LATEX SENSITIVITY EDUCATION BY ADVANCED
PRNCTICE NURSES IN PRIMARY CARE

SCholaréy Project for the Degree of M. 8. Na
MICHIGAN STATE UNIVERSITY
DEBORAH ANN WODAREK
2000

 

 

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LATEX SENSITIVITY EDUCATION BY ADVANCED
PRACTICE NURSES IN PRIMARY CARE

BY

Deborah Ann Wodarek

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

2000

ABSTRACT

LATEX SENSITIVITY EDUCATION BY ADVANCED
PRACTICE NURSES IN PRIMARY CARE

BY

Deborah Ann Wodarek

Between 1988 and 1992, the FDA received reports of more
than 1100 allergic or anaphylactic reactions and 15 deaths
related to the use of latex-containing medical devices and
products (Kellett, 1997). Once a person is sensitized to
latex, it takes minimal exposure to set off an allergic
reaction. An advanced practice nurse (APN) can expect to
encounter patients at risk for latex sensitivity, and by
using various roles of the APN, a nurse practitioner can
impact patients and their families.

The purpose of this project is to develop an
educational pamphlet that will increase patient awareness of
the prevalence and risk of latex allergy and minimize latex
crisis. The conceptual framework used for the project is
Pender’s Health Promotion Model, a paradigm well known in
nursing for health promotion.

The ease of use and clinical utility for the nurse
practitioner is an asset of this project. A limitation is
the lack of pre or post testing to determine validity. An
inclusive, research based pamphlet would be of great

assistance to APNs and their clients.

ACKNOWLEDGMENTS

I would like to acknowledge and thank my scholarly
project committee, especially Louise Selanders, RN, EdD,
Chair and also Patricia Peek, RN, MSN, CS, PNP, and Brigid
Warren, RN, MSN, for their enthusiastic support in writing
this project.

I would like to dedicate my scholarly project to
Thomas, my husband, and Thomas and Jeremy, our children, who
understood and encouraged my efforts. And for Mollie, for

her patience and support along the way.

iii

TABLE OF CONTENTS

LIST OF FIGURES

CHAPTER I
Overview

CHAPTER II
Review of Literature

CHAPTER III
Conceptual Framework

CHAPTER IV
Project Development

CHAPTER V
Summary

LIST OF REFERENCES

iv

Page

15

22

31

37

LIST OF FIGURES

Page

Figure 1: Health Promotion Model (Pender, 1987) . . . . . 16
Figure 2: Modified Health Promotion Model

(Woderek, 2000) . . . . . . . . . . . . . . . . 20

CHAPTER I

Overview

On March 29, 1991, the Food and Drug Administration
(FDA) issued a Medical Alert regarding allergic reactions to
latex-containing medical devices (Jackson, 1995). Health
care professionals were advised to identify their latex-
sensitive patients and prepare to treat allergic reactions
promptly (Gelb, 1991). Through early 1996, the FDA reported
more than 1,600 allergic or anaphylactic reactions and 23
patient deaths (Jackson, 1995).

In 1927, the first report of latex allergy appeared in
German literature (Grimm, 1927). In 1979 the first English
language report appeared (Nutter, 1979). Between 1988 and
1992, the FDA received reports of more than 1,100 allergic
or anaphylactic reactions and 15 deaths related to the use
of latex-containing medical devices and products (Kellett,
1997). The literature since 1979 includes numerous studies
and case reports documenting hypersensitivity to latex.
Barnett, Keller, and Murray (1997) give three case reports
about how increased latex contact in the work place has led
to disability secondary to anaphylactic reaction. Once a
person is hypersensitive, it takes minimal exposure to set
off an allergic reaction (Murray, 1997). Serious
anaphylactic reactions have occurred in many different in—

patient, out-patient, and even social settings including

vaginal deliveries, examinations, dental procedures, donning
gloves, and blowing up balloons (Gold & Sussman, 1997).

There are several theories that explain the recent
increase in prevalence of latex allergy. The most plausible
is the introduction of universal precautions in an effort to
prevent the spread of hepatitis B and HIV infections
(Centers for Disease Control, 1987). With universal
precautions, a single standard of blood and body fluid
precautions must be used with all patients at all times as
it is assumed that these fluids could be potentially
infected. One of the main ways to comply with universal
precautions is through glove use (Gold & Sussman, 1997).
Gold and Sussman state that the growing industry for latex
glove production has resulted in greater exposure of health
care workers and patients to latex products.

Increased demand for latex gloves created changes in
glove processing and manufacturing, including shorter wash
and shelf times, which have increased the amount of latex
protein antigens in gloves and other products (Levy,
Charpin, & Pecquet, 1992). Another possible reason for the
increased prevalence relates to greater awareness of latex
allergy and the corresponding increased recognition and
reporting (Kelly, Kurup, Reijula, & Fink, 1994).

The advanced practice nurse (APN) has a major role in
health promotion and disease prevention (Snyder & Mirr,
1995). With the growing number of people affected by latex

allergies, it is clear that an APN in family practice can

2

expect to encounter patients who either have symptoms of
latex sensitivity or are at significant risk. By using the
various roles of the APN, such as clinician, counselor,
assessor, change agent, and educator, a nurse practitioner
in primary care has the opportunity to impact patients and
their families.

Prevention can be categorized as primary prevention or
secondary prevention. In the case of latex sensitivity,
primary prevention concerns increasing patient knowledge of
risk factors that, if left unchecked, could lead to
sensitivity due to continuing exposure. Secondary
prevention is aimed at decreasing latex crisis in patients
who already have latex allergies. Barnett, Keller, and
Murray (1997) give three case reports about how increased
latex contact led to disability secondary to anaphylactic
reaction.

The purpose of this project is to develop an
educational pamphlet that will increase patient awareness of
latex allergy and decrease the risk of latex allergic
response. The pamphlet will focus on patients preventing
occurrences of crises by decreasing repetitive and
sensitizing exposure. This project is literature based.
However, projected means of evaluating the outcome of this
project would be research based and will be discussed in
greater depth in Chapter 5. On a more global scale,
increased awareness of latex sensitivity can reduce hospital

admissions and emergency treatment, reduce absenteeism by

reducing repeated latex exposure. Jackson (1995) believes
that because latex allergy is occupationally acquired, APNs
have a dual responsibility to protect patients. If APNs
take up the challenge of educating patients about latex
allergy and advocating for a latex-free environment, this
may prevent life-threatening situations (Strzyzewski, 1995).

The conceptual framework for this project is the Health
Promotion Model (HPM). Developed by Nola J. Pender, the
framework offers a guide for exploration of biopsychosocial
processes that motivate individuals to engage in behaviors
directed toward amplifying health (Pender, 1996). Well
known in nursing as a paradigm for health promotion, the HPM
has been used in a number of studies addressing enhanced
medication compliance (Lannon, 1997), the role of self-care
at home (Bohny, 1997), strategies for promoting a healthy
diet (Herron, 1991), and strategies for promoting health
protection (Bigbee & Jansa, 1991). The HPM proposes that
there are elements which are divided into cognitive—
perceptual factors, modifying factors, and variables
affecting likelihood of actions.

The HPM is an appropriate framework for interventions
by the APN toward prevention of anaphylaxis. A nurse
practitioner could impact the outcome by increasing a
patient’s knowledge about prevention and treatment, by
acting as a cue to take action, or by addressing modifying
factors or barriers to effective latex prevention. By

educating patient about their personal susceptibility and

4

risk factors, the APN can increase patients’ understanding
of the need for lifestyle changes. A supportive and caring
APN who is continually encouraging and assessing patients
and their families can serve as a vital cue to action and
can help patients develop skills needed to make alternative
choices to latex. The APN can promote a learning atmosphere
to include appropriate avoidance and treatment measures when
indicated to promote better living without latex. Goals and
treatment plans if a latex crisis evolves can be developed.
An APN, using the HPM as a conceptual framework, can be of

great use to patients interested in improving their health.

CHAPTER II

Review of Literature

The body of literature documenting risk factors for
latex sensitivity is significant and there is consensus
among researchers that an individual can greatly reduce his
or her risks by avoidance. Reis (1994) suggests the most
obvious prevention method is avoiding all rubber and elastic
products. However, often there are no alternative products
to those containing latex. In addition, many of the
products used are not labeled to identify latex content.
Sensitization

What is known is that severe allergic reactions can
occur after the most minute amount of particles have been
introduced cutaneously, mucosally, or parenterally.
Sensitization to latex is thought to be the process
responsible for systemic reactions. During the process of
sensitization, the first time the allergen is introduced to
the system no symptoms may occur. However, the immune
system prepares to react immediately to the substance the
next time the body comes into contact with the allergen
(Jackson, 1995). Due to the process of sensitization, many
individuals are fooled into thinking that the slight rash on
their hands under latex gloves or the rash under the elastic
of underwear is harmless. However, this rash may be a

precursor or early warning sign of latex allergy.

Through the process of sensitization, latex allergy
becomes a dynamic progression (Strzyzewski, 1995). Many
published reports (Jackson, 1995; AACN, 1995) document cases
of patients and health care workers who initially
experienced only contact dermatitis when exposed to latex-
containing products. After continual, repetitive contact
with latex they developed an anaphylactic reaction. There
have been several documented cases of nurses who were forced
to leave the health care profession because they experienced
shortness of breath and wheezing when they walked into a
room containing latex gloves (Adkins, 1997; Kellner, 1997;
Barnett, 1997; Murray, 1997).

The literature demonstrates that the evolution of this
allergy is becoming more widespread. In 1987 when the
Centers for Disease Control and Prevention recommended latex
glove use as a part of universal precautions in the
prevention of bloodborne pathogen transmission, reports of
localized reactions to latex-containing products increased
dramatically (Zaza, Reeder, Charles, & Jarvis, 1994). As of
1994, 402 adult patients have had allergic reactions to the
latex tipped catheter used to administer barium enemas. Of
those 402 patients, at least 15 died as a result of the
allergic reaction (Zaza et al., 1994).

Once sensitized to latex, an individual can progress to
develop a more serious allergic reaction. This type of

reaction occurs within minutes to hours of exposure and is

characterized by urticaria, dyspnea, angioedema,
bronchospasms, hypotension, and cardiac arrest.
Occupational Risk Factor

An article published in 1992 quotes the chairman of the
FDA’s Latex Sensitivity Group as estimating that 6% to 14%
of all health care workers are latex sensitive or allergic
(American Health Consultants, 1992). According to Beezhold
and Sussman (1997) latex sensitivity is the development of
immunological memory to latex antigens after exposure.
Subsequent use of antigen—containing materials can increase
sensitivity to the point of allergic reaction. By 1994, 21%
of 1,738 nurses surveyed by the Association of Operating
Room Nurses (AORN) reported having had a latex reaction
(Zaza et al., 1994). Currently, experts estimate that at
least 1 in 10 American health care workers has an allergy to
latex (Strzyzewski, 1995).

Although the literature clearly supports the premise
that latex allergy is an occupationally acquired health
hazard, workers’ compensation is frequently denied to those
people who are forced by the allergy to leave the health
care arena (Groce, 1996). In general, however, the
literature lacks a simple, specific, clinically focused
pamphlet describing risks of latex for the family practice
patient. Legal precedent has yet to be established that
would force an institution to provide disability or workers’
compensation to severely allergic employees when they are no

longer able to work (Jackson, 1995).

General Public

Leaving the individual’s profession isn’t always the
complete answer to the problem. Jackson (1995) estimated
that latex is currently present in more than 40,000 medical,
dental, and consumer products. This pamphlet will provide a
list of some consumer products containing latex. Allergic
reactions commonly occur in the dental office due to use of
equipment made from latex that is placed directly in contact
with mucous membranes of the mouth (Strzyzewski, 1995;
Heese, Peters & Koch, 1997). Reis (1994) gives examples of
further home exposure through wearing household cleaning
gloves, using latex condoms, blowing up balloons, and
handling sports equipment, especially tennis racket handles.
Groce (1996) discussed latex being found in finished cotton,
nylon and lycra spandex products. Natural rubber latex has
been used since the 19208 as the central core for other
fibers. Elastic yarns are made with a core of either
natural rubber fibers or lycra spandex with cotton wrapped
around it. Rubber yarns are used in foundation garments,
swimwear, surgical fabrics, elastic bandages, support hose,
underwear, shoe fabrics, and the tops of socks and hosiery
(Groce, 1996). Groce further explains waistbands are the
most likely place to find latex thread. Sewn-in waistbands
are more likely to contain latex threads than knitted-in
waistbands. Current Federal Trade Commission rules say that
a manufacturer does not have to list components of a garment

if the ingredient comprises less than 5% of the total.

Mitchell (1999) points out that 5% is a considerable amount
if the material is an allergen.

Latex allergic patients who experience a reaction
around streets that are being paved or roofs being repaired
do so for a reason. ‘According to Groce (1996), asphalt,
when combined with ground up tires in the paving process,
contains natural rubber. The latex sufferer also needs to
be aware of the natural rubber found in both passenger car
tires and commercial vehicle tires. Latex allergens have
been documented in tire dust, roadside dust, and air samples
from the Los Angeles area (Groce, 1996).

Protocols

Kerr (1999) and Seibel (1999) document a proactive
approach taken by some hospitals that recognize the
seriousness of allergies. These institutions have a no
latex balloon policy in an attempt to reduce exposure to
patients and staff members. Kerr (1999) further documents
that Shriners Hospital for Children in Springfield,
Illinois, take this a step further and send all donations of
toys or sports equipment through a test to determine latex
contents.

Avoidance could lengthen the patients quality of life
at home and in the workplace. The APN needs to become
familiar with products containing latex at work and at home
to educate patients (Strzyzewski, 1995). The APN needs to
be vigilant in educating patients of latex-containing

products. Adkins (1997), Coulombe (1998), and Stein,

10

Badger, & Pavesi (1995) offer as a guideline to individuals,
families, and professionals a list of latex-containing foods
and products. Because the information in this area is
continually changing, the APN needs to research updates
continuously.

Most literature and research has focused on the
history, clinical, and patient care aspects of latex allergy
among health care providers. Guidelines and standards for
providing care to patients in the family practice setting
are lacking. McCormick, Cameron, and Biel (1995) describe
how guidelines and standards for providing care to patients
with latex allergies has largely been left to the
occupational health professional. McCormick et a1. (1995),
Coulombe (1998), and Jezierski (1997) give examples of
established standardized protocols for treating known latex-
sensitive individuals and identifying those who are at high
risk. Because the effects of this allergy can be so
devastating, APNs have a major role in collaborating and
educating their colleagues. APNs possess a unique body of
knowledge and come in contact everyday with people who may
not even be aware of the hazards of latex allergy
(Strzyzewski, 1995).

Food Exposure

Though several latex crossreactive allergens have been
identified, food allergens most notably banana, avocado,
kiwi, chestnut, and soybean have been the most documented

(Zweiman, 1998). Delbourg, Guilloux, Vautrin, and Ville

ll

(1996) studied the relationship between banana
hypersensitivity and latex allergy in a population of 19
latex-allergic patients. Eight of 16 patients (50%)
reported symptoms after eating bananas, and banana skin
prick tests were positive in 5 of 14 patients (63%). They
further explained that in immunoblot experiments, 17 of the
19 patients (89%) exhibited specific banana IgE antibodies
and 16 allergenic components were identified. This study
helps to confirm the latex-tropical fruit correlation.
Testing

Post, Jennett, Zaglaniczny, Oesterle, Lebenbom—Mansour,
and Jarrett (1996) did a prospective study evaluating the
prevalence of IgE antibodies to latex and the value of a
high-risk history in predicting the presence of IgE
antibodies to latex. Questionnaire responses and serum
levels of IgE antibodies against latex proteins (ALASTA)
from 996 patients showed that history alone was not a
reliable predictor of latex allergy.

Heese, Peters, and Koch (1997) did a longitudinal
study, which included 81 members of a nursing school
evaluated prior to beginning training. Some had already
worked in a hospital for some months. A total of 8.6% of
these 81 volunteers had a positive prick test to latex
extracts. Recommendations from this study were to perform a
latex allergy evaluation prior to entry or employment in the
medical profession to minimize risks. Zweiman (1998) states

the diagnosis of latex allergy is frequently not easy, but

12

newer skin test and in—vitro blood testing may help.
According to Young & Meyers (1997), to date, the FDA has not
approved a standardized latex extract in the United States
for the skin prick test. Allergists must prepare their own
allergen by using extractions from latex gloves or raw latex
sap. Although this method is highly sensitive (90% to 95%),
some researchers have reported up to a 2% incidence of
anaphylaxis with these tests (Keller, 1997). Both the
intradermal and skin prick tests carry the possibility of
eliciting a systemic allergic reaction, or even anaphylaxis,
to the latex allergen (Young & Meyers, 1997). Precautions
should be taken before performing these tests, and emergency
medication and resuscitation equipment should be available.
The APN needs to weigh the importance of obtaining a
diagnosis to latex allergy through definitive testing
against the risk of conducting the test. Obtaining an
accurate clinical history may be the safer route to
determine latex sensitivity (Young & Meyers, 1997).
Radioallergosorbent testing has been used to measure
the serum level of latex-specific IgE (Kellett, 1997).
Estimates of the sensitivity of this method range from 50%
to 95% (Turjanmaa & Reunala, 1988; Young & Meyers, 1997).
The test uses a two—phase system with an insoluble allergen.
The allergen is first incubated in a sample of patient’s
serum to react with allergen—specific antibodies and is
followed by an incubation with radio—labeled heterologous

antihuman IgE to detect the allergen-specific antibodies of

13

the IgE isotype (Gleitch & Yunginger, 1981). Sensitivity
and specificity of the radioallergosorbent test depends on
the population being tested (Weido & Sim, 1995). According
to Kellett (1997), it is important to realize that the level
of reaction does not always equate with the level of IgE.
Patients who have had negative test results have had serious
reactions.

The literature does a adequate job of describing of how
to manage latex-sensitive individuals once sensitivity or
allergy has been determined. It is lacking, however, in
providing practitioners with diagnostic testing or the tools
or devices to help with teaching patients how to minimize

risk.

14

CHAPTER I I I

Conceptual Framework

Theories and models are useful in their ability to
provide guidance and direction for research and practice. A
useful theory should provide a researcher with important
variables that can be examined in relation to phenomena of
interest. Thus far, no single theory or model has captured
all potential variables related to nursing education.

The Health Promotion Model (HPM) was derived from
social learning theory to explain individuals’ behavior in
regard to promoting health (see Figure 1). Health as
defined by Webster (1988) is "state of fitness of the body
or of the mind" (p.446). According to Pender, "Health is
the actualization of inherent and acquired human potential
through goal-directed behavior, competent self—care, and
satisfying relationships with others while adjustments are
made as needed to maintain structural integrity and harmony
with relevant environments" (Pender, 1996, p.22). Health
for the latex-sensitive individual is self-care and control
of environmental factors. The more often a latex-sensitive
person comes into contact with the allergen, the more
sensitive they may become. This increases the individual’s
sensitivity with a higher likelihood of developing a life-
threatening anaphylactic reaction.

The HPM is utilized for this project because it has

been used as the theoretical basis for studying the impact

15

COGNITIVI-PIRCIPTUIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODIFYING [MOTORS PARTICIPRIIOI IN
EIALEE-PRGIDIING BIINVIORB
Dem hi
Importance of health ___ ograp c
characteristics
Perceived control Of ___ Biologic characteristics
health
Perceived self-efficacy ___ Interpersonal influences __., Likelihood of engaging in
health-promoting behaviors
Definition of health ___ Situational factors E
i
Cues to action
Perceived health status ___ Behavioral factors

 

 

 

 

 

 

 

 

Perceived benefit: of

health-promoting behaviors

 

 

Perceived barrier: to

health-promoting behaviors

 

 

 

 

 

 

Figure 1.

Health Promotion Model (Pender, 1987).

16

of health education. Opatz (1985) defines health promotion
as "systematic efforts by an organization to enhance the
wellness of its members through education, behavior changes,
and cultural support" (p.7). Pender (1996) defined health
promoting behavior as "directed toward increasing the level
of well-being and self-actualization" (p.53). Pender
further defines the HPM as "an attempt to depict the
multidimensional nature of persons interacting with their
environment as they pursue health" (p.53).

This model has potential application across the life
span from pediatric to geriatric nursing. The usefulness of
the HPM lies in the ability to examine the individual’s
level of well-being, self—actualization, and personal
fulfillment.

Pender (1987) has categorized health promoting behavior
into cognitive-perceptual factors, modifying factors, and
variables affecting likelihood of actions. Cognitive-
perceptual factors include importance of health, perceived
control of health, perceived self-efficacy, definition of
health, perceived health status, and perceived benefits and
perceived barriers to health-promoting behaviors. Modifying
factors (including demographics, biological characteristics,
interpersonal influences, situational factors, and
behavioral factors) are proposed to have a causal influence
on the cognitive-perceptual factors, which represent the

primary motivational factors of health—promoting behaviors.

l7

Pender (1987) discusses how health education is an
intervention capable of sustaining behavioral change.

Hamric and Spross (1989) describe primary care "as a mode of
practice delivered in ambulatory settings and that the
concept of primary care be coordinated, comprehensive care
delivered throughout a course of illness, inclusion of
health promotion as well as illness treatment, and the
emphasis on education" (p.383). Health education about
latex-sensitivity by primary—care providers can protect
patients from future difficulties. Primary-care providers
can take action to help patients reduce their risk of latex
sensitivity. This relates to Pender’s perceived control of
health risk. These actions can benefit not only
individuals’ health but also affect employment opportunities
and families.

Pender viewed environment, situational, and
interpersonal factors as modifiers of the central cognitive-
perceptual factors. King (1994) suggests Pender viewed the
environment as it relates to behavior rather than how it
relates to health. People who value health tend to seek
information about health-related issues (Pender, 1987). In
the case of people with latex sensitivity, education is
critical if the person is going prevent a latex crisis.
Although education about medical treatment is initiated at
the time of diagnosis, it needs constant reinforcement in
order to produce maximum health results. Each interaction

with the patient provides an opportunity to review patients'

18

knowledge about latex sensitivity and to assess their
motivation regarding prevention (Bandura, 1977).

As is applies to latex sensitivity, Pender’s health
promotion model must be adapted. The relevant cognitive-
perceptual factors include definition of health, perceived
benefits of health—promoting behaviors, and perceived
barriers to health—promoting behaviors. Modifying factors
as applied to latex sensitivity include household exposures,
occupational exposures, foods to avoid, and protective
measures (see Figure 2).

Pender gave little recognition to the impact that the
society standing has on the individual. Rather, she focused
on individuals, their perception of control, definition of
health, and decision-making capacity. Pender (1987)
admitted that the extent to which the HPM can explain
lifestyle patterning or specific behaviors remains to be
seen. The model neglected to address the behavior of
families and communities, which are important influences on
individual behavior. Pender’s model is further limited as
the existence or complexity of interrelationships among
factors is not acknowledged. For example, how do
interpersonal influences relate to one’s definition of
health? Is one’s age reflected in one's definition of
health? Hilton (1986) felt that further clarification was
needed in the area of self-esteem and questioned, "do
attitudes precede behavioral changes, or vice versa?"

(p.61).

19

COGNITIVE-PIRCIPTUIL

MODIFYING-IACTORS

 

7

 

Definition of health

 

 

 

Situational factors

—household exposures
(balloons, tires, tennis
shoes)

-foods to avoid
(bananas, avocado, kiwi)

 

 

 

 

Perceived benefits of
health-promoting

behavior

 

 

Biological characteristics
—individual susceptibility
to latex

-type of reaction

PIRTICIBAIIGN IN
H!ALEB*PROMDIINO“BIEIFIORS

 

 

Likelihood of engaging in
health-promoting behaviors
-avoiding latex allergy
~to change to non-latex

products

 

 

 

Perceived barriers
to healthepromoting

behaviors

 

 

 

 

Figure 2.

Modified Health Promotion Model

Demographic characteristics
-occupational exposures

(medical, dental)

?

 

 

 

Cues to action
-pamphlet
-utilization of pamphlet
by nurse practitioner in

patient education

 

 

 

 

 

20

(Wodarek, 2000)

 

 

According to Green and Raeburn (1990), health promotion
models must move beyond assessment of health and health
programs, toward implementation of these programs. The
individual and global environment context should be
considered to be of equal account.

According to the HPM, once people decide to engage in
preventive behavior, a cue is needed to motivate them into
action. Cues may be internal, such as the perception of a
symptom, or external, such as an advertisement or pamphlet.
Pender contends that the intensity of the cue must match the
level of readiness of the patient. For example, a patient
with a low level of readiness needs a high—intensity cue to
act (Pender, 1975).

Changes are required and change is rarely easy.
Advanced practice nurse will be assisted in developing their
empowering and health promoting skills with this pamphlet.

A sound theoretical base of knowledge will be essential as
APNs link theory to the practical tasks of assessment,
planning, implementation, and evaluation. The APN must
examine what health promotion has to offer the patient as

well as what the APN can offer health promotion.

21

CHAPTER IV

Project Development

Latex sensitivity is a challenging new disease process
that requires health care professionals to become more
knowledgeable to ensure provision of safe quality care and
to recognize their own risks. Most literature and research
has focused on the history, clinical, and patient care
aspects of latex allergy. Little has been written about the
education teaching material available for the primary care
patient. A latex allergy pamphlet was developed with the
intention for anyone involved in the education of patients’
to be aware of the prevalence of latex sensitivity.

This pamphlet will give the primary care patient a
greater understanding to latex allergy and will assist them
in formulating plans of action to provide safe quality care.
It will also be an interactive educational pamphlet
promoting transference of the learning back to the actual
primary care work environment. Areas of focus will include
identification of latex, reactions, foods to avoid,
products, to protection methods, and resources. It lacks a
comprehensive knowledge base but will assist the patient
into further research. It is hoped the pamphlet will assist
the patient in formulating an action plan to alternative
products and help to ensure a quality safe environment.

The pamphlet is at the fifth grade reading level, which

is appropriate for most healthcare material intended for the

22

public. Even this will be too difficult for many adult
Americans (Doak, 1996). A need clearly exists to match
materials to the needs of those with more limited literacy
skills. Le Welling (1992) felt the single most problem is
installation of a language that is a national language
related to vocabulary expansion, spelling or grammar
standardization to cover a sufficiently large majority of
the citizens. This pamphlet is written in English but could
be translated into other languages.
Project

In 1927 the first report of latex allergy appeared in
German literature (Grimm, 1927). In 1979 the first English
language report appeared (Nutter, 1979). Between 1988 and
1992, the FDA received more than 1100 reports of allergic or
anaphylactic reactions and 15 deaths related to the use of
latex—containing medical devices and products (Kellett,
1997). The literature since 1979 includes numerous studies
and case reports documenting hypersensitivity to latex.
Barnett, Keller, and Murray (1997) give three case reports
about how increased latex contact in the work place has led
to disability secondary to anaphylactic reaction. Once a
person is hypersensitive, it takes minimal exposure to set
off an allergic reaction (Murray, 1997). Serious
anaphylactic reactions have occurred in many different in-
patient, out-patient, and even social settings including

vaginal deliveries, and examinations, dental procedures,

23

donning gloves, and blowing up balloons (Gold & Sussman,
1997) .
LABS;

Natural latex is the white milky sap harvested from the
rubber tree hevea brasiliensis. The tree is grooved and the
sap then drains into collection cups placed at the end of
the grooves. Preservatives such as ammonia and sulfites are
added immediately to prevent auto coagulation of the sap.
During the conversion of liquid natural rubber latex into
the finished product, many accelerators, antioxidants,
emulsifiers, stabilizers, extenders, colorants, retarders,
stiffeners, ultraviolet light absorbers and fragrances are
added (Jackson, 1995). After processing, the product
contains 2% to 3% latex protein. It has not yet been
determined whether the latex or hevea proteins, the
chemicals used in the manufacturing process, or the
combination of the two cause the allergic reaction (Jackson,
1995). Natural rubber latex should not be confused with
butyl- or petroleum based synthetic rubbers. Synthetic
products, including latex house paints, have not been shown
to pose any hazard to latex sensitive individuals (Mitchell,
1999).

Reactions

There are three types of reactions to latex products.
The first is the chemical irritation dermatitis, the second
is type IV contact dermatitis, and the third type is the

type I immediate reaction (Kellett, 1997).

24

Chemical irritant reactions are the most common adverse
reactions associated with exposure to latex products. They
are caused by chemicals such as theorems used in
manufacturing. These reactions are especially prevalent
among individuals who wear latex gloves continually at work.
They usually cause a mild chemical dermatitis, which occurs
in 25% to 40% of regular glove wearers. Irritant reactions
do not involve the immune system, but they may be important
cofactors in the development of immunologic reactions to
latex (Kateraris, 1996).

Type IV reactions are somewhat minor delayed local
allergic reactions that are caused by chemicals added to the
latex during its manufacturing. Type IV dermatitis,
although caused by the same chemicals as the irritant
reaction, is a true allergic reaction involving the immune
system, but it is localized to the skin or mucous membrane
(Kellett, 1997). This is a delayed, hypersensitive,
cutaneous reaction to the rubber additives
mercaptobenzothizole and tetramethyithiuram (Bensky, 1995).

Type I allergic reaction are the antigen antibody
reactions mediated by the IgE mast cell system. These are
immediate reactions that can occur within minutes or one to
two hours after exposure. Immediate allergic reactions to
latex happen when latex proteins enter the body through the
skin, respiratory tract, or mucosal or serosal membranes
(Sussman, Tarlo, & Dolovich, 1991). Tarlo, Wang, and Ross

(1990) suggest in their data that the respiratory tract is a

25

very significant route of sensitization. This finding is
particularly important to the individual who often works in
environments with high levels of airborne latex because of
frequent repetitive exposure to latex.

Signs and Symptoms

Chemical irritants cause non—allergic skin rash
characterized by hand erythema, dryness, cracking, scaling,
and vesicle formation (Fay, 1991).

The contact dermatitis that occurs with type IV delayed
reactions presents with pruritus, edema, erythema,
vesiculation, crusting, thickening of skin (Jackson, 1995).
This itchy, red, mildly swollen rash first appears only on
areas of the skin which actually touched the latex but then
spreads beyond the contact area. These symptoms typically
emerge 10 to 30 hours after contact.

Signs and symptoms of a type I hypersensitivity
reaction include generalized urticaria, wheezing, dyspnea,
laryngeal edema, bronchospasm, tachycardia, angioedema,
hypotension, and cardiac arrest (Jackson, 1995). Symptoms
typically occur within minutes of exposure. In rare cases,
anaphylaxis may result (Sussman & Beezhold, 1995).

Risk Grccps

Generally, anyone who encounters significant exposure
to latex has the potential for developing a latex allergy.
Fisher and Sawins (1998) identify individuals with chronic
urologic conditions, patients with a history of multiple

surgeries, and atopic individuals in the high risk groups.

26

Many occupations are at particularly high risk for the
development of latex allergy. These include hairdressers,
greenhouse workers, food preparation personnel, housekeeping
staff, rubber manufacturer employees, homemakers, day care
workers, and dairy workers (Groce, 1996).

Mormann (1996) identifies children and adults afflicted
with spina bifida as being the highest risk group. These
patients become sensitized because of extensive exposure to
latex when undergoing multiple surgeries and
catheterizations along with repeated contact with medical
personnel wearing latex gloves (Fink, 1995). Health care
workers experience the second highest incidence (Mormann,
1996) .

Risk taking behaviors put average adolescents at high
risk. Daily exposure to latex containing items such as
school supplies (rubber bands, erasers, gym floors, and fast
food consumption (food handled with latex gloves), and
athletic supplies (sneaker soles, elastic on socks, handles
of racquets) can lead to sensitization in the currently
nonallergic individual (Fisher & Sawin, 1998).

Unfortunately the active adolescent has a difficult task
avoiding latex containing products. Further careful
discussion of contraceptive methods must be initiated for
the sexually active teen.

A further risk factor has been documented in
individuals with a history of food allergies to tropical

fruits, hazelnuts, chestnuts, or peaches, particularly if

27

symptoms escalate inseverity. Chen, Posch, Cremer, Raulf-
Heimsoth and Baur (1998) "hevein is the major cross-reacting
allergen with avocado in subjects with latex allergy"
(p.476). Health care workers with a history of atopy
(asthma, hayfever) or who have food allergies particularly
to bananas, avocado, chestnuts, and kiwi fruit are at risk
for sensitization to latex (McCormack, Cameron & Biel).

Lat 0

There are thousands of medical products that contain
latex. It is a difficult task to identify them, because
many products are not labeled with their contents, so it may
be necessary to contact each manufacturer for written
information.

Latex is a common component of many medical supplies,
including disposable gloves, airway and intravenous tubing,
syringes, stethoscopes, catheters, dressings and bandages.
Latex also is found in as many as 40,000 consumer products,
including condoms, balloons, athletic shoe soles, tires,
underwear leg and waist bands, rubber toys, nipples and
pacifiers (Mitchell, 1999). In the United States, recycled
or reclaimed rubber has been used to reinforce asphalt since
the early 1960s. The reclaimed rubber is formed from ground
whole tire rubber and ground tire tread. These tire
components contain natural rubber. More further, latex
allergens have been found in tire dust, roadside dust, and
air samples from the Los Angeles area (Groce, 1996).

Several hospitals across the country are no longer

28

permitting latex balloon to be brought in as gifts for
patients. Kerr (1999) reports Shriners’ Hospital for
Children is latex free and even donations of toys or sports
equipment must pass the latex free test.

Recommendaticns to the Latex Sensitive Patient

Although there is no treatment for the latex allergy,
patients can reduce their risk of reaction by avoiding
direct contact with latex. They should take steps to find
out which products in their environments contain latex and
the substitutes that can be used for those products. It is
also important to avoid breathing in latex particles from
powdered gloves.

Latex-allergic individuals should always wear a Medic-
Alert bracelet or necklace and talk to their health-care
providers and dentists about their allergies. Other
precautions include a prescription for an epinephrine self-
injection pen to use in case of a serious reaction. They
may even wish to carry non—latex gloves with them at all
times for use by emergency personnel if they need medical
attention. Researching area hospitals to determine their
latex allergy policies is another suggestion. Jackson
(1995) believes many companies are becoming knowledgeable
about latex sensitivities and are beginning to identify
their products that contain latex. Part of the APNs
responsibility is to become educated and educate others by
joining resource groups, support groups, and government

legislation to support non—latex alternatives.

29

Re sourcss

The World Wide Web contains numerous sites dealing with
information about latex allergy, with new material
continually being added. Below are just some examples:
Latex Allergy Links
http://www.netcom.com/~nam1/latex_allergy.html.

Latex Allergy Help

http://www.latexallergyhelp.com

Foundation for Latex Allergy Research and Education
http://www.flare.org

Latex Allergy Home Page

http://allergy.mcg.edu/physicians/ltxhome.html

3O

CHAPTER V

Summary

Latex products are everywhere, and anyone can become
allergic to latex. People with the highest risk are those
who have had many operations, especially in childhood.
People with spina bifida and urologic abnormalities are
especially at risk. Latex allergy can be mild, with
symptoms such as itchy, red, watery eyes, sneezing or runny
nose, coughing, rash or hives. It can also be very severe,
with symptoms like chest tightness, shortness of breath, and
shock. It may even cause death. A latex—sensitive person
can have a life-threatening allergic reaction with no
previous warning or symptoms. Some foods may cause an
allergic reaction in people who are allergic to latex. The
most common of these foods are banana, avocado, chestnut,
kiwi and tomato. It is recommended that latex-sensitive
individuals avoid only the foods that have given them an
allergic reaction to prevent possible nutrition problems.

Although there is no treatment for latex allergy,
individuals can reduce their risk of reaction by avoiding
direct contact with latex. Taking steps to find out which
products in the environment contain latex and the
appropriate product substitutes is essential for latex-
sensitive individual.

Young and Meyers (1997) emphasize it is possible to

create a safe environment for patients who need to avoid

31

latex. Further research needs to be done in manufacturing
regarding extraction of latex protein allergens from
products. Patients should be encouraged to use latex-free
products. Employers need to develop protocols that
employees can use to alter their work environment.
Implications for Practice

With the widespread use of latex containing products
within the health care industry, all primary care providers
should be advised of this potential problem. The allergy
status, including latex allergy, of all patients should be
known. Once latex allergy is established, avoidance of
latex containing products is important. Since the primary
care provider often has the most contact with a given
patient, continuing education on latex allergy should be
included in each visit (Fisher, 1998). Latex allergy is
becoming an enormous problem for the health care industry.
Practitioners need to act in a responsible manner to protect
patients or millions of other patients may become allergic
to the medical products that were designed to save lives
(Kellett, 1997).

Advanced practice nurses in family practice see
patients on a frequent basis through health promotion and
sick visits. Relatively frequent visits provide the APN
with opportunities to reinforce cautions and assist with
problem solving for finding latex—free alternative products.

For the patient who requires surgery, latex allergy

status should be discussed with the surgical team. Eighty

32

percent of anaphylactic reactions in the pediatric
population that occur during surgery are due to latex
allergy (Fisher, 1998). Since patients come in contact with
a variety of personnel in the office or clinic setting,
latex allergy in—service programs and educational pamphlets
should be available for all personnel.

APNs in all settings should consider latex allergy in
any patient with complaint of allergenic or dermatologic
symptoms. Once an latex allergy or a high-risk group
patient has been identified, latex precautions should be
instituted. Proposed interventions would include the
following: latex allergy sign on the chart and latex free
toys and activities in the waiting room. Supportive
services’ including pharmacies, nursing, and dentistry
should be informed, and appointments should be scheduled for
first thing in the morning, preferably Monday morning, in
order to avoid undue exposure to aerosolized latex glove
powder. The primary rule is antigen avoidance (Charous,
1994). Latex containing items in the room or on the
examination table should be removed whenever possible.

Those items that cannot be removed should be covered to
prevent possible patient contact. Latex allergy
information, including references for alternative products,
should be provided. Use of Medic Alert bracelets should be
advocated. Household items, including toys that potentially

contain latex, should be reviewed with patients and families

33

so that they can be removed and replaced with nonallergenic
items.

In education, strategies to teach health promotion as a
nursing role need to be formulated. Practical skills to
fulfill the health promotion role and all of its components,
such as counseling, educating, and managing, need to be
taught from a health promotion perspective. Nurses who
graduate with the knowledge that they have a unique skill
are in a unique position to help themselves and others
attain and maintain the balance and perspective associated
with a state of wellness (Fritz, 1984). The advanced
practice nurse has a major focus in the role of health
promotion and disease prevention (Snyder & Mirr, 1995).

This scholarly project focuses on the role of education
about latex crisis prevention through latex avoidance.

The Health Promotion Model is an appropriate conceptual
framework on which to base patient counseling regarding
risks of latex sensitivity. By evaluating patients’
potential risks and barriers to change, modifications can be
made to reach cues to action. APNs serve as that cue to
action. They provide information to affect patients’
perceived benefits of health-promoting behaviors and
perceived barriers to health-promoting behaviors, which
combine to form the likelihood of patients engaging in
health—promoting behaviors. NUrse practitioners can also

demonstrate the positive impact to patients of adopting

34

health behaviors, such as avoidance of latex products, by
providing a simple useable pamphlet.

The availability of a simple, clinically useful
pamphlet that explains threats of latex sensitivity based on
modifiable risk factors would be of great benefit to APNs.
Further strengths of this pamphlet are its applicability to
the general public in primary care and the illustration of
the need for more research studies.

A limitation of this project is that the pamphlet has
not been pre or post tested to determine validity. There
are numerous case study anecdotes but research based
pamphlets are lacking.

The major contribution of this project is the support
for future research to develop a more inclusive, clinically
useful pamphlet that addresses both objective and the
subjective state of the patient. The necessary research
would first require retrospective studies to determine the
most significant risk factors and then a long-term
prospective study to evaluate whether interventions to
reduce risk factors would result in less exposure
sensitivity. Future research could be both quantitative and
address incidence of latex sensitivity or it could be
qualitative and measure severity of latex sensitivity.
Advanced practice nurses have a role in research and could
be instrumental in such studies.

A pamphlet that meets the criteria of inclusiveness and

clinical utility would be of great assistance to APNs and

3S

could play a role in helping clients to reduce their risk of
developing latex sensitivity.

Effectiveness of the pamphlet could be demonstrated by
designing a simple questionnaire that assesses patients’
knowledge of latex sensitivity and its dangers. The
questionnaire could be administered to two groups of
patients controlled for demographic characteristics such as
socioeconomic status, education, and occupation. The
questionnaire would serve as a pre—test for one group which
would then read the pamphlet. The same questionnaire could
then be administered to this group and would serve as a
post-test to measure patients’ increased knowledge as a

result of the pamphlet.

36

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41

APPENDIX A
LATEX SENSITIVITY PAMPHLET

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