Management of a Patient with an Allergic Rhinitis - Essay Example

? Allergic Rhinitis Teacher’s ID Introduction The patient analyzed for this case study is given a pseudonym of Lara Johanson, a 19 years old female Caucasian who visited hospital for persistent sneezing, flowing nose and red eyes. The patient was examined by nursing practitioner who took her thorough personal medical and family history and physical examination. A general management of allergic rhinitis begins with history and manifestations, diagnosis involving tests and follow-up screening procedures. Allergic rhinitis is also known as hay fever and is supposed to be mediated by type-I hypersensitivity which is an extreme response of immune system against foreign bodies by build-up of antibodies. General nursing process begins with assessment of patient’s health history which involves their personal and family history (Burns, 2007). Secondly, an allergy assessment is performed by examining obvious symptoms and state of patient before these symptoms became apparent. Thirdly, occurrence of these symptoms is examined with relation to seasonal changes and related physical mental and physical problems. In the last stage of assessment, nature of antigen causing allergy is identified (Denise and Scandale, 2010). A patient is said to have this allergy when an ineffective breathing pattern and continuous sneezing is observed when encountered with triggers. Ineffective coping of chronic disorders is often followed by need for changes in environment of the patient. Possible problems encountered during management of the disorder include anaphylaxis, disturbed breathing pattern and failure to follow suggested therapy. The goal of interventions used for treating this patient were to restore normal breathing pattern, identify causes and control them, improve coping mechanism and avoid any complications. 2. History of the Patient A patient’s history must be comprehensive enough to provide information regarding onset and duration of the symptoms being experienced by the patient along with possible triggers. In addition to that, co-morbidity, family history of allergies, environmental exposure, and quality of life also play an important role in diagnosis. After preliminary form filing, the patient complained about seasonal flu in last five years which showed persistence despite usage of OTC medication without prescription. This was the first incident where patient entered into medical settings. The patient complained of frequent episodes of sneezing with large production and exhalation of clear mucus. Since some of the symptoms mentioned later were similar to Sinusitis therefore discharge of mucus and drainage were observed to identify if the patient has Sinusitis or allergic rhinitis. Furthermore, localized itching also confirmed it. 2.1 Response to Allergens Patient complained of 10-15 paroxysms when experiencing sneezing along with nasal congestion leading to breathing through mouth. The symptoms grew severe in the springs and especially near plantation. Patient also mentioned having episodes of atopic eczema. It is important to note that patients with atopy are at risk of developing allergic rhinitis (Burns, 2007). Lara also complained of reduced energy level and fatigue especially in late winters and spring while experiencing this state. Lara further complained of itchy nose which made her rub her nose repetitively and a crease was visible in the middle of her nose (Lang, n.d; Plaut and Valentine, 2005). Furthermore, she mentioned that the sneezing and itching is more aggressive right after waking up and in the morning. Out of symptoms defined by the patient, it was evident that she had experienced sneezing, pruritus, congestion and drainage which are some of the common symptoms of allergic rhinitis (Spector et al., 2003; Harvey, 2012). The onset of pruritus was more evident in palate, nose and throat leading to aggressive coughing. In addition to these conditions, Lara also complained about sleep apnea, overbiting and episodes of asthma. She also mentioned that her mother has persistent asthma which becomes severe during winters and early spring. Her father also had a tendency of developing eczema whenever faced with extreme physical strain and mental stress. Family history of eczema and asthma increases risks of developing allergic rhinitis (Lang, n.d). 2.2 Environmental and Occupational Exposure Further questions surrounded examination of the environmental and occupational exposure. When asked about her living conditions, she mentioned that her house has a small garden with many small indoor plants as well. Furthermore, the sneezing becomes aggressive when she stays in a room which is fully carpeted and has heavy curtains and this condition persists throughout the year so she prefers not to stay in that room for a long time. This particular information indicated a possibility of allergy to dust mites. However, she did not complain about aggressive episodes when she is in her college except presence of plants or too much humidity. When asked about her quality of life, Lara mentioned having severe fatigue, drowsiness and headaches along with above mentioned symptoms. She also mentioned having fever and body aches while being on vacation in a farm house earlier this year. Also, severe coughing and congestion was also reported. Although fever, cough and fatigue was controlled after OTC medication however she had to continue use of nasal corticosteroids for few months as they are considered most effective in treating congestion and other symptoms of allergic rhinitis when combined with antihistamines (Greiner, Hellins, Rotiroti and Scadding, 2011). Lara further complained of reduced quality of sleep and physical and mental efficiency in her academic life (Sheikh and Najib, 2013). 2.3 Skin-Pricking Test For further confirmation of the health condition experienced by Lara, a skin pricking test was recommended. According to Lang (2013), “The diagnosis of allergic rhinitis requires a positive history, demonstration of IgG-mediated potential to inhalant allergens by cutaneous (or in vitro) testing, and correlation between history and cutaneous (or in vitro) test findings. Immediate hypersensitivity skin testing is recommended as the preferred diagnostic study, because it is associated with lower cost, is more sensitive, and entails no delay in obtaining results.” It is important to note that as compared to other diagnostic tools like blood tests, patch testing, allergy challenge and non-conventional tests i.e. igG blood test, applied kinesiology, auricular cardiac reflex method and vega testing, SPT is more quick and provides reliable results (Allergy UK., 2013; Sheikh and Najib, 2013). During this test, a small amount of allergen was introduced on the skin of Lara’s inner forearm in order to examine a localised response (Kenny, 2011; Mehl et al., 2012). After sometime, a wheal along with redness was visible at the site of testing which was a positive response (Plaut and Valentine, 2005; Berger, 2002). Patient was suggested not to take any anti-histamine like cough mixtures etc along with other medications 48 hours before the test in order to avoid any negative reactions (Zieve and Stuart, 2012). There is a significant amount of research available that demonstrates SPT to be an important part of obtaining complete medical history of a patient (Karakaya, Ozturk and Kalyyoncu, 2012; Mpwaire et al., 2012). Furthermore examination indicated that the patient had enlarged nasal turbinates with thin discharge. The throat examination showed large tonsils and a cobblestone as well. Furthermore, polyps were also seen during nasal examination. Eyes were red and watery and periobital edema was also visible. Further examination involved listening to lungs and assessment of skin sensitivity or presence of eczema or asthma (Demoly et al., 2013) 3. Interventions Used During the Treatment After receiving test results, Lara came for a detailed visit next day however she had developed severe case of fatigue, sneezing and cough with continuous ear and facial pain. It was evident that she had developed a severe case of rhinitis. Since patient’s residence was full of allergens i.e. dust mites and pollens. It was important that she stayed away from the triggers in the first place. All these symptoms were accompanied by a severe case of sleep apnea, rhinorrhea and nasal obstruction. Management of allergic rhinitis began with avoidance of allergy triggers followed by use of steroid nasal spray to reduce congestion and sensitization (Min et al., 2001). For this purpose, an allergy chart was developed that would help nurse practitioner to shortlist possible allergens through identifying severity patterns of the allergy. The same chart had a column meant for medication as well and responses to such medication. 3.1 Avoidance To begin with treatment, lifestyle interventions were introduced to avoid allergens. Lara was recommended to ensure that doors and windows of her residence remained closed during the days when pollen count was high. Furthermore, she was also asked to keep the air conditioning high in such days. She was given details of the websites that helped in identifying pollen counts. Secondly, she was recommended to keep the windows of vehicle closed along with using air conditioner while travelling. While travelling in public transport, a mask was also recommended. Her parents were suggested to have a high efficiency particulate air (HEPA) filters installed in their temperature moderation units to keep the inner environment of their residence clean and humidity-free (Plaut and Valentine, 2005). Furthermore, frequent bathing was also recommended to get rid of pollens attached to body outdoors. Air-drying of clothes was also asked to be avoided since Lara’s residence had a garden that would increase the possibility of pollens attaching to the clothes. Other measures like washing bedding and vacuuming carpets and mattress weekly, using impermeable bed covers, avoiding pets and stuffed animals, removing carpets if possible, eliminating indoor plants, dehumidifying residence especially bedroom, presents in the house, eradicating mold/ mildew in the washrooms and avoiding tasks like vacuuming, dusting, cleaning etc (Turner and Kemp, 2010; Tran, Vickery and Blaiss, 2011). However, these preventive measures were required to be accompanied by medication to treat current problem faced by Lara. 3.2 Medication Since Lara was facing health problems involving ENT, therefore mere avoidance of allergy triggers was not the only part of the treatment. She was recommended with oral antihistamines for sporadic symptoms including itching, sneezing, discharge and watery eyes. The oral medication suggested included Fexofenadine HCI 60mg twice a day and Montelukast Sodium 10 mg once in a day at night (Denise and Scandale, 2010). Lara was also experiencing coughing due to post-nasal dripping (which may have required immunotherapy) however since she had just began to experience them, therefore these antihistamines were expected to control any extra mucus production. It is important to note that oral antihistamines are more effective in treating sporadic symptoms than nasal congestion. Therefore, nasal corticosteroid was also recommended to Lara. Nasal corticosteroids are an effective part of treatment for moderate to severe allergic rhinitis. Its continuous use tends to treat inflammation in the nose. For Lara, Nasonex (Momestasone Furoate) was used to treat congestion, sneezing, drainage and itching. Recommended dosage was 2 sprays in one nostril at night (Denise and Scandale, 2010; Small & Kim, 2011). It was hard to differentiate if Lara had perennial or seasonal rhinitis since she was allergic to dust mites and pollens therefore she was recommended to continue use of nasal spray for several months especially before spring. Intermittent and continuous use of antihistamines and nasal corticosteroids was suggested as part of long-term treatment. No nasal antihistamine or Anticholinergic was recommended till further examination. In addition to itching and nasal problems, Lara also experienced red, itchy and swollen eyes caused by conjunctivitis as a result of allergy (Williams, Edney, Maiden and Smith, 2013). She was recommended with Patanol (Olopatadine) to treat ocular itching twice a day (Denise and Scandale, 2010; Small & Kim, 2011; Williams et al., 2013). Before that, it was asked if she uses any contact lenses for eyesight and the answer was positive. She was suggested not to use eye drops while wearing contact lenses and use them only after 15- 20 minutes of using eye drops. It is important to note that the recommended nasal spray has reported to play role in reducing ocular itching and redness caused by dilatation of blood vessels. The reason for recommending use of this spray at night was the possibility of side effects which includes blurry image and stinging. To avoid any disturbance in patient’s quality of life, use of spray before sleep or after usual activities was recommended (Denise and Scandale, 2010). Since patient was already recommended with nasal corticosteroids and antihistamines having holistic effect against the symptoms recorded, therefore no nasal decongestant was recommended. Furthermore, allergic rhinitis does not require use of oral corticosteroids; therefore the treatment remained limited to these few medicines. Although presence of nasal polyps require attention of specialist instead of a primary physician however the polyps were found to be relatively in a primary state and patient gave negative answers when asked about loss of sense of taste or smell, one-sided congestion, discharge of blood or accompanying ear problems. Therefore, immunotherapy was no considered to be made part of current treatment nor possibility of referral was considered. 3.3. General Management Along with basic treatment due to severity of symptoms, Lara was also given some instructions regarding general management of the symptoms of experienced in the later stage. It was suggested that in addition to general avoidance based on guidelines given above, she should maintain a log of symptoms experienced along with the severity to identify what makes her symptoms aggravated and eliminate those factors. In order to manage mild symptoms, general OTC medicines meant for allergy like Zyrtec can be used after primary treatment (Small & Kim, 2011). However, no nasal decongestant was suggested for general management as Lara had a family history of high blood pressure and diabetes. If these measures fail to control general symptoms in future, she was recommended to set up an appointment with general physician covered by her insurance provider. She was also recommended to continue long-term use of Montelukast Sodium 10 mg as a long-term treatment since allergic rhinitis is a chronic disorder requiring persistent treatment (Small & Kim, 2011). It was also decided that if oral antihistamines and nasal corticosteroids do not work, next course of action would include nasal antihistamines and Leukotriene inhibitors. Immunotherapy will be used if these measures remain ineffective. 3.4 Immunotherapy It is important to note that Lara did not complain about any sinus infections or recurrence of otitis media (Min, 2010). Therefore, immunotherapy was not considered as a primary treatment. Immunotherapy involves insertion of allergen in patient’s body through injections in order to trigger positive changes in patient’s immune system. This mode of treatment was not preferred for Lara mainly because of its long-term duration comprising of over three years period, lack of immediate results and absence of major symptoms requiring aggressive treatment (Chang, Han and Rhee, 2009). However, immunotherapy is an effective treatment against house dust mites and pollens in severe cases seeking for long-term eradication (Min, 2010). Furthermore, this mode of treatment has a risk of anaphylaxis inherent to it (Rolland, Gardner, O'Hehir, 2009). The risk increases if the patient is asthmatic or allergic to other food items. However, it is highly effective and only treatment which can eradicate allergic rhinitis but limited instances of recurrence after immunotherapy have been reported. Furthermore, it is more effective for patients who are allergic to single allergen. In Lara’s case, she was allergic to multiple agents. Therefore, possibility of using immunotherapy was not considered. 4. Nursing interventions Providing information and recommendations to patient is an integral part of nursing job. In Lara’s case, patient needed to be educated about the causes of her health condition. Since medication would not help her if not taken in the long- run, therefore necessary measures to avoid allergy were recommended to her. Nursing practitioner informed Lara about her things that were required to be made part of her lifestyle i.e. basic medication and general management, for avoiding further recurrence of allergy. Nursing practitioner also helped Lara’s parents about avoidance of allergy and course of treatment. When Lara’s parents asked about not giving her any antibiotics for nasal discharge like normal flu, they were told that Lara had been experiencing allergic reactions to various triggers and she was not having common cold flu. Lara’s father had a history of sinusitis and he used nasal sprays in the past, he wondered if Lara is also developing sinus problems. He was explained a difference between sinus problems and allergic rhinitis and was also told that the purpose of nasal corticosteroids was to cure itching, nasal discharge, sneezing and red eyes. Lara was also explained that she will remain prone to the triggers therefore avoidance is the most appropriate strategy. She was suggested that to have strong guard, she should begin use of recommended nasal corticosteroids in late winter. This measure would help in having greater immunity against pollens in early spring. Lara was also suggested to contact the nursing staff if the condition persists after one week. 5. Conclusion Lara has been a patient of allergic rhinitis in past few years however self-medication and lack of diagnosis has aggravated her state. Recently, she experienced continuous itching on nasal area followed by aggressive sneezing, watery and red eyes and nasal congestion. Disturbance in sleep pattern especially in morning hours followed sneezing and transparent nasal discharge were observed. Other symptoms like minute polyps, cough, sleep apnea, post- nasal dripping, fatigue and reduced cognitive functioning were observed. It was found that Lara was experiencing sneezing and rhinorrhea when encountered with allergens which were found to be pollens and dust mites as Type-I hypersensitivity. It was difficult to diagnose if she had perennial or seasonal allergic rhinitis. When encountered with allergens, she experienced nasal obstruction as well. In order to be ascertain about the allergens, a skin pricking test was taken in which she showed responsiveness to pollens and dust mites. Further treatment suggested included avoidance by making changes in lifestyle and the environment in which patient was living. For medication, she was recommended oral antihistamines, nasal corticosteroids and eye drops for allergic conjunctivitis which is a co-morbid condition of allergic rhinitis. The nursing practitioner further suggested Lara to take OTC medication like Zyrtec and saline spray in usual days as part of long-term treatment. She was also suggested to follow avoidance plan religiously and begin use of antihistamines and corticosteroids at least two weeks before arrival of spring in future. The avoidance guidelines were meant to reduce exposure to pollens and dust mites. She was also suggested not to take any antibiotics as it was not a common cold. 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