hypersensitivity disorders cld
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The four types of Hypersensitivity reactionsTRANSCRIPT
Immune system Disorders 1
M A R I A C A R M E L A L . D O M O C M A T, R N , M S N
I N S T R U C T O R , C U R A A N D R E H A B N R G I I
S C H O O L O F N U R S I N G
N O R T H E R N L U Z O N A D V E N T I S T C O L L E G E
� Inflammatory and immunologic response
� is normally helpful and protect against infection and can development
� These responses also stimulates tissue growth and repair after injury
� But if prolonged and excessive or occur at inappropriate time
� Effect: normal cells, tissues or organs are damaged
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� Effect: normal cells, tissues or organs are damaged
Maria Carmela L.Domocmat, RN, MSN
W H A T H A P P E N S W H E N T H E I M M U N E S Y S T E M
D O E S N ’ T W O R K T H E W A Y I T S H O U L D ? ?
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Maria Carmela L.Domocmat, RN, MSN
� Overreaction
� Hypersensitivity
� Overreactions to invaders and foreign antigens
� Autoimmune response
� Underreaction
� Immunodeficiency
� Congenital
� Acquired
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� Autoimmune response
� When it fails to recognize self-cells and attack normal body tissues
Maria Carmela L.Domocmat, RN, MSN
Hypersensitivity Reaction
Hypersensitivity Reaction or Allergic Reaction
� an immune malfunction whereby a person's body is hypersensitized to
react immunologically to typically non-immunogenic substances.
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Maria Carmela L.Domocmat, RN, MSN
Definition of terms
� Atopy: the tendency to develop allergies for which there is a genetic disposition and that involve immunoglobulin E (IgE) antibody formation � AKA – atopic, allergic, hypersensitive
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� AKA – atopic, allergic, hypersensitive
� Allergy: describes the increased immune response to the presence of an allergen (i.e., antigen)
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
� People must progress through two-step process to become allergic
� 1) sensitization
� 2) reexposure to the allergen
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� 2) reexposure to the allergen
�
Maria Carmela L.Domocmat, RN, MSN
General categories of hypersensitivity reactions
� Immediate
� humoral or antigen-antibody
� Delayed
� cell-mediated
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Maria Carmela L.Domocmat, RN, MSN
I M M E D I A T E
Type I: Immediate hypersensitivity
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Types of Hypersensitivity
Type I: Immediate hypersensitivity
Type II: Cytotoxic hypersensitivity
Type III: Immune complex-mediated
hypersensitivity
D E L A Y E D
Type IV: Delayed Hypersensitivity
Maria Carmela L.Domocmat, RN, MSN
Hypersensitivity
There are four different types of hypersensitivities that result from different responses of the immune system:
Type I: Immediate hypersensitivity
- onset within minutes of antigen challenge
- examples are allergies to molds, insect bites
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- examples are allergies to molds, insect bites
Type II: Cytotoxic hypersensitivity
- onset within minutes or a few hours of antigen challenge
- examples are adult hemolytic anemia and drug allergies
Maria Carmela L.Domocmat, RN, MSN
Hypersensitivity
There are four different types of hypersensitivities that result from different responses of the immune system:
Type III: Immune complex-mediated hypersensitivity- onset usually within 2-6 hours
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- onset usually within 2-6 hours
- examples include serum sickness and systemic lupus
erythematosus
Type IV: Delayed Hypersensitivity- inflammation by 2-6 hours; peaks by 24-48 hours
- examples include poison ivy and chronic asthma
Maria Carmela L.Domocmat, RN, MSN
�A T O P I C A L L E R G I E S
�Allergic rhinitis or hay fever�Allergic rhinitis or hay fever
�Urticaria or Hives �A L L E R G I C A S T H M A
�A N A P H Y L A X I S
�A L L E R G Y T O S P E C I F I C A L L E R G E N
�Latex allergy
�bee venom, peanut, iodine, shellfish, drugs
Type I: Immediate hypersensitivity
� This is the type of hypersensitivity usually referred to as
“allergy”.
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Maria Carmela L.Domocmat, RN, MSN
Type I:
Immediate hypersensitivity
� occurs when an IgE antibody response is mounted against
an antigen in the environment that is usually harmless
� A single exposure to antigen isn’t enough to trigger
hypersensitivity, but the immune response may become
more severe with repeated exposure.
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more severe with repeated exposure.
Maria Carmela L.Domocmat, RN, MSN
Type I hypersensitivity – sensitization to an inhaled allergen
or bee sting17
Mast cell
cytokines
→→→→ →→→→
Maria Carmela L.Domocmat, RN, MSN
Antigens (red dots) from inhaled pollen are ingested and presented by macrophages to T cells. Activated T cells produce cytokines leading to the production of IgE, which binds to receptors on mast cells and causes the release of histamine, which is responsible for allergy symptoms. Onset is usually within minutes of contact with antigen.
� When the antigen enters through a respiratory mucosal
surface, it is taken up, processed and displayed by antigen-
presenting cells.
� When the presented fragments “lock on” to helper T cell
receptors, the T cells become activated, secreting
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receptors, the T cells become activated, secreting
cytokines.
� The cytokines, in turn, stimulate IgE-producing B cells.
� IgE binds to IgE-receptors on the surfaces of mast cells,
sensitizing them.
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Maria Carmela L.Domocmat, RN, MSN 20
histamine
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Maria Carmela L.Domocmat, RN, MSN
Maria Carmela L.Domocmat, RN, MSN 22
� Allergens can be contacted in the ff ways
� Inhaled
� Ingested
� Injected
� contacted
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� contacted
Maria Carmela L.Domocmat, RN, MSN
Atopic allergy
� Inhaled
� Plant pollens
� Fungal spores
� Animal dander
� House dust
� Grass
� Injected
� Bee venom
� Drugs
� Biologic subtances(ex: contrast dyes, Adenocotricotropic hormone)
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� Grass
� Ragweed
� Ingested
� Foods
� Food additives
� Drugs
Adenocotricotropic hormone)
� Contacted
� Pollens
� Foods
� Envt proteins
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Common Causes of Allergy
What are common allergenic foods?
� Legumes (Peanuts and Soybeans)
� Mollusks (snails, mussels, oysters, scallops, clams, squid)
� Milk
� Eggs
� Fish (cod, salmon, haddock, etc.)� Fish (cod, salmon, haddock, etc.)
� Crustacea (shrimp, crawfish, lobster. etc.)
� Wheat
� Tree nuts (almonds, walnuts, Brazil nuts, etc.)
� Selected food additives
M O S T C O M M O N T Y P E
I N C L U D E S :
Allergic rhinitis or hay fever
Atopic allergy 30
Allergic rhinitis or hay fever
Urticaria or hay fever
Maria Carmela L.Domocmat, RN, MSN
A K A : H A Y F E V E R
Allergic Rhinitis 31
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Allergic Rhinitis
� Triggered by reactions to airborne allergens
� Types:
� Seasonal: recur to same time of each of the year
� Often coincide with timing of large environmental exposure
� Chronic: or perennial rhinitis
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� Chronic: or perennial rhinitis
� Occur intermittently or continuous when exposed to allergen
� Non-allergic rhinitis
� Same manifestations are present
� Although no allergic cause is identified immune system does not appear to be involved
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Urticaria 36
Maria Carmela L.Domocmat, RN, MSN
� Urticaria may be acute (lasting less than 6 wk) or chronic
(lasting more than 6 wk).
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Maria Carmela L.Domocmat, RN, MSN
� Many substances can trigger hives, including:� Animal dander (especially cats)
� Insect bites
� Medications
� Pollen
Shellfish, fish, nuts, eggs, milk, and other foods
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� Shellfish, fish, nuts, eggs, milk, and other foods
� Hives may also develop as a result of:� Emotional stress
� Extreme cold or sun exposure
� Excessive perspiration
� Illness (including lupus, other autoimmune diseases, and leukemia
� Infections such as mononucleosis
Maria Carmela L.Domocmat, RN, MSN
Symptoms
� Itching
� Swelling of the surface of the skin into red- or skin-colored
welts (called wheals) with clearly defined edges
� The welts may get bigger, spread, and join together to form larger areas
of flat, raised skin.
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of flat, raised skin.
� They can also change shape, disappear, and reappear within minutes or
hours.
� The welts tend to start suddenly and go away quickly. When you press
the center of a red welt, it turns white. This is called blanching.
Maria Carmela L.Domocmat, RN, MSN
Hives or urticaria
Hives (urticaria) on the back and buttocks
� These are hives (urticaria) with the typical slightly-raised red
appearance, and are accompanied by itching. These are
located on the buttocks. Hives can be generalized over the
entire body or may be localized, and usually result from an
allergic reaction.
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allergic reaction.
Hives (urticaria) - close-up
� Hives (urticaria) are raised,
red, itchy welts. The
majority of urticaria
develop as a result of
allergic reactions.
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allergic reactions.
Occasionally, they may be
associated with
autoimmune diseases,
infections (parasitosis),
drugs, malignancy, or
other causes.
Maria Carmela L.Domocmat, RN, MSN
Hives (urticaria) on the chest
� Hives develop when histamine is
released into the small blood vessels
(capillaries). The capillaries dilate which
causes a welt, and fluid oozes into the
surrounding tissue, causing swelling.
Histamine also causes intense itching.
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Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
� Latex is a milky fluid that comes from the tropical rubber
tree,Hevea brasiliensis.
� Hundreds of everyday products contain latex. Some
common ones are
Gloves
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� Gloves
� Condoms
� Balloons
� Rubber bands
� Shoe soles
� Pacifiers
Maria Carmela L.Domocmat, RN, MSN http://www.nlm.nih.gov/medlineplus/latexallergy.html
Latex exposure is associated with 3 clinical
syndromes
� first syndrome - irritant dermatitis.
� It is a result of mechanical disruption of the skin due to the rubbing of gloves and accounts for the majority of latex-induced local skin rashes. It is not immune mediated, is not associated with allergic complications
� second syndrome - delayed (type IV) hypersensitivity reaction
Result in a typical contact dermatitis.
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� Result in a typical contact dermatitis.
� Symptoms usually develop within 24-48 hours of cutaneous or mucous membrane exposure to latex in a sensitized person.
� Third syndrome - immediate (type I) hypersensitivity
� most serious, and least common
� mediated by an immunoglobulin E (IgE) response specific for latex proteins.
Maria Carmela L.Domocmat, RN, MSN
See http://emedicine.medscape.com/article/756632-overview#showall for more information
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Maria Carmela L.Domocmat, RN, MSN http://www.mountnittany.org/assets/images/krames/7596.jpg
Allergic asthma48
Maria Carmela L.Domocmat, RN, MSN
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� See link: http://emedicine.medscape.com/article/137501-overview#showall for additional information
Maria Carmela L.Domocmat, RN, MSN http://cureasthmaguide.com/wp-content/uploads/2010/02/inflammed-airways-complex.jpg
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Maria Carmela L.Domocmat, RN, MSN http://www.dentalgentlecare.com/images/lungs-asthma.gif
Clinical
Manifestations
of Immediate
HypersensitivityHypersensitivity
ASTHMA
Anaphylaxis54
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001847/bin/19320.jpg
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Maria Carmela L.Domocmat, RN, MSN
H X : A C C U R A T E A N D D E TA I L E D H X
Describe onset and duration of problems
Nursing assessment 57
Ask abt work, school, home, environment, possible exposures
through hobbies, leisure time or sports activities
Ask presence of allergies among relatives
P H Y S I C A L A S S E S S M E N T
Maria Carmela L.Domocmat, RN, MSN
Clinical Manifestations of
Immediate Hypersensitivity
Allergy is characterized by a local or systemic
inflammatory response to allergens
Local symptoms:� Nose: swelling of the nasal mucosa, rhinorrhea
� Eyes: redness and itching of the conjunctiva (allergic conjunctivitis)
� Airways: bronchoconstriction, wheezing, sometimes
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� Airways: bronchoconstriction, wheezing, sometimes outright attacks of asthma
� Ears: feeling of fullness, possibly pain, and impaired hearing due to the lack of eustachian tube drainage.
� Skin: various rashes, such as eczema, hives and contact dermatitis.
� Head: while not as common, headaches are seen in some with environmental or chemical allergies.
Maria Carmela L.Domocmat, RN, MSN
Allergy is characterized by a local or systemic inflammatory response to allergens
Systemic allergic response � Is also called anaphylaxis
� Depending of the rate of severity, it can cause cutaneous reactions, bronchoconstriction, edema, hypotension, coma and even death.
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reactions, bronchoconstriction, edema, hypotension, coma and even death.
Maria Carmela L.Domocmat, RN, MSN
Hives Symptoms
� Itching
� Swelling of the surface of the skin into red- or skin-colored
welts (called wheals) with clearly defined edges
� The welts may get bigger, spread, and join together to form larger areas
of flat, raised skin.
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of flat, raised skin.
� They can also change shape, disappear, and reappear within minutes or
hours.
� The welts tend to start suddenly and go away quickly. When you press
the center of a red welt, it turns white. This is called blanching.
Maria Carmela L.Domocmat, RN, MSN
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001848/
Food allergies
� The body's immune system normally
reacts to the presence of toxins, bacteria
or viruses by producing a chemical
reaction to fight these invaders.
However, sometimes the immune
system reacts to ordinarily benign
substances such as food or pollen, to
which it has become sensitive. This
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which it has become sensitive. This
overreaction can cause symptoms from
the mild (hives) to the severe
(anaphylactic shock) upon subsequent
exposure to the substance. An actual
food allergy, as opposed to simple
intolerance due to the lack of digesting
enzymes, is indicated by the production
of antibodies to the food allergen, and
by the release of histamines and other
chemicals into the blood.
Maria Carmela L.Domocmat, RN, MSN
Food Allergy - Symptoms
� Nausea
� Diarrhea
� Abdominal cramps
� Pruritic rashes
� AngioedemaAngioedema
� Asthma/rhinitis
� Vomiting
� Hives
� Laryngeal edema
� Anaphylaxis
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Maria Carmela L.Domocmat, RN, MSN
S K I N T E S T S
• Scratch or prick test
Allergy tests 65
• Intradermal test
•O R A L F O O D C H A L L E N G E O R E L I M I N A T I O N D I E T
•L A B O R A T O RY T E S T S
CBC
Increased serum IgE
RAST (radioallergosorbent test)
Maria Carmela L.Domocmat, RN, MSN
� Skin Tests
� Individual is inoculated with allergen by scraping or injection
� Fast: results within 30’
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Maria Carmela L.Domocmat, RN, MSN
� Prep
� Discontinue Glucocorticoids and antihistamine 5 days b4 test (to avoid
suppressing allergic response during the test)
� Nasal sprays to reduce mucous membrane swelling can be continued
but shld be discontinued if with antihistamine
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but shld be discontinued if with antihistamine
Maria Carmela L.Domocmat, RN, MSN
Skin Tests: ID
Skin Tests: Intradermal or Scratch test
• The allergens are either injected intradermally or into small scratchings made into the patient's skin
• If the patient is allergic to the substance, then a visible inflammatory reaction will usually occur within 30 minutes.
• This response will range from slight reddening of the skin to full-blown hives in extremely sensitive patients.
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hives in extremely sensitive patients.
• Problems: some people may display a delayed-type hypersensitivity (DTH) reaction which can occur as far as 6 hours after application of the allergen and last up to 24 hours. This can also cause serious long-lasting tissue damage to the affected area. These types of serious reactions are quite rare.
Maria Carmela L.Domocmat, RN, MSN
Maria Carmela L.Domocmat, RN, MSN 70
http://www.allergyclinic.co.uk/images/pricktest.jpg
Maria Carmela L.Domocmat, RN, MSN 71
Oral Food Challenge
� Used to identify specific allergen if skin testing is not
conclusive and if keeping a food diary has failed to
determine the offending food items
� Prep - eliminate suspected foods 7-14 days b4 test
Eat defined suspected allergen for at least 1 day
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� Eat defined suspected allergen for at least 1 day
� Monitor s/s of allergy
� If with many food allergies – eat only 1 food type/day of
testing
Maria Carmela L.Domocmat, RN, MSN
� Laboratory tests
� CBC
� Increased eosinophils 12% (normal 1-2%)
� Increased WBC count, but percentage of neutrophils is normal (55-70%)
� Note: if acute infection occurs with rhinitis – both WBC and neutrophils
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� Note: if acute infection occurs with rhinitis – both WBC and neutrophils are increased)
� Increased serum IgE
� Only confirms the presence of infection
� But does not indicate specific allergen
� RAST (radioallergosorbent test)
� Shows blood level of IgE directed against a specific antigen
� Can determine specific allergies
� Expensive Maria Carmela L.Domocmat, RN, MSN
Management of Type I
Hypersensitivity Reaction74
Maria Carmela L.Domocmat, RN, MSN
Allergy management
1. Avoidance therapy - identify and prevent exposure to
allergen, control of environment
2. Symptomatic therapy
1. Teach how to use Epi-pen
Desensitization therapy
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3. Desensitization therapy
Maria Carmela L.Domocmat, RN, MSN
1. Avoidance therapy
� Avoid direct contact with allergen
� Airborne allergen
� Air-conditioning and air cleaning units
� Remove cloth drapes, upholstered furniture, carpet
Cover mattress and pillows with plastic or cotton fine mesh
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� Cover mattress and pillows with plastic or cotton fine mesh
� Pet-induced allergy
� Keep pet out of bedroom
� Thoroughly clean room to remove hair and dander
� Frequent bathing of pet
Maria Carmela L.Domocmat, RN, MSN
1. Avoidance therapy
� Avoid direct contact with allergen
� Latex allergy
� Avoid products with latex;
� use synthetic substances that do not contain latex protein
� Ex: Elastylite glove
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� Ex: Elastylite glove
� Note: always use latex-free products in the care of client
with known latex allergy
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy
� Drug therapy or Pharmaceutical approaches to allergy
treatment involve
� Decongestants
� Antihistamine
� Corticosteroids
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� Corticosteroids
� Mast cell stabilizers
� Leukotrine Antagonists
� Complementary and alternative Therapies
� Aromatherapy
� Eat unprocessed honey
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy
� Nasal Decongestants
� Action: prevent release of mediators such as histamine but do not clear the allergen
� Have similar action to adrenergic agents - cause vasoconstriction in inflamed tissues
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inflamed tissues
� Often contain ephedrine, phenylephrine, or pseudoephedrine
� Phenylephrine – 1 spray/nostril 4-6x/day ; Oxymetazoline -1 spray/nostril 2x/day ; pseudoephedrine (Sudafed)
� Note: caution not to use more frequently than directed or for longer than 4 days (overuse or continued use causes a rebound nasal congestion or rebound rhinitis and worsens the symptoms)
� S/E: dry mouth, increased BP, sleep difficulties
Maria Carmela L.Domocmat, RN, MSN
Nasal Spray 80
Maria Carmela L.Domocmat, RN, MSN
Nasal Decongestants:
Nursing Implications
� Decongestants may cause hypertension, palpitations, and
CNS stimulation—avoid in patients with these conditions
� Patients on medication therapy for hypertension should
check with their physician before taking OTC
decongestants
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decongestants
� Assess for drug allergies
Nasal Decongestants:
Nursing Implications
� Patients should avoid caffeine and caffeine-containing
products
� Report a fever, cough, or other symptoms lasting longer
than a week
Monitor for intended therapeutic effects
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� Monitor for intended therapeutic effects
2. Symptomatic therapy
� Antihistamine
� Compete with histamine at receptor site and block histamine from binding to the receptor –prevents vasodilation and capillary leak
� first generation antihistamines
� diphenhydramine (Benadryl) and chlorpheniramine (Chloratrimeton)
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� diphenhydramine (Benadryl) and chlorpheniramine (Chloratrimeton)
� common side effect : sedation, drowsiness, and dry mouth
� Use at night before bedtime to avoid feeling tired the next day.
� second-generation antihistamines
� loratadine (Claritin), fexofenadine (Allegra), and certirizine (Zyrtec)
� less likely to cause drowsiness and can be taken during the daytime.
Maria Carmela L.Domocmat, RN, MSN
Antihistamines:
Nursing Implications
� Gather data about the condition or allergic reaction that required treatment; also assess for drug allergies
� Contraindicated in the presence of acute asthma attacks and lower respiratory diseases
� Use with caution in increased intraocular pressure, cardiac
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� Use with caution in increased intraocular pressure, cardiac or renal disease, hypertension, asthma, COPD, peptic ulcer disease, BPH, or pregnancy
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Antihistamines:
Nursing Implications
� Instruct patients to report excessive sedation, confusion, or
hypotension
� Avoid driving or operating heavy machinery, and do not
consume alcohol or other CNS depressants
Do not take these medications with other prescribed or
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� Do not take these medications with other prescribed or
OTC medications without checking with prescriber
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Antihistamines:
Nursing Implications
� Best tolerated when taken with meals—reduces GI upset
� If dry mouth occurs, teach patient to perform frequent
mouth care, chew gum, or suck on hard candy (preferably
sugarless) to ease discomfort
Monitor for intended therapeutic effects
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� Monitor for intended therapeutic effects
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� Combined products
� Claritin-D.
� loratadine (Claritin) and pseudoephedrine (Sudafed) are combined in the over-the-counter product
� This allergy relief medicine gives the benefit of the antihistamine to
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prevent nasal allergies and the decongestant to open swollen nasal passages.
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy
� Corticosteroids
� Decreased inflam and immune response in many ways
� One way – prevent synthesis of mediators
� Nasal spray – prevent symtpoms of rhinitis
Systemic – can produce severe S/E; avoised for rhinites; used inly
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� Systemic – can produce severe S/E; avoised for rhinites; used inly
in short-term basis for other probmels assoc wth type I hypersen.
� Beclomethasone (Beconase) –
� 1-2 metered spray /nostril ; 1-2x/day
� fluticasone (Flovent, Flonase)
� 2 metered spray /nostril/day
Maria Carmela L.Domocmat, RN, MSN
Inhaled Corticosteroids:
Nursing Implications
� Contraindicated in patients with psychosis, fungal
infections, AIDS, TB
� Cautious use in patients with diabetes, glaucoma,
osteoporosis, PUD, renal disease, HF, edema
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� Teach patients to gargle and rinse the mouth with water
afterward to prevent the development of oral fungal
infections
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Inhaled Corticosteroids:
Nursing Implications
� Abruptly discontinuing these medications can lead to
serious problems
� If discontinuing, should be weaned for 1 to 2 weeks, only
if recommended by physician
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� Report any weight gain of more than 5 pounds a week or
the occurrence of chest pain
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2. Symptomatic therapy
� Mast cell stabilizers
� Prevent mast cell membranes from opening when allergen bnds to the IgE
� Prevent symptomes of rhinits but not useful during acute episodes
� cromolyn (NasalCrom, Intal)
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� cromolyn (NasalCrom, Intal)
� 1 spray/nostril/4-6x/day
� Use as directed (effectiveness depends on regular use)
� Start therapy 2-4 weeks b4 expected allergy season
Maria Carmela L.Domocmat, RN, MSN
Mast Cell Stabilizers:
Nursing Implications
� For prophylactic use only
� Contraindicated for acute exacerbations
� Not recommended for children younger than age 5
� Therapeutic effects may not be seen for up to 4 weeks
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� Teach patients to gargle and rinse the mouth with water afterward to minimize irritation to the throat and oral mucosa
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2. Symptomatic therapy
� Leukotrine Antagonists
� or Antileukotrienes
� Also called leukotriene receptor antagonists (LRTAs)
� Currently available agents
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� montelukast (Singulair)
� zafirlukast (Accolate)
� zileuton (Zyflo)
� 600mg 4x/day
� Do not take with terfenadine or theophylline – Zyflo increases plasma concentrations of these drugs
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy
� Leukotrine Antagonists
� Leukotrine
� Substances in the body that cause inflammation, bronchoconstriction,
and mucus production
� Result: coughing, wheezing, shortness of breath
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� Result: coughing, wheezing, shortness of breath
� Includes:
� zileuton (Zyflo)
� zafirlukast (Accolate)
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy
� Leukotrine Antagonists
� zileuton (Zyflo)
� 600mg 4x/day
� Do not take with terfenadine or theophylline – Zyflo increases plasma concentrations of these drugs
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concentrations of these drugs
Maria Carmela L.Domocmat, RN, MSN
2. Symptomatic therapy; Leukotrine Antagonists
� zafirlukast (Accolate)
� 20 mg BID
� Take 1 hr b4 or 2 hrs after eating (food
slows absorption of drug)
� There is an increased incidence of URI
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� There is an increased incidence of URI
when co-administered with inhaled
corticosteroids (drug reduced local
inflam and immune response)
� Reduce dose if also taking aspirin
(aspirin increases plasea concentration
of Accolate)
Maria Carmela L.Domocmat, RN, MSN
Antileukotrienes: Drug Effects
� Keep bronchial airways relaxed (open)
� Decrease mucus secretion
� Prevent vascular permeability
� Preventing inflammation
Mosby items and derived items © 2005, 2002 by Mosby, Inc.
� Preventing inflammation
http://www.chipola.edu/instruct/health-sciences/PowerPointPresentations/Pharmacology/Chapter_036.ppt
zileuton
Headache
Dyspepsia
Nausea
Dizziness
zafirlukast
Headache
Nausea
Diarrhea
Liver dysfunction
98
Dizziness
Insomnia
Liver dysfunction
• montelukast has fewer side effects
Liver dysfunction
Maria Carmela L.Domocmat, RN, MSN
http://www.chipola.edu/instruct/health-sciences/PowerPointPresentations/Pharmacology/Chapter_036.ppt
Antileukotrienes:
Nursing Implications
� Ensure that the drug is being used for chronic management
of asthma, not
acute asthma
� Teach the patient the purpose of the therapy
Improvement should be seen in about
Mosby items and derived items © 2005, 2002 by Mosby, Inc.
� Improvement should be seen in about
1 week
http://www.chipola.edu/instruct/health-sciences/PowerPointPresentations/Pharmacology/Chapter_036.ppt
Antileukotrienes:
Nursing Implications
� Check with physician before taking any
OTC or prescribed medications—many
drug interactions
� Assess liver function before beginning therapy
Mosby items and derived items © 2005, 2002 by Mosby, Inc.
� Medications should be taken every night on a continuous
schedule, even if symptoms improve
http://www.chipola.edu/instruct/health-sciences/PowerPointPresentations/Pharmacology/Chapter_036.ppt
2. Symptomatic therapy
� Complementary and alternative Therapies
� Aromatherapy
� Possible mechanism of action – competition and desensitization
� Eat unprocessed honey
� Indicated for those who have pollen allergies
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� Indicated for those who have pollen allergies
Maria Carmela L.Domocmat, RN, MSN
3. Desensitization therapy
� AKA:
� Hyposensitization
� Allergy shots
� Indicated when allergens are identified
and cannot be avoided easily
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and cannot be avoided easily
� Immunize with increasing doses of
allergen
� Mechanism of action – competition
Maria Carmela L.Domocmat, RN, MSN
3. Desensitization therapy
� Injection given
� weekly -1st year
� q other week – 2nd year
� q 3-4 wks – 3rd year
� 5 years- recommended course of treatment
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� 5 years- recommended course of treatment
� Or rally
� Sublingual immunotherapy (SLIT)
�
Maria Carmela L.Domocmat, RN, MSN
Desensitization or Hyposensitization
�has been effective for a few antigens, particularly bee
venom.
�is designed to cause an IgG response instead of an IgE
response.
104
�The allergen is either ingested or injected into the subject
starting in small amounts and increased to larger amounts.
Maria Carmela L.Domocmat, RN, MSN
Desensitization or Hyposensitization
�This treatment can have 2 effects:
1. T-helper 1 cells produce more IgG which binds to the
antigen so that it can’t bind to IgE receptors on mast
cells and cause release of histamines. – (Competition)
105
2. IgG binds to and removes the antigen before it binds to
T-helper 2 cells. The T- helper 2 cells will then not be
able to produce the B cells that will produce IgE.
Maria Carmela L.Domocmat, RN, MSN
Control of Type I Hypersensitivity Reactions
� Epinephrine
� Increases cAMP levels and inhibits degranulation,
� relaxes smooth muscles, increases cardiac output, and decreases
vascular permeability
� Antihistamines
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� Antihistamines
� block the H1 and H2 histamine receptors on cells and
� prevent degranulation
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Type II:
Cytotoxic hypersensitivity
� Antibody-mediated Cytotoxic Hypersensitivity
� Complement-mediated lysis
� Antibody dependent cell-mediated
cytotoxicity (ADCC)
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� cytotoxicity (ADCC)
� Opsonization
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
� Hemolytic anemias
� Hemolytic Transfusion Reactions
� Hemolytic Disease of the Newborn
� Drug-Induced Hemolytic Anemia
111
� Drug-Induced Hemolytic Anemia
Maria Carmela L.Domocmat, RN, MSN
Transfusion Reactions
� Due to antibodies that react with antigens on red blood cells
� Transfused cells are killed by complement-mediated lysis
112
Maria Carmela L.Domocmat, RN, MSN
113
Maria Carmela L.Domocmat, RN, MSN
ABO Blood Group System
Table 19.2
Hemolytic Disease of the Newborn
Figure 19.4
Hemolytic Disease of the Newborn
� Maternal IgG specific for red blood cell antigens crosses the
placenta and causes lysis.
� The most severe form of the disease, called erythroblastosis
fetalis, develops in an Rh+ fetus carried in an Rh- mother.
Rh is an antigen found on red blood cells.
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� Rh is an antigen found on red blood cells.
Maria Carmela L.Domocmat, RN, MSN
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Maria Carmela L.Domocmat, RN, MSN
Child with Rh hemolytic disease of the
newborn
� Why is the fetus edematous?
The child has hydrops fetalis. Patients with Rh hemolytic disease have severe anemias, which lead to high output failure and both left and right heart failure, the latter responsible for peripheral edema
118
responsible for peripheral edema and ascites. The liver in this fetus had massive hepatomegaly secondary to extramedullary hematopoiesis.
Maria Carmela L.Domocmat, RN, MSN
http://www.duke.edu/~ema5/Golian/Slides/5/hematology11_files/Hem282.jpg
119
� Brain of the above fetus. What
is causing the yellowish
discoloration?
The yellow pigment is
unconjugated, lipid soluble
Maria Carmela L.Domocmat, RN, MSN
unconjugated, lipid soluble
bilirubin derived from
macrophage destruction of the
Rh-sensitized fetal RBCs. The
condition is called kernicterus.
Kleihauer-Betke test in maternal blood post-
delivery
� The mother is O negative
and the baby is O positive.
Who do the normal
colored RBCs belong to
and what should the
mother be given to
� The normal staining cells
contain Hgb F and represent
fetal RBCs, while the pale
staining cells contain Hgb A
from the mother. She should
be given Rh immune
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mother be given to
prevent sensitization?
be given Rh immune
globulin (anti-D) to prevent
sensitization to the D
antigen.
Maria Carmela L.Domocmat, RN, MSN
Drug Induced Hemolytic Anemia
� Antibiotics covalently attach to proteins on red blood cells
� Penicillin, cephalosporin, Streptomycin
� This essentially creates a hapten-carrier complex that can
result in a B cell response to the drug
Red-blood cells bound to the drug are killed by
121
� Red-blood cells bound to the drug are killed by
complement-mediated lysis
Maria Carmela L.Domocmat, RN, MSN
Drug (p=penicillin) modified red blood cells induce the production of antibodies, because the bound drug makes them look foreign to the
122
look foreign to the immune system. When these antibodies are bound to them, the red blood cells are more susceptible to lysis or phagocytosis. Onset is dependent on the presence of specific antibodies.
Maria Carmela L.Domocmat, RN, MSN
� Symptoms:
� Fever, chills, nausea, clotting within vessels and lower back pain.
� Treatment:
� Stop the transfusion! Or discontinue offending drug
Plasmapheresis
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� Plasmapheresis
� Filtration of plasam to remove specific subtances to remove antibodies
� Symptomatic treatment
� Provide diuretic to increase urine output and reduce buildup of hemoglobin
� For Rh – mother
� Should be given Rh immune globulin (anti-D) or RhoGam
Maria Carmela L.Domocmat, RN, MSN
� If mother has not yet been sensitized or exposed to the
Rh+ fetus,
� She will be given an injection of Rh-immune globulin (Rhogam)at
� about 28 weeks of pregnancy,
� and within 72 hours after a birth, miscarriage, abortion, or amniocentesis.
124
� and within 72 hours after a birth, miscarriage, abortion, or amniocentesis.
� If receive injection at 28 weeks and after delivery, sensitization will be
prevented and Rh incompatibility should not be a problem during your
next pregnancy.
�
Maria Carmela L.Domocmat, RN, MSN
http://www.pregnancy.org/article/rh-incompatibility-and-why-you-need-rhogam?page=1
� The Rh-immune globulin contains antibodies to the Rh D
factor.
� These antibodies will destroy any red blood cells from the baby that
have entered the mother’s blood.
� The mother will not have a chance to form own antibodies to the Rh D
125
� The mother will not have a chance to form own antibodies to the Rh D
factor.
Maria Carmela L.Domocmat, RN, MSN
http://www.pregnancy.org/article/rh-incompatibility-and-why-you-need-rhogam?page=1
� It is important to receive Rh-immune globulin in all cases
when the baby's blood could leak into the mother’s system,
including:
� All pregnancies including ectopic (tubal) pregnancies
� Early miscarriages
126
� Early miscarriages
� After chorionic villus sampling
� After amniocentesis
Maria Carmela L.Domocmat, RN, MSN
http://www.pregnancy.org/article/rh-incompatibility-and-why-you-need-rhogam?page=1
� How Long Will the Effects Last?
� Sensitization usually doesn't happen until after the birth of an Rh-
positive baby.
� Therefore, in most cases Rh incompatibility is not a problem during
a woman's first pregnancy and delivery of an Rh-positive baby.
127
a woman's first pregnancy and delivery of an Rh-positive baby.
� However, later pregnancies and deliveries may be affected unless the
mother is treated with Rh-immune globulin after EVERY birth,
miscarriage, and abortion. Sensitization is permanent and the
effects are usually worse with each subsequent pregnancy.
Maria Carmela L.Domocmat, RN, MSN
http://www.pregnancy.org/article/rh-incompatibility-and-why-you-need-rhogam?page=1
�S E R U M S I C K N E S S
�S L E
Type III:
Immune complex-mediated
hypersensitivity
�R H E U M A T O I D A R T H R I T I S
�A G E
Type III hypersensitivity
� Involve reactions against soluble antigens circulating in
serum.
� Usually involve IgM, IgG antibodies.
� Antibody-Antigen immune complexes are deposited in
organs, activate complement, and cause inflammatory
129
organs, activate complement, and cause inflammatory
damage.
� Glomerulonephritis: Inflammatory kidney damage.
� Occurs with slightly high antigen-antibody ratio is present.
Maria Carmela L.Domocmat, RN, MSN
130
Type III hypersensitivity – immune complex formation
and deposition
Immune complexes of antigen (red dots) and antibody form in target organ
Immune complexes activate complement (green dots- C3a, C4a, and C5a), and mast cells (yellow cell) degranulate.
Inflammation and edema occur, and organ is damaged
Maria Carmela L.Domocmat, RN, MSN
Type III hypersensitivity – immune complex formation and
deposition
� In sensitized individuals, allergen (antigen) combined with
antibody leads to the formation of immune complexes,
which activate complement and the inflammatory
response.
The location of the inflammation depends on the location
131
� The location of the inflammation depends on the location
of the antigen - inhaled, under skin, systemic.
� Onset is usually within 2-6 hours.
Maria Carmela L.Domocmat, RN, MSN
Type III (Immune Complex) Reactions
� IgG antibodies and antigens form complexes that lodge in
basement membranes.
Figure 19.6
Serum sickness
� Group of symptoms that occur after receiving serum or
certain drugs
� Most common causes:
� Penicillin
Other antibiotics
133
� Other antibiotics
� Some animal-based drugs
� Less common- vaccines
Maria Carmela L.Domocmat, RN, MSN
Serum - does not contain white or red blood cells nor a clotting factor
� s/s
� 7-12 days after receiving the causative agent
� Fever arthralgia (achy joints)
� Rash
� Lymphadenopathy
134
� Lymphadenopathy
� Malaise
� Polyarthritis and nephritis
Maria Carmela L.Domocmat, RN, MSN
SLE
� Caused by immune-complexes lodged in :
� Vessels(vasculitis)
� Glomeruli (nephritis)
� Joints (arthralgia, arthritis)
� Other organs and tissues
135
� Other organs and tissues
Maria Carmela L.Domocmat, RN, MSN
Rheumatoid arthritis
� Caused by immune-complexes lodged in joint spaces
followed by destruction of tissue , and later, scarring and
fibrous changes
136
Maria Carmela L.Domocmat, RN, MSN
Management
� Usually self-limiting
� Symptoms subside after several days
� Symptomatic treatment
� Antihistamine for itching
137
� Aspirin for arthralgia
� Prednisone if severe symptoms
Maria Carmela L.Domocmat, RN, MSN
�P P D ( P O S I T I V E P R O T E I N D E R I VA T I V E ) T E S T F O R T B
Type IV:
Delayed Hypersensitivity
�C O N TA C T D E R M A T I T I S
�P O I S O N I V Y R A S H E S
�L O C A L R E S P O N S E T O I N S E C T S T I N G S
�T I S S U E T R A N S P L A N T R E J E C T I O N S
139Type IV hypersensitivity – delayed-type or contact
Antigen (red dots) are processed by local APCs
T cells (blue cells) that recognize antigen are activated and release cytokines
Inflammatory response causes tissue injury.
Maria Carmela L.Domocmat, RN, MSN
Antigen is presented by APCs to antigen-specific memory T cells that become activated and
produce chemicals that cause inflammatory cells to move into the area, leading to tissue injury.
Inflammation by 2-6 hours; peaks by 24-48 hours.
Type IV hypersensitivity
� the only type that is not antibody-mediated.
� This is the type involved in
� contact hypersensitivity (poison ivy, reactions to metals in jewelry);
� tuberculin-type hypersensitivity (the tuberculosis skin test);
140
� and granulomatous hypersensitivity (leprosy, tuberculosis, schistosomiasis and Crohn’s disease).
Maria Carmela L.Domocmat, RN, MSN
� It is called delayed because its onset may vary;
� the length of the delay varies from 72 hours in contact and tuberculin-type to 21-28 days in granulomatous hypersensitivity.
141
Maria Carmela L.Domocmat, RN, MSN
� In Type IV hypersensitivity, antigen presented by APCs
activates antigen-specific memory T cells (which have
been sensitized by prior exposure), causing them to
release cytokines that activate and attract other T cells and
phagocytic cells to the area. Where the source of antigen
142
phagocytic cells to the area. Where the source of antigen
is at the skin surface, the APC migrates from the dermis,
through lymphatic vessels to a lymph node in order to
present antigen to a T cell.
Maria Carmela L.Domocmat, RN, MSN
� In the TB skin test, a small amount of soluble antigen
(tuberculin) is injected into the skin.
� The T cells that are activated by the antigen secrete
cytokines that draw other cells to the site.
143
� Within four hours, neutrophils have arrived, followed by
an influx of monocytes and T cells at about 12 hours.
� The peak of activity is at about 48-72 hours, at which
point the area has become red and swollen.
Maria Carmela L.Domocmat, RN, MSN
144
Maria Carmela L.Domocmat, RN, MSN
145
Maria Carmela L.Domocmat, RN, MSN
Contact Hypersentivity
� History and physical
examination provide
diagnostic clues
Jelly Fish Hypersensitivity
� In this case, the
erythematous reaction
developed one week
after the contact with a after the contact with a
jelly fish
Acute Graft Rejection is a manifestation of Acute Graft Rejection is a manifestation of
delayed hypersensitivitydelayed hypersensitivity
Fluid Accumulation in Delayed Hypersensitivity ReactionsFluid Accumulation in Delayed Hypersensitivity Reactions
Fluid Accumulation in Delayed Hypersensitivity ReactionsFluid Accumulation in Delayed Hypersensitivity Reactions
Patch test to identify the allergen for contact
eczema 151
Dendritic cell
Management
� Removal of offending allergen
� Reaction is self-limiting – 5-7 days
� Symptomatic treatment
� Monitor reaction site and sites distal for circulation adequacy
153
� Corticosteroids or other anti-inflam
� Benadryl is not recommended – bcoz histamine is not the main
mediator and IgE is not the cause
Maria Carmela L.Domocmat, RN, MSN
154
Maria Carmela L.Domocmat, RN, MSN
Have an allergy-free day!
155