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Gout: The Devil is Biting My Toe.

Gout: The Devil is Biting My Toe

Author: Mark Parkinson RPh: President AFC CE

Credit Hours 1- Approximate time required: 60 min.

Educational Goal:

To give a basic overview of gout, Gouty Arthritis and Hyperuricemeia

Educational Objectives:

1. Give the definition of gout and Hyperuricemia

2. Enumerate the causes, contributing factors, signs and symptoms, and triggers for gout.

3. List who is at risk for getting gout

4. Explain treatment therapies and Adult Foster Care issues with gout

Procedure:

1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Gout: The Devil is Biting My Toe

“Gout is a disease in which a defect in uric acid metabolism causes excess of the acid and its salts (urates) to accumulate in the bloodstream and the joints. It results in attacks of acute gouty arthritis and chronic destruction of the joints… The excess of urates also damages the kidneys, in which stones may form.”

The Bantam Medical Dictionary Revised Ed 1990

Dictionaries give such wonderfully precise descriptions of mankind’s diseases. Unfortunately, they are incapable of describing just how painful those diseases are. Gout can lead to one of the most painful afflictions a person can experience. Attacks can last from several hours to several weeks. Fortunately, Gout is not very common, but its occurrences are increasing. Because of this increase and the severity in which patients suffer, I have written this article to prepare the Adult Foster Care Provider to recognize and understand what is going on.

History of Gout

Gout is one of the oldest described maladies of mankind, with writings about it dating back as far back as ancient Egypt. The accounts describes patients suffering horribly with fever, chills and excruciating, burning pain, like hundreds of hot sharp needles poking under the skin. Attacks most often occurred in the big toe above the ball of the foot (first metatarsophalangeal joint).The attacks would last for weeks. Over time the gout attacks became more frequent, eventually leading to kidney disease, heart disease and disabling arthritis.

In the past Doctors could not do much for the patient. Most victims of Gout were unaware they even had a disease it until they suffered a very painful acute attack of arthritis in a joint. Because the causes where unknown, it was popularly believed to be the result of a gluttonous lifestyle. The pain painful attack was seen as a punishment for extravagant excesses. One cartoon from the 1700’s depicted a gout attack as the devil biting the foot of its victim. It was not until the 1960s that Doctors had medications to treat the condition.

Today, after much research, we know what gout is, what causes it, who’s at risk and how to manage the disease. With proper diagnosis and care, modern medicine has reduced the severity of the disease to simply a somewhat painful inconvenience.

What is Gout?

Gout is a condition of having too much uric acid in the body. Under the right conditions (concentration, temperature, etc.), uric acid collects into hard needle-like crystals. The crystals tend to collect in the body’s cartilage, especially in the joints. When the crystals become large enough, they act as needles, doing quite a bit of damage to the surrounding tissues. Tissue damage causes localized inflammation and swelling. Very quickly the affected area can become so painfully inflamed that the patient can’t even stand the weight of a bed sheet on the joint. Uric acid crystals can also collect in other areas of the body in hard lumps called tophi (frequently in the middle outer edge of the ear). They can also collect in the kidneys, causing damage and contributing to the development of kidney stones.

Gout is a progressive disease that, if left uncontrolled, will advance to worsening conditions. The progression is described in 4 stages.

1. Asymptomatic Hyperuricemia. At this stage, uric acid concentrations are higher than normal though not enough to form large amounts of crystals. Usually the blood concentration is less than 6.8 mg/dl. There are many people who naturally never progress beyond this stage.

2. Acute Gouty Attacks. When higher concentrations of uric acid occur, crystals start to form and are deposited in the joints or tendons. Lower temperatures make the crystals form faster, such as seen in the feet and ear lobes. It also explains why a majority of attacks start at night, when the average body temperature tends to be lower. Gravity seems to be a factor in where the crystals collect, with the vast majority happening in the lower extremities and in the fingers. Up to 90% of flare-ups happen in the big toe. Each episode can last from 3 to 14 days. Often the initial incident is the first and only indication that the patient has the disease.

3. Intercritical Period. This is the period between episodes. Crystals may still be present but not in high enough concentrations to cause inflammation. It could last from days to years, depending on how well the patient manages their condition.

4. Chronic Gout. At this stage the patient has persistent, uncontrolled Hyperuricema. Active untreated or non-responsive gouty arthritis, manifesting itself as frequent flare-ups. Typically, multiple joints are affected. Uric acid crystals have persisted long enough to start collecting in tophi. Tissue damage and inflammation has continued long enough that the damage is starting to become permanent. Because effective treatments are readily available, the patient appears to be unwilling or unable to control their disease, creating the need for more aggressive management by outside caregivers.

What Causes Gout?

Uric acid is produced in the body by the breakdown of proteins that we eat. It also results from the normal breakdown and turnover of our cells. As uric acid is washed away in the blood stream it combines with other chemicals to become urate (uric acid salts). Normally urates are removed from the body, mainly in the urine. Some people can’t eliminate all the urates that their body produces. Concentrations start to build up in the blood, causing Hyperuricema.

About 90 % of those with Hyperuricema are not able to eliminate urates fast enough. Less than 10% have a problem with abnormally overproducing urates. Genetics seems to be the key factor in who develops this condition. Those afflicted have problems producing enough of the enzyme Uricase, which breaks down uric acid. There are other causes that can also be factors, such as kidney diseases, renal insufficiencies and some medications.

The primary drug classes that can cause gout are Aspirin, Niacin, Cyclosporine and the Thiazides, like Hydrochlorothiazide (HTCZ), which is used as a diuretic (water pill). It is also worthy to note that 75% of gout cases are accompanied by Metabolic Syndrome (Prediabetes), which causes abdominal obesity, hypertension, insulin resistance and abnormal lipid levels.

Not everyone who has Hyperuricema develops the painful symptoms of Gouty Arthritis. Diet can play a key role. Even with excretion problems, if you reduce the foods that lead to urates to a low enough levels, the body will be able to keep up. More about diet later.

Who’s at Risk for Developing Gout?

Even though no one knows exactly how many people have Hyperuricema and are at risk for attacks, one study showed that in the 1990’s 8 million people received gout therapy. Each year that number increases. Scientist agree that this increase is probably due to living longer, obesity, diet choices and alcohol consumption.

Age is a risk factor. As a person get older the risks increase. In the same article mentioned above, it was shown that those aged 65 to 74 had a prevalence of 31 per 1000. In ages 75 and older gout prevalence increased to 41 per 1000.

Gender is a risk factor. Males are 9 times more likely to develop gout. In women, the risk increases after menopause, narrowing the gender gap to 1 woman for every 3 men.

If your parents had gout you have a 20% chance of developing it yourself.

British people are 5 times more likely to develop gout.

American blacks (but not African blacks) are more likely to have problems with gout than other ethnic racial groups.

Lifestyle and diet choices increase the risk of gout. Especially alcoholic beverages (particularly beer), purine rich meats (red meat, internal organs meats, shellfish and oily fish), and high fructose corn syrup drinks.

Signs and Symptoms of Gout

How can a person tell if they’re having a Gouty Arthritis attack and not some other condition? That’s a good question. Early recognition of the signs and symptoms of Gouty Arthritis can lead to faster therapy applications.

As mentioned earlier, the majority of attacks happen at the base of the big toe. The first incident rarely happens to more than one joint (85 – 90% of cases). Other area of flares are (in occurrence order) insteps, ankles, heels, knees, wrists, fingers, and elbows. Occurrence will most likely happen at night. Flare sights will have swelling that is very painful. The skin will be warm, red or purple in color, and, later on, possibly itchy and peeling. Infections and gout are the only things that cause peeling as the inflammation subsides. The site will become extremely sensitive to touch. In some case fevers can accompany flares. The attack will usually take 2-4 hours to develop. Flares can last for days or weeks and will eventually resolve themselves with or without medication.

Many conditions mimic gout. Only a doctor finding uric crystals from samples of the flare area can tell for sure that it’s gout and not something else. Other conditions that look similar to it are Rheumatoid Arthritis (which usually involves several joints at once) and Psuedogout. Psuedogout is cause by calcium based crystals and usually happens in the knees, wrist and shoulder. If you are concerned, just ask the Doctor to sample for urate crystals.

What Can Trigger Attacks?

Once an attack of Gouty Arthritis has occurred the patient is at increased risk for future attacks. Whenever the conditions are right, crystals can form again. Binge eating and drinking can cause a sudden increase in urates. Dietary causes account for about 12% of gout cases. Other triggers are gout-causing medication use, renal failure, frequent dehydration, fevers, weight gain, surgeries, lead poisoning and injury to the joint.

One more curious note, gout attacks tend to happen more often in the spring.

How is Gout Treated?

There are two aspects to gout therapy: 1. Acute attack relief, and 2. Preventing the attacks from reoccurring.

1. Acute attack relief

The goals of therapy are the reduction of the inflammation and pain relief. First line medications are:

Non-steroidal Anti-inflammatory agents (NSAIDs) work by disrupting the chemical pathway of inflammation. Pain relief follows inflammation reduction. In the past, Indomethacin was the preferred agent, but ibuprofen and naproxen have similar effectiveness. NSAIDs have a number of side effect issues, but in the short run they can be dealt with. For example, a stomach acid blocker or antacids can relieve GI problems.

Colchine (Colcrys) is a medicine that decreases uric acid deposition and helps stop the inflammation process. It causes dose-limiting GI problems and is usually prescribed as, “Take 1 tablet every hour until attack resolves or diarrhea occurs.”

Corticosteroids are synthetic versions of our body’s own anti-inflammatory hormones. Commonly used versions are Prednisone (Deltasone) and Methylprednisolone (Medrol). They are powerful medications, but they have multiple serious side effects. They are usually used only when NSAIDs and Colchine are not advisable.

Cold Packs can be used to reduce inflammation, but some practitioners avoid their use because the reduced temperatures can lead to more urate crystals being formed. Aspirin should also be avoided because it too can cause crystals to form

2. Prevent future attacks (Prophylaxis)

The goals of therapy are to reduce or eliminate future flares and avoid permanent damage to the joints and kidneys.

Diet and lifestyle modification.

Diet and lifestyle modifications alone can reduce or eliminate future gout flares and are considered a first-line therapy.

A diet rich in dairy products with a supplement of at least 500 mg of Vitamin C daily has been shown to reduce gout flares.

Uric acid production can be managed by reducing the consumption of purine-rich meats and alcohol. Purine-rich vegetables do not seem to increase gout attacks, so they are of no concern, except for high fructose corn syrup.

Proper hydration promotes the flushing out of metabolic wastes, including uric acid.

Weight loss can also prevent reoccurring gout attacks. Unfortunately, there are certain weight loss techniques that can actually increase uric acid production and would be counterproductive. Very low caloric diets promote the breakdown of body tissue, leading to more metabolic uric acid production. Low carbohydrate diets rely heavily on proteins for caloric intake, thus increasing the amount of dietary uric acid. A diet alternative would be a calorie reduced, moderate aerobic exercise regime of more than 45 minutes at a time (avoid heavy exercise, which breaks down tissue, increasing metabolic uric acid).

Pharmaceutical Prophylaxis

When diet and exercise are not enough and when it’s economically feasible, gout-preventing meds can be taken. But first the risk versus reward of gout-causing meds like aspirin and niacin should be reevaluated.

Common medications that reduce the risk of gout flares are:

Allopurinol - Effective for both overproducers and underexcreters. It comes as a generic and has been a first-line med for 50 years.

Febuxostat (Uloric) - A newer drug in the same drug class. It has no generic and provides a valuable alternative to allopurinol.

Probenecid - Used for correcting defective underexcretion and comes as a generic. Probenecid requires proper hydration to avoid kidney stone formation.

Colchine (Colcrys) - can also be used for long-term prevention at lower doses.

Pegloticase (Krystexxa) - An injected medication given every two weeks. Its use is reserved for cases that do not respond to other gout medications.

Adult Foster Care Issues

The most common reason for gout therapy failure is patient noncompliance – both with lifestyle and diet changes, and with pharmaceutical regime adherence. You, the caregiver, are in an excellent position of being able to properly follow through with all the needed therapies. By doing so, you will be making a major positive impact on the quality of life of your resident. Avoiding even one attack is worth the effort

If you have a gout sufferer under your care you must have a plan of action in place before a gouty flare occurs. Have your plan written into the patient’s file. Make sure that all substitute caregivers know where to find your plan of action.

The plan of action should include when to call the doctor, when to call emergency services, contingency plans for nighttime attacks, standing doctor’s orders when an attack happens (for example, the use of cold packs and/or discontinuing certain meds if the attack is prolonged). You will have to request those orders when the patient moves in. You might even have to suggest the standing orders if the doctor is unfamiliar with care homes.

Conclusion

Unlike times in the past the prognosis for Arthritic Gout suffers is quite good. If a patient suffers from a Gouty Arthritis attack, the condition can be relieved quickly. The chances of further attacks can be diminished significantly by adherence to the appropriate prophylaxis therapies. The Adult Foster Care Provider can help the patient and assist with the necessary life changes that are required by therapy.

Other Sources for Help

American College of Rheumatology

1800 Century Place Suite 250

Atlanta Ga. 30345

www.rheumatology.org

Arthritis Foundation

1330 West Peachtree Street

Atlanta Ga. 30345

www.arthritis.org

References

1. Michael L Snaith, ABC of Rheumatology: GOUT, HYPERURICAEMIA, AND CRYSTAL ARTHRITIS. BMJ 310 : 521 (Published 25 February 1995)

2. R D Sturrock Gout, Easy to misdiagnose. BMJ 320 : 132 (Published 15 January 2000)

3. Dixie-Ann Sawin, Breaking the Chain of Gout: Pharmacist strategies to improve outcomes in gout and Hyperuricemia. U.S. Pharmacist-part 2 of 2 (Published February 2010)

4. Gout. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Gout

5. Gout and Hyperuricemia. Medicinenet.com.

http://www.medicinenet.com/gout/discussion-8.htm

6. Gout- Topic Overview WebMD.

http://www.webmd.com/a-to-z-guides/gout-topic-overview

7. Carol Eustice, What is Gouty Arthritis. About.com. http://arthritis.about.com/od/gout/g/goutdefinition.htm

8. Gout. Medline Plus.

http://www.nlm.nih.gov/medlineplus/ency/article/000422.htm

9. William C. Hiel Jr., Gout. EMedicineHealth.

http://www.emedicinehealth.com/gout/article_em.htm

10. Anthony di Fabio, Gouty Arthritis. Arthritis Trust of American. (published 1997) http://www.arthritistrust.org/Articles/Gouty%20Arthritis.pdf

11. Colchicine. RXList the Internet Drug Index. http://www.rxlist.com/colchicine-drug.htm

Gout: The Devil is Biting My Toe

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Oh my ACHING Back! The Dangers of Lifting.

Oh my ACHING Back! The Dangers of Lifting

Author: Mark Parkinson RPh: President AFC CE

Credit Hours 2- Approximate time required: 120 min.

Educational Goal:

To give instructions on how to lift correctly without injury

Educational Objectives:

1. Explain why back injuries are so serious.

2. Explain the Supervisor role in training and lifting education.

3. List and Describe Lift resources and equipment.

4. Present a lift training program.

5. Explain what to do in patient falls

Procedure:

Disclaimer

Oh, my ACHING Back! The Dangers of Lifting

“Help, I’ve Fallen”

You have seen the commercials on TV. An elderly woman yells, “Help! I’ve fallen and I can’t get up.” If that scene was shot in a care home, you would hear the patient yell followed shortly by the caregiver yelling even louder, “Help, my resident has fallen and I threw out my back trying to get them up.” Every job has its hazards. For In Home caregiving, especially elderly care, back injury is an ever present danger, a career stopper, and a business killer. Proper patient transferring and lifting techniques are the only sure ways to protect yourself, your business, and the patient from further injury.

Healthcare Workers Sustain More Costly Lifting Injuries

At first glance, caregiving may seem like easy work, but In Home caregiving can be very physically demanding. Whether you’re in adult foster care, developmental disabled, or mental health homes, there always seems to be the need to pick up someone who’s fallen, assist in transferring, bathing, or lifting heavy supplies and furniture. These manual lifting tasks have the potential to and have caused significant pain and injury to care workers and care home owners. Healthcare industry workers sustain four-five times more overexertion injuries than any other type of worker.

Back injuries are expensive, too. Nationally, an average lower back injury runs about $24, 000.00. If surgery is involved, the cost jumps to an average of $40,000.00. Even with worker’s compensation insurance, the costs of increased insurance premiums, time, pain, and absenteeism from work is very high. With the costs so high and potential injury so great, patient transferring, preventing falls, and lifting heavy items should be a priority concern for any In Home caregiver.

Ergonomics for the Prevention of Injuries

Ergonomics as defined by OSHA is “the science of fitting workplace conditions and job demands to the capabilities of the working population. Effective and successful ‘fits’ assure high productivity, avoidance of illness and injury risks, and increased satisfaction among the workforce.” In layman terms, that means to establish work training and work practices that everyone can live with that prevent injury. It is the duty of home care owners to establish these programs. The content of this CE is written with the intent that it could be utilized as part of a training program for care homes. I give permission for care homes to copy and use any or all of this article for their own or business use.

In-Home Caregiver Program - Patient Transferring, Lifting, and Falls

Information for Owners - Management Involvement

No program will last for long without the involvement of the boss. Owners of care homes should:

1. Establish practices and policies for safe patient handling. Owners have to communicate to everyone how to properly and safely lift. You’ll find the easiest way to accomplish this goal is by a setting up a program that everyone has to go through. Elements of such a program are A) communicate the importance of proper techniques. B) a training program C) a test to demonstrate knowledge gained D) follow through. One idea for training and testing is for the owner or other caregiver to become the patient. Showing and actual hands-on practice, along with reading, is a powerful way to teach.

2. Supply the proper equipment and resources to accomplish the lifting task. I think I just heard a collective moan form the owners’ wallets. While it is true that a small business must keep expenses down, you’ll find that the proper tool at the proper time does save more money than the tool itself. An inexpensive transfer belt is a lot cheaper than increased worker compensation premiums. More on equipment later. A lot of resources don’t cost any money. These include team lifts. The more bodies that lift, the easier the lifting task is. Owners must establish an environment where workers can ask for and get the assistance they need. If you are getting those types of phone calls, your lifting program is working.

3. Follow through. It’s one thing to establish a program. It is another to do the program, employee after employee, year after year. A check-off form attached to the employee’s file will help. Make it a habit. Also keep track of the equipment. Make sure it doesn’t walk off on its own or need repair. Periodically, it is good to ask questions of your employees. Ask them what they need, which tasks are the hardest, should the home be rearranged to make the job easier or safer. This accomplishes two things. Employees can sometimes come up with some pretty good suggestions. It strengthens employee-owner relations. Follow through is simply a good business practice.

4. If an injury occurs, reporting it should be one of the first steps. The owner has to create an environment where the employee feels safe reporting an injury. Once informed, the owner has to report it to their workers compensation insurance program. It’s the law. Failure on either count might lead to denial of a claim, negligence charges, and law suits or worse.

Lifting and Transferring Equipment

With medical costs and insurances skyrocketing, large nursing homes and hospital corporations are spending millions on new lifting equipment and implementing no-lift policies. Care homes do not have those resources but some savvy owners are upgrading their own homes in a more cost effective way. Make connections with the large health institutions’ equipment managers in your area and you might pick up a good deal on used equipment. Also, keep an eye on the second-hand stores where some medical devices can be purchased for pennies on the dollar. You might advertise on the Internet or local newspaper to purchase used equipment.

New patient transfer equipment that is well within the reach of most care home budgets include:

Transfer or Gait Belts

Traditionally, these were belt-like devices made out of canvas with a metal cinch clasp on one end. It was placed around the hips of the patient, giving caregivers a convenient place to hold on to. While those old belts can still be purchased for less than $5.00 a piece used, they are being replaced by gait belts with a superior design. The new designs are two to three times as wide, made of easy-to- clean synthetic materials, a quick-release plastic clasp, and multiple soft handle loops sticking out. They are easier to use and clean than the older version. They cost a bit more, but new units cost less than $40.00.

Transfer Boards

A transfer board is any material or object that can hold up under the weight of the patient that they can slide on to get from one place to another. Literally, a highly polished board with a good finish will do the trick. Commercial versions are much easier to use for the caregiver and the patient. Transfer boards come in astounding varieties, ranging from simple ones running about $10-20 to extremely versatile or specialized units going for hundreds of dollars.

Swivel Boards or Discs

These devices are placed under the feet of the patient to assist in turning in the pivot-transfer method. They are designed to function even with the heaviest patients. Quality units run hundreds of dollars.

Transfer Benches

A transfer bench is a cross between a bath bench and a transfer board. All are designed to be bath capable. The simplest are just bath benches that are long enough to extend over the bath tub side wall. Used versions can be picked up inexpensively. More advanced versions come complete with swivel chairs mounted on rollers. They make bathing your residents very easy and virtually fall free. They run up to $500, depending on how many features you want. Good units can be purchased for around $200- $400 each.

Power Lifts

Power lifts are any powered device that aids in a patient standing or transferring. These are the most expensive, with some devices running thousands of dollars. The most common versions in care homes are power lift easy chairs that residents bring with them from home. Make arrangement to purchase used chairs when a client moves on. Or better yet ask, the family member donate the chair.

Stand-Assist Devices

Stand–assist devices are basically handles that the patient holds on to while they stand. The patient uses them to pull themselves up. The model can be free standing, fixed to a bed, or chair. There is even a version that attaches to the top of a car door that makes it easier to get in out of a car. These are simple devices and most can be purchased for $100 or less. These are the easiest to pick up used.

Insurance Coverage

Depending on the patient’s diagnosis, some devices are covered by insurance. Durable medical device salesman can assist you in the particulars of the paperwork. A prescription will likely be needed. It would be to your benefit to learn about the insurance process so you can utilize the coverage in similar future circumstances.

Training Program

Overview

Every year, thousands of healthcare workers go to work to help their patients only to have a lifting injury and become a patient themselves. It is ironic that the act of assisting the patient, if not properly done, may cause harm to that very patient. To help keep you and your charges from unwanted injury, the following program was developed.

Awareness

In-home care giving may seem like an easy job, but at times it can be quite physically demanding. The caregiver must take the responsibility to always be aware of what is required of them and accomplish those tasks safely. Do not fall into the trap of doing things the quick and sloppy way. Such thinking has led to many patient injuries, caregiver back surgeries, and lives full of pain.

If an injury does occur, report it immediately. A stitch in time really does save nine. No one wants to see you hurt or work while you are hurt. Call the management at any time when there is a need. Help will always be there for you.

Limitations

Remember that when you work with the elderly or bed ridden, inactivity and osteoporosis robs the bones of their strength and makes them brittle. Arthritis can result in sore and stiff joints, making regular movements difficult. It’s easy to get dizzy if you get up too fast. Some patients have injuries that make one side weaker than the other. Always try to compensate for the weak side.

Before the Lift

Think about what you are doing. Figure out the proper lifting technique for the task. Utilize the proper equipment, clear the area or path of hazards, and get help if you need it. Gather the items you need before the lift or transfer. Never leave an “at-risk” person alone in a precarious position.

A special Note: Get Help

You are not in this alone, and you are not superhuman. If the lifting is too heavy, get help, either from the proper equipment available or the assistance of someone else. Many hands always make the lifting easier and safer.

Know Your Patients

Everyone has varying capabilities and weakness. If you are new to the job, make it a priority to learn what disabilities your charges have. Don’t be surprised in the middle of a lift that a patient can’t do this or that function. Always be aware that patients can have bad days that reduce their capacities.

Proper Body Mechanics

Every lifting job is different, but there are common elements to all proper lifts or patient transfers

1. Face the person or object and establish a solid base of support. Place your feet shoulder length apart on solid, slip-free ground.

2. Keep your back straight.

3. Bend at the knees and not the lower back as much as possible.

4. Hold the object as close to you as possible.

5. Tighten your stomach muscles when lifting.

6. Lift as much as you can with your legs.

7. Never twist when you lift. Make adjustments with you footing instead.

8. Push rather than pull when you can.

9. Maintain good communication in team lifts.

10. Lift with smooth efforts, no sudden jerking.

Patients are not the only heavy things that you might be required to lift. A 25-pound bag of potatoes, flipping a mattress, or moving furniture around can overstrain the back if improper body mechanics are used.

Patient Transfers

Moving a patient from one place to another is an essential required skill for any care- giver. But awkward positions, tight, in-home spaces, and unpredictable patient movements can make transferring a patient a dangerous task. Over the years, techniques have been developed that will enable you to the move the patient easily and safely.

Rolling a Patient in Bed

1. Insure that there is enough room to roll the patient in the direction that is needed.

2. Have the patient bend the opposite knee in the direction you want to roll.

3. Cross the opposite arm you want to go and have the patient reach in that direction

4. Place your hands on the shoulder and hip area and gently push until the roll is complete.

Setting the Patient on the Edge of the Bed From a Reclining Position

1. Bring the patient to the edge of the bed. This may take leveraging from top to bottom a little at a time. Avoid pulling heavy patients all at once.

2. Dangle both feet over the edge of the bed.

3. Put one arm under the patient’s shoulders and one arm over the hip, slightly lower down the leg.

4. Start by pulling the lower half of the body over the edge of the bed and then utilizing the natural pull of gravity lift from the shoulders until the patient is upright.

Note: if the patient is so large that it puts you in an awkward position, you might have to divide the task into two steps. Legs first, then lift the shoulders.

Transferring From Sitting to Sitting. Pivot Transfer

1. Secure the transfer destination. If it is a wheelchair. place it against the bed. Lock the wheels. Remove or swing away the foot rests. Remove the arm of the chair that is against the bed, if required.

2. Bring the patient to the edge of the thing they are sitting on (bed, chair, or car seat).

3. Utilize a transfer belt, if one is available.

4. Place your foot in front of the patient’s toes to prevent slipping.

5. Bend at your knees and reach around and grab on the patient belt.

6. Tell the patient you’re about to lift and count to three. If there is some difficulty, you can start a forward rocking motion on each count, one, two, and lift on three.

7. Have the patient push off with their hands or place their hands on your shoulders or upper arms, never around your neck.

8. Lift straight up utilizing the natural pull of your weight and lift from your legs. Tighten your stomach muscles to help take the strain off your lower back. Never lift from your lower back muscles.

9. Once the patient is standing and while you are still holding the belt, turn the entire body by taking small steps with your feet. Do not twist from the waist.

10. Gently support the downward movement of the body by bending your legs and keeping your back straight until the patient is safely seated. Keep the patient in your center of gravity by placing your feet on the outside of the patient’s feet and your knees on the outside of the patient’s knees.

Note: Position the destination chair on the strong side of the patient. Provide verbal cues for example, “turn, turn, OK, sit.” Positioning the receiving wheelchair at a slight 30-degree angle creates a bigger receiving “target” for the patient.

Repositioning the Patient in a Chair

1. Have the patient lean forward with their shoulders toward their knees.

2. Place yourself in front on the patient with knees against the knees of the patient.

3. Bend at your knees and grab hold of the patient’s belt (or transfer belt if it is needed).

4. On the count of three, roll your feet on to your toes and push with your knees against the patient’s knees, utilizing your own natural leverage to lift the patient’s bottom off the cushion.

5. Gently slide the patient forward into the desired position. Don’t lift the patient.

Sliding Board transfer

A transfer board is any sturdy board that is placed as a “bridge” between two positions and the patient slides to their destination.

1. Place the patient at the edge of the place they are sitting on. Lean the patient away from their destination.

2. Place one end of the board under the elevated hip. Be careful not to pinch the skin. Place the other end at the destination securely.

3. Have the patient “scoot” along the board with your guidance so they do not lose their balance and fall. Let the patient do the work or if necessary use several abbreviated pivot transfers.

Note: Utilize gravity by making the destination lower than the starting position if you can. Have the patient take advantage of any secure hand holds that are available. For difficult transfers like from a small car, an intermediate destination might be of use, utilizing two transfer boards.

Special Notes for Transferring the Patient to a Car

Make sure the car seat is moved back as far as it can go. Recline the back of the seat slightly to provide more room. After the patient is in, you can straighten the seat into a more comfortable position. Roll the window down so that the car door can become a handhold.

What To Do in Falls

A patient falling is always a major concern. Unfortunately, it is almost inevitable with In Home care that a patient will end up on the floor. Keep your ears tuned in. It is most likely you will hear a fall before you see one. Prompt action is required. Always inspect the area and the patient before taking any action.

Lifting a patient from the floor is particularly dangerous for the patient and the caregiver. If the lift is not done right, the patient can suffer further injury and the caregiver can end up injured, too.

First: Prevent the Fall in the First Place

As you walk with the patient, find the center of balance and place your hand there. For most, it is the lower back, conveniently close to the belt line. Grab on the belt, if there is one. If you need to, apply a transfer belt. As you walk, feel for unusual movement and give balance when needed to keep the patient on their feet.

Many falls happen when the patient tries to get up to fast. Do not pull the patient up from a relaxed position all at once. Set them up and tell them to get ready to stand up. Make sure they scoot their bottom to the edge, straighten up, firmly place their feet, and get their balance ready.

Transfer boards are handy when going from sitting to sitting positions or standing to a difficult sitting place, for example, getting into a car or bath tub. Place a stool or chair outside the car or tub and place the transfer board between them. Have the patient sit on the transfer board and slide the patient to their destination.

Second: During the Fall

Usually you can keep a patient upright by helping to maintain balance, but there are times when that isn’t going to be adequate. Sometimes the patient is going down no matter what you do. Don’t let them take you down with them or jerk your back out of place as you try to assist them.

1. If the patient is falling, do not try to stop it. Control the fall instead.

2. Steer the fall to a safe place.

3. Slow the speed of the fall down from YOUR center of gravity, bending properly as you go down. A safe way is to drop your center of gravity a little slower than the patient.

4. Protect the patient’s head.

5. Let the patient slide down your leg to the floor. Bend at the hips and knees as you

lower them.

Third: After the fall

If you were not present when the patient fell, first be sure the area is safe for you to go into. For example, be aware of electrical wires and broken glass hazards. When a patient falls, most will want to get up right away. Don’t let them until you have made an injury assessment.

Injury Assessment

1. Call the owner and 911 as per company policy when the patient has lost consciousness, has uncontrolled bleeding, stopped breathing, if the pupils are dilated inappropriately for the room lighting or if one pupil is larger than the other or any other life-threatening circumstance. If you feel overwhelmed, call the owner.

2. Check for a sign of a fracture. The patient will report pain, tenderness. or hearing a pop or snap. You might notice swelling or bruising.

3. Hip fractures are of particular concern and are noticed by one leg being shorter than the other, there is an unusual angle to the leg, or the patient feels or hears a “crackling” when they move or they are unable to move. If a hip fracture is suspected, DO NOT move the patient. Make them comfortable and get help immediately, then keep them warm with a blanket.

4. Assess for signs of confusions or altered speech. Questions you can ask are: What year is it? Do you know where you are? Which room is yours? What were you trying to do before you fell?

5. Check for cuts and bleeding from head to toe. Skin tears look very severe but they are usually not life threatening. Head cuts have a tendency to bleed a lot, even minor ones.

6. If you suspect a head, neck, or spinal injury, DO NOT move the patient. Get help immediately.

When calling 911, be calm and communicate clearly. Note any pertinent details. It is better to give too much information than not enough. Always call the owner, too.

If There Are No Injuries

If there are no injuries that you can see, help the patient get up in stages. There are several reasons for doing this. Unnoticed injuries will present themselves sooner and you can abort the attempt easier and safer. It saves you from lifting the dead weight of the patient. It’s good for bruised egos and embarrassed patients to do the work themselves. It makes them feel less of an invalid.

Stages from the floor

1. Have the patient sit up.

2. Turn the patient over until they are on their knees.

3. Have them lift one knee up.

4. Lift patient to an upright position, utilizing proper body mechanics. If needed, have a chair nearby and lift them to the seat first then stand them up. Do all these steps slowly with plenty of time for patient orientation in between.

Note: patient transfer belts make the operation easy for you and safer for the patient.

Conclusion

Do your patient, yourself, and your back a favor and be prepared before you lift or assist in transferring a patient. Know proper lifting techniques before you lift, think through the lift before you act, get the necessary equipment or help, use proper body lifting mechanics, communicate clearly, and lift with safety in mind. Remember, furniture and heavy supplies can be just as damaging to you as an improper patient lift.

Helping others shouldn’t result in injuring yourself or the patient. Remember, you won’t be helping anyone if you find yourself on the wrong side of a back surgery.

Mark Parkinson RPh.

Resources

1.Guide lines for Nursing Homes, Ergonomics for the Prevention of Musculoskeletal Disorders. OSHA

lhttp://www.premierinc.com/safety/topics/back_injury/downloads/Final_OSHA_Guidelines_nursing_homes.pdf

2.Transferring. University of Missouri- Kansas City

http://cas.umkc.edu/casww/transfrg.htm

3. Back Injury Prevention. Premier Inc. com

http://www.premierinc.com/safety/topics/back_injury/

4. Ergonomics. OSHA, United States Dept. of Labor

http://www.osha.gov/SLTC/ergonomics/

5. Wirnani Garner, How to Do Proper Body Mechanics for Lifting. EHow Health.com

http://www.ehow.com/how_2302456_do-proper-body-mechanics-lifting.html

6. Em M. Pijl Zieber, Back care and Patient Transferring Techniques. LETHBRIDGE COMMUNITY COLLEGE

HEALTH & ALLIED WELLNESS. 2002 revised 2004

http://people.uleth.ca/~em.pijlzieber/BACK%20CARE%20LAB.pdf

7. Melissa Sandoval, How to Use a Transfer Board to Move a Patient. EHow Health.com

http://www.ehow.com/how_5621732_use-transfer-board-move-patient.html

8. Transferring Using a Transfer Board, Krames Patient Education. Wishard

http://wishardhealth.kramesonline.com/HealthSheets/3,S,40382

Oh my ACHING Back! The Dangers of Lifting

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The Fungus Amongus.

The Fungus Amongus

Author: Mark Parkinson RPh: President AFC CE

Credit Hours 1.5- Approximate time required: 90 min.

Educational Goal:

To familiarize the In Home Care Giver with the concepts of fungal infections.

Educational Objectives:

1. Enumerate the prevalence of fungal infections and explain the reasons why it is so high.

2. Describe the signs and symptoms of fungal infections.

3. Explain how to prevent and treatment fungal outbreaks

4. Explain why relapse rates are so high and what to do about it.

5. How to overcome patient non-compliance issues.

Procedure:

Disclaimer

The Fungus Amongus

Who Has the Fungus Amongus?

There are a lot of nasty things that like to chew on us (besides tax collectors and ex-spouses, that is). Among the most prevalent is a group of fungi known as dermatophytes. You might know them better by their common names, athlete’s foot, jock itch, ring worn, and nail fungus.

At any given time, more than 30 percent of the population can have fungi growing on them somewhere. Athlete’s foot alone will infect more than 70 percent of all adults at least once in their lifetime. In populations that have poor hygiene or compromised immune systems, the infection rate soars. Since a majority of foster care clients comes from these groups, caregivers should be aware of and know how to deal with “The Fungus Amongus.”

Why Is Fungus So Prevalent?

Fungus is a group of organisms that is related to yeasts and molds. They were here long before man came along and will be here long after we’re gone. Fungi need only two things to survive - a carbon-based food source and water. They can spread in two ways. They grow like plants, extending themselves along root like filaments called hyphae and they produce spores that are microscopic and can travel in the air. Since they have been here a long, long time it’s safe to say that fungus and fungal spores can be found pretty much everywhere in our environment.

Fungi come in a wide variety. The fungus that likes to grow on us is called Dermatophytes. As fungi, dermatophytes can survive just about anywhere, but they seem to thrive in warm, damp environments. They don’t even need a human host to survive. This makes fungal infections very contagious. All it takes is for the skin to come in contact with a source of a fungus and that person can become infected. Once infected, that person is now a fungal source and they can spread it to any other surface they come in contact with where the conditions are right for growth. Unfortunately for most humans, hot sweaty feet are ideal conditions for fungus to grow, especially between the two smallest toes.

It is now easy for you to understand that the highest risk areas for the spread of dermatophytes are warm, damp communal areas like gym showers, bathrooms, and pools - plenty of moist surfaces and lots of skin to come in contact with contaminated areas. And the highest prevalence for athlete’s food is found in young to middle-age men.

You Can Be Fungus-Free

Regardless of the source or the prevalence, healthcare providers can identify and eliminate fungus from their homes. It can be done in two phases. First, the home: Professional cleaners say that you usually don’t have a fungus problem, you actually have a moisture problem. First, if you can control how much moisture there is, you can control how much fungus there is. Second, the infected person: antifungal medications and moisture control usually do the trick. Being fungus free is mostly about timely action and knowing what to do.

Luckily, fungal infections are not life threatening. For most, they just result in a chronic itch and stinging pain when the skin cracks. Complications can arise when secondary infections take advantage of the weakened skin area. Due to this and its contagious nature, care providers must learn to screen for and treat fungal infections quickly and effectively. If you know what you’re doing, fungus is easily identified and eradicated. Of course, the first place to start is with yourself and your home then move on to your current residents. After your home is fungus free, all you have to do is carefully screen new move-ins. Your home can be free from fungal infections

Signs and Symptoms

To get rid of the fungus amongus, caregivers must know what to look for and where to find it. First, let’s all get on the same page.

Medical Language

In medical terms, skin fungi are dermatophytes. The three main infectious types are trichophyton, epidermophyton, and microsporum. Dermatophytic infections of the skin can manifest themselves anywhere on the body. Infections are named by the beginning term “tinea” and the ending term dependent on the area of involvement. Thus tinea capitis affects the scalp, tinea barbae- the face, tinea unguum- the nails, tinea manuum- the hands, tinea cruris- the groin area (jock itch), and tinea pedis is the feet (athlete’s foot). But outside of understanding medical literature and other health professionals, who cares what the Latin name is? What really matters is what it looks like. What is the physical appearance of a fungal infection? To know what you’re looking for, you have to understand what is going on in the affected area.

Anatomy

The skin is the largest organ of your body and is composed of multiple layers of tissue. The two main groups are the dermis and epidermis. The epidermis is the skin’s outermost layer. It is made up of skin cells that provide protection for the inner skin layers. Basal cells at the bottom of the epidermis reproduce and move the new skin cells outward thus replacing the outermost cells that wear off.

When an infection occurs, dermatophytes invade and start to grow under the top most layers of the epidermis skin cells. The basal cells respond by overproducing cells trying to slough off the infection. As the excess cells reach the skin’s surface, they cause the first visible appearance of a fungal infection. (Understanding this will become important in treatment. More about that later.) If the infection gets bad enough, the body’s immune system senses the infection and tries to contain and stop it by inflammation, sensitivity, and other immune responses. That sensitivity is most often felt as an itching sensation alerting us to the presence of an active infection.

The Different Varieties

Now that we have covered the basics and are all on the same page, let us review what some of the most common fungal infections look like. Starting from the top:

Tinea Capitis (cradle cap)

Not all flaky dandruff is from a dry scalp. If you encounter a bad case of dandruff that just won’t go away with dandruff treatment, talk to the doctor about the possibility of fungus. More pronounced infections can appear as round bald patches with tiny black dots that are actually hair shafts that have broken off. Patches can appear scaly and can also be red or swollen with puss-filled sores. The scalp is usually itchy.

Dermatophytosis (ringworm)

Ringworm, of course, is not a worm at all but it does look like there is one under the skin. Infections are itchy and have red, raised, scaly patches that may blister and ooze. The patches have sharply-defined edges. Red patches are often redder around the outside with normal skin tone in the center. This may look like a ring. And just in case you are wondering, you can catch ringworm from handling infected pets.

Tinea Curuis (jock itch)

Jock itch (or any folds of the body like under the breast, anus, or fat folds) is basically ring worm. The signs are itching in the fold of the skin, red, raised, scaly patches that may blister and ooze. The patches usually are redder on the outside with sharply defined edges, abnormally light or dark skin and patches can have a bad smell.

Tinea Pedis (athlete’s foot)

The classic signs of athlete’s foot are itchy flaky or peeling skin, most often accompanied by bad odor. There are three main types of athlete’s foot. The most common is interdigital tinea pedis or fungus in between the toes. In this type of infection, the skin within the toe web will appear as inflamed, scaly, and with soggy white tissue. Splitting of the skin, called fissures, may be present between or under the toes. Hypereratotic or moccasin-type infection is a more prolonged infection that covers the soles and lower sides of the foot (where a moccasin would cover). The skin appears darker, scaly, flaky, reddened, and slightly thicker. The least common form is called acute vesicular tinea pedis, where fluid-filled cysts or blisters (vesicles) form, pop, and create open sores. The inflammation is usually quite itchy.

Tinea unguium or Onychomycosis (nail fungus)

Dermatophytes can get under and even in the nails of the hand and foot. Typically, the nail thickens and a white, yellow, or brown discoloration occurs. Occasionally, pitting and small fissures are present. Sometimes the nails get so thick that it interferes with walking and shoe apparel. Toe nail fungus is a long-term problem. It is very difficult to treat. It can also act as a repository for the dermatophytes that can continually re-infect the surrounding skin. A podiatrist (foot doctor) is another option for treatment and is better equipped to handle thickened nails.

Look-Alike Conditions.

There are other conditions that can mimic fungal infections. Maladies like eczema, seborrhea, and localized allergic reactions have been mistakenly identified as fungal outbreaks. Fortunately, you as a caregiver don’t have to tell them apart. You are just screening for the possibility of infection and the doctor will do the diagnosis. The guiding principle is “when in doubt send them out,” to the doctor, that is.

Complications

Life is never as simple as black and white. The same is true with fungal infections. Complications can arise that may need attention. The most common complication is odor. As the fungus spreads, the skin is compromised, leaving an opening for bacteria to grow. Signs of a bacterial infection are swelling, red streaks, and pain. The body can fight off these infections by itself, but those with weakened immune systems may need antibiotic help. These secondary infections can produce very unpleasant odors. Controlling the bacteria is the key to controlling the odor. For those with compromised immune systems like diabetics, uncontrolled fungal infections can be the first step toward amputations.

Two less common but nevertheless serious complications are the ID reaction and asthmatic attacks. The ID reaction or dermatophytid is in basic terms a localized allergic reaction to the fungus. It is typically seen as a generalized, diffuse rash. It might look very nasty but the condition will go away by itself when the infection is cured. There have been some reports of increased asthma attacks when fungal infections are present. It would be wise to keep a rescue inhaler handy when treating fungus.

Treatments

Now let’s talk about how to get rid of the Fungus Amongus

Prevention

Prevention is always the best cure. Fungus needs a wet environment to thrive and direct contact to the skin to spread. If you can control these two conditions, you can pretty much keep you home fungal infection free. Good hygiene techniques are your best bet at prevention.

Bathrooms

Bathrooms and showers are always damp and can be hard to maintain a surface free of fungus. Molds also grow in the same conditions as fungus, so if you see mold, there is a good chance that fungus is there also. Here are a few cleaning tips:

Increase ventilation by running a fan or opening a window.
Wipe down bath tubs and showers and keep plumbing in good repair.
Porous or absorbent material may have to be thrown away if they become moldy.
Don’t paint or caulk over moldy corners.
Choose cleaning products that say they are disinfectant cleaners. Cleaning an area by itself will not kill all the fungus, and disinfecting an area without cleaning also leaves behind hiding places for the fungus to grow back. You can use separate products but choosing a disinfectant cleaner is more efficient use of your time. It is important to leave the disinfectant on the surface for about 10 minutes so that it can penetrate the surface and kill the fungus.
While treating a fungal infection, clean surfaces more often.

Laundry

Towels, wash rags, socks, and clothing can be a source for the spread of the fungus amongus. Bleach kills fungus, also the “Hot” settings on you laundry machines kills as well. Keep you dryer vents clear and your dryer will run hotter.

Shoes

It’s hard to wash shoes, but let’s face it, they need it from time to time. Bacteria can really make them stink. What good is it to treat the infection if you continually put the same infected shoes on. A few cleaning tips for shoes (and slippers).

You can purchase special disinfecting shoe insert machines. One idea is to let the business buy the machine and rent it to those with a problem. It could pay for itself or even be a source of income.
Treat shoes with antifungal powders.
Pour rubbing alcohol onto shoes and let stand for five minutes. This will kill the bacteria, too. (It could also ruin shoes- be careful.)
If you’re desperate or the above is impractical, place the shoes into an airtight plastic bag and put them in the freezer overnight. That will kill the fungus amongus and eliminate odor-causing bacteria.
If you have sweaty feet, you may have to buy ventilated shoes.

Feet

Keep feet dry. Dry in between the toes after bathing. Don’t share towels. It might also be a good idea to have a separate towels for infected areas to keep the infection from spreading to different parts of the body. Change socks often. Flip flops or shower shoes are also be a good idea, especially in communal areas that are not under your control.

Cures

Non-Pharmacological Treatment

Even with your best effort sometimes an infection will slip past your prevention efforts, or you have a new client move in with an active infection. It is good to note that (depending on the severity of the case and hygiene efforts of the patient) about 30-40 percent of infections can resolve themselves. There is a lot of anecdotal evidence that changing the pH [p(H)] can kill off fungus. So, home remedies like soaking your feet in vinegar, baking soda, boric acid, or bleach might or might not help. You can try these on yourself but you cannot use them on your resident without a doctor’s permission.

Pharmacological Treatment

Most infections respond well to topical antifungal agents. For severe or topical treatment failure, oral medications may be needed. In addition, depriving the infection of moisture through the use of a dry powder or zinc oxide-based diaper rash cream may be a good add-on treatment. For scalp infection, there are antifungal shampoos.

In cases where there is significant pain and rash, the doctor might use a topical steroid in addition to an antifungal or in a combination steroid/antifungal product. You should know as a caregiver that applying topical treatments to fissures and open sores are going to sting.

One note of interest, fungi are complicated structure that are not easily mutated. Therefore you don’t see much medication-resistant strains developing.

More Medical Terminology

In considering treatments, it is important to understand the difference between the terms fungistatic and fungicidal. Fungistatic means to halt the progression or growth of the organism. Fungicidal means to kill it off. You can probably guess that a fungistatic agent take longer to eradicate the outbreak.

Topical (on top of the skin)

Topical agents are the first-line therapy for most doctors. They are safe, easy-to-use, and inexpensive. In clinical trials, fungicidal agents are the most effective while undecyline acid is the least effective.

Table 1. Nonprescription Antifungal Products

Agent	Brand Names	Formulations	Dosing	Minimum Effective Duration	Comments
Azole
clotrimazole 1%	Desenex^® Lotrimin^® AF	cream, lotion, powder, solution, spray solution	BID	4	fungistatic
ketoconazole 2%	EXTINA^® Nizoral^®	Cream 1% Shampoo*	BID	6	fungistatic
miconazole 2%	Desenex^®, Lotrimin^® AF, Micatin^®, Micozole, Monistat^®	cream, lotion, gel, powder , spray powder, spray solution	BID	4	fungistatic
tolnaftate 1%	Lamisil AF Defense^™, Tinactin^®	cream, powder, spray powder, spray solution, solution	BID	4	fungistatic
undecylenic acid		5% to 25%	BID	4	fungistatic
5% to 25%	Desenex^®	cream, powder, powder spray, liquid
Allylamines
terbinafine 1%	Lamisil AT^®	cream, spray solution, gel	QD	1	fungicidal
Benzylamines
butenafine 1%	Lotrimin^® Ultra	cream	BID for 1 week, then QD for 4 weeks	5	fungicidal

* Shampoo is dosed differently, see container for proper use.

Table 2. Prescription Products for the Treatment of Tinea Pedis

Agent	Brand Names	Formulation	Dosing	Minimum Effective Duration	Comments
Azoles
econazole 1%	Spectazole^®	cream	QD	4	fungistatic
oxiconazole 1%	Oxistat^®	cream, lotion	QD or BID	4	fungistatic
sertaconazole 2%	ERTACZO^®	cream	BID	4	fungistatic
sulconazole 1%	Exelderm^®	solution	BID	4	fungistatic
itraconazole 200 mg^a	SPORANOX^®	capsules, oral solution, injection	QD-BID	1-4^b	fungistatic
fluconazole 50 to100 mg	DIFLUCAN^®	Tablets, injection for intravenous infusion only, oral suspension	QD	4-6^b	fungistatic
Allylamines
naftifine 1%	NAFTIN^®	cream, gel	QD‐BID	4	fungistatic
terbinafine 250 mg^a	LAMISIL^®	tablets	QD po	2^b	fungistatic the most effective oral agent
Others
ciclopirox 0.77%	Loprox^®	Cream, gel, lotion, shampoo	BID	4	fungistatic

^aNot FDA-approved for the treatment of Tinea pedis.

Source of tables 1 and 2: Gina J. Ryan PharmD, BCPS, CDE, Fostering Patient Adherence in the Management of Tinea Pedis

Oral Medications

There are times when topical therapy is not enough. The doctor may choose to use or add on an antifungal oral medication. Itraconazole, terbinafine, and fluconazole come as oral tablets.

Tea Tree Oil

There are many antifungal products that contain tea tree oil. Despite some reports, tea tree oil does not kill fungus. It is believed to help by instantly reliving the itch. Without the constant scratching, wounds heal faster by themselves.

Preventing Recurrence

There is a high relapse rate for fungal infections. As many as 70 to 80 percent of cases relapse. In my opinion, the two major reasons for this are poor hygiene and incomplete eradication of the existing fungal infection. Let me explain further.

Remember that fungus invades under the skin. The body tries to slough it off by over producing skin cells. That is the visual signs of infection. Most uninformed patients will treat the infection until all visible signs are gone. Unfortunately for those patients, there is still a full-blown infection going on that they can’t see. So, in essence, they never really cure themselves in the first place and the infection comes roaring back.

The key to preventing recurrence is proper education and regular inspections.

Teach proper hygiene techniques to your staff, family, and clients.

Reinforce and reward good efforts.

Tell patients about how they might still be infected and to continue therapy long after all visible signs of the fungus amongus are gone.

The rule of thumb is fungistatic meds require two-four additional weeks and fungicidal treatments require one week after all visible signs are gone.

Regular inspection of the home and patient is just good patient care.

If despite your best efforts the infections keep coming back, then most likely the patient is getting re-infected from an outside source. Check for pets or neighborhood animals with balding spots (possibly an active fungal infection). Look for moldy spots in their environment. If you can’t identify or illuminate the source, you may have to use antifungal powders on a continual basis as a preventative measure. Getting a PRN order from the doctor would do the trick.

Noncompliance Issue

One more piece of patient information for you. If there is an open fissure or wound, antifungal treatments will sting - sometimes a lot. Warn your patients beforehand and inform them that the sting will go away as the body heals. If noncompliance because of pain becomes an issue, you might ask the doctor for a topical steroid cream or tea tree oil.

Conclusion

The fungus amongus may be common in the general population, but it doesn’t have to be prevalent in your home. With proper hygiene and patient care technique, you can completely eliminate it from your home. In the end, it will be one less thing for you to worry about.

Good luck in your efforts.

References:

1. What is a Dermatologist?, Consumers' Research Council of America.

http://www.consumersresearchcncl.org/Healthcare/Dermatologists/derma_chapter1.html

2. Gina J. Ryan PharmD, BCPS, CDE. Michael Cantrell, DPM. Fostering Patient Adherence in the Management of Tinea Pedis, Apr 10. 2010. Power-pakCE.

http://www.powerpak.com/course/preamble/106739

3. Athlete’s Foot. Health Spot.

http://www.ihealthspot.com/Home/PatientEducation/FamilyPractice/tabid/10431/ctl/View/mid/17218/Default.aspx?ContentPubID=940

4. Athlete’s Foot. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Athlete's_foot

5. Guha Krishnaswamy, James H. Quillen. Dermatology for the practicing allergist: Tinea pedis and its complications. Mar.29,2004. Clinical and Molecular Allergy.

http://www.clinicalmolecularallergy.com/content/2/1/5

6. Jock Itch. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001879/

7. Onychomycosis. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Onychomycosis

8. Tinea Capitis. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001881/

9. Ringworm. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002411/

10. Athlete’s Foot (Tinea Pedis). Our Health Network.Com

http://www.ourhealthnetwork.com/conditions/FootandAnkle/AthletesFoot.asp

11. Epidermis. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Epidermis_(skin)

12. A Brief Guide to Mold, Moisture, and Your Home. U.S. Environmental Agency.

http://www.epa.gov/mold/cleanupguidelines.html

13. How to Disinfect Used Shoes. WikiHow.com.

http://www.wikihow.com/Disinfect-Used-Shoes

14. Tisha Tolar. How to Disinfect Showers for Athlete's Foot. eHOW.com.

http://www.ehow.com/how_5681103_disinfect-showers-athlete_s-foot.html

15. Mary Marlowe Leverette. How to Prevent Spread of Athlete's Foot in Laundry. About.com

http://laundry.about.com/od/laundrybasics/a/athletesfootlaundry.htm

16. Ivan Bristow, Manfred Mak. Fungal foot infection: the hidden enemy? Wounds uk, 2009, Vol 5, No 4

http://www.woundsinternational.com/pdf/content_9316.pdf

The Fungus Amongus

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The Creepy Crawlies-Scabies and Lice.

The Creepy Crawlies-Scabies and Lice

Author: Mark Parkinson RPh: President AFC CE

Credit Hours 1.5- Approximate time required: 90 min.

Educational Goal: To educate Care providers about Head, Body and Pubic Lice and Scabies and help them control outbreaks.

Educational Objectives:

1. Give a description of Lice and Scabies that infest Humans.

2. Provide the signs and symptoms of outbreaks.

3. Tell the importance and details of a home screening program.

4. Enumerate the different treatment strategies.

5. Discuss the necessity follow up on therapy.

Procedure:

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Disclaimer

The Creepy Crawlies: Scabies and Lice

The Caregiver’s Nightmare

Not all skin infections are caused by bacteria, viruses, and fungi. Some of the most common infections that trouble mankind are the result of infestations of slightly bigger critters, lice and mites.

Lice and mites are parasites that live off the blood of their unwilling hosts and are found anywhere humans gather. They are extremely annoying and a major pain in the neck to get rid of. Although they are not usually the cause of any serious health consequences, they do carry several social stigmas. Those who are infested claim to die of embarrassment.

For a business that lives and dies on its reputation, lice and mites outbreaks can be a real caregiver’s nightmare. Your business can die from embarrassment. If you think your home is immune from such troubles, just think of all the visitors who come IN to your home. Friends, children, grandchildren, and home health nurses (who are exposed to who knows what in their daily rounds). Whether you operate an Adult Foster Care, Developmentally Disabled or a Mental Health Home, stay in business long enough and chances are you will have to deal with the Creepy Crawlies.

Just what are these things and how do you get rid of them, or, better yet, keep them out of your home in the first place? By the end of the article, you should have the answers to these questions.

Lice (Cooties)

Lice infestations are medically known as Pediculosis and can occur in all classes and environments, anywhere humans gather together. Lice are tiny, wingless, parasitic insects. The three most common varieties that infest humans are head lice, body lice, and public lice (crabs). They live exclusively on humans and die without human host. They do not jump or fly but crawl or fall from one human host to another. Spread of an outbreak usually occurs by direct skin or hair contact but also can spread thru fomites (inanimate objects that spread the condition, like shared hats, bedding, or clothing).While lice can occasionally cause significant illness (typhus and trench fever), most commonly lice infestation causes skin irritation (pronounced itchiness) and embarrassment from social stigmas.

Head Lice

According to the National Pediculosis Association (NPA) “With the exception of the common cold, head lice affects more school aged children than all other communicable childhood diseases combined.” Head lice are 2-3 mm in length (about the size of a sesame seed), are gray-white in color, and can live for about one month. Mature females can lay between seven to 10 eggs a day. The eggs are deposited into yellowish white colored cases called nits and attach to hairs by a glue-like substance. In six to 12 days, the eggs hatch into nymphs. In an additional 10 days, the nymphs mature into egg-producing adults. Head lice must feed every 24 to 48 hours and require host bodies’ humidity to survive.

Body Lice

A slightly larger cousin to the head louse is the body louse. It lives in the seams of clothing and transfers to the body to feed. It has a similar life cycle to that of head lice, but unlike head lice this louse can live up to 30 days away from the host’s body. Because body lice live on the clothing or bedding of the host, it is more susceptible to proper hygiene.

Pubic Lice (Crabs)

Pubic lice are shorter and more round, giving them a crab-like appearance. Pubic lice have shorter life spans (three weeks) and lay fewer eggs (three per day), but their eggs hatch quicker (six to eight days). Primarily thought of as a sexually transmitted disease, crabs can unfortunately be transferred to children and can be found on the host’s eyebrows and lashes and arm pits.

Scabies (the seven-year itch)

Scabies are caused by parasitic itch mites. They are arachnoids and are related to spiders. Individual mites are very tiny - 0.3 to 0.4 mm long - and can be detected by a magnifying glass or microscope. These mites burrow into the skin, which results in an allergic response causing intense itching. Like lice, itch mites do not fly or jump and are transmitted from host to host by direct contact or from fomites. The eggs hatch in three to 10 days, mature into adult in another 10 days, and adults mites live three to four weeks. Females can begin laying eggs within two to three hours after burrowing into the host’s skin and lay two to three eggs a day. Because they are so tiny their presences can go unnoticed for weeks until the allergic response becomes pronounced. It may take up to three to four weeks for the host to notice any signs of infestation. The outbreak can spread to quite a few contacts before it is noticed, thus making the condition very contagious. Human scabies are very dependent on their hosts and can only live away from them for 24 to 36 hours.

Caregiver Strategies

Lice and itch mites have plagued mankind for thousands of years and have resisted all attempts at eradication. Fortunately, individual infestations are easily controllable, but you cannot control where the next possible source of these critters will come from. The first and best defense against these parasites is alert and well-informed caregivers. This defense strategy has been described as hyper-responsiveness. Caregivers must know what to look for, screen their charges regularly, and quickly and aggressively treat any outbreaks.

Signs and Symptoms

To stop the spread of outbreaks, caregivers must be constantly on the lookout for the warning signs of infestation in patients. You might think that you should keep an eye out for the critters, but these creepy crawlies are very small and usually are not the first noticeable signs. Other symptoms are easier to notice and therefore screen for. Common to all of these outbreaks are:1) pronounced and persistent itch, 2) sores that might be weepy or crusted over, and 3) a tickling feeling, as if something is crawling on the skin or in the hair.

Lice Symptoms

Lice are sensitive to light and can quickly hide, but their nits are cemented down and do not move. So besides the itch, nit egg cases are the most easily recognizable infestation symptom. Nits are yellowish-white oval and are less than a millimeter long. You can tell them apart from other everyday flecks because of how they are attached. Nits are cemented in place at a slight angle and are not easily removed. You can find viable nits anywhere around the body, but there are a few areas where they are more commonly found. Head lice commonly lay the nits at the base of the hair around the ears or neck line. Pubic lice nits are found in the groin area, and body lice nits can be found in the seams of clothing and bedding. I want to emphasize, though, that viable nits can be found almost anywhere around a host body.

Scabies Symptoms

Itch mites and the eggs are too small to see with the naked eye, so caregivers have to look for other signs. The human body is allergic to mites and their feces. So caregivers will typically see allergic rashes around mosquito bite-like dots. Females burrow into the surface layer of the skin, so you might also see thin, pencil-like lines or four or more dots closely in a row. Common wisdom says that rashes are found between the adult’s fingers but according to PubMed website “Mites may be more widespread on a baby's skin, causing pimples over the trunk, or small blisters over the palms and soles. In young children, the head, neck, shoulders, palms, and soles are involved. In older children and adults, the hands, wrists, genitals, and abdomen are more involved.” Caregivers should not be surprised to see a scabies rash anywhere. Another common scabies sign is that the itch sometimes is felt more intensely at night when there are less mental distractions.

Screening For Just the Possibility

Lice and mite infestations are socially and emotionally charged issues.To keep you out of hot water, I recommend establishing a solid outbreak prevention policy and stick to it with no favoritism. The NPA -National Pediculosis Association, has some good guidelines that you can utilize, and there is a reference at the end of the article for you to look through. In addition, I recommend that every new client be screened by you. Older patients can be screened at bathing time. Children, teens, and others should have regularly scheduled screenings. A strictly adhered to schedule is less socially judgmental, thus easier for clients to accept. The time frequency should be determined by how much uncontrolled interactions clients have with the public at large.

Because of the contagious nature of infestation, if one household member is diagnosed, all household members should be screened, including caregivers. Once treatment has commenced, the caregiver must screen the patient to see if the treatment is working. If after a few days the lice are slower or show no signs of death, then you might have a resistant critter and the doctor should be given the details. Seven to 10 days after treatment, everyone should be screened again just in case some eggs hatched or there was a re-infestation from the original source.

For lice screening, your job will be made easier by using a magnifying glass and a nit comb. Regular combs and brushes are not fine enough. Nit combs are the tools of choice and metal is better than plastic. Wet hair is also easier to comb through. If the hair is very curly or tangled, a conditioner will facilitate easy combing.

The Next Step

Once there is a confirmed diagnosis and after everyone is screened, what is next?

First, treat everyone affected. “Oregon allows providers to treat. A best practice would be to consult the dotor or nurse who would then determine if the individuals condition requires physican care. Another best practice would be to double check with the pharmacist that the otc will not interact adversely with the medications the person takes, especcially topical ointments. The provider would have to have the residents consent to treat and it should be well documented”

Second, notify everyone concerned for at least 14 days prior to the first sign of symptoms. There is a good reason for this, and it is worth the possible embarrassment it might cause. The infection has to have come from someone else. More often than not, an alert caregiver will see the signs of infestation before the source does. If you don’t send out the warning, then the outbreak will spread. There is even the possibility that your clients will be re-infested by the original source and you will have to go through the whole process again. Be sure to give the notice in a non-judgmental way so you will get less flack and more cooperation.

Third, treat the house.

The House

The caregiver’s best friends for treating the house for scabies and lice infestations is the vacuum cleaner and the washer and dryer. Most vacuum cleaners provide sufficient suction to remove lice, loose nits, and mites from the environment. You will have to vacuum things that you normally wouldn’t clean, like mattresses, chair backs, soft toys, anywhere the hair might touch. If you can’t clean or vacuum the item, isolate it for at least14 days, (or a month if body lice are diagnosed). Remember that these critters die after a day or two away from the host, but there may be eggs that hatch a week later. There are furniture lice sprays that can be effective, but these are pesticides that can be harmful to people, pets, and the environment. The eggs will most likely survive such treatments. House fumigation is expensive and probably overkill. Washing and drying clothing and bedding will remove eggs and pests. Remember “water removes but HOT kills.” Cleaning dryer vents and screens make them hotter. Commercial driers at laundry mats are hotter still and when in doubt a steam iron is the hottest. Dry cleaning also works. Don’t forget items away from the home like toys, combs and brushes in school lockers, or uniforms and hats stored at work.

Treatments

There are medication, topical and manual eradication treatments available. The doctor will decide which treatments to use but you, your client, and the budget have a say in the decision.

Ivermectin (Stromectol) is an oral antiparasitic medication usually reserved for scabies and treatment failures because of side effects, especially in the elderly.

Topical lotions and shampoos are usually the treatment of choice because of the ease of use and cost. They are OTC- Pyrethrins (A-200, Pronto, R&C, Rid and Triple X), Permethrin 1% (Nix), RX- Permethrin 5% (Elimite cream)Malathion (Ovid), Benzyl Alcohol (Ulesfia)- the only non- pesticide treatment. It kills lice by shock and suffocation, Lindane (Kwell)- most toxic to humans. Permethrin 5% cream is the treatment of choice for scabies.

These are powerful medications, and the instruction and side effects profiles should be read, understood, and followed. Conditioners and lotions will block the effect of topical medications. Long hair may require more than one bottle. Getting one large bottle and treating others with it is prescription and insurance fraud. Keep yourself out of trouble and get everyone their own prescription. It may take up to 12 hours for the lice to start to die. Meticulously using a nit comb every two or three days will help ensure no re-infestation occurs. There is no such thing as overkill in the meticulous use of nit combs. That’s where the term “nitpicker” comes from. As a general guideline, we are not talking minutes, we’re talking about taking an hour or more if the hair is long. Hair pins can act like bookmarks and can speed up the process. Some clinicians say the main reason for treatment failure is a result of not being thorough enough with the nit comb.

Because of side effects and environmental concerns, the National Pediculosis Association-(NPA) is steering the public away from pesticides, favoring an approach that is more labor intensive. It is possible and may even be required by circumstances that you avoid medication and manually remove all lice and their nits. The NPA website has full instructions, if you are so inclined. See Other Source of Help. Remember this would be considered treatment and must be doctor-approved.

There is no product that kills 100% of the eggs, so there will be some manual eradication efforts required. There is one new treatment that has just been approved for use in the U.S. It is called the LouseBuster. It uses a control flow of heated air to kill lice and their eggs. It requires a trained technician so you, the caregiver, would not be the one to do the work. Insurance coverage and availability of the treatment maybe an issue. It does have the additional advantage of a very quick kill off. Usually, no time quarantine is necessary for students to return to school after treatment. (That alone might make it worth it). Even with the LouseBuster treatment, a two-three day follow-up nit comb screening would be wise.

Follow Up

As stated earlier, it is very important to screen everyone in the household in the case of a louse or scabies outbreak. Effectiveness of topical lice treatment should be verified after 12 hours. After two-three days, a follow-up screening should be conducted. Most Doctors will have you retreat for lice and scabies in a week to 10 days. These also have to be followed up on. You may get tired just reading about all the follow up that is required of you, but it is far better than re-infestation. They don’t call scabies the seven-year itch for nothing.

Conclusion

Scabies and louse infestations happen all the time and can come from anywhere. Once there is an outbreak, it will not go away by itself. The best solution to the problem is the hyper-responsive caregiver who is prepared to: 1. Recognize an outbreak by its symptoms, 2. Control its spread through socially responsible communication, 3. Properly clean and screen, 4.Treat the problem with proper medicines and meticulous techniques and 5. Prevent it from coming back with adequate follow through. I hope you never have to experience an outbreak, but if you do, I hope this article has made you more prepared. And, yes, I found myself itching more often while I wrote this article.

Other Sources of Help

1. Center for Disease Control and Prevention- Treatment general guidelines

Head lice - http://www.cdc.gov/parasites/lice/head/treatment.html

Scabies- http://www.cdc.gov/parasites/scabies/health_professionals/institutions.html

2. The National Pediculosis Association

http://www.headlice.org/

Click on the free education down loads line at the bottom of the page and follow the instruction to receive the following guide.

http://www.headlice.org/downloads/ccguide.pdf (Child Care Giver Guide)

References:

1. Alan Rockoff MD, Melissa Conrad Stoppler MD, Scabies. Medicinenet.com

http://www.medicinenet.com/scabies/article.htm

2. Scabies. Wikipedia The Free encyclopedia.