L

Life-threatening Reactions Occurring Less Than 1 Hour after Exposure to Latex

Type IV Reactions Occurring More Than 1 Hour After Exposure to Latex Protein

Discomfort reaction to additives such as thiurams and carbamates; eczema; irritation; redness

Client Will (Specify Time Frame)

• 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:

• Take a thorough history of the client at risk. EB: A clinical history is essential for diagnosing latex allergy (Pollart, Warniment, & Takahiro, 2009). EB: The vast majority of the clients diagnosed with latex allergy are informed of their diagnosis when seeking medical care during which they would be exposed (Garcia, 2007).

• 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. EB: Latex allergy is an IgE-mediated hypersensitivity to NRL, presenting a wide range of clinical symptoms such as angioedema, swelling, cough, asthma, and anaphylactic reactions (Deval et al, 2008).

• Consider the use of a provocation test (cutaneous, sublingual, mucous, conjunctival) for latex allergy diagnosis confirmation. EB: Latex allergy diagnosis was confirmed by specific provocation tests (Nucera, Schiavino, & Pollastrini, 2006). EB: The nasal provocation test is a more sensitive testing method as compared to the glove use test (Unsel et al, 2009).

• Consider a blood test to measure serum IgE levels. EB: Because skin prick testing is not available in the United States, measurement of latex-specific serum IgE levels is the best option (Pollart, Warniment, & Takahiro, 2009). EB: In theory, allergy blood testing may be safer, because it does not expose the client to any allergens (Siles & Hsieh, 2011).

• All latex-sensitive clients are treated as if they have NRL allergy. EB: The primary treatment for suspected latex allergy is avoidance of exposure to the latex protein (Gawchik, 2011). EB: Recent studies have demonstrated that adopting latex-free strategies in health care facilities has reduced the prevalence of latex sensitization and allergy in children with spina bifida (26.7% to 4.5%), myelomeningocele (4% to 1.2%), and a history of multiple surgeries (42% to 7%) (Venkata & Lerman, 2011).

• 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. EB: The management strategy recommended by the American Society of Anesthesiology consists of a complete medical history and questionnaire (from the parents), application for a medical alert bracelet, a latex-free cart, a list of latex-free devices and alternatives, signage on the client’s medical records that highlights his/her latex allergy, and “Latex Allergy” signs in the perioperative area (Venkata & Lerman, 2011). EB: A latex-controlled environment is defined as one in which no latex gloves are used in the room or surgical suite and no latex accessories (catheters, adhesives, tourniquets, and anesthesia equipment) come in contact with the client (Joint Task Force on Practice Parameters, 2010). EB: Clients who are latex allergic should have a surgical procedure performed as the first case in the morning, when the levels of latex aeroallergens in the environment are the lowest (Cleveland Clinic, 2011).

• In select high-risk atopic individuals, a specific immunotherapy regimen should be discussed with their health care provider. EB: Current subcutaneous and sublingual immunotherapy schedules have been tested for treatment of latex allergy with evidence of efficacy, but the risks of adverse events are high (Rolland & O’Hehir, 2008). EB: Sublingual immunotherapy represents an efficient therapeutic tool for the management of latex allergic clients (Nucera et al, 2008).

 The most effective approach to preventing NRL anaphylaxis is complete latex avoidance. EB: Symptoms of latex allergy resolve quickly with avoidance. However, elevated IgE levels can remain detectable more than 5 years after exposure, suggesting that long-term avoidance of latex should be recommended for clients with known latex allergy (Pollart, Warniment, & Takahiro, 2009). EB: The use of no-latex gloves is the best choice from the preventive point of view (Filon & Cerchi, 2008).

 Materials and items that contain NRL must be identified and latex-free alternatives must be found. EB: Effective in September 1998, all medical devices were required to be labeled regarding their latex content (Hubbard, 1997). EB: Latex-free synthetic rubber such as neoprene, nitrile, styrene butadiene rubber (SBR), butyl, and Viton are polymers that are available as alternatives to natural rubber (Deval et al, 2008).

 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. EB: The use of low-protein, low-allergenic, powder-free gloves is associated with a significant decrease in the prevalence of type I allergic reactions to NRL among health care workers (Palosuo et al, 2011).

 If latex gloves are chosen for protection from blood or body fluids, a reduced-protein, powder-free glove should be selected. EB: Evidence within Europe demonstrates that the many benefits of NRL [gloves] can be retained by purchasing low-allergen, low-protein and powder-free gloves, thereby reducing the risk of type I and type IV sensitization as well as allergic reactions (Palosuo et al, 2011).

• See Box III-1 for examples of products that may contain NRL and safe alternatives that are available. EB: Clients who are known to be allergic should avoid any product that might contain latex until latex content is determined by contacting the manufacturer. Even products labeled “safe latex” (which indicates lower proportions of natural latex) cam cause latex allergy. There is no safe latex for latex allergy sufferers (Deval et al, 2008).

Client Will (Specify Time Frame)

• 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 obstetrical procedures. EB: Although the prevalence of latex allergy in the general pediatric population is less than 4%, the prevalence in specific at-risk populations may be as great as 71%. Children at risk for developing latex sensitivity include those with spina bifida; those with congenital urological, gastrointestinal, and tracheoesophageal defects; those who have undergone multiple (i.e., more than five) surgeries; and those with a history of atopy (Venkata & Lerman, 2011). EB: Health care workers have the second highest risk of developing latex allergy, particularly those who work in operating rooms, laboratories, or hemodialysis centers (Pollart, Warniment, & Takahiro, 2009). EB: A latex-directed history is the primary method of identifying latex sensitivity, although both skin and serum testing are available and are increasingly accurate (Society of Gastroenterology Nurses and Associates, 2008).

• Clients with spina bifida are a high-risk group for NRL allergy and should remain latex free from the first day of life. EB: Latex allergy in spina bifida children is a multifactorial situation related to a disease-associated propensity for latex sensitization, early exposure, and number of surgical procedures. Prophylactic measures to avoid the exposure, not only in the sanitary environment, through the institution of latex-safe routes and every day, prevent potentially serious allergic reactions (Ausili et al, 2007). EB: Children with spina bifida or urogenital abnormalities, or those who are expected to have multiple surgical procedures, should avoid exposure to latex products from birth to prevent development of latex allergy (Pollart, Warniment, & Takahiro, 2009).

• Assess for NRL allergy in clients who are exposed to “hidden” latex. EB: NRL is a ubiquitous allergen as it is a component of more than 40,000 products in everyday life (Deval et al, 2008). EB: A clinical history is essential because we cannot deny possibility of exposure to latex products in everyday life (Sekiya et al, 2011).

• See care plan for Latex Allergy Response.

Client Will (Specify Time Frame)

 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. These are symptoms and laboratory results associated with liver disorders (Ghany & Hoofnagle, 2011; McKinley, 2009).

 Evaluate liver function tests. Standard liver panels include the serum enzymes aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase, and γ-glutamyltransferase; total, direct, and indirect serum bilirubin; and serum albumin. CEB: A platelet count of less than 160,000 per mm³ has a sensitivity of 80% for detecting cirrhosis in clients with chronic hepatitis C (Heidelbaugh & Bruderly, 2006). Many times hepatitis C is asymptomatic (CDC, 2012b) and is found during a routine examination when an elevated liver function test returns (Poole, 2009).

 Discuss with the client/family preparations for other diagnostic studies, such as ultrasounds, CT, and MRI exams (Beaumont & Leadbeater, 2011).

 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. Prolonged prothrombin time and decreased production of clotting factors can result in bleeding.

• Monitor for signs of hemorrhage, especially in the upper GI tract, as it is the most frequent site. Synthesis of coagulation factors is affected with liver impairment (Tripodi, Chantarangkul, & Mannucci, 2008).

• 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 (Dienstag, 2011). If taking either OTC medications or herbals, discuss signs and symptoms of toxic hepatitis. Toxic hepatitis is caused by direct toxins, drugs, herbs, and industrial chemicals. The risk of toxicity with aspirin, ibuprofen, naproxen sodium, and acetaminophen increases with frequency and in combination with use of alcohol (Poole, 2009).

 In clients receiving drugs associated with liver injury, review risk factors in order to prevent potentially severe drug reactions. Drug-induced liver disease accounts for about 50% of hepatitis cases. The most common risk factors are advanced age, alcohol use history, pregnancy, and genetic predisposition (Kim, Hattori, & Phongsamran, 2010).

 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 (Dienstag, 2012). It is common for clients to take multiple pain medications, all containing acetaminophen. Toxicity from acetaminophen is increasing because more adolescents are taking acetaminophen in combination with opioids (Bond, Ho, & Woodward, 2012).

 Evaluate the serum acetaminophen-protein adducts in the client with possible liver failure from excessive intake of acetaminophen. CEB: This diagnostic test was helpful in determining if liver failure is associated with acetaminophen toxicity (Dienstag, 2012).

 If the client is on statin medications, ensure that liver enzyme testing is done at intervals. Liver enzymes can become elevated from taking statin medications; it is uncommon, but possible for statins to cause actual liver damage (Zamor & Russo, 2011).

 If the client is an alcoholic, refer to a cessation program. It is essential the client stop drinking as soon as possible to allow the liver to heal. Alcoholism is associated with malnutrition, which is harmful to the liver (O’Shea et al, 2010). Alcoholism is also associated with formation of proteins called cytokines, which cause inflammation and resultant damage to the liver (Jeong & Gao, 2008). It has been noted that serum levels of AST, ALT, total bilirubin, prothrombin time, and red blood cells, once elevated, may return to normal within 4 weeks of cessation of alcohol (Zeng, Li, & Chen, 2008). See care plan for Ineffective Denial and Dysfunctional Family Processes.

 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. Proteins can be increased as client can tolerate, and serum protein, albumin levels, and bilirubin levels indicate improved liver function. Improved nutrition will help the client with liver dysfunction regain strength and increase activity (McKinley, 2009).

 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. For those clients showing signs of fatty liver involvement, sound nutritional support can reduce the severity and also mitigate the already existing secondary malnutrition (Zeng, Li, & Chen, 2008).

• Encourage vaccinations for hepatitis A and B for all ages. Hepatitis A can affect anyone in the United States. Vaccination can prevent hepatitis A and B, which at times can cause liver failure (CDC, 2011, 2012a; Poole, 2009).

• Measure abdominal girth if individual presents with abdominal distention and pain. Increasing abdominal distention and pain are signs of impending portal hypertension with presence of fluid shifts resulting in ascites (Ghany & Hoofnagle, 2012).

• Assess for tenderness and/or pain level in the right upper quadrant. Tenderness in this area is a symptom of biliary, liver, and/or pancreatic problems. This pain along with a palpable mass and weight loss are a classic triad for malignancies (Sauerland et al, 2009).

• Use standard precautions for handling of blood and body fluids. Review sterile techniques when giving intravenous solution and/or medications. EB: This is imperative in order to decrease the incidence of hepatitis B and hepatitis C viruses. The viruses have been spread in health care settings when injection equipment and intravenous solutions were mishandled and became contaminated (Poole, 2009).

 Observe for signs and symptoms of mental status changes such as confusion from encephalopathy. Assess ammonia level if mental changes occur (Sargent, 2007).

Client Will (Specify Time Frame)

• 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?) EB: Loneliness is based on the subjective situation in which the client is engaged and may be either social or emotional (Gierveld & Van Tilburg, 2010). EBN: Persons most at risk for loneliness include the elderly; college students; the ill and/or disabled; and the bereaved and isolated (Elsadr, Noureddine, & Kelley, 2009). Refer to care plan for Social Isolation.

• Use active listening skills. Establish a therapeutic relationship and spend quality time with the client. EB: Empathetic listening is an indispensable component of healing (LoboPrabhu et al, 2008).

• 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.). EBN: Clients’ perception of general health, symptoms, and social support influences health status outcome (Beal & Stuifbergen, 2007).

 Assess the isolated, bereaved client for risk of suicide and make appropriate referrals as necessary. CEB: Bereaved persons are at excess risk for suicidal ideation compared to nonbereaved people. Heightened suicidal ideation in bereavement is associated with loneliness and severe depressive symptoms (Stroebe, Stroebe, & Abakoumkin, 2005). EB: Grief therapy reduces the risk of suicidal ideation in high risk groups (deGroot et al, 2010). Refer to care plan for Risk for Suicide.

 Assess the client who is alone for substance abuse and make appropriate referrals. EBN: Those who abuse substances combat loneliness by projecting an enhanced self-image and thus, easier acceptance by a group (Wiklund, 2008).

• Evaluate the client’s desire for social interaction in relation to actual social interaction. CEB: Those involved in the study of human personality agree that most people basically are motivated to be accepted and perhaps loved (DeWall, Baumeister, & Vohs, 2008).

• Assist the client with identifying loneliness as a feeling and also aid in further identifying the causes related to this feeling. EB: A person measures his or her level of loneliness by assessing those feelings and experiences involving isolation and lack of communication with others (Griffin, 2010).

• Explore ways to increase the client’s support system and participation in groups and organizations. EBN: Both formal and informal social support is important. In the older population, it has been shown that social support is an important factor in reducing feelings of loneliness (Heravi-Karimool et al, 2010).

• Encourage the client to be involved in meaningful social relationships and provide support of one’s personal attributes. EBN: Self-respect and the respect of other for one’s own personal values have been shown to be important for self-esteem and quality of life (Drageset et al, 2009).

• Encourage the client to develop closeness in at least one relationship. EB: Health care providers should recognize the importance of social relationships in the health outcome of adults and recognize that the lack of social relationships most probably affects the client’s mortality (Holt-Lunstad, Smith, & Layton, 2010).

Adolescents