Nursing diagnosis – latex allergy response

Latex Allergy Response
DEFINITION
A hypersensitive reaction to natural latex rubber products
DEFINING CHARACTERISTICS
Immediate reactions (1 hr of exposure) can be life-threatening
• Contact urticaria progressing to generalized symptoms
• Edema of the lips, eyelids, sclera, tongue, uvula, and/or throat
• Shortness of breath or tightness in the chest, wheezing or
bronchospasm leading to respiratory arrest
• Hypotension, syncope, and cardiac arrest
• Abdominal pain or nausea
• Complaints of increasing body warmth and/or restlessness
• Erythema, itching, and/or tearing of the eyes and/or face
• Nasal congestion, erythema, itching, and/or rhinorrhea
Type 1V Reactions (1 hr after exposure)
• Generalized discomfort
• Eczema, irritation, and/or redness
RELATED FACTORS
• Absent immune system response
• Hypersensitivity to natural latex rubber
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
• Tissue integrity
EXPECTED OUTCOMES
The patient will
• Regain vital signs, respiratory status, and laboratory values.
• Exhibit skin that is moist, clear, and free of erythema, edema, itching,
urticaria, and breakdown.
• Express awareness of allergic response to latex-containing products.
SUGGESTED NOC OUTCOMES
Comfort Level; Immune Hypersensitivity Response; Knowledge:
Infection Control; Tissue Integrity: Skin and Mucous Membrane
INTERVENTIONS AND RATIONALES
Determine: Determine whether patient has had past episodes of latex
allergy; food, pollen, or drug allergy. Report contacts with latex
products including when, where, and what. History will lead to
more precise assessment.
Monitor respiratory status; include rate, rhythm, skin color, and
breath sounds. Be particularly alert for signs of bronchospasms and
complaints of dyspnea. Assess heart rate, rhythm, and blood pressure.
Check skin carefully for urticaria. Document findings. These measures
detect changes in status to more accurately determine interventions.
• LATEX ALLERGY RESPONSE
Remove all latex products from immediate proximity of patient and
staff treating the patient to prevent inadvertent use of products by
staff or patient, increasing the risk for contact and allergic reaction.
Perform: Administer prescribed drugs and treatments as ordered.
Wheezing and shortness of breath can quickly deteriorate to
respiratory distress and failure. Skin with urticaria and itching is
uncomfortable and unsightly so patients appreciate timely administration
of treatment.
Inform: Teach patient and his or her family to avoid latex products
to prevent future contact and allergic reactions. Provide instruction
about household items that contain latex (provide a written list) and
tell them about nonlatex substitutes. Prevention is the foundation of
treatment of latex allergies.
Instruct patient and his or her family about importance of seeking
immediate medical treatment of allergic reactions to foster timely
intervention.
Attend: Provide emotional support and encouragement to help
improve patient’s self-concept.
Involve patient in planning and decision making, and have him or
her perform self-care activities. Having the ability to participate will
encourage greater compliance with the plan for activity.
Manage: When latex allergy is confirmed, document and label record
clearly to prevent future contact with the allergen.
Emphasize need to inform all healthcare providers about patient’s
sensitivity to latex. Stress the importance of wearing a medical identification
bracelet that specifies latex allergy to prevent future
contact and allergic reactions.
Provide documentation of latex allergy for the patient to take to
employer; with the patient’s permission, communicate with employee
health department and discuss patient’s need to avoid contact with
latex products to prevent further contamination.
SUGGESTED NIC INTERVENTIONS
Allergy Management; Anaphylaxis Management; Environmental Risk
Protection; Latex Precautions; Risk Identification; Teaching: Individual
Reference
Crippa, M., et al. (2006, August). Prevention of latex allergy among health
care workers and in the general population: Latex protein content in devices
commonly used in hospitals and general practice. International Archives of
Occupational and Environmental Health, 79(7), 550–557.

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