Allergic Rhinitis

Allergic rhinitis, commonly known as hay fever, is a chronic condition characterized by inflammation of the nasal passages due to an allergic response to certain airborne allergens. This condition can significantly impact the quality of life, causing discomfort, sleep disturbances, and impaired daily activities.

Understanding the basics of allergic rhinitis is essential in recognizing and managing this condition effectively.

Table of Contents

• What is Allergic Rhinitis?
• Pathophysiology
• Statistics and Incidences
• Causes
• Clinical Manifestations
• Assessment and Diagnostic Findings
• Medical Management
  • Pharmacologic Management
• Nursing Management
  • Nursing Assessment
  • Nursing Diagnoses
  • Nursing Care Planning and Goals
  • Nursing Interventions
  • Evaluation
  • Documentation Guidelines

What is Allergic Rhinitis?

Although allergic rhinitis (AR) is a common disease, its 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 an 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. The use of environmental controls is not adequately explored in most patients; for many patients, the removal of the trigger can have a dramatic effect; the 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 a child with allergic rhinitis includes:

Nursing Assessment

Assessment of the child includes:

• 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 the 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 are 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 how to use nasal sprays by blowing the nose first and 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 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.