NURSING PROCESS: THE PATIENT WITH ALLERGIC RHINITIS
The examination and history of the patient reveal sneezing, often in paroxysms, thin and watery nasal discharge, itching eyes and nose, lacrimation, and occasionally headache. The health history includes a personal or family history of allergy. The allergy as-sessment identifies the nature of antigens, seasonal changes in symptoms, and medication history. The nurse also obtains sub-jective data about how the patient feels just before symptoms be-come obvious, such as the occurrence of pruritus, breathing problems, and tingling sensations. In addition to these symp-toms, hoarseness, wheezing, hives, rash, erythema, and edema are noted. Any relationship between emotional problems or stress and the triggering of allergy symptoms is assessed.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Ineffective breathing pattern related to allergic reaction
· Deficient knowledge about allergy and the recommended modifications in lifestyle and self-care practices
· Ineffective individual coping with chronicity of condition and need for environmental modifications
Based on assessment data, potential complications may include the following:
· Impaired breathing
· Nonadherence to the therapeutic regimen
The goals for the patient may include restoration of normal breathing pattern, increased knowledge about the causes and con-trol of allergic symptoms, improved coping with alterations and modifications, and absence of complications.
The patient is instructed and assisted to modify the environment to reduce the severity of allergic symptoms or to prevent their oc-currence. The patient is instructed to reduce exposure to people with upper respiratory infections (URIs). If a URI occurs, the pa-tient is encouraged to take deep breaths and cough frequently to ensure adequate gas exchange and prevent atelectasis. The patient is instructed to seek medical attention because allergy symptoms along with a URI may compromise adequate lung function. Compliance with medications and other treatment regimens is encouraged and reinforced.
Instruction includes strategies to minimize exposure to allergens, desensitization procedures, and correct use of medications. The nurse informs and reminds the patient of the importance of keep-ing appointments for desensitization procedures because usually dosages are adjusted on a weekly basis, and missed appointments may interfere with the dosage adjustment.
Patients also need to understand that medications for allergy control should be used only when the allergy is apparent. This is usually on a seasonal basis. Continued use of medications when not required may cause an increased tolerance to the med-ication, with the result that the medication is not effective when needed.
Although allergic reactions are infrequently life-threatening, they require constant vigilance to avoid allergens and modification of the lifestyle or environment to prevent recurrence of symptoms. Allergic symptoms are often present year-round and create dis-comfort and inconvenience for the patient. Although patients may not feel ill during allergy seasons, they often do not feel well either. The need to be alert for possible allergens in the environ-ment may be tiresome, placing a burden on the patient’s ability to lead a normal life. Stress related to these difficulties may in turn increase the frequency or severity of symptoms.
To assist the patient in adjusting to these modifications, the nurse must have an appreciation of the difficulties encounteredby the patient. The patient is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively.
Respiratory and cardiovascular functioning can be significantly altered during allergic reactions by the reaction itself or by the medications used to treat reactions. The respiratory status is eval-uated by monitoring the respiratory rate and pattern and by as-sessing for breathing difficulties or abnormal lung sounds. The pulse rate and rhythm and blood pressure are monitored to assess cardiovascular status regularly or any time the patient reports symptoms such as itching or difficulty breathing. In the event of signs and symptoms suggestive of anaphylaxis, emergency med-ications and equipment must be available for immediate use.
Knowing about the treatment regimen does not ensure adher-ence. Having the patient identify potential barriers and explore acceptable solutions for effective management of the condition (eg, installing tile floors rather than carpet, not gardening in the spring) can increase adherence to the treatment regimen.
The patient is instructed about strategies to minimize exposure to allergens, the actions and adverse effects of medications, and the correct use of medications. The patient should know the names, dose, frequency, actions, and side effects of all medications taken.
Instruction about strategies to control allergic symptoms is based on the needs of the patient as determined by the results of tests, the severity of symptoms, and the motivation of the patient and family to deal with the condition. Suggestions for patients sensitive to dust and mold in the home are given in Chart 53-5.
If the patient is to undergo immunotherapy, the nurse re-inforces the physician’s explanation regarding the purpose and procedure. Instructions are given regarding the series of injec-tions, usually given initially every week and then at 2- to 4-week intervals. These instructions include remaining in the physician’s office or the clinic at least 30 minutes after the injection so that emergency treatment may be given if the patient has a reaction; avoiding rubbing or scratching the injection site; and continuing with the series for the period of time required. In addition, the patient and family are instructed about emergency treatment of severe allergic symptoms.
Because antihistamines often produce drowsiness, the patient is cautioned about this and other side effects of the particular medication. Operating machinery, driving a car, and performing activities requiring intense concentration should be postponed. The patient is also informed about the dangers of drinking alco-hol when taking these medications because they tend to exagger-ate the effects of alcohol.
The patient must be aware of the effects caused by overuse of the sympathomimetic agents in nose drops or sprays. A condition referred to as rhinitis medicamentosa may result (Fig. 53-6). After topical application of the medication, a rebound period may occur in which the nasal mucous membranes become more ede-matous and congested than they were before the medication was used. Such a reaction encourages the use of more medication, and a cyclical pattern results. The topical agent must be discontinued immediately and completely to correct this problem.
Follow-up telephone calls to the patient are often reassuring to the patient and family and provide an opportunity for the nurse to answer any questions. The patient is reminded to keep follow-up appointments and is informed about the importance of con-tinuing with treatment. The importance of participating in health promotion activities and health screening is emphasized to the patient.
Expected patient outcomes may include:
1) Exhibits normal breathing patterns
a) Demonstrates lungs clear on auscultation
b) Exhibits absence of adventitious breath sounds (crack-les, rhonchi, wheezing)
c) Has a normal respiratory rate and pattern
d) Reports no complaints of respiratory distress (shortness of breath, difficulty on inspiration or expiration)
2) Demonstrates knowledge about allergy and strategies to control symptoms
a) Identifies causative allergens, if known
b) States methods of avoiding allergens and controlling in-door and outdoor precipitating factors
c) Removes from the environment items that retain dust
d) Wears a dampened mask if dust or mold may be a problem
e) Avoids smoke-filled rooms and dust-filled or freshly sprayed areas
f) Uses air conditioning for a major part of the day
g) Takes antihistamines as prescribed; participates in hypo-sensitization program, if applicable
h) Describes name, purpose, side effects, and method of administration of prescribed medications
i) Identifies when to seek immediate medical attention for severe allergic responses
j) Describes activities that are possible, including ways to participate in activities without activating the allergies
3) Experiences relief of discomfort while adapting to the in-conveniences of an allergy
a) Relates the emotional aspects of the allergic response
b) Demonstrates use of measures to cope positively with allergy
4) Absence of complications
a) Exhibits vital signs within normal limits
b) Reports no symptoms or episodes of anaphylaxis (ur-ticaria, itching, peripheral tingling, fullness in the mouth and throat, flushing, or difficulty swallowing) or cough-ing, wheezing, or difficulty breathing
c) Demonstrates correct procedure to self-administer emer-gency medications to treat severe allergic reaction
d) Correctly states medication names, dose and frequency of administration, and medication actions
e) Correctly identifies side effects and untoward signs and symptoms to report to physician
f) Discusses acceptable lifestyle changes and solutions for identified potential barriers for compliance with treat-ment and medication regimen
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