SKIN & SOFT TISSUE INFECTIONS

Ruth Anne Rye

MSIPC Fundamentals

October 2014

ManifestationsClassification of wounds Surgical: acute, chronic Non-surgical

- cellulitis - scalded skin syndrome - pressure ulcers - venous insufficiency ulcers

- diabetic neuropathy ulcers - Varicella and Zoster

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.

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.

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

PRESSURE ULCER STAGINGNational Pressure Ulcer Advisory

Panel, Feb 2007

Stages I, II, III, IV, Unstageable/Unclassified

http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-staging

Resource: Pressure Ulcers: Avoidable or Unavoidable? Results of NPUAP Consensus Conference. Feb. 2011

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

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

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

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.

Regulation related to pressure ulcer prevention

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 practibwl level of physical, mental and psychosocial well-being ….

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

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

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.

DIAGNOSIS/CONFIRMATION* Suspicion* Definitive - skin scraping

RECOVERY* Microscopic evaluation* Ink test (not widely used/accepted)

Incubation period

1. Primary infestation: 2-6 weeks2. Re-infection: Symptoms may appear almost immediately after exposure

Signs and symptoms

• Intense itching• Red rash and bumpy eruptions• Pus-filled lesions and nodules

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

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

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 off, change all linens, towels, and clothing and wash5. Disinfect mattress, pillow covers, floors, multiple-use items, bedside equip6. Discard topicals used by symptomatic

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

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

PREVENTION STRATEGIES

• Skin assessments• Suspect? Immediate search for new additional cases• Education - HCW,patients, and others

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

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.

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

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

RISK FACTOR? weakened immunity

Cancer, lymphoma, trauma, AIDS Chemotherapy, radiation Anti-rejection drugs Long-term cortisone therapy

Distribution on the skin

Localized* Linear distribution on the skin following nerve pathways (dermatome)* Usually unilateral

Disseminated* Greater than 2 dermatomes involvedOR* Generalized disruption of more than 10-12 extradermal vesicles

TRANSMISSIONcauses chickenpox

LOCAL Via skin-to-skin contact with fluid from

blisters

DISSEMINATED May be by airborne route (viral

shedding high)

COMPLICATIONS

Post-herpetic neuralgia Bacterial infection of blisters Systemic spread over body or to

internal organs

TREATMENT

Oral antiviral drugs Pain relievers - topical, oral, or IV, and

cool compresses Corticosteroids for severe infections Nerve blocks

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

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

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 guidelinesdue any time!

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.

Symptoms

Pruritis (itching): Caused by an allergic reaction to lice bites

Sores on the head

Tickling sensation

Sleeplessness and irritability

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

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

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)

Resource

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

Bed BugsBed bugs are small, wingless insects about the size ofan 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.

Recognize - Report

DETECTMattresses – 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, 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

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)

Interventions

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

of effectiveness!

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.