COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 412 Effective Date: August 31, 2006 SUBJECT: TREATMENT OF PEDICULOSIS (LICE) AND SCABIES 1. PURPOSE: This policy shall provide guidelines for nursing personnel, in collaboration with the Med/Surg physicians and Public Health staff, in the care ad treatment of Individuals with the parasitic infestation of lice or scabies, to prevent infestation of others, and to prevent occurrence of re-infestation through effective health teaching. 2. POLICY: 1. When Pediculosis or Scabies is suspected, contact the Med/Surg physician ad request examination to confirm the diagnosis. These conditions are rarely emergent and can usually wait for examination by the unit Med/Surg physician. 2. Due to specific required guidelines, consult the Public Health Officerwith all issues. 3. Effective treatment for lice/scabies infestation requires a physician s order for medication 4. Permethrin should NOT be stockpiled on units. It should be ordered only in amounts needed to treat specific Individual(s). 5. It Nits are found on eyebrows/eyelashes, contact physician for appropriate ophthalmic ointment. 6. If irritation or sensitization occurs after application of medication, discontinue use and do immediate, thorough washing with water and notify physician. 7. Prior to use of Ovide as alternative to Nix, check Individual for sensitivity to the product or any of its components. 8. If Ovide is used, warm Individual to stay away from lighted cigarettes, open flames, electric heat sources while hair is wet. Ovide lotion is flammable. 3. DEFINITION: Pediculosis is the infestation of human beings by lice (Pediculosis humanus, var. capitis or corporis or Phthirus pubis). Scabies is an infectious disease of the skin produced by the burrowing action of the human parasitic mite (Sarcoptes scabiei). -1-
4. EQUIPMENT: 1. Fine tooth comb 2. Medication prescribed by physician 3. Appropriate linen receptacle 4. Cotton-tipped swabs/applicators 5. two bath towels 6. Wash cloth or face towel (to assist with shielding eyes from shampoo) 5. IMPLEMENTATION AND INTERVENTION (For all Infestations): NURSING ACITON A. Check physician s order A. To prevent error and to ensure proper treatment to the type of parasitic infection B. Identify the Individual B. Always identify by I.D. photo C. Explain the procedure to Individual C. Stress the importance good hygiene to prevent recurrent attack D. Bag all exposed dirty clothing, bed D. Follow NPPM Handling Procedures linens, and towels as contaminated for Linen and Clothing and A.D. linen. Standard Precautions E. Follow reporting procedures Administrative Directive Reporting of Diseases/Conditions. Notify Public Health and NOD. 6. PEDICULOSIS CAPITIS (HEAD LICE): E. Contacts need to be investigated and treated. Public Health Nursing will provide consultation on contact investigation and infection control precautions. Pediculosis capitis (head lice) refers to infestation of the head, eyebrows, eyelashes, and beard caused by Pediculosis humanus var. capitis. Clinical features include minute white nits (eggs) attached to hair shaft in series usually on the occipital and temporal areas of the scalp. Saliva of the louse produced marked itching with resultant excoriation. Secondary infection with crusting may occur with osterior occipital nodes being enlarged and tender. The head louse is a small, elongated insect 2-3 mm in length and is usually found grasping the hair shaft near the scalp with its specially adapted claws. Permethrin 1% (Nix) Cream Rinse is used. It is a synthetic pyrethroid. After a regular shampoo, towel dry the hair, then apply the Permethrin Crème Rinse. Saturate the hair and scalp for 10 minutes followed by rinsing. Nits -2-
should be combed after treatment. One application of Nix should be adequate if procedure is followed meticulously. If live lice persist seven days after treatment, a second application may be performed. Treatment with Nix may temporarily exacerbate pruritus, erythema, edema of scalp. Use (Malathionbased) Ovide, which is applied for 8-12 hours fro treatment failure. Treatment failure refers to continued presence of live lice 7 days after the second treatment with Permethrin 1%.. A. Thoroughly wash hair with regular shampoo, rinse with water, and towel dry B. SHAKE WELL BEFORE USING. Apply a sufficient volume of Nix to saturate the hair and scalp. Nix should remain on the hair for 10 minutes before being rinsed off with water. C. If Ovide is used for treatment failure, it should be applied on dry hair in amount just sufficient to thoroughly wet the hair and scalp D. Follow CONTACT ISOLATION requirements got pediculosis for 24 hours after start of effective therapy E. Bag all clothing, bed linens, towels, ect., which have come into contact with the infested person, particularly hats, headbands, pillowcases, towels, and other articles, which may have had contact with the hair F. Clean Individual combs, brushes, curlers, ect., thoroughly with hot, soapy water. Rinse, and then immerse and soak in a solution of isopropyl alcohol. Allow to air dry. G. Examine all other Individuals on the unit for head lice or nits and those Individuals from other units who may have shared hats or towels. A. Permethrin (Nix) is intended for use after hair has been washed with regular shampoo. B. A single treatment is sufficient to eliminate head lice in 99% of all Individuals. Nits are usually killed and will not hatch. Remove nits with fine tooth comb after hair is dry C. Hair should remain uncovered and should be allowed to dry naturally after Ovide application. After 8-12 hours, the hair should be shampooed with regular shampoo and rinsed. Using a fine tooth comb, remove dead lice and eggs. If lice are still present after 7-9 days, repeat with a second application of Ovide. D. Wear gloves while handling infected material. A separate room may be considered but is not necessary E. Use appropriate yellow infectious (contaminated) linen bags. See A.D. Standard Precautions and NPPM Handling Procedures for Linen and Clothing. Only authorized staff should bag and deliver infectious linen. F. If any material (e.g. gross dirt or oil) is left on items, disinfection will not be effective. Refer to NPPM- Disinfection of Commonly Shared Grooming Supplies. G. Consider treating those without visible evidence of infection who have shared hats, towels, pillows, combs, or have had head to head contact. Request treatment orders for all with -3-
H. Follow reporting procedures of A.D. Reporting of Diseases/Conditions Notify Public Health and the NOD I. If still not effective after the second Ovide treatment, consult with the Public Health Office. visible lice or nits. H. Public Health Nurse will consult on infection control measures. 7. PEDICULOSIS CORPORIS (Body Lice): Pediculosis corporis (body lice) refers to the infestation of the body caused by Pediculus humanus var. corporis. The body louse lives in the seams of the undergarments but feeds on the skin. The nits may remain viable for one (1) month. Clinical appearances are long pruritic excoriation on the body. Bites from body lice cause characteristic minute hemorrhagic points on the skin. Pediculoss corporis may be treated with compete bathing, and washing the linen and clothing in very hot water. Laundering of clothing in which the lice ad their nits are found should be above 52C (126F) for ten minutes or discard the clothing when practical. No medication ordinarily needs to be applied to the skin or hair. A. Have Individual take a warm bath. If crusted lesions are present they should be soaked in warm water. B. Have Individual put on clean clothing. Change all bedding and towels. C. Bag all clothing, bedding, and towels, which have come into contact with the Individual s skin D. Examine the skin and inner seams of clothing which contacts skin of other Individuals who have had close contact or share clothing with infected person for lice or nits. E. Follow CONTACT ISOLATION requirements for pediculosis for 24 hours after start of effective therapy. A. Crusted lesions may represent a secondary bacterial infection, so consult physician. The use of pesticide shampoo or lotions is usually unnecessary since these lice live in clothing, not the skin. B. Good hygiene is the best prevention of body lice C. Use appropriate yellow infectious (contaminated) linen bags. Hot water laundering is the primary treatment of body lice. D. Ask physician to confirm diagnosis. Examine entire unit. E. Masks are not needed. Wear gloves when handling infected material. A separate room may be considered but -4-
F. Follow reporting procedure of A.D. Notify Public Health and NOD is not necessary. F. Contacts who are suspected to have exchanged clothing, need to be investigated and treated y the above method (no medication necessary). Public Health Nurse will consult on infection control measures and contact investigation 8. PEDICULOSIS PUBIS (Pubic Lice Crabs ): Pediculosis pubis (pubic lice or crabs ) refers to investation of the perineal area caused by Phthrius pubis. Chief symptom is marked as itching of all affected areas. Lice may infest pubic, chest, axillary hair, beard, and eyeichses. Reddish brown dust formed from excretion of the insects may be found on the underclothing. Erythematous macules and papules with excoriation and secondary infection may be seen. Pediculosis pubis may be more resistive to treatment. The nits are difficult to remove from areas with heavy hair growth. It is most commonly sexually transmitted. Permethrin 1% (Nix) Cream Rinse is used for treating both head and pubic lice. It is a synthetic pyrethroid. After a regular shampoo, towel dry the hair, then apply the Permethrin Crème Rinse. Saturate the hair and scalp for 10 minutes followed by rinsing. Nits should be combed or removed by forceps after treatment. One application of Nix should be adequate if the procedure is followed meticulously. If live lice persist seven days after treatment, a second application may be ordered. Treatment with Nix may temporarily exacerbate pruritus, erythema, or edema of scalp. Emphasize the need for treatment of sexual partners to prevent re-infestation. A. Apply a sufficient quantity of the medication to the dry hair and skin of the pubic area; (include chest, axillary hair and beard if infected) B. Follow CONTACT ISOLATION requirements for pediculosis for 24 hours after start of effective therapy. A. Sexual contacts with affected Individual should be treated simultaneously. Arrange this with physician. DO NOT APPLY MEDIATION to eyebrows/eyelashes. Get a prescription for appropriate eye ointment. B. Masks are not needed. Wear gloves when handling infected material. A separate room may be considered but is not necessary. See Section 12 under Disease Specific Isolation Precautions regarding appropriate -5-
C. Have Individual put on clean clothing. D. Bag all clothing, bed linens, towel, ect., which may have come into contact with the infested person. E. Follow reporting procedure of A.D. Notify Public Heath and NOD isolation precautions. D. Use appropriate yellow infectious (contaminated) linen bags. Only authorized staff should bag and deliver infectious linen. E. Sexual and other intimate contacts need to be investigated and treated if infected. Public Heath Nurse will consult on infection Control measures and contact investigation 9. SCABIES (Typical, Non-Crusted): Scabies is a cutaneous infestation with the tiny human itch mite Sarcoptes scabiei. Scabies occurs as a result of direct contact with the infected person (including sexual contact), or occasionally by contact through very recent soiled bed linen, clothing, ect. Both male and female parasites live upon the skin. The female parasite burrows into the superficial skin to deposit her eggs. The burrow is seen most commonly between the finders but may occur in any natural fold of the skin or in pressure areas. Pruritus occurs and the scratching of the skin may produce secondary infection. Primary symptom is itching at night. Permethrin (Elimite) formulated as a (5%) cream is not the recommended treatment of choice for scabies. It is applied form the neck to the soles of the feet for at least 12 hours, then washed off. If hands must be washed during this time period, an application to the hands must be reapplied after each washing. Individuals should be advised that itching, mild burning and/or stinging may occur after application of Elimite. Pruritus may persist for 1-2 weeks after successful treatment and should not be assumed to represent treatment failure. It is secondary to the Individual s reaction to the products released by the death of the parasites. Individuals diagnosed with scabies need to be in CONTACT ISOLATION for 24 hours. A. Have Individual take a warm bath if crusted lesions are present. Allow the skin to dry and cool before treatment is applied. A. Without crust, medication penetrates effectively. Crusted lesions may represent secondary bacterial infection, or atypical scabies. -6-
B. Apply PERMETHRIN (ELIMITE) CREAM TO DRY skin in a thin layer to Individual(s) entire body from neck down to soles of feet. Rub in thoroughly C. Follow CONTACT ISOLATION precautions for Scabies for 24 hours after start of therapy. D. Have Individual put on clean clothing at beginning of the 12-hour treatment. E. Bag all clothing, bed linens, towels, ect., which have come into contact with the infested person within the 72 hours prior to treatment ad during treatment. F. After 12 hours, remove the medication by thoroughly washing. G. Have Individual again change clothing, bedding, and towels, at the end of 12 hour treatment. H. Identify all Individuals suspected of being sexual contacts or having intimate skin contact within the period of suspected infestation. I. Follow reporting procedure. Notify Public Health Office and NOD J. Perform terminal cleaning of the Individual s room after completion of treatment B. Elimite contains 5% Permethrin. Nix contains 1% Permethrin. C. Wear gloves when handling skin and infected material. Separate room may be considered but is not necessary. Masks are not needed. E. Use appropriate yellow infectious (contaminated) linen bags. Only authorized staff should bag and deliver infectious linen. G. CHANGE ALL BED LINENS AND CLOTHES DAILY FOR ONE WEEK H. Sexual and other intimate contacts should be treated regardless of visible signs or symptoms. I. Public Health Nurse will consult on contact isolation requirements and other infection control precautions, and on contact investigation. 10. ATYICAL SCABIES (Crusted, Keratotic, or Norwegian Scabies): Individuals in long-term care facilities may have a number of different types of scabies. A severe variant of scabies known as crusted, keratotic, or Norwegian scabies can occur particularly in Individuals who are debilitated or immuno-suppressed including Individuals with HIV and in Individuals with Down s syndrome. Skin lesions consist of widespread hyperkeratotic, crusted nodules and plaques. The nails are frequently involved and demonstrate thickening and subungual debris. Secondary bacterial infection, septicemia, and death can occur. These individuals are heavily infested with thousands of mites and are highly contagious and require special control measures to prevent transmission of the disease. Transmission of mites can occur with much less direct skin contact when -7-
large numbers of mites are present on the skin of a Individual. Any person who has had contact with a crusted scabies Individual or that Individual s environment must be considered exposed and should be evaluated for preventive treatment. If crusted scabies is diagnosed or suspected, a consultation with the Public Health Officer or designee is required for proper treatment and control measures for Individuals and their contacts. Effective management of scabies in long-term care facilities requires the application of safe and effective scabicide to symptomatic individuals and asymptomatic contacts of cases. If crusted scabies is diagnosed or suspected, a consultation with the public health officer or designee is required for proper treatment and control of Individuals and their contacts. Individuals with crusted scabies need to be in CONTACT ISOLATION until deemed noninfectious by the treating Med/Surg physician and the Public Health Officer or Public Health Nurse. The treatment of crusted scabies is more difficult and usually requires multiple applications of scabicides, therefore, a number of different regimens may be used. Follow all procedures, nursing action, and key points as outlined previously for scabies (typical, non-crusted) type. A. Assign Individual to a private room. Have Individual take a warm bath soaking in tub for at least 10 minutes. B. Wear gloves and long sleeved gown. The gloved areas around the wrist must be tight fitting. To insure the wrist areas are snug fitting, use surgical gloves. Apply the prescribed medication on the entire body from the neck down to the soles of feet. C. Bag all clothing, bedding, and towels daily that have been in A. Isolate affected Individual during the treatment period. Restrict contact with others until treatment regimen has been complete and scrapings are negative for live mites. Individual is to remain in a private room until skin scrapings are confirmed negative and public health clearance is obtained. B. Gloves and gown are to be worn by everyone who attends Individual or handles laundry or clothing. Remove gown and gloves before leaving the room. Wash hands and arms thoroughly C. The Individual s room should be disinfected daily -8-
Individual s room. D. A complete terminal cleaning upon completion of treatment and prior to any other Individual using the room must be done. 11. EVALUATION (Applies To All Infestations): -Document the extent and areas of infestation including all actions taken and Individuals reaction to having this condition -Any broken areas of the skin from scratching or any other cause must be recorded ad treated to prevent infection of the areas. -The overall cleanliness of the Individual should be noted and recorded throughout care. -Record how the Individual tolerated the treatment and the apparent level of success. -9-