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-basedrecommendation provides the bestopportunity for improving outcomesincluding the incidence ofpressure ulcers. Numerous federaland professional organizations havepublished evidenced-based guidelines toprevent pressure ulcers.
5 RISK FACTORS and CONTRIBUTING FACTORS for pressure ulcer development Altered arterial and/or venous blood flowCognitive impairmentDecreased sensory impairmentDehydrationDiabetesExternal device - brace, cast, dressing, Friction, ImmobilityIncidence of previous pressure ulcerInadequate nutritional intake and weight lossMoistureShearUnrelieved pressureVascular insufficiency
6 PRESSURE ULCER STAGING National Pressure Ulcer Advisory Panel, Feb 2007 Stages I, II, III, IV, Unstageable/UnclassifiedResource: Pressure Ulcers: Avoidable or Unavoidable? Results of NPUAP Consensus Conference. Feb. 2011
7 PRESSURE ULCER PREVENTION Risk assessment Identify patient at risk - onadmission, at defined periodicintervals, and if significantchange 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 factorsProvide education - healthcarepersonnel, patients, familiesImplementation and documentation of interventionsShingles - Zostavax
9 IMPLEMENTATION AND DOCUMENTATION OF INTERVENTIONS Maintain personal hygieneRelieve or reduce pressure (pressure redistribution)Inspect skin dailyMeasure (assess) impact of interventionsModify 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 theSKIN 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 managementResults: 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 developpressure sores unless …(2) A resident having pressure soresreceives necessary treatment andservices ….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 servicesRule 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 (www.npua.org) 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 scabiesis a parasitic mite that causes intense pruritis (itching),rashes and lesions. Infestation is notlife threatening, but a nuisance disease that is commonly found is health care facilities,schools and other settings,and can result incrisis, fear, and panic.
16 Incubation period1. Primary infestation: 2-6 weeks2. Re-infection: Symptoms may appearalmost immediately after exposureSigns and symptomsIntense itchingRed rash and bumpy eruptionsPus-filled lesions and nodules
17 TREATMENT Permethrin cream 5%(Elimite) 90% effective after one May require two treatments for eradicationIvermectinOral, dosed according to weightUse alone or in combination with permethrinLindane 1% (Kwell)- MDCH does not recommend use
18 TREATMENT protocolIsolation precautions - private room unless treating roommateHCW - wear PPEBathe and dryApply scabicideWashed off? ReapplyLeave on recommended time -usually 12 hrs.Remove by washing thoroughlyRe-examine at 2 and 4 weeks
19 ENVIRONMENT1. Change all linens2. Bag all items worn in last week,and wash3. Non-washable items - dry clean, orhot dryer 20 min, or seal 5-7 days4. After scabicide off, change all linens,towels, and clothing and wash5. Disinfect mattress, pillow covers,floors, multiple-use items, bedside equip6. Discard topicals used by symptomatic
20 Assessment of treatment failure Poor application techniqueContinued contact with untreatedFailure of resident to respondContinued use of steroids during txFailure to kill scabies mite in clothes,upholstered furniture or carpeting
21 NORWEGIAN SCABIES Referred to as crusted scabies Hundreds to millions of mitesVery contagiousItch - minimal or absent, or extremeMost often occurs in the elderly
23 RESOURCEMichigan 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 FACTSVirus remains dormant or inactive in nerve cells of the body after the infection clearsAbout 20% who had chickenpox will get zosterMost get only onceMore common over age 50, immunosuppressive drugs, immune system not working properly
26 SYMPTOMSBurning 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 siteMay have fever or headacheRash becomes blisters - last two to three weeksFollowed by pus or dark blood, then crust/scab, disappearsPain often severe
28 Distribution on the skin Localized* Linear distribution on the skin following nerve pathways (dermatome)* Usually unilateralDisseminated* Greater than 2 dermatomes involvedOR* Generalized disruption of more than extradermal vesicles
30 TRANSMISSION causes chickenpox LOCALVia skin-to-skin contact with fluid from blistersDISSEMINATEDMay 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 compressesCorticosteroids for severe infectionsNerve blocks
33 STRATEGIES TO CONTROL LOCAL Standard precautions Lesions covered by clothes? No restrictionDISSEMINATEDChickenpox-negative personnel (no history of disease or neg titer) should not enter roomPatient in private room until lesions crusted
34 PREVENTION Reduce risk of shingles and associated pain in persons 60 and older ZostavaxResources:Prevention of Herpes Zoster.Recommendations of theAdvisory Committee on Immunization Practices (ACIP).MMWR June6, 2008 / 57(05);1-30CDC Vaccines and Preventable DiseasesShingles (Herpes Zoster Vaccination
35 EMPLOYEE HAS ZOSTER? Cover local lesions? Work Refer for clinical managementDisseminated - Don’t work until all lesions dry and crustedInclude in Work Restriction PolicyNote: HICPAC revision of Personnel Health guidelinesdue any time!
36 Pediculosis - LICEPediculosis 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 SymptomsPruritis (itching): Caused by an allergic reaction to lice bitesSores on the headTickling sensationSleeplessness 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, andlocated on a hair shaft ¼” from scalp* Empty nit cases are more visible and are dullyellow in color Inspect nape of neck and areabehind the earsNits are firmly attached and not easily removedQuestions? 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 usefulTreatment with pediculocides - Follow with nit removal* Permethrin 1% (Nix) – Shampoo. Carefully follow labeldirections. Recommended by American Academy ofPediatrics
40 Treatment of the Environment Check all household/patients prior to cleaningLaunder 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 hoursVacuum - everything possibleInspect hairbrushes, combs, etc. and clean - wash, boil, or Lysol (refer to manual)
41 ResourceMichigan 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 fromliving organisms, and to body heat and feed on humanblood when possible – also on pets. They come out tofeed at night. They can live for more than a year withoutfood (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 bugbites, sometimes respiratory symptoms in areas of highinfestation, 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, undergroundeconomy, increases in secondhand merchandise, changes in bedbug 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 standsGeneral – Behind baseboards, around window casings, behind electrical plates, in telephones, radios, TVs, clocksDark spotting and stainingEggs, eggshells, molted skin of maturing nymphsRusty or reddish spots of bloodBed bugs themselvesSometimes a sweet, musty, or “buggy” smellREPORT to person authorized to act
44 Respond: Recommendations Develop Bed bug Management Plan:Policy, include person/title of person responsible/authority to actProcedure from recognition to responseRegular resident skin assessment, environmental awareness and “inspection”, preventive strategies, treatment, Education – personnel, resident, family, volunteersInclude in facility Integrated Pest Management Plan (IPM)
45 Interventions Judicious use of effective pesticide(s) Steam Ambient heatFreezingCanines – detectionCountless 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 2010Download:http://michigan.gov/documents/emergingdiseases/Bed_Bug_Manual_v1_full_reduce_326605_7.pdfJoint 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), 2010National Pest Management Association (NPMA) Guidelines. Response to Bed Bugs in Medical Facilities.