1. SKIN & SOFT TISSUE INFECTIONS
Ruth Anne Rye
MSIPC Fundamentals
October 2014

2. Manifestations Classification of wounds Surgical: acute, chronic
Non-surgical cellulitis scalded skin syndrome pressure ulcers venous insufficiency ulcers
- diabetic neuropathy ulcers - Varicella and Zoster

3. 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.

4. 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.

5. 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

6. PRESSURE ULCER STAGING National Pressure Ulcer Advisory Panel, Feb 2007
Stages I, II, III, IV, Unstageable/Unclassified
Resource: Pressure Ulcers: Avoidable or Unavoidable? Results of NPUAP Consensus Conference. Feb. 2011

7. 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

8. continued - Identify problem based on risk factors
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

9. 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

10. 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 symergistic 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.

11. Regulation related to pressure ulcer prevention
Federal Tag …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 practibwl level of physical, mental and psychosocial well-being ….

12. Regulation, continued Michigan Nursing Home Rule
R 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

13. References and Resources
National Pressure Ulcer Advisory Panel ( serves as authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research.
*See Educational and Clinical Resources

14. SCABIES Prevention and Control
Sarcoptes scabei, commonly known as scabies
is a parasitic mite that causes intense pruritis (itching),rashes 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.

15. DIAGNOSIS/CONFIRMATION * Definitive - skin scraping RECOVERY
* Suspicion
* Definitive - skin scraping
RECOVERY
* Microscopic evaluation
* Ink test (not widely used/accepted)

16. Incubation period
1. Primary infestation: 2-6 weeks
2. Re-infection: Symptoms may appear
almost immediately after exposure
Signs and symptoms
Intense itching
Red rash and bumpy eruptions
Pus-filled lesions and nodules

17. TREATMENT Permethrin cream 5%(Elimite) 90% effective after one
May require two treatments for eradication
Ivermectin
Oral, dosed according to weight
Use alone or in combination with permethrin
Lindane 1% (Kwell)- MDCH does not recommend use

18. 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

19. ENVIRONMENT
1. Change all linens
2. Bag all items worn in last week,
and wash
3. Non-washable items - dry clean, or
hot dryer 20 min, or seal 5-7 days
4. After scabicide off, change all linens,
towels, and clothing and wash
5. Disinfect mattress, pillow covers,
floors, multiple-use items, bedside equip
6. Discard topicals used by symptomatic

20. Assessment of treatment failure
Poor application technique
Continued contact with untreated
Failure of resident to respond
Continued use of steroids during tx
Failure to kill scabies mite in clothes,
upholstered furniture or carpeting

21. 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

22. PREVENTION STRATEGIES
Skin assessments
Suspect? Immediate search for new
additional cases
Education - HCW,patients, and
others

23. RESOURCE
Michigan Scabies Prevention and Control Manual. Michigan Department of Community Health 2005
_Michigan_Scabies_Prevention_and_
Control_Manual_131983_7.pdf

24. 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.

25. 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

26. 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

27. RISK FACTOR? weakened immunity
Cancer, lymphoma, trauma, AIDS
Chemotherapy, radiation
Anti-rejection drugs
Long-term cortisone therapy

28. Distribution on the skin
Localized
* Linear distribution on the skin following nerve pathways (dermatome)
* Usually unilateral
Disseminated
* Greater than 2 dermatomes involved OR
* Generalized disruption of more than extradermal vesicles

30. TRANSMISSION causes chickenpox
LOCAL
Via skin-to-skin contact with fluid from blisters
DISSEMINATED
May be by airborne route (viral shedding high)

31. COMPLICATIONS Post-herpetic neuralgia Bacterial infection of blisters
Systemic spread over body or to internal organs

32. TREATMENT Oral antiviral drugs
Pain relievers - topical, oral, or IV, and cool compresses
Corticosteroids for severe infections
Nerve blocks

33. STRATEGIES TO CONTROL LOCAL Standard precautions
Lesions covered by clothes? No restriction
DISSEMINATED
Chickenpox-negative personnel (no history of disease or neg titer) should not enter room
Patient in private room until lesions crusted

34. PREVENTION Reduce 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);1-30
CDC Vaccines and Preventable Diseases
Shingles (Herpes Zoster Vaccination

35. EMPLOYEE HAS ZOSTER? Cover local lesions? Work
Refer for clinical management
Disseminated - Don’t work until all lesions dry and crusted
Include in Work Restriction Policy
Note: HICPAC revision of Personnel Health guidelines
due any time!

36. 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.

37. Symptoms
Pruritis (itching): Caused by an allergic reaction to lice bites
Sores on the head
Tickling sensation
Sleeplessness and irritability

38. 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

39. 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

40. 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)

41. Resource
Michigan Head Lice Manual. A comprehensive guide to identify, treat, manage, and prevent head lice. Updated August 2013

42. Bed Bugs Bed bugs are small, wingless insects about the size of
an appleseed. They are attracted to carbon dioxide from
living organisms, and to body heat and feed on human
blood when possible – also on pets. They come out to
feed at night. They can live for more than a year without
food (blood meal). Both male and females 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, but 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, underground
economy, increases in secondhand merchandise, changes in bed
bug habits, people don’t recognize bed bugs or signs of infestation.

43. 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

44. 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)

45. Interventions Judicious use of effective pesticide(s) Steam
Ambient heat
Freezing
Canines – detection
Countless others – with varying degrees of effectiveness!

46. 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:
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.