels
• Pharmacologic Therapy
▪ Mast cell stabilizers – reduce the release of
histamine (e.g. intranasal cromolyn
sodium [NasalCrom])
▪ Corticosteroids – in more severe cases of
allergic rhinitis (e.g. beclomethasone,
budesonide, fluticasone)
▪ Leukotriene modifiers (e.g. zafirlukast
[Accolate])
• Immunotherapy / Allergy Vaccine Therapy /
Allergen desensitization
▪ Administration of gradually increasing
quantities of specific allergens to the
patient
▪ Goal: Decrease IgE antibodies, reduce
mediator cell sensitivity
▪ Patient is monitored at least 30 minutes
after the injection
▪ Adverse effects: erythema, induration,
anaphylaxis
• Patient Teaching
▪ Modify the environment
▪ Reduce exposure to people with URTI
▪ If with URTI, deep breathing and coughing
exercises
▪ Adherence to medication schedules and
other treatment regimen
FOOD ALLERGIES
• Food allergy is an immune system reaction
that occurs soon after eating a certain food.
Even a tiny amount of the allergy-causing food
can trigger signs and symptoms such as
digestive problems, hives or swollen airways.
In some people, a food allergy can cause severe
symptoms or even a life-threatening reaction
known as anaphylaxis.
• Food allergy affects an estimated 8% of
children under age 5 and up to 4% of adults.
While there's no cure, some children outgrow
their food allergies as they get older.
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LESSON: NURSING CARE OF PATIENT WITH ALLERGIC REACTIONS
• It's easy to confuse a food allergy with a much I. Irritant contact dermatitis: erythema &
more common reaction known as food pruritus
intolerance. While bothersome, food II. Type IV (allergic contact dermatitis):
intolerance is a less serious condition that …swelling, crusty thickened skin, blisters
does not involve the immune system. III. Type I (latex allergy): … rhinitis,
• Risk factors: genetic predisposition and conjunctivitis, urticaria, laryngeal edema,
exposure to allergens early in life through the bronchospasm, asthma, angioedema,
GIT or RT anaphylaxis, cardiovascular collapse
• Classic allergy symptoms: urticaria, • Management: Contact dermatitis
dermatitis, wheezing, cough, laryngeal edema, ▪ Avoid exposure
angioedema ▪ Thorough washing and drying of hands
• GI symptoms: itching; swelling of lips, tongue ▪ Use of powder-free gloves
and palate; abdominal pain; nausea; cramps; ▪ Use of water- or silicone-based
vomiting; diarrhea moisturizing creams
• Medical Management ▪ Avoid oil- or petroleum-based skin agents
▪ Eliminate the food responsible for the with latex products
hypersensitivity • Management: Latex Allergy
▪ H1 blockers, adrenergic agents, ▪ Epinephrine, fluids, vasopressors,
corticosteroids, cromolyn sodium corticosteroids
▪ EpiPen device ▪ Airway and ventilator support
• Nursing Management ▪ Wearing of medical identification
▪ Symptom diary ▪ Carrying EpiPen
▪ Read food labels LATEX
▪ Compliance with elimination SOURCES ALTERNATIVES
▪ Balanced diet - Chewing gum - None
- Condoms, - Polyurethane
LATEX ALLERGY diaphragms condoms
- Rubber bands - String or clips
• Latex allergy is a reaction to certain proteins - Pacifier - Silicone products
found in natural rubber latex; a product made - Adhesive bandages - Cotton pads and
from the rubber tree. If you have a latex plastic tape
allergy, your body mistakes latex for a harmful
substance.
• Latex allergy may cause itchy skin and hives
or even anaphylaxis, a potentially life-
threatening condition that can cause throat
swelling and severe difficulty breathing. Your
health care provider can determine if you have
a latex allergy or if you're at risk of developing
a latex allergy.
• Routes
a. Cutaneous – gloves
b. Percutaneous and parenteral IV lines,
catheters and hemodialysis equipment
c. Mucosal – latex condoms, catheters,
airways, nipples
d. Aerosol – powder from latex gloves
• Risk Factors
▪ Health care workers
▪ Working in rubber industry
▪ Female
▪ Multiple surgeries
▪ Patients with spina bifida
▪ Frequent wearers of gloves (e.g.
hairdressers, food handlers, auto
mechanic)
▪ Allergy to kiwi, bananas, pineapples,
mangoes, grapes, avocados, and chestnuts
• Clinical Manifestations

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