NR 507 Week 1 – Open Forum Discussion
Identify the correct hypersensitivity reaction:
Allergic rhinitis is an inflammatory, IgE-mediated disease that causes an inflammatory response of the nasal mucous membranes after being exposed to an inhaled antigen that is characterized by nasal congestion, rhinorrhea (runny nose), sneezing, nasal itching, and inflammation on the inside lining of the nasal cavity (Seidman et al., 2015). Based on the fact that allergic rhinitis is IgE-mediated, it is classified as a Type I hypersensitivity reaction (McCance & Huether, 2019).
Explain the pathophysiology associated with the chosen hypersensitivity reaction:
The primary cause of IgE production in the human body is exposure to an environmental antigen, with repeated exposure required to “sensitize” the person so that subsequent exposures elicit an allergic response (McCance & Heuther, 2019). Subsequent exposures to the specific antigen the person is now sensitized against are followed by the binding of the antigen to IgE-Fc receptors on a mast cell’s surface (called cross-linking), resulting in the activation of intracellular signals and mast cell degranulation, which releases biochemical mediators (McCance & Heuther, 2019). The most potent of these biochemical mediators is histamine, which causes constriction of bronchial smooth muscle, increased vascular permeability, and vasodilation, along with enhancing the chemotactic activity of other factors that attract eosinophils to the site of the inflammation and prevent them from leaving the inflamed area (McCance & Heuther, 2019). Mast cells also initiate the synthesis of bioactive lipid-derived mediators such as leukotrienes, platelet-activating factors, and prostaglandins, which operate slower than histamine but can cause similar and more prolonged clinical symptoms such as recruiting neutrophils and more eosinophils, promoting increased vascular permeability and edema, inciting bronchoconstriction and/or rhinitis, and causing further histamine release from the mast cells (McCance & Heuther, 2019).
Typical antigens that induce Type 1 hypersensitivity reactions include pollen, molds and fungi, foods, animal dander, cigarette smoke, household dust, and almost anything else that can be encountered in the environment (McCance & Heuther, 2019). The clinical manifestations of Type 1 hypersensitivity reactions are attributed, for the most part, to the biological effects of histamine released from mast cells. Tissues most commonly impacted contain large numbers of mast cells and are sensitive to the effects of histamine, such as the tissues found in the gastrointestinal tract, the skin, and the respiratory tract (McCance & Heuther, 2019). Allergic inflammatory symptoms reflect the portal of entry of the antigen; for example, an antigen ingested will cause symptoms in the GI tract, whereas an inhaled antigen will cause symptoms in the respiratory tract (McCance & Heuther, 2019).
Identify at least three subjective findings from the case:
Subjective findings include the patient-reported symptoms of rhinorrhea, sneezing, and nasal stuffiness.
Identify at least three objective findings from the case:
Objective findings include eyelid redness and swelling, conjunctival swelling and erythema, inflamed nares, allergic shiners (lower lid venous swelling), and allergic crease (a lateral crease on the nose).
NR 507 Week 1 – Open Forum Discussion
Management of the Disease
*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.
Identify two strongly recommended medication classes for the treatment of the condition and provide an example (drug name) for each:
Two medication classes that are strongly recommended for the treatment of allergic rhinitis include intranasal steroids (INS) and second-generation oral antihistamines.
INS medications are indicated for patients with a clinical diagnosis of allergic rhinitis whose symptoms affect their quality of life and include medications such as fluticasone propionate (Flonase) and mometasone furoate (Nasonex) as prescription options with triamcinolone acetonide (Nasacort Allergy 24 hr) as an OTC option (Seidman et al., 2015).
Second-generation oral antihistamines are recommended for patients with mild to moderate symptoms such as sneezing, rhinorrhea, nasal blockage, and itching and are low-cost with a rapid onset. The current recommendation for second-generation oral antihistamines is due to their limited penetration of the CNS and reduction of sedation-related side effects seen in the first-generation oral antihistamines and include medications such as cetirizine (Zyrtec) and loratadine (Claritin) as OTC options and levocetirizine (Xyzal) as a prescription option (Seidman et al., 2015).
Describe the mechanism of action for each of the medication classes identified above:
Intranasal steroids, such as Flonase, work by inhibiting mast cells, macrophages, and other biological mediators to produce anti-inflammatory and vasoconstricting effects (Wolters Kluwer, 2019). INS are very effective and directly modulate the pathophysiology of allergic rhinitis by decreasing the release of mediators from mast cells and inhibiting the recruitment of white blood cells to the nasal secretions as well as being able to cause a decrease in antigen-induced hyperresponsiveness of nasal mucosa to subsequent invasions by allergens and histamine release (Seidman et al., 2015).
Second-generation oral antihistamines are a class of drugs known as H1 receptor antagonists that compete with histamine by binding to the cellular receptor and blocking histamine’s ability to attach to the cell and trigger the inflammatory response (Wolters Kluwer, 2019). These second-generation oral antihistamines were created to have less sedating and anticholinergic side effects that occurred with the older oral antihistamines such as Benadryl (Seidman et al., 2015).
NR 507 Week 1 – Open Forum Discussion
Identify two treatment options that are NOT recommended (I.e., recommended against):
Two treatment options that are not recommended for treating allergic rhinitis include imaging studies and oral leukotriene receptor antagonists (LTRAs). Imaging studies are not recommended as there are no radiologic findings specific to allergic rhinitis, the risk of radiation exposure outweighs the benefits of radiologic results, and imaging studies are costly for the patient (Seidman et al., 2015). LTRAs are not recommended as they are more expensive than oral antihistamines and less effective for nasal-related symptoms. However, there has been a benefit shown for those patients who suffer from allergic rhinitis and asthma (Seidman et al., 2015).
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). Elsevier.
Seidman, M. D., Gurgel, R. K., Lin, S. Y., Schwartz, S. R., Baroody, F. M., Bonner, J. R., Dawson, D. E., Dykewicz, M. S., Haskell, J. M., Han, J. K., Ishman, S. L., Krouse, H. J., Malekzadeh, S., Mims, J. W. W., Omole, F. S., Reddy, W. D., Wallace, D. V., Walsh, S. A., Warren, B. E., . . . Nnacheta, L. C. (2015). Clinical Practice Guideline. Otolaryngology–Head and Neck Surgery, 152(1_suppl), S1–S43. https://doi.org/10.1177/0194599814561600
Wolters Kluwer. (2019). Nursing 2019 Drug Handbook (39th ed.). Wolters Kluwer.
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Share with the class the name of your disease process assigned to you by your faculty this week. Tell us if
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a practice exemplar. If this is a completely new disease that you will learn about, tell us if it relates to your
nursing practice in terms of the populations for which you care.
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