SKIN & SOFT TISSUE
INFECTIONS
Ruth Anne Rye
MSIPC Fundamentals
October 2015
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
-
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
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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 STAGING
National Pressure Ulcer Advisory
Panel, Feb 2007
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Stages I, II, III, IV, Unstageable/Unclassified.
“Never” event.
PRESSURE ULCER PREVENTION
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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
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Develop an individualized plan of
care
- Identify problem based on risk
factors
- Realistic, time-framed goals
- Interventions that address risk
factors
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Provide education - healthcare
personnel, patients, families
IMPLEMENTATION AND
DOCUMENTATION OF
INTERVENTIONS
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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.
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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.
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SKIN: S = surface, K = keep turning, I = Incontinence
management, N = Nutrition and hydration management
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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: Skilled Nursing facilities
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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 ….
Regulation, continued
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Michigan Nursing Home Rule
R 325.20707 Nursing care and services
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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
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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
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.
DIAGNOSIS/CONFIRMATION
* Suspicion
* Definitive - skin scraping
RECOVERY
* Microscopic evaluation
* Ink test (not widely used/accepted)
Incubation period
1. Primary infestation: 2-6 weeks
2. Re-infection: Symptoms may appear
almost immediately after exposure
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 person’s
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 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 removed, 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
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
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 & airborne
until lesions dry and crusted
SCABIES PREVENTION STRATEGIES
• Skin assessments – define intervals
• Suspect? Immediate search for new/
additional cases
• Education - HCW, patients, families,
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
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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
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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
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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 (facility decision)
•
Greater than 2 dermatomes involved
OR
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Generalized disruption of more than 10-12
extradermal vesicles
TRANSMISSION
causes chickenpox
LOCAL
n Via skin-to-skin contact with fluid from
blisters
DISSEMINATED
n May be by airborne route (viral
shedding high)
COMPLICATIONS
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Post-herpetic neuralgia (BHN)
Bacterial infection of blisters
Systemic spread over body or to
internal organs
TREATMENT
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Oral antiviral drugs
Pain relievers - topical, oral, or IV, and
cool compresses
Corticosteroids for severe infections
Nerve blocks
STRATEGIES TO CONTROL
LOCAL
n Standard precautions if lesions covered
n Lesions covered by clothes? No restriction
DISSEMINATED
n Personnel: Chickenpox-negative (no history
of disease or neg titer) should not enter room
n Patient: Standard Precautions plus Contact
and Airborne until lesions dry and crusted
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
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705al.htm
CDC Vaccines and Preventable Diseases
Shingles (Herpes Zoster Vaccination
http://www.cdc.gov/vaccines/vpd-vac/shingles/default
EMPLOYEE HAS ZOSTER?
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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 guidelines
due 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
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Pruritis (itching): Caused by an allergic reaction to
lice bites
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Sores on the head
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Tickling sensation
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Sleeplessness and irritability
Identification of head lice –
Inspection method
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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
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Mechanical removal (time consuming)
* Lice or nit combs - remove lice and eggs.
Electronic combs useful
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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
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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
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Michigan Head Lice Manual. A
comprehensive guide to identify, treat,
manage, and prevent head lice.
Updated August 2013
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
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.
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
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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:
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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
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Judicious use of effective pesticide(s)
Steam
Ambient heat
Freezing
Canines – detection
Countless others – with varying degrees
of effectiveness!
References and Resources
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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/emergingdi
seases/Bed_Bug_Manual_v1_full_reduce_326605_7.
pdf
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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.