H&I 2: Hypersensitivity- Pearson
In anaphylactic reactions, the airway obstruction may be a result of facial angioedema, bronchospasm, or laryngeal edema. In these cases, the nurse will:
-Administer oxygen per nasal cannula at a rate of 2-4 L/min. Apply oxygen emergently, and obtain a physician order for oxygen administration to increase the alveolar oxygen and its availability to cells of the body. -Insert a nasopharyngeal or oropharyngeal airway, and arrange for immediate intubation as indicated. -Ensuring an adequate airway is vital to preserve life. -Administer subcutaneous epinephrine 1:1000, 0.3-0.5 mL, as prescribed. This may be repeated in 5-15 minutes if necessary. Also, administer parenteral diphenhydramine (deep intramuscular or IV) as prescribed. Epinephrine is a potent vasoconstrictor and bronchodilator, counteracting the effects of histamine. Diphenhydramine is an antihistamine that blocks histamine receptors and their effect. These medications can rapidly reverse manifestations of anaphylaxis. -Provide calm reassurance. Hypoxemia and air hunger terrify the patient. Anxiety can impair the patient's ability to cooperate with treatment and can increase the respiratory rate, making breathing less effective. -Comfort measures may be helpful when attempting to calm small children and may include distraction (e.g., reading a story, singing to the child), letting the child hold a soft or beloved object, and allowing the child to sit on the parent's lap when possible.
Airway, breathing, and circulation (the ABCs) are of greatest importance for the patient with an anaphylactic reaction. When a hemolytic reaction to an incompatible blood transfusion occurs, the patient is at risk for injury. Possible high-priority nursing diagnoses are the following:
-Airway Clearance, Ineffective -Cardiac Output, Decreased -Injury, Risk for -Ventilation: Spontaneous, Impaired -Shock, Risk for.
When cardiac output falls to where tissue perfusion is impaired and hypoxia results, a state of anaphylactic shock exists. In this event, the nurse should:
-Insert one or more large-bore (18 gauge or larger) IV catheters. It is important to insert IV catheters as soon as possible to provide sites for rapid fluid replacement. -Administer warmed IV solutions of lactated Ringer or normal saline as prescribed. These isotonic solutions help to maintain intravascular volume. Solutions are warmed to prevent hypothermia from the rapid administration of large amounts of fluid at room temperature (~70°F [21.1°C]). -Insert an indwelling catheter, and monitor urinary output frequently. As the cardiac output drops, the glomerular filtration rate falls. With an output of less than 0.5 mL/kg/hr in less than 6 hr, the patient is at risk for acute renal failure from ischemia (Hughes, 2014). -Place a tourniquet above the site of an injected venom (e.g., a bee sting), and infiltrate the site with epinephrine as prescribed. Use of a tourniquet and the vasoconstriction resulting from epinephrine infiltration reduce further absorption of the allergen. -Once normal breathing is established, place the patient flat with the legs elevated. This position enhances perfusion of the central organs, such as the brain, heart, and kidneys ***Aggressive infusion of IV fluids may lead to hypervolemia and pulmonary edema. Assess for shortness of breath and crackles in the lungs.
Peripheral vasodilation and increased capillary permeability resulting from the release of histamine can significantly impair cardiac output. In all cases in which a patient is exhibiting a hypersensitivity reaction, the nurse should:
-Monitor vital signs frequently, noting fall in blood pressure, decreasing pulse pressure, tachycardia, and tachypnea. These changes in vital signs may indicate shock. -Assess skin color, temperature, capillary refill, edema, and other indicators of peripheral perfusion. -As cardiac output falls, peripheral vessels constrict, and tissue perfusion is impaired. -Monitor level of consciousness. A change in level of consciousness (lethargy, apprehension, or agitation) often is the first indicator of decreased cardiac output.
Priority goals for the patient with hypersensitivity may include the following:
-Patient will avoid known substances that provoke hypersensitivity response. -Patient will describe self-care to reduce symptoms of seasonal allergies. -Patient will describe proper self-administration of medications prescribed by the primary care provider or specialist. -Patient will help determine substances that cause hypersensitivity by keeping an accurate food journal.
Potential outcomes may include the following:
-patient exhibits decreased symptoms and decreased frequency of hypersensitivity responses. -Patient demonstrates proper technique when using an epinephrine autoinjector. -Patient provides accurate and thorough information in food or activity and symptom journal.
Substances Known to Trigger Anaphylaxis in Sensitized Individuals:
1) Hormones -Insulin -Vasopressin -Parathormone 2) Enzymes -Trypsin -Chymotrypsin -Penicillinase 3) Pollens -Ragweed -Grass -Trees 4) Foods -Eggs -Seafood -Nuts and nut by-products -Grains -Beans -Cottonseed oil -Chocolate 5) Vitamins -Thiamine -Folic acid 6) Insect Venom -Yellow jacket -Hornet -Paper wasp -Honey bee 7) Occupational Agents -Rubber products -Industrial chemicals (ethylenes) 8) Antibiotics -Penicillins -Cephalosporins -Amphotericin b -Nitrofurantoin 9) Local Anesthetics -Procaine -Lidocaine 10) Medical Diagnostic Agents -Sodium dehydrocholate -Sulfobromophthalein 11) Antiserum -Antilymphocyte gamma globulin
The following laboratory tests may be ordered to identify possible allergens or hypersensitivity reactions:
1. WBC count with differential -This test can detect high levels of circulating eosinophils. Eosinophils normally constitute a very small percentage (1-4%) of the total of WBCs. Eosinophilia, however, often is present in patients with type I hypersensitivities. 2. Radioallergosorbent test (RAST) -This test measures the amount of IgE directed toward specific allergens. Test results are compared with control values and used to identify hypersensitivities. RAST poses no risk for an anaphylactic reaction. It is particularly useful in detecting allergies to some occupational chemicals and toxic allergens 3. Blood type and crossmatch -These tests are ordered before any anticipated transfusions. They determine the patient's ABO blood group and Rh status. Two major antigens, designated A and B, may be present on RBCs. Patients with the A antigen are designated as blood type A; those with the B antigen are designated as blood type B. When neither antigen is found on the RBCs, the individual is identified as type O. A third major RBC antigen is the Rh antigen. Individuals with this antigen are called Rh-positive; those without are called Rh-negative. Because a blood transfusion is actually a transplantation of living tissue, antigen matching is vital to prevent significant hypersensitivity reactions. Once blood type is determined, a sample of the patient's blood is mixed with a sample of matching donor blood and observed for antigen-antibody reactions in the crossmatch portion of this test. Although this procedure greatly reduces the risk of a hemolytic transfusion reaction (type II hypersensitivity), it does not totally eliminate it. 4) Indirect Coombs test -This test detects the presence of circulating antibodies (other than ABO antibodies) against RBCs. The patient's serum is mixed with the donor's RBCs. If the patient's serum contains antibodies to an RBC antigen, agglutination (clumping together) will occur. This is called a positive response. The normal value is negative (no agglutination). This test is also part of the crossmatch of a blood "type and crossmatch." 5) direct Coombs test -This test detects antibodies on the patient's RBCs that damage and destroy the cells. This test is used following a suspected transfusion reaction, to detect antibodies coating the transfused RBCs. It also can identify hemolytic anemia when the cause is unknown. In the direct Coombs test, the patient's RBCs are mixed with Coombs serum, which contains antibodies to IgG and several complement components. Agglutination occurs if the patient's RBCs are coated with antibodies; it means the test is positive. As with the indirect Coombs test, the normal test result is negative (no agglutination). 6) Immune complex assays -These tests may be performed to detect the presence of circulating immune complexes in suspected type III hypersensitivity responses. These assays are particularly useful in diagnosing suspected autoimmune disorders. Nonspecific assays of IgG-, IgM-, and IgA-containing immune complexes, which do not detect specific antibodies, as well as specific antibody assays, may be done. The normal result is a test negative for circulating immune complexes. A negative test does not, however, rule out an immune complex hypersensitivity response. In some cases, a negative result indicates that the disease process has reached a later stage, in which complexes are no longer circulating but have initiated extensive tissue damage, such as glomerulonephritis 7) complement assay -This test also is useful in detecting immune complex disorders. In these disorders, complement is, in effect, used up by the development of antigen- antibody complexes. Decreased levels are seen on examination. Both total complement level and amounts of individual components of the complement cascade can be determined.
allergy:
A hypersensitivity response to environmental or exogenous antigens.
serum sickness:
A systemic type III hypersensitivity response, usually in response to a drug such as penicillin or a sulfonamide
transfusion reaction
A type II or cytotoxic hypersensitivity reaction to blood of an incompatible type.
anaphylaxis:
An acute systemic type I hypersensitivity (allergic) response that may result in shock and death. It occurs in highly sensitive persons following exposure to a specific antigen, usually through injection or ingestion.
allergen
An environmental or exogenous antigen that provokes a hypersensitivity response.
hypersensitivity:
An overreaction of the immune system to an antigen or antigens.
Within the hospital environment, healthcare workers and patients can be exposed to a variety of items that frequently contain natural rubber latex (NRL). These items may include, but are not limited to,
Band-Aids™, blood pressure cuffs, bulb syringes, Fleet enemas, sterile gloves, IV bags, personal protective equipment (PPE), reflex hammers, and tourniquets -Products such as balloons, condoms, and rubber bands commonly are made of latex
localized response:
Common manifestations of type I hypersensitivity, they are typically atopic responses; that is, they have a strong genetic predisposition. Atopic reactions are the result of localized, rather than systemic, IgE-mediated responses to an allergen. They are prompted by contact of the allergen with IgE in the bronchial tree, nasal mucosa, and conjunctival tissues.
Cell-mediated immune responses
Direct or indirect inactivation of antigen by lymphocytes.
antigen:
Foreign substance that triggers the immune response.
Maintaining a patent airway (or establishing airway clearance in the event of anaphylactic shock) is the highest priority in caring for the patient experiencing a hypersensitivity response. Placing the patient in
Fowler or high Fowler position allows optimal lung expansion and ease of breathing
What symptoms related to potential hypersensitivity would you teach Ms. Jackson to report?
Hypersensitivity symptoms could be rash, hives, difficulty breathing, local inflammation, and fever.
Antigen-antibody responses characterize types
I, II, and III hypersensitivity, which are also known as immediate hypersensitivity responses
Contact dermatitis is a classic example of a type
IV reaction. -Intense redness, itching, edema, and thickening affect the skin in the area exposed to the antigen. Fragile vesicles often are present as well. -Many antigens can provoke this response; poison ivy is a prime perpetrator. In the healthcare setting, an allergic response to latex also can produce contact dermatitis
Immediate or type I hypersensitivity is facilitated by
IgE with the primary cellular component being the mast cell or basophil. -The reaction initially involves the production of IgE in response to certain antigens and is intensified by the release of histamine and other mediators from the mast cells
Type II reactions are primarily mediated by
IgM or IgG antibodies that are bound to cell surface antigens.
systemic response:
Results because of a widespread antibody-antigen reaction. Systemic responses include anaphylaxis, urticaria, or angioedema.
Type IV hypersensitivity reactions are mediated by
T cells rather than antibodies and are involved in the development of many autoimmune and infectious diseases
you are caring for a patient who is having a severe hypersensitivity response. How do you assess the patient's oxygenation status?
To assess for oxygenation, you will assess level of consciousness, anxiety, nasal flaring, respiratory rate and pattern, O2 sub stats, blood gases, and chest movement. You should also listen for breath sounds.
You are caring for a patient with seasonal hypersensitivity resulting in rhinorrhea, sore throat, and sinus congestion. What actions will improve the patient's comfort?
You can administer nonsteroidal anti-inflammatory drugs (NSAIDs) as prescribed to decrease inflammation and reduce the pain of sore throat. An over-the-counter decongestant or antihistamine may also help the patient be more comfortable. Nonpharmacologic comfort interventions may include suggesting the patient drink a soothing tea, use soft tissues, and rest as needed. You can discuss strategies that minimize exposure to allergens, such as limiting time spent outside, avoiding activities that lead to hypersensitivity responses such as using a lawn mower, and considering air filters.
What teaching would you provide to Ms. Jackson regarding his risk for hypersensitivity?
You would educate the mother to be alert for hypersensitivities because she herself has so many, and to bring Ron to the emergency department immediately if he has any problems with the immunizations.
When a potent allergen enters the bloodstream and triggers a widespread antibody-antigen reaction and response to these chemical mediators, a systemic response, such as
anaphylaxis, urticaria, or angioedema, results.
Type IV hypersensitivity responses result from an exaggerated interaction between an
antigen and normal cell-mediated mechanisms. -This exaggerated interaction results in the release of soluble inflammatory and immune mediators (from the lysozymes within the macrophages) and recruitment of killer T cells, causing local tissue destruction
In a hypersensitivity reaction, an antigen-antibody or
antigen-lymphocyte interaction causes a response that is damaging to body tissues.
Type IV hypersensitivity is an
antigen-lymphocyte reaction resulting in a delayed hypersensitivity response.
for mild to moderate airway problems in a reaction do the following:
assess respiratory rate and pattern, level of consciousness and anxiety, nasal flaring, use of accessory muscles of respiration, chest wall movement, and audible stridor; palpate for respiratory excursion; and auscultate lung sounds and any adventitious sounds, such as wheezes. Extreme anxiety or agitation, nasal flaring, stridor, and diminished lung sounds indicate air hunger and possible airway obstruction, necessitating immediate intervention.
Type II hypersensitivity responses may necessitate aggressive management of
bleeding or renal failure
Type IV reactions differ from other hypersensitivity responses in two ways. First, they are cell-mediated immune responses, not antibody-mediated responses, and involve T cells of the immune system. Second, type IV reactions are
delayed rather than immediate, developing 24-48 hours after exposure to the antigen.
Type II reactions are tissue-specific and the manifestations vary. They usually include
dyspnea or fever
Type II reactions may be stimulated by an
exogenous antigen, such as foreign tissue or cells, or by a drug reaction, in which the drug forms an antigenic complex on the surface of a blood cell, stimulating the production of antibodies. -The resulting antigen-antibody reaction destroys the affected cell; for example, the administration of certain drugs, such as penicillins, may cause a condition known as drug-induced hemolytic anemia. Withdrawal of the drug stops the reaction and cell destruction.
Type IV reactions are delayed and are variable. They may include
fever, erythema, and itching.
Type I reactions are localized. Typical manifestations occur as
hypotension, wheezing, GI or uterine spasm, stridor, or urticaria.
Reactions are also classified as
immediate or delayed hypersensitivity responses. -Anaphylaxis and transfusion reactions are examples of immediate hypersensitivity reactions; contact dermatitis is a typical delayed response.
Exposure to an allergen that initiates a type I hypersensitivity reaction can occur through
ingestion of a food or medication, injection of a medication, inhalation of a triggering substance, or absorption via skin contact.
With a type I hypersensitivity response, managing the patient's airway takes highest priority, followed by
maintaining cardiac output
Assess the
mucous membranes of the nose and mouth; assess the skin for lesions or rashes; and assess eyes (tearing and redness), respiratory rate, and breath sounds.
factors associated with the development and severity of anaphylaxis include
older age, lung disease, antigen's route of entry, amount of antigen introduced, rate of absorption for the antigen, and degree of individual hypersensitivity.
The immediate treatment for anaphylaxis is
parenteral epinephrine, an adrenergic agonist (sympathomimetic) drug that has both vasoconstricting and bronchodilating effects. These qualities, combined with its rapid action, make epinephrine ideal for treating an anaphylactic reaction.
other examples of cell-mediated responses are a
positive tuberculin test and episodes of graft rejection.
Anyone can have a hypersensitivity reaction. However, risk generally increases with
previous exposure, because antigens must be formed with the first exposure before hypersensitivity is likely to occur. -Age, sex, concurrent illnesses such as asthma or other respiratory disease, and previous reactions to related substances have been identified as having a role in the risk for hypersensitivity -Having a family member with an allergy increases the chance that an individual will have an allergy, even to different allergens or by showing different bodily manifestations. If one parent has an allergy of any type, chances are one in three that each child will have an allergy
A type III (immune complex-mediated) reaction is treated by
removing the offending antigen and interrupting the inflammatory response.
Observe the patient for the presence of
rhinorrhea, sneezing, pruritus, urticaria, or atopic eczema. Inquire as to the frequency, onset, and duration of the symptoms. Ask the patient about known risk factors for hypersensitivities (e.g., medications, household dust, bee stings); reaction signs and symptoms (rash, hives, difficulty breathing); type of treatment for hypersensitivity reactions; allergy skin testing; history of asthma, hay fever, or dermatitis; and use of herbal supplements and over-the-counter and prescription medications.
immune complex, or type III, hypersensitivity reactions are mediated by
soluble immune complexes and mostly involve IgG. -Antigens causing a type III reaction may be exogenous (bacterial, viral or parasitic) or endogenous (autoimmune disease, e.g., SLE).
Type III, or immune complex-mediated, hypersensitivity reactions result from
the formation of IgG or IgM antibody-antigen immune complexes in the circulatory system. -When these complexes are deposited in vessel walls and extravascular tissues, complement is activated, and chemical mediators of inflammation, such as histamine, are released. -Chemotactic factors attract neutrophils to the site of inflammation. -When neutrophils attempt to phagocytize the immune complexes, the lysosomal enzymes released increase tissue damage
When administering immunizations, what special precautions would you take based on Ron's history?
the nurse might ask the mother whether Ron has ever had any problems eating eggs, as the MMR uses egg embryos. She would also want to know if he has had any reaction to antibiotics, because some of the immunizations have antibiotics in them.
What patient teaching would you provide to improve this patient's comfort?
the patient should be advised to ask his healthcare provider about an over-the-counter decongestant or antihistamine, especially if he has increased blood pressure. The patient should also try to get extra rest and avoid allergens that cause the hypersensitivity.
Common hypersensitivity reactions, such as allergic asthma, allergic rhinitis (hay fever), allergic conjunctivitis, hives, and anaphylactic shock, are typical of
type I, or IgE-mediated, hypersensitivity. -This type of hypersensitivity response is triggered when an allergen interacts with free IgE, causing IgE to bind to mast cells and basophils.
A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a
type II, or cytotoxic hypersensitivity, reaction. -IgG- or IgM-type antibodies are formed to a cell-bound antigen, such as the ABO or Rh antigen. -The binding of these antibodies with the antigen activates the complement cascade, resulting in destruction of the target cell -This type of reaction causes hemolytic disease of the newborn.
Type III reactions are immune-mediated and manifest with
urticaria, fever, and joint pain.
Endogenous antigens (which are produced by the body) also can stimulate a type II reaction, resulting in an
utoimmune disorder such as Goodpasture syndrome, in which antigens form to specific tissues in the lungs and kidneys. Hashimoto thyroiditis and autoimmune hemolytic anemia are additional examples of autoimmune type II reactions.
You are working with an adult patient who has developed a type I hypersensitivity to insect venom and who has limited English proficiency. What teaching techniques would be most appropriate for addressing his learning needs? What other resources could you call upon for assistance?
you should obtain the services of an interpreter or nurse with the appropriate language skills. If an interpreter is not available, you should determine if there are any printed materials, e-health, or community resources available in the patient's language. If none of these resources exist, you should proceed with visual aids to help communicate meaning, taking care that these aids are not overly simplistic or juvenile. Verbal communication should rely on concrete concepts and be presented in short sentences using simple words.
What nursing care can you provide to improve the patient's oxygenation status?
you will administer O2 at the prescribed liters, give subcutaneous epinephrine, and give Benadryl as prescribed by the physician. In addition, you will provide a calm environment to lessen patient anxiety.
What learner characteristics and learning factors would you need to address in order to improve compliance in a 15-year-old woman who experiences contact dermatitis when exposed to sodium lauryl sulfate in cosmetics?
you would need to consider the patient's developmental level and the high school culture to which she belongs. It is important for females of this age to fit in with their peers and feel good about their appearance, and the patient likely continues using the cosmetics for these reasons. You need to discuss these issues with the patient and assess her willingness to seek out and use alternative products that do not contain sodium lauryl sulfate.
