Allergic Rhinitis Nursing Care Management

Allergic rhinitis, the hay fever you see constantly, is a chronic inflammation of the nasal passages from an allergic response to airborne allergens. Patients underrate it, but it wrecks sleep, comfort, and daily function. Most of your work is identifying the trigger and teaching the family to control it.

What is Allergic Rhinitis?

Allergic rhinitis (AR) is common, and its effect on daily life is real. In children it is most often caused by sensitization to animal dander, house dust, pollens, and molds. Pollen allergy seldom appears before age 4 or 5. Sensitization to outdoor allergens can occur in children older than 2 years, and is more common in those older than 4 to 6 years.

Pathophysiology

To understand AR, understand what the nose does. It filters, humidifies, and regulates the temperature of inspired air across a large surface area spread over 3 turbinates in each nostril. Temperature regulation runs on a triad: a thin layer of mucus, cilia, and vibrissae (hairs) that trap airborne particles. Blood flow to each nostril sets the size of the turbinates and the airflow resistance. The nature of the filtered particles matters: irritants like cigarette smoke and cold air cause short-term rhinitis, but allergens set off a cascade that leads to more significant, prolonged inflammation. Rhinitis is a local defense in the nasal airways trying to keep irritants and allergens out of the lungs.

Statistics and Incidences

AR has no race or sex predilection, though people from nonwhite backgrounds seek care less often than whites. Clinically significant sensitization to indoor allergens can 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 the Pollution and Asthma Risk: an Infant Study (PARIS), 9.1% of the 1859 toddlers in the cohort reported allergic rhinitis-like symptoms at age 18 months.

Causes

AR comes from an immunoglobulin E (IgE)-mediated reaction to allergens in the nasal mucosa. The most common allergens are dust mites, pet danders, cockroaches, molds, and pollens.

Clinical Manifestations

Expect rhinorrhea (runny nose), nasal congestion (stuffiness), postnasal drainage from excess mucus, repetitive sneezing from irritation, and itching of the palate, ears, nose, or eyes. Watch for the allergic salute, when the child pushes the nose upward and backward to relieve itching and open the air passages.

Assessment and Diagnostic Findings

No studies are needed if the history is straightforward. When the history is confusing, these help:

• Skin-prick testing. Highly sensitive and specific for aeroallergens, but a false positive can occur without matching clinical features, especially when skin mast cells activate easily under pressure or other physical stimuli.
• Serum allergen-specific IgE testing. Patients may be sensitive at a molecular level before the IgE response shows on standard skin testing, which can produce positive lab results that are not triggering symptoms.
• Nasal smear. Eosinophils usually indicate an allergy.
• CBC with differential. May show increased eosinophils. A count within the reference range does not exclude AR, but an elevated count is suggestive.

Medical Management

Treatment splits into three categories: avoiding allergens or controlling the environment, medications, and allergen-specific immunotherapy (sublingual or allergy shots). Environmental control is underused. For many patients, removing the trigger has a dramatic effect; the hard part is identifying and eliminating it. Pulling a feather pillow or blanket is simple, removing a family pet is not.

Pharmacologic Management

Drug classes for AR include antihistamines, corticosteroids, decongestants, saline, sodium cromolyn, and leukotriene receptor antagonists.

• 2nd-generation antihistamines. Antihistamines are classed as sedating versus nonsedating and first- versus second-generation (the most accepted split). First-generation agents are mostly over-the-counter and appear in many combination cough, cold, and allergy products.
• Intranasal antihistamines. An alternative to oral agents. Azelastine and olopatadine are the only ones available in the United States.
• Intranasal corticosteroids. The most effective class. These potent anti-inflammatory agents cut AR symptoms in more than 90% of patients.
• Intranasal antihistamine and corticosteroid combinations. Emerging for patients who need both.
• Intranasal decongestants. Effective for short-term control. They decrease nasal discharge and congestion and are available without a prescription.
• Leukotriene receptor antagonists. Montelukast is approved as monotherapy and works best when significant congestion is the main complaint.
• Allergen immunotherapy. Daily sublingual (SL) tablets may replace weekly injections in some patients depending on the allergen. Depending on the tablet, start therapy at least 3 to 4 months before the allergen season being treated.
• Intranasal mast cell stabilizers. Effective in about 70 to 80% of patients. They stabilize mast cells and block degranulation.

Nursing Management

Nursing Assessment

Take a history that pins down seasonal variation, environmental triggers, and the timing of symptoms. If a child only has trouble during the week, look at the classroom or daycare for pets or molds.

Nursing Diagnoses

• Ineffective airway clearance related to obstruction or thickened secretions.
• Disturbed sleep pattern related to nasal obstruction.
• Self-concept disturbance related to the condition.
• Anxiety related to lack of knowledge about the disease and procedures.

Nursing Care Planning and Goals

Goals for the child: no longer breathes through the mouth; airway back to normal, especially the nose; sleeps 6 to 8 hours a day; child and parents describe their anxiety and coping patterns; child and parents understand the disease and treatment.

Nursing Interventions

• Identify the allergen. Easiest for dust mites. Pollen is harder because daily activities have to change. Keeping windows closed year-round works well in air-conditioned homes.
• Use nasal sprays correctly. Teach the patient and parents to blow the nose first, then give the medication.
• Clean the house thoroughly. Routinely clean furniture and equipment that harbor dust and pollens.
• Encourage medication compliance. Give pharmacologic treatment as ordered.

Evaluation

Goals are met when the child no longer breathes through the mouth, the airway is normal, the child sleeps 6 to 8 hours a day, and child and parents describe their coping and understand the disease and treatment.

Documentation Guidelines

Document the 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; and attainment of or progress toward desired outcomes.