SKIN & SOFT TISSUE INFECTIONS Ruth Anne Rye MSIPC Fundamentals October 2015.
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Transcript of SKIN & SOFT TISSUE INFECTIONS Ruth Anne Rye MSIPC Fundamentals October 2015.
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SKIN & SOFT TISSUE INFECTIONS
Ruth Anne Rye
MSIPC Fundamentals
October 2015
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ManifestationsClassification of wounds Surgical: acute, chronic Non-surgical -
cellulitis - scalded skin syndrome - pressure ulcers - venous insufficiency ulcers
- diabetic neuropathy ulcers - Varicella and Zoster
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PRESSURE ULCERS
DEFINITION:
A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
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Best practices for pressure development:
Implementing a guideline-based
recommendation provides the best
opportunity for improving outcomes
including the incidence of
pressure ulcers. Numerous federal
and professional organizations have
published evidenced-based guidelines to
prevent pressure ulcers.
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RISK FACTORS and CONTRIBUTING FACTORS for pressure ulcer development Altered arterial and/or venous blood flow Cognitive impairment Decreased sensory impairment Dehydration Diabetes External device - brace, cast, dressing, Friction, Immobility Incidence of previous pressure ulcer Inadequate nutritional intake and weight loss Moisture Shear Unrelieved pressure Vascular insufficiency
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PRESSURE ULCER STAGINGNational Pressure Ulcer Advisory
Panel, Feb 2007
Stages I, II, III, IV, Unstageable/Unclassified. “Never” event.
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PRESSURE ULCER PREVENTION
Risk assessment - Identify patient at risk - on
admission, at defined periodic
intervals, and if significant
change in status
- Utilize assessment tool: Braden Scale or Norton
Scale
- Analyze risk factors
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continued
Develop an individualized plan of care
- Identify problem based on risk factors
- Realistic, time-framed goals
- Interventions that address risk factors
Provide education - healthcare
personnel, patients, families
Implementation and documentation of interventions
Shingles - Zostavax
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IMPLEMENTATION AND DOCUMENTATION OF
INTERVENTIONS
Maintain personal hygiene Relieve or reduce pressure (pressure
redistribution) Inspect skin daily Measure (assess) impact of interventions Modify interventions as indicated by analysis
of assessment
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Using evidence to effect positive outcome, i.e. preventing p.u.
Summary: St. Vincent Medical Center developed a comprehensive, interdisciplinary set of guidelines, known as the
SKIN bundle, to provide staff with a synergistic group of interventions to implement for the prevention of pressure ulcers in all patients with a Braden score of 18 or less.
SKIN: S = surface, K = keep turning, I = Incontinence management, N = Nutrition and hydration management
Results: The program reduced the incidence of pressure ulcers by more than 90%, including completely eliminating state 3 and 4 facility-acquired pressure ulcers for a significant amount of time.
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Regulation related to pressure ulcer prevention: Skilled Nursing facilities
Federal Tag 314 - …must ensure that (1) A resident does not develop pressure sores unless … (2) A resident having pressure sores receives necessary treatment and services …. Federal Tag 309: Synopsis – The facility must
provide the necessary care and services to attain or maintain his/her highest practical level of physical, mental and psychosocial well-being ….
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Regulation, continued
Michigan Nursing Home Rule
R 325.20707 Nursing care and services
Rule 707 (i)
A patient shall receive skin care as required according to written procedures to prevent dryness, irritation, itching, and decubitus
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References and Resources
National Pressure Ulcer Advisory Panel (www.npua.org) serves as authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research.
Institute for Healthcare Improvement (IHI) – How-to Guide: Prevent Pressure Ulcers
Agency for Healthcare Research & Quality (AHRQ) Wound Ostomy & Continence Nurses Society
(WOCN) And others
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SCABIES Prevention and Control
Sarcoptes scabei, commonly known as scabies is a parasitic mite that causes intense pruritis (itching),rash and lesions. Infestation is not life threatening, but a nuisance disease that is commonly found is health care facilities, schools and other settings,and can result in crisis, fear, and panic.
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DIAGNOSIS/CONFIRMATION* Suspicion* Definitive - skin scraping
RECOVERY* Microscopic evaluation* Ink test (not widely used/accepted)
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Incubation period
1. Primary infestation: 2-6 weeks2. Re-infection: Symptoms may appear almost immediately after exposure
Symptoms• Intense itching• Red rash and bumpy eruptions• Pus-filled lesions and nodules
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TREATMENT
Permethrin cream 5%(Elimite)• 90% effective after one treatment.• May require two treatments for
eradication
Ivermectin • Oral, dosed according to person’s weight• Use alone or in combination with permethrin
Lindane 1% (Kwell)- MDCH does not recommend use
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TREATMENT protocol
• Isolation precautions - private
room unless treating roommate• HCW - wear PPE• Bathe and dry• Apply scabicide• Washed off? Reapply• Leave on recommended time – usually 12 hrs.• Remove by washing thoroughly• Re-examine at 2 and 4 weeks
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ENVIRONMENT
1. Change all linens2. Bag all items worn in last week, and wash3. Non-washable items - dry clean, or hot dryer 20 min, or seal 5-7 days4. After scabicide removed, change all linens, towels, and clothing and wash5. Disinfect mattress, pillow covers, floors, multiple-use items, bedside equip6. Discard topicals used by symptomatic
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Assessment of treatment failure
• Poor application technique• Continued contact with untreated persons• Failure of resident to respond• Continued use of steroids during tx• Failure to kill scabies mite in clothes, upholstered furniture or carpeting
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NORWEGIAN SCABIES
• Referred to as crusted scabies • Hundreds to millions of mites• Very contagious• Itch - minimal or absent, or extreme • Most often occurs in the elderly
Precautions:Standard plus contact & airborneuntil lesions dry and crusted
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SCABIES PREVENTION STRATEGIES
• Skin assessments – define intervals• Suspect? Immediate search for new/ additional cases• Education - HCW, patients, families, and others
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RESOURCE
Michigan Scabies Prevention and Control Manual. Michigan Department of Community Health 2005
www.michigan.gov/documents/BHS_NHM
_Michigan_Scabies_Prevention_and_
Control_Manual_131983_7.pdf
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SHINGLES(HERPES ZOSTER)
Shingles is a painful localized skin rash often with blisters caused by the varicella virus (VZV). Anyone who has had chickenpox can develop shingles.
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REVIEW THE FACTS
Virus remains dormant or inactive in nerve cells of the body after the infection clears
About 20% who had chickenpox will get zoster
Most get only once More common over age 50,
immunosuppressive drugs, immune system not working properly
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SYMPTOMS
Burning pain, tingling or extreme sensitivity one area of body, usually one side (trunk, buttocks, also arms, legs, eye)
1-3 days later rash at that site May have fever or headache Rash becomes blisters - last two to three
weeks Followed by pus or dark blood, then
crust/scab, disappears Pain often severe
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RISK FACTOR? weakened immunity
Cancer, lymphoma, trauma, AIDS Chemotherapy, radiation Anti-rejection drugs Long-term cortisone therapy
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Distribution on the skin
Localized• Linear distribution on the skin
following nerve pathways (dermatome)• Usually unilateral
Disseminated (facility decision)• Greater than 2 dermatomes involved
OR• Generalized disruption of more than
10-12 extradermal vesicles
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TRANSMISSIONcauses chickenpox
LOCAL Via skin-to-skin contact with fluid from
blisters
DISSEMINATED May be by airborne route (viral
shedding high)
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COMPLICATIONS
Post-herpetic neuralgia (BHN) Bacterial infection of blisters Systemic spread over body or to
internal organs
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TREATMENT
Oral antiviral drugs Pain relievers - topical, oral, or IV, and
cool compresses Corticosteroids for severe infections Nerve blocks
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STRATEGIES TO CONTROL
LOCAL Standard precautions if lesions covered Lesions covered by clothes? No restriction
DISSEMINATED Personnel: Chickenpox-negative (no history
of disease or neg titer) should not enter room Patient: Standard Precautions plus Contact
and Airborne until lesions dry and crusted
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PREVENTIONReduce risk of shingles and associated pain
in persons 60 and older
Zostavax
Resources:
Prevention of Herpes Zoster.Recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR June6, 2008 / 57(05);1-30http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705al.htm
CDC Vaccines and Preventable DiseasesShingles (Herpes Zoster Vaccinationhttp://www.cdc.gov/vaccines/vpd-vac/shingles/default
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EMPLOYEE HAS ZOSTER?
Cover local lesions? Work Refer for clinical management Disseminated - Don’t work until all lesions
dry and crusted
Include in personnelWork Restriction Policy
Note: HICPAC revision of Personnel Health guidelinesdue any time!
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Pediculosis - LICE
Pediculosis is an infestation of lice, not an infection. It does not pose a significant health hazard and is not known to spread disease. It can occur on the head, body, or pubic area.
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Symptoms
Pruritis (itching): Caused by an allergic reaction to lice bites
Sores on the head
Tickling sensation
Sleeplessness and irritability
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Identification of head lice – Inspection method
Use applicator stick to inspect hair and scalp by carefully parting the hair and examine for crawling lice or nits (eggs attached to the hair shaft).
* Most recently laid will be opaque, white, shiny, and
located on a hair shaft ¼” from scalp
* Empty nit cases are more visible and are dull
yellow in color Inspect nape of neck and area
behind the ears Nits are firmly attached and not easily removed Questions? Refer to local health department, or
school nurse or teacher familiar with lice
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Treatment consider only if lice or viable eggs observed
Mechanical removal (time consuming)* Lice or nit combs - remove lice and eggs.
Electronic combs useful
Treatment with pediculocides - Follow with nit removal* Permethrin 1% (Nix) – Shampoo. Carefully follow label
directions. Recommended by American Academy of Pediatrics
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Treatment of the Environment Check all household/patients prior to
cleaning Launder personal items - clothing, bedding,
towels, toys. Wash at least 10 min, dry high heat 30 min.
Can’t wash? Seal in plastic bag for 14 days; or freeze 24 hours
Vacuum - everything possible Inspect hairbrushes, combs, etc. and clean -
wash, boil, or Lysol (refer to manual)
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Resource
Michigan Head Lice Manual. A comprehensive guide to identify, treat, manage, and prevent head lice. Updated August 2013
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Bed BugsBed bugs are small, wingless insects about the size of anappleseed. They are attracted to carbon dioxide from livingorganisms, and to body heat and feed on human blood whenpossible – also on pets. They come out to feed at night. They canlive for more than a year without food (blood meal). Both male andfemales feed on blood. No evidence that they transmit disease to humans.Some people can experience skin irritation from bed bug bites,sometimes respiratory symptoms in areas of high infestation, butbut many do not react to bites at all.
Resurgence of bedbugs in recent years – eradicated by DDT,then…resistance developed, ?? increase in world wide travel, undergroundeconomy, increases in secondhand merchandise, changes in bedbug habits, people don’t recognize bed bugs or signs of infestation.
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Recognize - Report
DETECT Mattresses – seams. Tufts, folds Furniture – cracks in bed frame, head board,
underneath, in dressers/bedside stands General – Behind baseboards, around window
casings, behind electrical plates, in telephones, radios, TVs, clocks
Dark spotting and staining Eggs, eggshells, molted skin of maturing nymphs Rusty or reddish spots of blood Bed bugs themselves Sometimes a sweet, musty, or “buggy” smell REPORT to person authorized to act
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Respond: Recommendations
Develop Bed bug Management Plan: Policy, include person/title of person responsible/ authority to act Procedure from recognition to response Regular resident skin assessment, environmental
awareness and “inspection”, preventive strategies, treatment, Education – personnel, resident, family, volunteers
Include in facility Integrated Pest Management Plan (IPM)
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Interventions
Judicious use of effective pesticide(s) Steam Ambient heat Freezing Canines – detection Countless others – with varying degrees
of effectiveness!
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References and Resources
Michigan Manual for the Prevention and Control of Bed Bugs. Comprehensive guidance to identify, treat, manage and prevent bedbugs. MDCH 2010
Download:http://michigan.gov/documents/emergingdiseases/Bed_Bug_Manual_v1_full_reduce_326605_7.pdf
Joint Statement on Bed Bug Control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA), 2010
National Pest Management Association (NPMA) Guidelines. Response to Bed Bugs in Medical Facilities.