Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for urticaria and angioneurotic edema
- Describe the diagnostics and laboratory values for urticaria and angioneurotic edema
- Apply nursing concepts and plan associated nursing care for patients with urticaria and angioneurotic edema
- Evaluate the efficacy of nursing care for patients with urticaria and angioneurotic edema
- Describe the medical therapies that apply to the care of urticaria and angioneurotic edema
Hives, or urticaria, is a type I hypersensitivity allergic reaction involving the skin. Angioedema, or angioneurotic edema, is a condition that is manifested by urticaria and dispersed swelling of the deeper skin layers. Urticaria may appear anywhere on the body, while angioedema typically occurs in the face, hands, feet, or throat. These conditions often occur together, but each can appear without the presence of the other.
Urticaria
Urticaria is a common allergic disorder. This reaction is usually the result of exposure to triggers like food, medications, insect stings, physical stimuli, latex, blood transfusions, bacterial or viral infections, pet dander, plants, and pollen. Urticaria can appear anywhere on the body, including the mucous membranes, gastrointestinal tract, and the larynx.
Pathophysiology
When mast cells and basophils in the epidermis release chemical mediators, urticaria develops due to swelling from capillary and venous vasodilation. Urticaria may be immune-mediated or nonimmune-mediated. With immune-mediated mast cell activation, urticaria is caused by type I hypersensitivity reactions when the IgE antibodies attach to high-affinity mast cell and basophil cell surface receptors. With autoimmune disorders, urticaria is caused by mast cell degranulation due to IgE receptor antibodies crosslinking with IgE receptors. Nonimmune-mediated reactions may be caused by medications and by physical or emotional stimuli that activate mast cells (Benedetti, 2021).
Cold urticaria is a subtype of urticaria triggered by exposure to cold. The cold can be from water, objects, or weather. The cold stimulates mast cells to release histamine, causing capillary and venous vasodilation that results in urticaria. Cold urticaria is either acquired or familial atypical, an autosomal dominant condition inherited from one affected parent.
Clinical Manifestations
As shown in Figure 24.6, urticaria is characterized by edematous, red or pink wheals that vary in size from 2 to 4 mm. Pruritus and angioedema may also be present with this disorder. This condition may appear within minutes and can take three weeks or longer to resolve. If the condition lasts for more than six weeks, it is considered chronic. Bradycardia or tachycardia and tachypnea may also be present. Severe cases may include wheezing, fever, fatigue, dry mouth, abdominal pain, diarrhea, tremors, night sweats, and lymphadenopathy (Benedetti, 2021). Symptoms of cold urticaria include fever, conjunctiva infection, chills, headache, sweating, and arthralgia (joint pain).
Assessment and Diagnostics
The nursing assessment for urticaria should include vital signs as well as a review of the relevant body systems to identify potential causes and determine the case’s severity.
- A head examination should assess for any signs of angioedema, malar rash (erythematous flat or raised rash across the bridge of the nose and cheeks), enlarged thyroid, dry eyes, dry mouth, or lymphadenopathy, and the oropharynx should be assessed for signs of infection.
- An abdominal examination should assess for any enlargement or tenderness of the kidneys or spleen as well as any masses.
- A neurological examination should assess for signs of tremor, hyporeflexia, or hyperreflexia.
- A musculoskeletal examination should assess for inflamed or deformed joints.
- A skin examination should assess for urticaria, hyperpigmentation, jaundice, cutaneous ulceration, or small papules.
- Hives should be assessed for distribution, size, frequency, and duration.
Nurses should also assess for potential triggers like exposure to medications, detergents, new foods, or recent infections, and ask if the patient has experienced prior lesions or has any complaints of pruritus, angioedema, dyspnea, or rhinorrhea (runny nose) (Benedetti, 2021).
Diagnostics and Laboratory Values
Diagnosis of urticaria is generally done with examination and history. In the event of persistent wheals that are not healing, a skin biopsy may need to be done to rule out urticarial vasculitis, inflammation of the small vessels of the skin. Patients presenting with urticaria may be referred for allergy skin testing as well as laboratory tests like complete blood count, liver tests, blood chemistries, and thyroid-stimulating hormone. Thyroid-stimulating hormone levels assessed as chronic urticaria can be associated with thyroid disease. For more severe cases or those with abnormal laboratory results, further testing to assess kidneys, liver, intestines, and thyroid may need to be done (Benedetti, 2021). Cold urticaria may be diagnosed by applying ice cubes to the skin on the forearm for 1 to 5 minutes. A positive result is when urticaria is present at the application site. Those with cold urticaria may develop leukocytosis, increased C-reactive protein levels, or raised erythrocyte sedimentation rate (ESR).
Nursing Care of Patients with Urticaria
Nurses play an important role in managing care for patients with urticaria. The care plan should include performing an assessment to recognize and analyze cues, prioritizing hypotheses, generating solutions, taking action, and evaluating care and outcomes. If any outcomes have been deemed nonsatisfactory, then the nurse must reassess using the Clinical Judgment Measurement Model and start over with recognizing and analyzing cues and then following subsequent steps until a satisfactory outcome is reached.
Recognizing and Analyzing Cues
Recognizing and analyzing cues requires the nurse to complete a physical examination and take both a personal and family history of allergies. Physical examination findings may reveal any of the clinical manifestations described previously. A nursing assessment should include the patient’s exposure risks in order to attempt to identify the triggering allergen.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After documenting examination and history findings, the nurse should verify orders that are received from the provider. Interventions may be aimed at improving symptoms, administering medications, patient education about avoidance therapy, and promoting home-based care. Nursing interventions for improving symptoms may include administering medications and eliminating identified or suspected triggers causing urticaria. Medications may include antihistamines and system corticosteroids. Other interventions may include avoiding heat, stress, tight clothes, NSAIDs, and alcohol, as those items can further aggravate the reaction. Patients with cold urticaria should be educated to avoid cold stimuli. The nurse should also educate the patient on the importance of maintaining their medication or treatment regimen to improve and prevent symptoms. Since anaphylaxis is a risk with any allergic reaction, the nurse must assess and be ready to intervene in the event of this type of emergency.
Discharge planning includes educating the patient and family on self-care at home and the importance of adhering to the treatment plan, correctly using medications, and minimizing exposure to triggering allergens and other substances that aggravate the reaction. The purpose, procedure, and schedule of any prescribed regimens from the provider should be reinforced to ensure patient or family understanding. Any side effects from medications or treatments should also be explained to the patient and family, as well as the name, dosage, and frequency of each medication and actions to take in the event of side effects. Patients with any type of urticaria should have an EpiPen, as hives can progress to anaphylaxis. The patient and family should be educated on proper use of an EpiPen or use of inhaled epinephrine and the need to call 911 for emergency treatment and monitoring following usage.
Evaluation of Nursing Care for Patients with Urticaria
Evaluation is an essential part of the nursing process. The nurse should compare observed outcomes against expected outcomes. This allows the nurse to evaluate for signs of improvement, decline, or if unchanged. The nurse should then use their judgment to assess whether the interventions were effective or if other interventions are needed.
Evaluating Outcomes
The nurse will want to evaluate expected outcomes for patients with urticaria. The nurse can determine if symptoms have improved based on clinical examination as well as patient verbalization. The nurse can determine the patient’s level of comprehension by having the patient verbalize or reiterate the teachings regarding diagnosis, medications, treatment, schedule, home care, and allergen avoidance measures. The patient should also be able to demonstrate how to properly administer their medications and be able to describe signs and symptoms like anaphylaxis, angioedema, difficulty swallowing, wheezing, difficulty breathing, peripheral tingling, and urticaria that is not resolving.
Medical Therapies and Related Care
Medical therapies include avoiding the use of NSAIDs, limiting the use of items that can further aggravate the reaction, and eliminating the known or suspected allergen that caused the reaction. NSAIDs should be avoided as they can not only cause urticaria but also worsen urticaria that is present. Antihistamines may be prescribed as they suppress the release of histamine and help relieve itching and swelling associated with urticaria. Systemic corticosteroids may be prescribed for more severe cases but are not designed for long-term use. Corticosteroids inhibit histamine release by stabilizing mast cell membranes and reduce inflammatory effects of histamine. Treatments for cold urticaria include warmth, bed rest, and corticosteroids for acute cases.
Angioneurotic Edema
Angioneurotic edema is also known as angioedema. As previously stated, it can occur alongside the presence of urticaria, alone, or as a component of anaphylaxis. This disorder involves swelling of the deeper skin layers and most commonly occurs in the face (eyelids, lips, tongue, cheeks), hands, feet, genitalia or throat. Angioedema can also occur in mucous membranes of the gastrointestinal tract, bronchi, and larynx. While not as common, the reaction can also be found on the back.
Pathophysiology
Angioedema is either histamine-mediated or bradykinin-mediated. Histamine-mediated angioedema is more common; it occurs due to mast cell and basophil activation. When there is re-exposure to the causative allergen, the mast cells and basophils release histamine. Histamine contributes to an increase in vascular permeability, resulting in swelling of the deeper skin layers or mucosa (Memo & Tiwari, 2023).
Bradykinin-mediated angioedema is either due to genetics, angiotensin-converting enzyme inhibitor-associated angioedema, or acquired C1-inhibitor deficiency. Vascular permeability is increased and results in edema. Hereditary angioedema is either secondary to angiopoietin-1, F12 gene, plasminogen, or an unknown gene mutation that contributes to abnormal accumulation of C1 inhibitor or bradykinin (Memo & Tiwari, 2023).
Clinical Manifestations
Angioedema is characterized by non-pitting swelling of the dermis and subcutaneous layers. The reaction may appear suddenly, within a few seconds or minutes, or slowly over one to two hours. If the reaction occurs slowly, the patient may experience itching and burning sensations prior to the onset of swelling. This reaction generally resolves within twenty-four hours. While it is rare, a recurrence can occur at three- to four-week intervals.
Assessment and Diagnostics
A physical examination is required to assess for swelling, severity, and any resulting complications like dyspnea or anaphylaxis. Airway management is the top priority with angioedema as airway obstruction can lead to hypoxia, brain damage, and death. The nurse should assess the head, feet, hands, airway, and back. The nurse should also ask the patient or family about onset, duration, difficulty breathing, associated symptoms such as urticaria, and any possible triggers, such as a medication or food. The use of angiotensin-converting enzyme (ACE) inhibitors should also be assessed in the event the angioedema is a result of ACE inhibitor–associated angioedema.
Diagnostics and Laboratory Values
The patient’s vital signs should be measured in order to obtain a baseline and identify any potential complications. If the cause of angioedema is not clear, C1 inhibitor levels may need to be assessed to check for acquired C1-inhibitor deficiency. C1 inhibitor is a serine protease inhibitor. Low levels can result in angioedema and laryngeal edema. Additionally, complement factor C4 levels can be drawn and assessed. Low levels of C4 proteins may indicate hereditary angioedema or acquired C1-inhibitor deficiency (Frank, 2024).
Nursing Care of Patients with Angioneurotic Edema
Nurses play an important role in managing care for those with angioedema. Nursing care includes conducting an assessment to recognize and analyze cues, prioritizing hypotheses, generating solutions, taking action, and evaluating care and outcomes. If any outcomes have been deemed nonsatisfactory, then the nurse must reassess by using the Clinical Judgment Measurement Model and start over with recognizing and analyzing cues and then following subsequent steps until a satisfactory outcome is reached.
Recognizing and Analyzing Cues
As part of recognizing and analyzing cues, the nurse should conduct a physical examination and take the patient’s personal and family history of allergies. Physical examination findings may reveal any of the clinical manifestations described previously. An assessment should also include the patient’s exposure risks in order to attempt to identify the triggering allergen.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After documenting findings from the examination and history, the nurse should verify orders that are received from the provider. Interventions may be aimed at improving symptoms, administering medications, educating the patient about avoidance therapy, and promoting home-based care. Nursing interventions for improving symptoms may include administering medications and eliminating identified or suspected triggers causing angioedema. If the cause is unknown, any nonessential medications should be stopped. Medications may include epinephrine in extreme cases or those causing difficulty breathing. Antihistamines or corticosteroids may also be prescribed. The nurse should also educate the patient on the importance of maintaining their medication or treatment regimen to improve and prevent symptoms. Since anaphylaxis is a risk with any allergic reaction, the nurse must assess and be ready to intervene in the event of this type of emergency.
Discharge planning includes educating the patient and family on self-care at home and on the importance of adhering to the treatment plan, correctly using medications, and minimizing exposure to the causative allergen. The purpose, procedure, and schedule of any prescribed regimens from the provider should be reinforced to ensure patient or family understanding. Any side effects from medications or treatments should also be explained to the patient and family, as well as the name, dosage, and frequency of each medication and actions to take in the event of side effects.
Evaluation of Nursing Care for Patients with Angioneurotic Edema
Evaluation is an essential part of the nursing process. The nurse should compare observed outcomes against expected outcomes. This allows the nurse to evaluate for signs of improvement, decline, or no change. The nurse would then use their judgment to assess whether the interventions were effective or if other interventions are needed.
Evaluating Outcomes
The nurse will want to evaluate expected outcomes for patients with angioedema. The nurse can determine if symptoms have improved based on clinical examination as well as patient verbalization. The nurse can determine comprehension by having the patient verbalize or reiterate what they have learned regarding diagnosis, medications, treatment, schedule, home care, and allergen avoidance measures. The patient should also be able to demonstrate how to properly administer their medications and be able to describe signs and symptoms like anaphylaxis, difficulty swallowing, wheezing, difficulty breathing, peripheral tingling, and urticaria.
Medical Therapies and Related Care
Management of angioedema may include the use of epinephrine, antihistamines, or corticosteroids. Most reactions resolve on their own within two to four days. However, the patient should be monitored for airway obstruction; a tracheostomy may be a necessary intervention should this type of emergency happen. For ACE inhibitor–associated angioedema, fresh frozen plasma and C1 inhibitor concentrate may be given.