Allergic Reactions

Assessment and
Management of Patients
with Allergic Disorders
Allergic Reaction:Physiologic Review
• Direction: Fill the missing word or phrase in the

following statement. Write your answer in capital
letters on your notebook.
• 1. An allergic reaction is …
• 2. Allergy is a hypersensitivity reaction characterised by the

action of _________ antibodies and a __________ to
allergic reactions.
• 3. An allergen is …
• 4. _______ is a term often used to refer to IgE-mediated

diseases with a genetic component
• 5. When the body encounters an ___________, a series of

events occur to render the invader harmless.
• 6. When lymphocytes respond to foreign bodies,
_________ are produced.
• 7. A family of closely related proteins capable of acting as

antibodies is called _______________.
• 8. ______ are connective tissue cells that contain heparin

and histamine in their granules.
• 9. An abnormal heightened reaction to a stimulus of any

kind.
• 10. Another term for urticaria is ________.

• 11. Antibodies are capable of binding with a wide
variety of antigens.
• 12. Antibodies of IgM, IgG and IgE neutralizes toxins

and viruses as well as causes the lysis of bacteria and
other foreign cellular material.
• 13. IgM are involved in allergic disorders and some

parasitic infections
• 14. Two or more IgM molecules bind into mast cells or

basophils to release histamine, kinins, SRS-A and the
neutrophil factor.
• 15. Specificity refers to the specific reaction of an

antigen to an antibody.
• 16. Hapten is an immunologically active site on an

antigen.
• 17. Antigen molecules are bivalent causing them to

clump together easily.
• 18. B lymphocytes are programmed to produce one

specific antibody.
• 19.T-cells secrete lymphokines that encourages cell

growth.
• 20. There are three types of chemical mediators.
• 21. Mast cells are found in the skin and mucous

membranes.
• 22.The immediate hypersensitivity response is

realised by primary mediators like serotonin.
• 23. Diphenhydramine is an antihistamine that

displays an affinity to H1 receptors.
• 24. Eosinophil Chemotactic Factor of Anaphylaxis

(ECF-A) affects the movement of eosinophils to the
site of allegens.
• 25.Platelet activating factor (PAF) is responsible for

initiating platelet aggregation and leukocyte
infiltration at sites of immediate hypersensitivity
reactions.
• 26. Prostaglandins are saturated fatty acids that

produce smooth muscle contractions as well as
vasodilation and increased capillary permeability.
• 27. Fever and erythema that occurs with

inflammation in allergic conditions are due in part to
prostaglandins.
• 28.Leukotrienes are potent in causing

bronchospasm.
• 29. Bradykinin is a polypeptide with the ability to

cause decreased vascular permeability and
vasoconstriction.
• 30. Serotonin acts as a potent vasoconstrictor of

smooth muscles.
Session Objectives
At the end of the session, the student will:
• Discuss the physiologic events in an allergic

condition or hypersensitivity
• Describe the types of hypersensitivity
• Design a nursing management plan for a patient

with allergic conditions utilizing the nursing process.
Hypersensitivity
• An abnormal, heightened reaction to any type of
stimulus.
• Does not occur with the first exposure to an

allergen.
• Sensitization initiates the humoral response or build

up of antibodies.
Types of Hypersensitivity Reactions
Anaphylactic (Type 1) Hypersensitivity
• The most severe form of hypersensitivity reaction;

most severe immune-mediated reaction.
• It is often explosive in onset characterised by

edema accompanied by bronchospasm, and
cardiovascular collapse.
• Begins within minutes of antigen exposure

mediated by IgE antibodies.
• Typically occurring on a specific antigen re-

exposure, it requires the release of pro
inflammatory mediators.
• Plasma cells produce IgE antibodies in the lymph

nodes assisted by TH2 cells*
• IgE binds to membrane receptors on mast cells

found in connective tissue and basophils.
• During re-exposure, antigens bind to adjacent IgE

antibodies, activating a cellular reaction that triggers
degranulation and the release of chemical
mediators (histamine, leukotrienes, and ECF-A).
• Primary mediators are responsible for the

symptoms of Type 1 hypersensitivity.
• If chemical mediators continue to be released, a

delayed reaction may occur.
• Symptoms are determined by the amount of the

allergen, the amount of mediator released, the
sensitivity of the target organ and the route of
allergen entry.
• Type I hypersensitivity may include both local and

systemic reactions
Cytotoxic (Type II) Hypersensitivity
• Occurs when the system mistakenly identifies a

normal constituent as foreign.
• Involves the binding of either IgG or IgM antibody to

the cell-bound antigen resulting to a complement
cascade and the destruction of the cell to which the
antigen is bound.
• Associated with several disorders, e.g.
• Myasthenia gravis, the body mistakenly

generates antibodies against normal nerve
ending receptors.
• In Goodpasture syndrome, it generates

antibodies against lung and renal failure.
• Haemolytic disease of the newborn
• Transfusion reaction
Immune Complex (Type III)
Hypersensitivity
• Involves immune complexes that are formed when

antigens bind to antibodies.
• The complexes are cleared from the circulation by

phagocytosis.
Immune Complex (Type III)
Hypersensitivity
• Upon deposition to a tissue or vascular
endothelium:
• Increased amount of circulating complexes
• Increased presence of vasoactive amines
Increase in vascular permeability;

Tissue injury
Delayed-Type (Type IV) Hypersensitivity
• Also known as cellular hypersensitivity occurs 24 to

72 hours after exposure to an allergen
• Mediated by sensitized T cells and macrophages.
• Lymphokines are released to attract, activate and

retain macrophages at the site.
• Macrophages release lysosomes, causing tissue

damage.
• Edema and fibrin are responsible for positive

tuberculin syringe
• Results from exposure to cosmetics, local

anesthetics, and plant toxins.
• Primary exposure results in sensitisation.
• Reexposure results in hypersensitivity reaction

composed of low molecular weight molecules that
bind with proteins or carriers and are processed by
the Langerhans cells of the skin.
• Itching, erythema and raised lesions

How is type IV different from Type 1
hypersensitivity reaction?
Diagnostic Evaluation
Usually normal except with infection
CBC with Differential Eosinophil level of 5-15% is nonspecific
but is suggestive of allergic reaction
Evaluation of immunodeficiency
Evaluation of drug reactions
Initial laboratory screening
Total Serum IgE Levels Allergy among children with bronchiolitis
Differentiation of allergic and non-allergic
dermatitis/asthma
• Skin Tests
• Entails intradermal injection or superficial

application of solution at several sites
• Several solutions could be applied at varied sites
• Positive reactions are clinically significant when

correlated with history, physical findings and other
laboratory results.
• Essentials before skin testing:
• Corticosteroids are withheld for 48 to 96 hours
• Not performed during periods of bronchospasm
• Epicutaneous tests are performed before other

testing methods
• Emergency equipment must be readily available.

• Types of skin tests
• Prick skin test
• Scratch test
What do a
• Intradermal skin testing negative skin test
signifies?
• Interpretation of skin test result
• Skin tests are more reliable for atopic sensitivity
• Positive skin test correlate highly with food allergy
• Use of skin test is limited in the diagnosis of

medication hypersensitivity
• Provocative Testing
• Direct administration of the suspected allergen to

the sensitive tissue with observation of target
organ response.
• Helpful in identifying clinically significant allergens
• Limited to one allergen per session

• Radioallergosorbent Test (RAST)
• A radioimmunoassay that measures allergen-

specific IgE.
• A sample of patient’s serum is exposed to

allergen particle complexes
• If antibodies are present, they will combine with

radio labelled allergens
• Radioallergosorbent Test (RAST)
• Also indicates the quantity of allergen necessary

to evoke an allergic reaction
• Values are from 0 to 5
• Values of 2 or greater are considered significant.
• Limited allergen selection and reduced sensitivity

compared with intradermal skin test, lack of
immediate results and cost
Allergic Disorders
Anaphylaxis
Allergic Rhinitis
Contact Dermatitis
Atopic Dermatitis
Dermatitis Medicamentosa
Urticaria and Angioneurotic Edema
Hereditary Angioedema
Food Allergy
Serum Sickness
Latex Allergy
Allergic Disorders
• Anaphylaxis
• A clinical response to an immediate immunologic

reaction between a specific antigen and an antibody
due to a rapid release of IgE-mediated chemicals.
• Two types of IgE-mediated reactions:
• Atopic disorders
• Non-atopic disorder
Allergic Disorders
• Pathophysiology
Release of histamine, Activation of platelets,
prostaglandins and eosinophils and
inflammatory leukotrienes neutrophils
Vascular permeability
Smooth muscle spasm,
flushing, urticaria,
bronchospasm, mucosal
angioedema,
edema, inflammation
hypotension and
bronchoconstriction
Allergic Disorders
• Common causes of Anaphylaxis
• Foods (peanuts, tree nuts and shell fish)
• Medicines (antibiotics, allopurinol, radiocontrast

agents, anesthetic agents, vaccines, hormones,
aspirin, NSAIDS)
• Insect stings
How is anaphylaxis
• Latex risk identified?
Allergic Disorders
• Anaphylactic reactions could involve multiple organ
systems.
Peripheral tingling and a sensation of warmth,
fullness of mouth and throat; nasal congestion,
Mild
periorbital swelling, pruritus, sneezing and tearing
First 2 hours of exposure
Flushing, warmth, anxiety and itching

Bronchospasm and laryngeal edema with dyspnea,
Moderate
coughing, cyanosis and hypotension
First 2 hours of exposure
Progresses abruptly to bronshospasm, laryngeal

edema, severe dyspnea, cyanosis and hypotension.
Severe
Dysphagia, abdominal cramping, vomiting, diarrhoea
and seizures; Cardiac arrest + coma
Allergic Disorders
What is non-
allergenic
anaphylaxis?
• Caused by the release of mast cell and basophil

mediators triggered by non-IgE-mediated events.
• Could be local or systemic

Allergic Disorders
Suggest preventive measures for

anaphylaxis.
• EpiPen Auto Injector delivers remeasured doses of

0.3 mg or 0.15 mg of epinephrine.
• Immunotherapy
• Medical identification
Allergic Disorders
• Medical Management
• CPR
Dependent
• Epinephrine, 1: 1,000 dilution on
the
• Supplemental oxygenation severity
of
• Antihistamines & Corticosteroids the
reaction
• IVF, volume expanders
• Vasopressor agents
Allergic Disorders
• Nursing Management
• Assess for s/s of anaphylaxis
• Notification of rapid response team

Allergic Disorders
• Allergic Rhinitis
• Most common respiratory allergy mediated by Type I
hypersensitivity reaction unless due to other causes
• Occurs with allergic conjunctivitis, sinusitis and

asthma
• Complications: Allergic asthma, chronic nasal

obstruction, chronic otitis media with hearing loss and
anosmia
Allergic Disorders
• Demonstrate seasonal variations
• Thunderstorm-related asthma attacks

Allergic Disorders
Ingestion or inhalation of airborne
pollens/molds
Sneezing and nasal congestion;

clear, watery nasal discharge
Nasal, throat and soft

palate itching
Dry cough or hoarseness
Headache, pain over paranasal

sinuses, epistaxis
Allergic Rhinitis
• Assessment and Diagnostic Findings
• History, PE
• Diagnostic Tests
• Nasal smears, peripheral blood counts, total

serum IgE, epicutaneous and intradermal
testing, RAST, food elimination and challenge,
nasal provocation tests
Exercise
• State two nursing diagnoses for a patient with
allergic rhinitis. Provide rationale through a
background knowledge.
• Write your answer in capital letters on your

notebook.
Allergic Rhinitis
Remove allergens
Avoidance
Environmental controls (HEPA filter use..)
therapy
Personal hygiene
Antihistamines (Nonsedating H1 receptor
antagonist [loratadine, cetirizine, fexofenadine])
Decongestants
Adrenergic agents
Pharmacologic
Mast cells stabilizers (Cromolyn sodium)
therapy
Corticosteroids (Beclomethazone,
Dexamethasone)
Leukotriene Modifiers (Zileuton, Zafirlukast,
Montelukast)
Immunotherapy Allergen vaccine therapy
Allergic Rhinitis
• Nursing Interventions
Improve breathing Take deep breaths and cough frequently
pattern Seek prompt medical attention
Promote
understanding of Strategies to minimize allergen exposure,
Allergy and its desensitization, pharmacologic therapy
control
Coping with a Verbalization of feelings and concerns in a

chronic disorder supportive environment
Monitoring and
managing potential Anaphylaxis and impaired breathing
complications
Contact Dermatitis
• A type IV delayed hypersensitivity reaction
• An cute or chronic skin inflammation that results from

direct skin contact with allergens.
• Allergic
Differentiate the types of
• Irritant contact dermatitis based
on etiology, clinical
• Phototoxic presentation, diagnostic
testing and treatment
• Photo allergic
Atopic Dermatitis
• Type I hypersensitivity disorder characterized by
inflammation and hypersensitivity of the skin.
• Elevation in serum IgE
• Peripheral eosinophilia
• Large amount of histamine in the skin
• Itching Redness Pallor Lesions

Atopic Dermatitis
• Also referred to as atopic dermatitis/eczema
syndrome (AEDS) to include both allergic and
nonallergic disorders.
• Chronic with remissions and exacerbations
• Could lead to asthma and allergic rhinitis
• Results from interactions of susceptibility genes,

environment, defective skin barrier function and
immunologic responses.
Atopic Dermatitis
Wearing of cotton fabrics
Washing with mild detergents
Maintaining room temperature at 20 to 22.20C
Antihistamines
Decrease itching
Keeping skin moisturised and hydrated
and scratching
Corticosteroids
Antibiotics
Avoid animals, dust, sprays and perfumes
Use of immunosuppressive agents
What could be the main concern of the nurse in

teenage patients with atopic/contact
dermatitis?
Dermatitis Medicamentosa
• A Type 1 hypersensitivity disorder applied to skin
rashes associated with certain medications.
• Occurs in approximately 2-3% of hospitalized

patients
• Appears suddenly but disappears rapidly as

medication is withdrawn
• Rashes could be accompanied with systemic

symptoms.
• A Type 1 hypersensitive reaction of the skin
characterized by the sudden appearance of pinkish,
edematous elevations in varied size and shapes
accompanied with itchiness.
• May involve any part of the body including mucous

membranes, the larynx and the GIT
• Hives may remain for a few minutes to several

hours and disappears; may appear episodically -
Chronic urticaria
• Angioneurotic edema (angioedema) involves the
deeper layers of the skin resulting in more diffuse
swelling than hives.
• May cover the entire back (lips, eyelids, cheeks,

hands, feet, genitalia and tongue; mucous
membrane, larynx, bronchi, and GI canal.
• Skin may appears normal but with a reddish hue
• Skin does not pit on pressure

• Angioneurotic edema (angioedema)
• Swelling may appear suddenly in a few

seconds/minutes to 1-2 hours often proceeded by
burning sensations.
• Individual swelling usually lasts 24 to 36 hours

and could recur every 3 to 4 weeks
• Angiotensin-converting enzyme inhibitors and

penicillin may be a cause
• A rare potentially life threatening condition due an
inherited autosomal dominant trait.
• Not an immunologic disorder but resembles allergic

angioedema.
Trauma
Edema
Skin Respiratory Tract Digestive tract
Diffused swelling Respiratory Severe

that does not itch obstruction; abdominal
asphyxiation pain
Tracheostomy, Epinephrine, antihistamines, Corticosteroids

Cold Urticaria
• Familial atypical cold urticaria (FACU) and Acquired

cold urticaria (ACU) are induced by temperature
exposure.
• FACU is an autosomal dominant condition and

symptoms usually begin at birth
• ACU affects most commonly among young adults
• Idiopathic nature
Cold Urticaria
• Clinical Manifestations
• Appearance of hives when exposed to cold

weather, water or after coming in contact with
cold objects
• Ice cube provocation testing

Cold Urticaria
• Avoidance of cold stimuli
• Bed rest, warmth
• Corticosteroids
• Must carry an EpiPen

Food Allergy
• Type I hypersensitivity reaction due to genetic
predisposition and exposure to allergen early in life.
• Urticaria, dermatitis, wheezing, cough, edema,

angioedema and GI symptoms.
• Detailed allergy history, PE
• Skin testing
Food Allergy
Avoidance therapy
Pharmacologic therapy (H1 blockers,
Medical
antihistamines, adrenergic agents,
Management
corticosteroids and Cromolyn sodium);
EpiPen
Nursing
Prevent future exposure to allergens
Management
• If you developed food allergy, what will you do?

Latex Allergy
• The allergic reaction to natural rubber proteins
• Natural rubber latex is derived from the sap of

rubber tree
• Conversion of the liquid to finished product

involves the use of more than 200 chemicals.
• Not all objects with latex could elicit the same

allergic reactions
Latex Allergy
• Routes of exposure
Exercise
• Differentiate Irritant contact dermatitis, allergic
contact dermatitis and latex allergy in terms of
Cause, S/S and treatment.
• How could latex allergy be a Type 1 or Type IV

hypersensitivity?
• Write your answer in capital letter on your notebook.

Latex Allergy
• Assessment and diagnostic findings
• Based on history and diagnostic test results
• Sensitization by skin testing, RAST, EIA or ELISA or

the level of Hevea latex-specific IgE antibody in serum.
• Chemical testing of rubber production using patch test
• TRUE test, nasal challenge and dipstick test

Latex Allergy
Avoidance therapy
Medical
Antihistamines, Emergency Kit (Epi)
Management
Medical ID band
Identify high risk patients

Nursing
Latex allergy protocols
Management
Strategies/precautions of latex allergy
• Clinical Manifestations
Local Hives, angioedema

Apprehension; edema, wheezing;
Dyspnea;
Systemic respiratory collapse; Vascular collapse
with shock (rapid, weak pulse; falling
blood pressure; cyanosis)
Source: Monahan, et al (2007). Phipp’s Medical-Surgical Nursing,
8th Ed., Mosby Elsevier*

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Assessment and

• Direction: Fill the missing word or phrase in the

• 2. Allergy is a hypersensitivity reaction characterised by the

• 4. _______ is a term often used to refer to IgE-mediated

• 5. When the body encounters an ___________, a series of

• 7. A family of closely related proteins capable of acting as

• 8. ______ are connective tissue cells that contain heparin

• 9. An abnormal heightened reaction to a stimulus of any

• 10. Another term for urticaria is ________.

• 12. Antibodies of IgM, IgG and IgE neutralizes toxins

• 13. IgM are involved in allergic disorders and some

• 14. Two or more IgM molecules bind into mast cells or

• 15. Specificity refers to the specific reaction of an

• 16. Hapten is an immunologically active site on an

• 17. Antigen molecules are bivalent causing them to

• 18. B lymphocytes are programmed to produce one

• 19.T-cells secrete lymphokines that encourages cell

• 20. There are three types of chemical mediators.

• 21. Mast cells are found in the skin and mucous

• 22.The immediate hypersensitivity response is

• 23. Diphenhydramine is an antihistamine that

• 24. Eosinophil Chemotactic Factor of Anaphylaxis

• 25.Platelet activating factor (PAF) is responsible for

• 26. Prostaglandins are saturated fatty acids that

• 27. Fever and erythema that occurs with

• 28.Leukotrienes are potent in causing

• 29. Bradykinin is a polypeptide with the ability to

• 30. Serotonin acts as a potent vasoconstrictor of

• Discuss the physiologic events in an allergic

• Describe the types of hypersensitivity

• Design a nursing management plan for a patient

• Does not occur with the first exposure to an

• Sensitization initiates the humoral response or build

• The most severe form of hypersensitivity reaction;

• It is often explosive in onset characterised by

• Begins within minutes of antigen exposure

• Typically occurring on a specific antigen re-

• Plasma cells produce IgE antibodies in the lymph

• IgE binds to membrane receptors on mast cells

• During re-exposure, antigens bind to adjacent IgE

• Primary mediators are responsible for the

• If chemical mediators continue to be released, a

• Symptoms are determined by the amount of the

• Type I hypersensitivity may include both local and

• Occurs when the system mistakenly identifies a

• Involves the binding of either IgG or IgM antibody to

• Myasthenia gravis, the body mistakenly

• In Goodpasture syndrome, it generates

• Haemolytic disease of the newborn

• Involves immune complexes that are formed when

• The complexes are cleared from the circulation by

• Increased amount of circulating complexes

• Increased presence of vasoactive amines

Increase in vascular permeability;

• Also known as cellular hypersensitivity occurs 24 to

• Mediated by sensitized T cells and macrophages.

• Lymphokines are released to attract, activate and

• Macrophages release lysosomes, causing tissue

• Edema and fibrin are responsible for positive

• Results from exposure to cosmetics, local

• Primary exposure results in sensitisation.

• Reexposure results in hypersensitivity reaction

• Itching, erythema and raised lesions

• Entails intradermal injection or superficial