L
Latex Allergy Response
Defining Characteristics
Life-Threatening Reactions Occurring Less Than 1 Hour after Exposure to Latex
Protein
Bronchospasm; cardiac arrest; contact urticaria progressing to generalized symptoms; dyspnea; edema of the lips; edema of the throat; edema of the tongue; edema of the uvula; hypotension; respiratory arrest; syncope; tightness in chest; wheezing
Client Outcomes
Client Will (Specify Time Frame)
• Identify presence of natural rubber latex (NRL) allergy
• List history of risk factors
• State reasons not to use or to have anyone use latex products
• Experience a latex-safe environment for all health care procedures
• Avoid areas where there is powder from NRL gloves
• State the importance of wearing a medical alert bracelet and wear one
• State the importance of carrying an emergency kit with a supply of nonlatex gloves, antihistamines, and an autoinjectable epinephrine syringe (EpiPen), and carry one
Nursing Interventions
• Identify clients at risk: those persons who are most likely to exhibit a sensitivity to NRL that may result in varying degrees of reactivity. Consider the following client groups:
Persons with neural tube defects including spina bifida, myelomeningocele/meningocele.
Children who have experienced three or more surgeries, particularly as a neonate, and adults who have undergone multiple surgeries.
Atopic individuals (persons with a tendency to have multiple allergic conditions) including allergies to food products. Particular allergies to fruits and vegetables including bananas, avocado, celery, fig, chestnut, papaya, potato, tomato, melon, and passion fruit are significant.
Persons who possess a known or suspected NRL allergy by having exhibited an allergic or anaphylactic reaction, positive skin testing, or positive IgE antibodies against latex.
Persons who have had an ongoing occupational exposure to NRL, including health care workers, rubber industry workers, bakers, laboratory personnel, food handlers, hairdressers, janitors, policemen, and firefighters.
• Take a thorough history of the client at risk.
• Question the client about associated symptoms of itching, swelling, and redness after contact with rubber products such as rubber gloves, balloons, and barrier contraceptives, or swelling of the tongue and lips after dental examinations.
• Consider the use of a provocation test (cutaneous, sublingual, mucous, conjunctival) for latex allergy diagnosis confirmation.
• Consider a blood test to measure serum IgE levels.
• All latex-sensitive clients are treated as if they have NRL allergy.
• Clients with spina bifida and others with a positive history of NRL sensitivity or NRL allergy should have all medical/surgical/dental procedures performed in a latex-controlled environment.
• In select high-risk atopic individuals, a specific immunotherapy regimen should be discussed with their health care provider.
The most effective approach to preventing NRL anaphylaxis is complete latex avoidance.
Materials and items that contain NRL must be identified and latex-free alternatives must be found.
In health care settings, general use of latex gloves having negligible allergen content, powder-free latex gloves, and nonlatex gloves and medical articles should be considered in an effort to minimize exposure to latex allergen.
If latex gloves are chosen for protection from blood or body fluids, a reduced-protein, powder-free glove should be selected.
• See Box II-1 for examples of products that may contain NRL and safe alternatives that are available.
• Assess the home environment for presence of NRL products (e.g., balloons, condoms, gloves, and products of related allergies, such as bananas, avocados, and poinsettia plants).
• At onset of care, assess client history and current status of NRL allergy response.
Seek medical care as necessary.
• Do not use NRL products in caregiving.
• Assist the client in identifying and obtaining alternatives to NRL products.
Client/Family Teaching and Discharge Planning
• Provide written information about NRL allergy and sensitivity.
Instruct the client to inform health care professionals if he or she has an NRL allergy, particularly if the client is scheduled for surgery.
• Teach the client what products contain NRL and to avoid direct contact with all latex products and foods that trigger allergic reactions.
• See Box II-2 for examples of products found in the community that may contain NRL and safe alternatives that are available.
• Teach the client to avoid areas where powdered latex gloves are used, as well as where latex balloons are inflated or deflated.
• Instruct the client with NRL allergy to wear a medical identification bracelet and/or carry a medical identification card.
• Instruct the client to carry an emergency kit with a supply of nonlatex gloves, antihistamines, and an autoinjectable epinephrine syringe (EpiPen).
Risk for Latex Allergy Response
Risk Factors
Allergies to avocados; allergies to bananas; allergies to chestnuts; allergies to kiwis; allergies to poinsettia plants; allergies to tropical fruits; history of allergies; history of asthma; history of reaction to latex; multiple surgical procedures, especially from infancy; professions with daily exposure to latex.
Client Outcomes
Client Will (Specify Time Frame)
• State risk factors for natural rubber latex (NRL) allergy
• Request latex-free environment
• Demonstrate knowledge of plan to treat NRL allergic reaction
Nursing Interventions
• Clients at high risk need to be identified, such as those with frequent bladder catheterizations, occupational exposure to latex, past history of atopy (hay fever, asthma, dermatitis, or food allergy to fruits such as bananas, avocados, papaya, chestnut, or kiwi); those with a history of anaphylaxis of uncertain etiology, especially if associated with surgery; health care workers; and females exposed to barrier contraceptives and routine examinations during gynecological and obstetric procedures.
• Clients with spina bifida are a high-risk group for NRL allergy and should remain latex free from the first day of life.
• Children who require regular medical treatments at home (catheterization, home ventilation, etc.) should be assessed for NRL allergy.
• Assess for NRL allergy in clients who are exposed to “hidden” latex.
• See care plan for Latex Allergy Response.
Ensure that the client has a medical plan if a response develops. Prompt treatment decreases potential severity of response.
• See care plan for Latex Allergy Response. Note client history and environmental assessment.
Client/Family Teaching and Discharge Planning
A client who has had symptoms of NRL allergy or who suspects he or she is allergic to latex needs to give this information to health care providers.
Provide written information about latex allergy and sensitivity.
• Health care workers should avoid the use of latex gloves and seek alternatives such as gloves made from nitrile.
• Health care institutions should develop prevention programs for the use of latex-free gloves and the absence of powdered gloves; they should also establish latex-safe areas in their facilities.
Risk for impaired Liver Function
Risk Factors
Hepatotoxic medications (e.g., acetaminophen, statins); HIV co-infection; substance abuse (e.g., alcohol, cocaine); viral infection (e.g., hepatitis A, B, C, E, Epstein-Barr)
Client Outcomes
Client Will (Specify Time Frame)
• State the upper limit of the amount of acetaminophen can safely take per day
• Have normal liver enzymes, serum and urinary bilirubin levels, white blood cell count (WBC), red blood cell count (RBC)
• Be free of unexplained weight loss, jaundice, pruritus, bruising, petechiae, gastrointestinal bleeding, hemorrhage
• Be free of abdominal tenderness/pain, increased abdominal girth, and have normal-colored stool and urine
• Be able to eat frequent small meals per day without nausea and/or vomiting
• If alcohol abuse is factor, state relationship between abuse and worsening gastrointestinal and liver disease
Nursing Interventions
Watch for signs of liver dysfunction including fatigue, nausea, jaundice of the eyes or skin, pruritus, gastrointestinal bleeding, coagulopathy, infections, increasing abdominal girth, fluid overload, shortness of breath, mental status changes, light-colored stools, dark urine, and increased serum and urinary bilirubin levels.
Evaluate liver function tests.
Discuss with the client/family preparations for other diagnostic studies, such as ultrasounds, CT, and MRI exams.
Evaluate coagulation studies such as international normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT), especially with bleeding of the mouth or gums.
• Monitor for signs of hemorrhage, especially in the upper GI tract, as it is the most frequent site.
• Obtain a list of all medications, including over-the-counter NSAIDs, acetaminophen, and herbal remedies. Review risk of drug-induced liver disease. The list includes some antibiotics, anticonvulsants, antidepressants, antiinflammatory drugs, antiplatelets, antihypertensives, calcium channel blockers, cyclosporine, lipid-lowering drugs, chemotherapy drugs, oral hypoglycemics, tranquilizers, and more. If taking either OTC medications or herbals, discuss signs and symptoms of toxic hepatitis.
In clients receiving drugs associated with liver injury, review risk factors in order to prevent potentially severe drug reactions.
Determine the total amount of acetaminophen the client is taking per day. The amount of acetaminophen ingested should not exceed 3.25 g per day, or even lower in the client with chronic alcohol intake.
Evaluate the serum acetaminophen-protein adducts in the client with possible liver failure from excessive intake of acetaminophen.
If the client is on statin medications, ensure that liver enzyme testing is done at intervals.
If the client is an alcoholic, refer to a cessation program.
Provide frequent smaller meals for easier digestion. Provide diet with optimal carbohydrates, proteins, and fats. Consult with a registered dietitian to discuss best nutritional support.
Recognize that severe malnutrition may result in acute liver failure, which is reversible with improved nutrition.
Review medical history with the client, recognizing that obesity and type 2 diabetes, along with hypertriglyceridemia and polycystic ovarian syndrome are major risk factors in the development of liver disease, specifically nonalcoholic fatty liver disease.
• Encourage vaccinations for hepatitis A and B for all ages.
• Measure abdominal girth if individual presents with abdominal distention and pain.
• Assess for tenderness and/or pain level in the right upper quadrant.
• Use standard precautions for handling of blood and body fluids. Review sterile techniques when giving intravenous solution and/or medications.
Observe for signs and symptoms of mental status changes such as confusion from encephalopathy. Assess ammonia level if mental changes occur.
Prescreen pregnant women for hepatitis B surface antigens. If found, recommend nursing case management during pregnancy.
Recommend implementation of postexposure prophylaxis, including the HBV vaccine birth dose within 12 hours postpartum, for an infant born to a hepatitis B surface antigen-positive woman. This consists of a birth dose of hepatitis B immune globulin (HBIG) and the HBV vaccine on an accelerated schedule. Recommend that this child also undergo serology testing to confirm a protective immune response 3 to 9 months after completing the three-dose vaccine series.
• Encourage vaccinations for hepatitis A and B for all ages.
Recognize that children can develop fatty liver disease, which can result in liver failure. Most children are asymptomatic, but others complain of malaise, fatigue, or vague recurrent abdominal pain.
During a well-baby visit, assess for signs of potential liver problems. Observe for prolonged jaundice, pale stools, and urine that is anything other than colorless. Consult with physician to order a split bilirubin as needed.
• Encourage rest, optimal nutrition (high carbohydrates, sufficient protein, essential vitamins and minerals) during initial inflammatory processes of the liver.
Client/Family Teaching and Discharge Planning
• Teach the client and family to examine all medications the client is taking, looking for acetaminophen as an ingredient, and reinforce the 3.25-g upper limit of intake of acetaminophen to protect liver function.
• For the caregiver or client with hepatitis A, B, or C, teach the need for careful handwashing, use of gloves, and other precautions to prevent spread of any of these diseases.
• Teach avoidance of high-risk behaviors that cause hepatitis and ways to avoid those behaviors.
• Educate clients and their caregivers about treatment options and interventions for hepatitis. Recommend other informational support: risk factors, side effects of the different treatment options, and dietary advice.
• Recommend psychological support if possible during education sessions.
• For those clients with mental health problems, collaborate with outreach programs to teach signs/symptoms of hepatitis, risk factors, and factors that increase transmission.
Risk for Loneliness
Client Outcomes
Client Will (Specify Time Frame)
• Maintain one or more meaningful relationships (growth-enhancing versus codependent or abusive in nature)
• Sustain relationships that allow self-disclosure and demonstrate a balance between emotional dependence and independence
• Participate in personally meaningful activities and interactions, that are ongoing, positive, and relevant socially
• Demonstrate positive use of time alone when socialization is not possible
Nursing Interventions
• Assess the client’s perception of loneliness. (Is the person alone by choice, or are there other factors that contribute to the feelings of loneliness? Is the client in one of the at-risk populations for loneliness?)
• Use active listening skills. Establish a therapeutic relationship and spend quality time with the client.
• Assess the client’s ability and/or inability to meet his/her physical, psychosocial, spiritual, and financial needs; assess how unmet needs challenge the client’s ability to socially integrate. NOTE: See care plan for Disturbed Body Image if loneliness is associated with chronic illness and/or afflictions (MS, skin disturbance, mental illness etc.).
Assess the isolated, bereaved client for risk of suicide and make appropriate referrals as necessary.
Assess the client who is alone for substance abuse and make appropriate referrals.
• Evaluate the client’s desire for social interaction in relation to actual social interaction.
• Assist the client with identifying loneliness as a feeling and also aid in further identifying the causes related to this feeling.
• Explore ways to increase the client’s support system and participation in groups and organizations.
• Encourage the client to be involved in meaningful social relationships and provide support of one’s personal attributes.
• Encourage the client to develop closeness in at least one relationship.
• Assess the client’s social support system.
• Evaluate the family stability of younger and middle adolescent clients; advocate and encourage healthy, growth-producing relationships with both family and other support systems.
• Evaluate peer relationships.
• Encourage social support for clients with disabilities such as mental illness, visual impairment, or deafness and make appropriate referrals when necessary.
• For older adolescents, encourage close relationships with peers and involvement with groups and organizations.
• Assess the client’s adaptive sensory functions or any other health deviations that may limit or decrease his or her ability to interact with others.
• Assess older caregivers of persons with chronic conditions such as Alzheimer’s or other dementias, Parkinson’s etc. for depression related to loneliness.
• Identify support systems in elderly populations.
• When relocation is necessary for older adults, evaluate relocation stress as a contributing factor to loneliness.
• Identify risk factors for loneliness in older persons confined to extended care facilities (ECFs).
• Encourage support by friends and family when the decision to stop driving must be made.
• Provide activities that are pleasurable to the client.
• Refer to the care plan for Social Isolation for additional interventions.
The preceding interventions may be adapted for home care use.
Assess for depression with the lonely elderly client and make appropriate referrals.
• If the client has unexplained somatic complaints, evaluate these complaints to ensure that physical needs are being met, and assess for a possible relationship between somatic complaints and loneliness.
• Identify alternatives to being alone (e.g., telephone contact, Internet).
Client/Family Teaching and Discharge Planning
• Identify the type of loneliness that the client is experiencing—emotional and/or social.
• Encourage family members’ involvement, if possible, in helping to alleviate client’s loneliness.
• Include the family, if possible, in all client-teaching activities, and give them accurate information.
• Provide appropriate education for clients and their support persons about disease transmission and treatment if applicable.
• Refer to the care plan for Social Isolation for additional interventions.