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

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Presentation on theme: "SKIN & SOFT TISSUE INFECTIONS Ruth Anne Rye MSIPC Fundamentals October 2014."— Presentation transcript:

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

2 Manifestations Classification of wounds n Surgical:acute, chronic n 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 n Altered arterial and/or venous blood flow n Cognitive impairment n Decreased sensory impairment n Dehydration n Diabetes n External device - brace, cast, dressing, Friction, Immobility n Incidence of previous pressure ulcer n Inadequate nutritional intake and weight loss n Moisture n Shear n Unrelieved pressure n Vascular insufficiency

6 PRESSURE ULCER STAGING National Pressure Ulcer Advisory Panel, Feb 2007 n Stages I, II, III, IV, Unstageable/Unclassified and-clinical-resources/npuap-pressure-ulcer- staging n Resource: Pressure Ulcers: Avoidable or Unavoidable? Results of NPUAP Consensus Conference. Feb. 2011

7 PRESSURE ULCER PREVENTION n 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 n Develop an individualized plan of care -Identify problem based on risk factors -Realistic, time-framed goals - Interventions that address risk factors n Provide education - healthcare personnel, patients, families n Implementation and documentation of interventions n Shingles - Zostavax

9 IMPLEMENTATION AND DOCUMENTATION OF INTERVENTIONS n Maintain personal hygiene n Relieve or reduce pressure (pressure redistribution) n Inspect skin daily n Measure (assess) impact of interventions n Modify interventions as indicated by analysis of assessment

10 Using evidence to effect positive outcome, i.e. preventing p.u. n 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. n SKIN: S = surface, K = keep turning, I = Incontinence management, N = Nutrition and hydration management n 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 n 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 …. n 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 n Michigan Nursing Home Rule R 325.20707 Nursing care and services n 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 n 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 * 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 treatment. 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 n Virus remains dormant or inactive in nerve cells of the body after the infection clears n About 20% who had chickenpox will get zoster n Most get only once n More common over age 50, immunosuppressive drugs, immune system not working properly

26 SYMPTOMS n Burning pain, tingling or extreme sensitivity one area of body, usually one side (trunk, buttocks, also arms, legs, eye) n 1-3 days later rash at that site n May have fever or headache n Rash becomes blisters - last two to three weeks n Followed by pus or dark blood, then crust/scab, disappears n Pain often severe

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

28 Distribution on the skin n Localized * Linear distribution on the skin following nerve pathways (dermatome) * Usually unilateral n Disseminated * Greater than 2 dermatomes involved OR * Generalized disruption of more than 10-12 extradermal vesicles


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

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

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

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

34 PREVENTION Reduce risk of shingles and associated pain in persons 60 and older Zostavax n 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? n Cover local lesions? Work n Refer for clinical management n Disseminated - Don’t work until all lesions dry and crusted n 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 n Pruritis (itching): Caused by an allergic reaction to lice bites n Sores on the head n Tickling sensation n Sleeplessness and irritability

38 Identification of head lice – Inspection method n 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 n Nits are firmly attached and not easily removed n Questions? Refer to local health department or school nurse or teacher familiar with lice

39 Treatment consider only if lice or viable eggs observed n Mechanical removal (time consuming) * Lice or nit combs - remove lice and eggs. Electronic combs useful n 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 n Check all household/patients prior to cleaning n Launder personal items - clothing, bedding, towels, toys. Wash at least 10 min;dry high heat 30 min. n Can’t wash? Seal in plastic bag for 14 days; or freeze 24 hours n Vacuum - everything possible n Inspect hairbrushes, combs, etc. and clean - wash, boil, or Lysol (refer to manual )

41 Resource n 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 n Dark spotting and staining n Eggs, eggshells, molted skin of maturing nymphs n Rusty or reddish spots of blood n Bed bugs themselves n Sometimes a sweet, musty, or “buggy” smell REPORT to person authorized to act

44 Respond: Recommendations Develop Bed bug Management Plan: n Policy, include person/title of person responsible/ authority to act n Procedure from recognition to response Regular resident skin assessment, environmental awareness and “inspection”, preventive strategies, treatment, Education – personnel, resident, family, volunteers n Include in facility Integrated Pest Management Plan (IPM)

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

46 References and Resources n Michigan Manual for the Prevention and Control of Bed Bugs. Comprehensive guidance to identify, treat, manage and prevent bedbugs. MDCH 2010 Download: seases/Bed_Bug_Manual_v1_full_reduce_326605_7. pdf n 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 n National Pest Management Association (NPMA) Guidelines. Response to Bed Bugs in Medical Facilities.

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