DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

BACHELOR OF SCIENCE IN NURSING

Case Presentation of
ALLERGIC RHINITIS
Presented to the Nursing Clinical Instructor of
Davao Doctors College
In partial Fulfillment of the Requirements in
Nursing Care Management 103

Christine Joy Catacata, Harlene Climaco, Dinalyn Dalayap,

Angelika Dublas, Katreena Anne Dumapias,
Art Benedict Esteves
August 2015

TABLE OF CONTENTS
A. Objectives
I. General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
II. Specific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
B. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
C. Definition of Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
E. Patients Profile
I. Biographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I. Past Health History . . . . . . . . . . . . . . . . . . . . . . . .. . . .1
II. Present Health History . . . . . . . . . . . . . . . . . . . . . .. . . .2
III. Family History (with Genogram) . . . . . . . . . . . . . . .. . . 3
F. Review of Anatomy and Physiology.. . . . . . . . . . . . . . . . . .. . ..4
G. Comprehensive Health Assessment . . . . . . . . . . . . . . . . . . . . . 7
H. Pathophysiology
I. Etiology (Tabular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
II. Symptomatology (Tabular) . . . . . . . . . . . . . . . . . . . . . . . 18
III. Schematic Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
IV. Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
I. Course in the ward/ Treatment/ Interventions
I. Medical Management

1.) Doctors Progress Notes . . . . . . . . . . . . . . . . . . .. 24

2.) Laboratory/ Diagnostic Examinations. . . . . . . . . . .27
3.) Pharmacologic (Drug Study) . . . . . . . . . . . . . . . . .37
II. Surgical Management (Tabular) . . . . . . . . . . . . . . . . . . . . 57
III. Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
J. Discharge Plan
I. METHODS Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
K. Bibliography

E. PATIENTS PROFILE

Name: Jumamil, Nenita Dimalaluan

Hospital Number: 00261058

Address: B7, L25, P2, Aguila St.,

Patient Number: IP15-008715

Awang Subd, Bacaca, DVO

Age: 61Y3M3D

Attending Physician: Dr. Batalla

Sex: Female
Nationality: Filipino
Civil Status: Married
Religion: Christian
Occupation: Govt. Employee

Chief Complain: Cough and Fever

Admission Diagnosis: Urticaria, SVI, allergic rhinitis; ess hpn

Past Health History:

Patient was known having thyroid disorder, essential hypertension that started 11
years ago. She is taking Losartan 50mg, once per day as her maintenance. She
had undergone TAHBSO in the early 1990s as well as Laparoscopic
Cholecystectomy last 2013. She had bronchial asthma that started last year and
taking Avamyst as her emergency drug but effect has poor compliance. She has
allergy in Levofloxacin.
3 days prior to admission, patient had onset of fever with a temperature of 38.
4*C associated with productive cough with yellow phlegm seen. Patient self

medicated Paracetamol 500 mg/tab and Sinecod(Ambroxol) which only provided

temporary relief. Patient also noticed muscle pain on the same day, medicated
with Norgesic Forte, still temporary relief was provided. On the night prior to
admission, patient still have persisted condition, hence the admission.
Present Medical History: During rounds, Patient was received lying on bed in
moderate high back rest. With ongoing #1 PNSS @ 80cc/hr at her left
metacarpal vein. Patient was alert, conscious and coherent during interaction
and can clearly verbalize her thoughts and concerns. Non productive cough was
observed. Patient still complained about chest pain during coughing.
Family History: On the paternal side,
Current Lifestyle:

F. ANATOMY AND PHYSIOLOGY

Anatomy of the nasal cavity

The nasal cavity extends from the external opening, the nostrils, to
the pharynx (the upper section of the throat), where it joins the remainder of the
respiratory system. It is separated down the middle by the nasal septum, a piece
of cartilage which shapes and separates the nostrils. Each nostril can be further
divided into roof, floor, and walls. The nasal cavity can be divided into the
vestibule, respiratory and olfactory sections.
Nasal vestibule
The nasal vestibule is the dilated area at the nostril opening.
Respiratory section
The respiratory section of the nasal cavity refers to the passages through which
air travels into the respiratory system. The respiratory section of each nostril
contains four conchae (protrusions or bumps) which are also referred to as
turbinate bones or lobes and are covered by the nasal mucosa. Underlying these

conchae are meatuses (passages to interior body structures). The meatuses of

the nasal cavity connect to the paranasal sinuses.
Olfactory region
The olfactory receptors (receptors for smell sensations) are found in this section
of the nasal cavity. Bowmans glands are also found in this section of the nasal
cavity.
Surrounding structures
Para-nasal sinuses
The nasal cavity is surrounded by a ring of paranasal sinuses and meatuses in
the nasal cavity connect to these structures. The sinuses develop as outgrowths
of, and drain into, the nasal cavity. The mucosa of the sinuses connects to the
nasal mucosa.
Nasolacrimal ducts
Nasolacrimal ducts are the ducts which connect the lacrimal (tear) ducts in the
eye to the nasal cavity.
Oral cavity
The nasal cavity is separated from the oral cavity (interior of the mouth) by the
hard palate.

Anatomy of the nasal mucosa

The nasal mucosa, also called respiratory mucosa, lines the entire nasal cavity,
from the nostrils (the external openings of the respiratory system) to the pharynx
(the uppermost section of the throat). The external skin of the nose connects to
the nasal mucosa in the nasal vestibule. A dynamic layer of mucus overlies the
nasal epithelium (the outermost layer of cells of the nasal mucosa).

The initial one-third of the nasal cavity is lined by stratified squamous

epithelium (smooth epithelium consisting of flat surfaced cells), several cell layers
thick. The outmost layer of squamous cells overlies a layer of proliferative cells
(cell which divide and replicate to form new cells) which is attached to a
basement membrane, a network of tough fibres which supports the epithelium.
The posterior two-thirds of the cavity is lined with pseudo-stratified columnar
ciliated epithelium (a type of epithelium in which cells arrange themselves in
columns and project tiny hairs called cilia) containing goblet cells (mucus
producing cells), and which overlies a basement membrane.
The nasal sub-mucosa underlies the basement membrane. This layer is made up
of glands which secrete watery substances and mucus, nerves, an extensive
network of blood vessels and cellular elements like blood plasma. The entire
mucosa is highly concentrated with blood vessels and contains large venous-like
spaces; bodies which have a vein-like appearance and swell and congest in
response to allergy or infection.
Mucosa of the olfactory system
Unlike other nasal mucosa, the epithelium of the olfactory system does not
project cilia. This mucosa contains nerves which connect to the olfactory nerve.
Physiology of the nasal cavity
The nasal cavity functions to allow air to enter the respiratory system upon
respiration. Structures within the cavity regulate the flow of air and particles it
contains. The olfactory region of the nasal cavity regulates the sense of smell.

Conchae (turbinate bones)

The conchae (turbinate bones) of the nasal mucosa expand the total surface
area of the mucosa and create turbulence in air entering the respiratory passage.
This causes air to swirl as it moves through the nasal cavity and increases
contact between infiltrating air and the nasal mucosa, allowing particles in the air

to be trapped before entering other parts of the respiratory system (e.g. the
lungs).

Olfactory system
The olfactory system functions to process sensory information related to smell.
Bowmans glands
Bowmans glands secrete the majority of the mucus which overlies the nerves of
the olfactory system. They also secrete the pigment which gives this mucus its
yellow colour. Mucus secreted by these glands dissolves odours as they enter
the nose, enabling them to interact with the olfactory receptors.
Surrounding structures
Paranasal sinuses
The paranasal sinuses function to resonate speech and produce mucus which
enters the nasal passage. Other functions of the sinuses are not well understood.
Nasolacrimal ducts
The nasolacrimal ducts drain tears from the lacrimal (tear) ducts of the eyes, to
the nasal mucosa.
Physiology of the nasal mucosa
The nasal mucosa plays an important role in mediating immune responses to
allergens and infectious particles which enter the nose. It helps
prevent allergens and infections from invading the nasal cavity and spreading to
other body structures, for example the lungs. The mucus secreted by and
which lines the mucosa provides a physical barrier against invasion by
pathogens (harmful microorganisms). It is sticky and traps pathogens when they
enter the nasal cavity.

Trapping pathogens enables components of the mucus to attack and destroy the
microbes. For example, an antibody called IgA prevents pathogenic microbes
from attaching to cells of the mucosa and in doing so prevents them from
invading the cells. Lysozyme (enzymes which breakdown bacteria) is another
component of the nasal mucus. It works to degrade pathogenic microbes. The
epithelial or outer cells of the nasal mucosa are constantly being worn away and
replaced by new cells from the underlying proliferative (regenerative) layer. This
provides additional protection as it ensures that pathogens which do manage to
invade the outer cell layer are removed as the epithelial cells are sloughed off.
However, in some individuals abnormal responses of the nasal mucosa occur
and immune responses are mounted against allergens which the body does not
usually recognise as pathogenic and thus does not usually mount an immune
response to. In these individuals the mucosa, which usually functions to protect
the body from invading microorganisms, is also thought to play a role in the
pathological allergic response referred to as a type 1 hypersensitivity reaction.
This type of allergic response is mediated by B cells (antibody producing cells of
the immune system), which begin producing immunoglobulin type E (IgE).
Epithelial cells
Epithelial cells form the epithelium or surface layer of the nasal mucosa.
Historically nasal mucosa epithelial cells were thought to simply:
1.

Provide a physical barrier to the invasion of infectious microorganisms and

allergic particles;

2.

Work in conjunction with mucus glands and cilia to secrete and remove
mucus and foreign particles from the nasal cavity.

However, recent evidence suggests the functions of epithelial cells are much
broader and that they also regulate immune responses which occur if the
physical barrier fails and pathogens infiltrate cells of the nasal mucosa. The
epithelium contains antigen-binding proteins (protein chain sections of an
antibody that recognise and join to antigens). These proteins are involved in the
processes through which allergens are presented to antigen presenting cells.

These cells are responsible for introducing pathogens to the T-lymphocyte cells
(T cells) which in turn function to mount an immune response to destroy
allergens presented to them. Antigen presenting cells capture antigens as they
enter the body and present them to nave T cells. That is; T cells that have not
previously encountered, and therefore do not yet recognise as pathogenic, the
specific antigen being presented. Thus, antigen-binding proteins in the epithelium
catalyse the series of processes through which T cells begin to recognise and
respond to allergens.
Epithelial cells also release factors which enhance inflammatory responses. The
most important of these factors are cytokines (proteins which regulate the
duration and intensity of immune responses). Allergens can directly activate the
epithelial cells to produce an inflammatory response, or the epithelial cells may
mount such a response in response to T cell recognition of the antigen. Epithelial
cells also appear be involved in the IgE-producing processes which perpetuate
allergic responses.
Endothelial cells
Endothelial cells are cells which line the walls of the arteries that feed the nasal
mucosa. They are also involved in allergic responses. They primarily function to
attract leukocytes (white blood cells) circulating in the blood to the site of
inflammation.
Mucus glands
Glands in the nasal mucosa produce a sticky mucus which moistens air and
traps bacteria as they enter the respiratory passage.
Cilia
Cilia or small hairs which project from the epithelium and line the nasal mucosa
create motions which drain mucus from the nasal passage to the throat from
where it is swallowed and digested by stomach juices. The activity level of cilia is
dependent on temperature and in cold temperatures cilia become less active.

Mucus may accumulate in and drip from the nostrils (runny nose) in these
conditions. Infectious particles and allergens also impair cilia activity and can
lead to symptoms such as a congested or runny nose.
Underlying blood vessels
The thin walled veins on which the nasal mucosa rests function to warm air
entering the respiratory passage. Due to the high concentration of blood vessels
in the nasal cavity, changes in these blood vessels contribute to nasal
congestion. For example, constriction of these blood vessels decreases airway
resistance, making it easier for air to enter the respiratory system. The nasal
nerves also regulate the congestion response.
Nerves
Innervation of the nasal mucosa is regulated by the trigeminal and maxillary
nerves which also provide sensations to other areas of the face. The trigeminal
nerve regulates sensations including touch, pressure and temperature in the
nose, while sympathetic and parasympathetic innervation (innervation which
controls involuntary movements like constriction and dilation of the blood
vessels) occurs via the maxillary nerve. The different types of nerves found in the
nasal cavity and mucosa have various functions. For example, constriction of
blood vessels which feed the nasal cavity is regulated in part by the sympathetic
nervous system, while the parasympathetic nervous system plays a role in
regulating secretions of mucus from nasal glands. Other nerves in the nasal
cavity influence the dilation of blood vessels, nasal secretions, inflammation and
interactions between nerves and the mast cells which mediate allergic
responses.
Venous-like spaces
Venous-like spaces found throughout the nasal mucosa swell and become
congested in response to allergens and infection.

H. PATHOPHYSIOLOGY
I. ETIOLOGY
PREDISPOSING FX
Pneumonia

()

JUSTIFICATION
Pneumonia is found among people with Allergic
rhinitis, especially people who are female, 50-59
old,

also

have

Allergic

rhinitis,

and

take

medication Singulair. We study 86 people who

have Pneumonia and Allergic rhinitis from FDA
and social media. (http://www.ehealthme.com/cs
/allergic+rhinitis/pneumonia)
Bronchial Asthma

Rhinitis and asthma have been evaluated and

treated

as

separate

disorders,

but

recent

advances in the understanding and knowledge of

the underlying processes have moved current
opinion towards the concept of unifying the
management of these disorders. The united
airway disease hypothesis proposes that upper
and

lower

airway

diseases

are

both

manifestations of a single inflammatory process.1

The upper and lower airways interface more than
the air and the blood but regulate most of the
human body interactions within its environment.
Living an entire life with a clean and silent twostep air filter which is not replaceable suggests
abilities of plasticity, regulation, teaching, renewal
and local to systemic control functions. Togias A.
Rhinitis and asthma: evidence for respiratory
system integration. J Allergy Clin Immunol
2003;111:117184.

Age

Structural changes in the nose associated with

aging, predisposes the elderly to rhinitis. It would
be safe to say that the many changes that occur
in the connective tissue and vasculature of the
nose predisposes aging individuals to chronic
rhinitis making the percentage of the elderly with
nasal symptoms significantly higher than the
general population. (Curr Allergy Asthma Rep.
2006 Mar; 6(2):125-31.)

Genetic

Allergic rhinitis is an atopic (genetic) condition

which often runs in a family. Those with a family
history of the disorder have a greater likelihood of
experiencing the condition themselves. Some
evidence suggests that irregular IgE responses
and

sensitisation

to

specific

environmental

allergens is genetically determined, although the

genetic components of the allergic rhinitis are not
well understood. Specific genes which might pass
on the irregular IgE response trait have not been
identified. . Maternal factors (e.g. exposures of
the mother during pregnancy) are also known to
influence the likelihood of allergy in the offspring.
(Kneepkens CM, Brand PL: Clinical practice:
Breastfeeding and the prevention of allergy. Eur J
Pediatr 2010, 169:911-917.)

PRECIPITATING FX

()

JUSTIFICATION

Air pollution

In addition to previously described allergens,

exposure to high levels of pollutants including
oxides of nitrogen, ozone, sulfur dioxide, black
smoke

large

particulates,

particulate

carbon

matter,

monoxide,

and

small
volatile

organic compounds have been considered as

important

contributing

factors

in

both

exacerbation and etiology of allergic airway

diseases (Utell and Samet 1993; Devalia et al
1994; Krishna et al 1995)
Lack of proper Hygienic

According to the hygiene hypothesis, infections

Measures

with viruses and perhaps other intracellular

organisms also influence the developing immune
system: the T-cell responses to these infections
generate Th1-like cytokines such as IL-12 and
IFN- that down-regulate Th2 responses. Thus,
the core of the hygiene hypothesis is based on
the observations that Th1 responses induced by
microbial

stimulation

can

counterbalance

allergen-induced Th2 responses. (Matricardi et al

1997, 2000)
Nutrient Intake

There has not been much data published on the

effects of diet on symptoms of seasonal allergies
yet, however I have observed in my medical
practice that the change to a high-nutrient diet is
accompanied by a wide variety of benefits,
including an improvement in allergy symptoms. I
have seen many allergic patients slowly reduce
the severity of their allergies and over time many
became entirely non-allergic. When you follow a
high-nutrient

diet,

you

are

creating

an

environment in your body that promotes proper

immune

function

and

regulation

of

the

inflammatory response, which may help to blunt

allergy symptoms. (Nagel G, Nieters A, Becker N,
et al: The influence of the dietary intake of fatty
acids and antioxidants on hay fever in adults.
Ownership of pets

Allergy 2003, 58:1277-1284.)

Pet ownership was found to markedly increase
the risk of sensitization to pets (Al-Mousawi et al
2004). The prevalence of asthma, rhinitis, and
skin allergy was significantly more common in
families with animals than in those without (Bener
et al 2004). The secretary proteins from a large
number of animals carry or contain powerful
allergens

capable

of

causing

severe

hypersensitivity reactions. (Nolte H, Backer V,

Porsbjerg C: Environmental factors as a cause
for the increase in allergic disease. Ann Allergy
Asthma Immunol 2001, 87:7-11.)

II. SYMPTOMATOLOGY

III. SCHEMATIC DIAGRAM

IV. NARRATIVE
In allergic rhinitis, your body overreacts to some stimulus in the
environment that stimulus is called an allergen. The most common culprit is
pollen. Pollen can come from trees or grass. Pollen also tends to be seasonal. In
other words, some types of pollen are out in the type of environment with
different temperature and that gives rise to yet another term thats synonymous
with allergic rhinitis or seasonal allergies. Basically anything that can get into the
air that you can inhale can act as an allergen to somebody who suffers from
allergic rhinitis. When allergen goes into the nose and that allergen is going to
come into contact with this mast cell over here. Being a mast cell or basophil, on
its surface it has a particular protein thats shaped like a Y and that protein is
called an Immune Globulin which is shorten to Ig and this particular type of
immune globulin is called IgE. This pollen is going to get bound by this IgE
molecule, and that IgE molecule, just a protein sitting on the surface of this
basophil is going to alert that cell to its presence. In a person with allergic rhinitis
this cell over reacts and it overreacts big time. And when it sees that pollen grain
it starts letting out little molecules into its environment that tell all the celld around
it to get excited as well. So this whole group of nasal mucosa gets overreacted.
The most common type of molecule that gets excited is called histamine.
Histamine is going to cause all sorts of problems with inflammation and it can be
really severe that the mucosa can thicken up big time and get really engorged
and edematous, swollen that happens all through out the nose because these
basophils or mast cells arent just sitting in one particular area but they are
scattered everywhere. In adittion on being swollen, this mucosa is going to start
to produce mucus, the mucus is going to drip down along the turbinates that is
going to drip down the sides of the nose. Its going to pull on the base of your
nasal cavity, as this mucus pulls down in your nasal cavity its going to head
down towards your throat so you can cough up as well. Also as the mucosa
swells up, it can swell the nasolacrimal duct and shut, leading to watery eyes.
Also when the eustachian tube gets swollen bad enough, it can block the tube
and cause fluid to back up and thats going to lead to symptoms that are stiffness

and decreased ability to hear. Ofcourse theres also nerves in your nose that
ultimately end in your brain and as they get inflamed with all the process thats
happening in your nose, they become irritated and send signals to your body
particularly the signal to sneeze and then swelling continues to get bigger and
more pronounce and more pronounced and it can actually completely block off
this entire nose. When that happens air cant get by and when that happens
breathing will become a problem.

COURSE IN THE WARD

LABORATORY TESTS

URINALYSIS
EXAMINATION

RESULT RANGE REMARKS/ JUSTIFICATION

RBC
RBC

229^/uL
41^HPF

0-11
0-2

High. Some crenated

High

Conventional

CBC,PLT
EXAMINATION

RESULT RANGE

REMARKS/ JUSTIFICATION

Heemoglobin

142^g/L

120-140

High

Neutrophils

0.50

0.55-

Low.

0.65
Lymphocyte

0.32

0.35-

Low.

0.45
Monocyte

0.14

0.6-0.12

High.

Absolute

0.9

0.0-0.8

High.

Monocyte

CHEST XRAY
INTERPRETATION:

A comparison with the radiograph dated Feb 19,2015 discloses the same pleural
thickening in the left lateral hemithorax. Both lungs are clear lungs. The lateral
costrophenic sinuses are sharp. Heartsize is within normal limits. The
configuration is unremarkable. Pulmonary vascularity is normal. Hili are not
enlarged. Degenerative joint changes are again appreciated.

MEDICATIONS
DATE
MEDICATION
July 27, 15
Losartan 50mg, 1tab, OD
Xanor 250mcg, OD
Montelukast+Levocitirizine10/5mg
1tab,OD, HS
Levopront 10mL, TID, PO
PRN MEDICATIONS

DATE
July 27, 15

MEDICATION
Paracetamol 1tab (for fever)
Norgesic Forte 1tab (for body pain)

TIME
8AM
9PM
9PM
8AM, 2PM,8PM

TIME
PRN
PRN

K. BIBLIOGRAPHY
BOOKS:

2
3
4

6
7

Al-Mousawi MS, Lovel H, Behbehani N, et al. Asthma and

sensitization in a community with low indoor allergen levels
and low pet-keeping frequency. J Allergy Clin Immunol.
2004;114:138994.
Apter AJ, Gent JF, Frank ME. Fluctuating olfactory sensitivity
and distorted odor perception in allergic rhinitis. Arch
Otolaryngol Head Neck Surg. 1999;125:100510.
Ashmore M. Human exposure to air pollutants. Clin Exp Allergy.
1995;25(Suppl 3):1222.
Baldini M, Lohman IC, Halonen M, et al. A polymorphism in the
5 flanking region of the CD14 gene is associated with
circulating soluble CD14 levels and with total serum
immunoglobulin E. Am J Respir Cell Mol Biol. 1999;20:976
83.
Barnes KC, Neely JD, Duffy DL, et al. Linkage of asthma and
total serum IgE concentration to markers on chromosome 12q:
evidence from Afro-Caribbean and Caucasian populations.
Genomics. 1996;37:4150.
Bener A, Mobayed H, Sattar HA, et al. Pets ownership: its effect
on allergy and respiratory symptoms. Allerg Immunol (Paris)
2004;36:30610
Bodner C, Godden D, Seaton A. Family size, childhood
infections and atopic diseases. Thorax. 1998;53:2832.