infection prevention
infection prevention
By Carol Calabrese , RN , BS , CHESP , CIC
What ’ s That Itch All About ?
As a person ages , their skin becomes fragile , and an elderly person can develop a skin condition called senile purpura which causes a purple discoloration on the skin . Assessing the resident ’ s skin condition is a good starting point as well as reviewing their medications and lab results .”
My first exposure to scabies was as a novice infection preventionist . Issues always seem to happen on a Friday at 3 p . m . or just before you go on vacation . As I was in the office trying to clear things off the desk , the phone rang , and it was one of the nursing units asking for me to check out a patient ’ s skin rash . The patient had been in the hospital for about five days and had come to the hospital from a long-term care facility . This was all new to me , so I was unsure of several things . What causes purpuric skin conditions in the elderly ?
As a person ages , their skin becomes fragile , and an elderly person can develop a skin condition called senile purpura which causes a purple discoloration on the skin .
Assessing the resident ’ s skin condition is a good starting point , as well as reviewing their medications and lab results .
Many residents may be taking multiple medications so it essential to evaluate the medications they are taking and which one ( s ) if any have itching ( pruritus ) as a side effect . Antibiotic treatment should be evaluated first and then move onto the other drugs .
There is a wide variety of medications that have itching as a side effect . These include common cardiovascular drugs , metabolic , psychotropic , opioid / analgesics , steroids , chemotherapeutic and other drugs like radiopaque contrast agents have itching as a side effect .
A study conducted at John Hopkin ’ s between 2013 and 2018 identified through chart review that 9802 patients developed pruritus after drug initiation and more than 1.5 million did not develop any . Females ( 70 percent ) were most likely to have this complication and were between the ages of 50 and 79 years . Forty percent of the patients were black . Heparin caused more of an issue and trimethoprimsulfamethoxazole and calcium channel blockers were the major drug categories that caused itching .
Assess the resident ’ s lab values . If labs have not been performed recently and the resident has a history of renal , liver , blood disorders as well as psychological , labs may need to be ordered .
There are several lab values that should be checked . These include vitamin D deficiency , iron deficiency , as well as thyroid issues can cause itching . In addition , itching can be caused by liver disease and can mimic Scabies as the itching is more prevalent at night and the palms of hands as well as soles of their feet or limbs . S . aureus is part of the normal skin flora ; however , 90 percent of skin lesions with skin inflammation and / or lesions are caused by
Most of the time , by the time you think you have a problem , Scabies will have had the opportunity to spread . One to two cases should be considered an outbreak , as this is something that normally is not observed . However , outbreaks of Scabies are more common in long-term care facilities and aggregate-living facilities than you might imagine . Scabies outbreaks extend beyond the patients / residents to healthcare personnel , their families and visitors .”
S . aureus . This is possibly due to mast cell mediation and histamine release .
Individuals with advanced kidney and liver disease may also experience severe itching . ( An example is an elevated creatinine or bilirubin ).
So , utilizing nursing assessment skills is critical to evaluating the cause of itching prior to saying this is a potential for an outbreak . Also ask yourself , what is going on in the facility ? If the facility is undergoing renovation , be sure that the infection control risk assessment ( ICRA ) is being adhered to . Back in the late 1980s , prior to ICRAs , we had a major issue with dust mites in the long-term care facility in which I worked . The facility was undergoing major renovation . Unfortunately , the dermatologist insisted it was Scabies even though skin scrapings were not performed .
Ensure that all the barriers are intact and negative pressure is being maintained . The unit ( s ) used for negative pressure should have their filters checked and changed if needed to ensure proper functioning . Talk with environmental services ( EVS ) personnel to confirm cleaning is being performed to minimize dust and plant operations is changing the air filters in the HVAC as needed .
These steps are necessary to be sure you have ruled out other potential causes of itching as the work involved is time-consuming and treatment for Scabies has a neurotoxicity side effect and if treatment isn ’ t needed then that is a plus .
After a thorough investigation as to other causes of itching has been completed and ruled out , you may move on to developing a working hypothesis to evaluate that this may be an outbreak .
Most of the time , by the time you think you have a problem , Scabies will have had the opportunity to spread . One to two cases should be considered an outbreak , as this is something that normally is not
8 • www . healthcarehygienemagazine . com • jan-feb 2025