Allergic Response: Threats to Health Status

1. Infantile eczema (atopic dermatitis)
   1. Introduction: Eczema is an allergic skin reaction, most commonly to foods (e.g., cow’s milk, eggs). It is most common in infants and young children (under 2 yr). Infantile eczema generally undergoes permanent, spontaneous remission by age 3 years; however, approximately 50% of children who have had infantile eczema develop asthma during the preschool or school-age years.
   2. Assessment:
      1. Erythematous lesions, beginning on cheeks and spreading to rest of face and scalp.
      2. May spread to rest of body, especially in flexor surfaces, e.g., antecubital space.
      3. Lesions may ooze or crust over.
      4. Severe pruritus, which may lead to secondary infection.
      5. Lymphadenopathy near site of rash.
      6. Unaffected skin tends to be dry and rough.
      7. Systemic manifestations are rare-but child may be irritable, cranky.
   3. Analysis/nursing diagnosis:
      1. Impaired tissue integrity related to lesions.
      2. Pain related to pruritus.
      3. Risk for (secondary) infection related to breaks in the skin (first line of defense) and itching.
      4. Knowledge deficit related to care of child with eczema, prognosis, how to prevent exacerbations.
   4. Nursing care plan/implementation:
      1. Goal: promote healing of lesions.
         1. Wet method: frequent tepid baths (up to 4 times a day) followed by immediate application of a lubricant while the skin is still moist; no soap or very mild, nonperfumed soap is used (e.g., Dove, Neutrogena); most useful method if child lives in a dry climate.
         2. Dry method: infrequent baths; cleanse skin with nonlipid, hydrophilic agent (e.g., cetaphil); most useful method if child lives in a humid climate.
         3. Can add cornstarch to bath water to relieve itching and promote healing; keep skin well hydrated by applying emollients containing petrolatum or lanolin, which are occlusive and prevent evaporation of moisture.
         4. Apply wet soaks with Burow’s solution (aluminum acetate solution; topical astringent and antiseptic); wet soaks should not be used for more than 3 days at a time.
         5. Protect child from possible sources of in® fection; standard precautions to prevent infection.
         6. Absolutely no immunizations during acute exacerbations of eczema because of the possibility of an overwhelming dermatitis, allergic reaction, shock, or even death.
         7. Apply topical creams/ointments as prescribed: A and D emollient ointment, hydrocortisone cream to promote healing.
      2. Goal: provide relief from itching/keep child from itching.
         1. Administer systemic oral antihistamines as ordered (e.g., Benadryl or Atarax) to break itch-scratch cycle. Most useful at bedtime when itching tends to increase.
         2. Keep nails trimmed short-may need mittens (preferable not to use elbow restraints, because the antecubital space is a common site for eczema).
         3. Use clothes and bedlinens that are nonirritating, i.e., pure cotton (no wool or blends).
         4. Institute elimination/hypoallergenic diet: No milk or milk products.
            1. Change to lactose-free formula, e.g., Isomil.
            2. Avoid eggs, wheat, nuts, beans, chocolate.
         5. No stuffed animals or hairy dolls.
      3. Goal: provide discharge planning/teaching for parents and child.
         1. Include all above information.
         2. Include information on course of disease: characterized by exacerbations and remissions throughout early years.
         3. Include information on prognosis: 50-60% will go into spontaneous (and permanent) remission during preschool years; 40-50% will develop asthma/ hayfever during school-age years.
   5. Evaluation/outcome criteria:
      1. Lesions heal well, without secondary infection.
      2. Adequate relief from itching is achieved.
      3. Parents verbalize understanding of eczema, prognosis, and how to prevent exacerbations.

2. Asthma
   1. Introduction: Asthma is generally considered a chronic, lower airway disorder characterized by heightened airway reactivity with bronchospasm and obstruction. The exact cause of asthma is unknown; however, it is believed to include an allergic reaction to one or more allergens, or “triggers,” that either precipitate or aggravate asthmatic exacerbation. The child usually exhibits other symptoms of allergy, such as infantile eczema or hayfever; in addition, 75% of children with asthma have a positive family history for asthma. The onset is usually before age 5 and remains with the child throughout life, although some children experience dramatic improvement in their asthma with the onset of puberty. Most children do not require continuous medication. Early relief of symptoms with a combination of drugs can reverse bronchospasm.
   2. Assessment:
      1. Expiratory wheeze.
      2. General signs and symptoms of respiratory distress, including anxiety, cough, shortness of breath, crackles, cyanosis due to obstruction within the respiratory tract, use of accessory muscles of respirations.
      3. Cough: hacking, paroxysmal, nonproductive; especially at night.
      4. Position of comfort for breathing: sitting straight up, leaning forward, which is the position for optimal lung expansion.
      5. Peak Expiratory Flow Rate (PEFR) is in the yellow zone (50-80% of personal best) or in the red zone (<50% of personal best).
   3. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to bronchospasm.
      2. Anxiety related to breathlessness.
      3. Knowledge deficit, actual or potential, related to disease process, treatment, and prevention of future asthmatic attacks.
      4. Activity intolerance related to dyspnea and bronchospasm.
   4. Nursing care plan/implementation:
      Treatment is aimed toward improvement of ventilation, correction of dehydration and acidosis, and management of concurrent infection.
      1. Goal: provide patent airway and effective breathing patterns.
         1. Initiate oxygen therapy (by tent, face, mask or cannula), as ordered, to relieve hypoxia, with high humidity (to liquefy secretions)
         2. Administer corticosteroids as ordered (PO or IV) to reduce inflammation, relieve edema (prednisone, Decadron) and decrease bronchial hyperreactivity.
         3. Administer bronchodilators, as ordered, to relieve the obstruction: epinephrine (1:1000), nebulized albuterol, Brethine. Inhalers may be used with metered dose inhalers (MDIs) to ensure proper delivery of the medication.
         4. Administer antibiotics as ordered; infection is commonly either a trigger or complication of asthma.
         5. Note: methylxanthines (theophylline, aminophylline) are third-line agents that are rarely used to treat asthma.
      2. Goal: relieve anxiety.
         1. Provide relief from hypoxia (refer to goal 1), which is the chief source of anxiety.
         2. Remain with child, offer support.
         3. Administer sedation as ordered.
         4. Encourage parents to remain with child.
      3. Goal: teach principles of prophylaxis.
         1. Review home medications, including cromolyn sodium.
         2. Review breathing exercises.
         3. Discuss precipitating factors (“triggers”) and offer suggestions on how to avoid them.
         4. Teach how to use peak expiratory flowmeter to monitor respiratory status and determine need for treatment.
         5. Introduce need for child to assume control over own care.
   5. Evaluation/outcome criteria:
      1. Adequate oxygenation provided, as evidenced by pink color of nailbeds and mucous membranes and ease in respiratory effort.
      2. Anxiety is relieved.
      3. Child verbalizes confidence in, and demonstrates mastery of, skills needed to care for own asthma.