TREATMENT PLANS

4.1 RED STREAK OR CELLULITIS

1. Report to your referral doctor. While you are waiting to report, follow this plan.
2. Patient education should include information in chart 4.1.

Patient Education

1. Activity: little or none. rest in bed until you are feeling better.

2. If skin was broken, you should wash the area well with soap and warm water, four times a day.

3. If you have an inflamed area (tender, warm, red or swollen), soak in warm soapy water or apply warm, soapy cloths:

• Soak a cloth in warm, soapy water.
• Apply to skin
• Cover with plastic wrap to keep the heat in.
• Do this 4 times a day, in 15-minute sessions.

4. Medicine should include one of the following antibiotics:

Give I.M. shot of PROCAINE PENICILLIN (Wycillin®) EVERY 24 HOURS.

Weight Approximate age dose:

• less than 15 lbs less than 4 months 150,000 units
• 15-24 lbs 4-17 months 300,000 units
• 25-34 lbs. 18 months-3 years 450,000 units
• 35 lbs or more 4 years or more 600,000 units

OR, if allergic to PENICILLIN give ERYTHROMYCIN (200mg/5ml suspension or 250 mg tablets) four times a day for 10 days:

Weight Approximate age dose:

• less than 15 lbs less than 4 months 60mg (1.5 cc)
• 15-24 lbs 4-17 months 80mg (2cc)
• 25-34 lbs. 18 months-3 years 140mg (3.5 cc)
• 35 lbs or more 4 years or more 200mg (5cc)
• 50-89 lbs 7-11 years 250mg (1 tablet)
• 90 lbs or more 12 years or more 500mg (2 tablets)

Other plan may include additinal patient education and medicine. Go to "4.17 Plan: General, for most skin problems".

5. Recheck as follows:

• Every 24 hours until OK.
• Before patient stops taking the antibiotic.

Examine:

1. vital signs: T, P, R
2. skin problem

If patient is getting I.M. PENICILLIN shots, 24 hours after temperature is back to normal switch to oral PENICILLIN as follows:

Give PENICILLIN V (250mg/5ml suspension or 250 mg tablets) four times a day for a total of 10 days of antibiotic:

Weight Approximate age dose:

• less than 15 lbs less than 4 months 50mg (1cc)
• 15-24 lbs 4-17 months 75mg (1.5cc)
• 25-34 lbs. 18 months-3 years 125mg (2.5cc)
• 35 lbs or more 4 years or more 200mg (4cc)
• 50 lbs or more 7 years or more 250mg (1 tablet)

4.2 INFECTED WOUND

1. Report to your referral doctor, unless he has signed for you to treat this problem without contacting him.

Always report if:

• patient is an infant.
• wound occurred when working with sea mammal (such as a seal or walrus), fish slime, or rabbit.

these infections are often serious and difficult to treat.

• wound was from human or animal bite. this patient needs transport to hospital.
• patient looks sick.
• you think wound is serious or large.

If you CANNOT reach a doctor, follow this plan until you can:

2. Wash and bandage the wound:

• Wash the wound well (p. 344).
• If wound has sutures (stiches), you may need to remove some or all of them so wound can drain.
• Cover with a dry bandage.

3. Medicine should include an antibiotic:

If wound occurred when working with a sea mammal (such as seal or walrus), fish slime or rabbit, treat as follows:

Give TETRACYCLINE (250mg capsules or tablets).

• Do NOT give to: pregnant women child under the age of 8. ·
• Dose: 500mg (2 capsules or tablets) four times a day for 10 days.

For other infected wounds, give one of the following antibiotics:

Give CLOXACILLIN (Tegopen® 125mg/5ml suspension) OR DICLOXACILLIN (250mg capsules) 4 times a day for 10 days:

• less than 15 lbs less than 4 months 100mg (4cc)
• 15-24 lbs 4-17 months 175mg (7cc
• 25-49 lbs. 18 months-6 years 250mg (10cc)
• 50 lbs or more 7 years or more 250mg (1 capsule)

OR, If allergic to PENICILLIN: Give ERYTHROMYCIN (200mg/5ml suspension OR 250mg talets) 4 times a day for 10 days:

• less than 15 lbs less than 4 months 60mg (1.5cc)
• 15-24 lbs 4-17 months 80mg (2cc)
• 25-34 lbs. 18 months-3 years 140mg (3.5cc)
• 35-49 lbs. 4-6 years 200mg (5cc)
• 50-89 lbs. 7-11 years 250mg (1 tablet)
• 90 lbs. or more 12 years or more 500mg (2 tablets)

4. Patient education:

• Tell patient to wash the area well with soap and warm water 4 times a day.

5. Other plan may include the following:

• If patient has NOT had a TETANUS booster shot in the past 10 years: Give I.M. booster shot of TETANUS TOXOID and DIPTHERI A (Td.)
• Dose: 0.5cc I.M.
• Give additional patient education and medicine as needed.
• Go to "4.17 Plan: General, for most skin problems".

6. Recheck as follows:

• In one day if patient looks sick or has fever of 101 or higher.
• In two days if patient is NOT feeling better, in one day if patient is feeling worse
• Before patient stops taking the antibiotic.

Examine:

1. vital signs: T, P
2. skin problem

4.3 ABCESS

1. Report to your referral doctor. While you are waiting to report, follow this plan:

Patient Education

1. Do NOT squeeze the abscess!
2. Apply heat (wet or dry), 4 times a day in 15 minute sessions.
3. For example, soak a cloth in warm, soapy water, then apply to skin and cover with plastic wrap to keep in heat.
4. See your CHA/P if the abscess drains
5. Prevent spread of infection by washing hands after touching the abscess area.
6. Medicine should include one of the following antibiotics: Give CLOXACILLIN (Tegopen® 125mg/5ml suspension) OR DICLOXACILLIN (250mg capsules). · 4 times a day for 7 days:

Weight Approximate age dose:

• less than 15 lbs less than 4 months 100mg (4cc)
• 15-24 lbs 4-17 months 175mg (7cc)
• 25-49 lbs. 18 months-6 years 250mg (10cc)
• 50 lbs or more 7 years or more 250mg (1 capsule)

OR, if allergic to PENICILLIN: Give ERYTHROMYCIN (200mg/5ml suspension or 250 mg tablets) · four times a day for 7 days:

Weight Approximate age dose:

• less than 15 lbs less than 4 months 60mg (1.5 cc)
• 15-24 lbs 4-17 months 80mg (2cc)
• 25-34 lbs. 18 months-3 years 140mg (3.5 cc)
• 35 lbs or more 4 years or more 200mg (5cc)
• 50-89 lbs 7-11 years 250mg (1 tablet)
• 90 lbs or more 12 years or more 500mg (2 tablets)

4. Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For most skin problems".

5. Recheck as follows:

• every 24 hours until the abscess is healed.
• before patient stops taking the antibiotic

Examine:

1. vital signs: T,P.
2. abscess

If abscess drains, do the following:

• Wear examination gloves.
• Remove as much of the pus as possible.
• Wash out the abscess well.
• Use water with POVIDONE-IODINE (Betadine®), HYDROGEN PEROXIDE, or soap.

It may help to irrigate with a syringe.

• Place a piece of sterile gauze inside the abscess.
• Use a hemostat, if needed.
• Pack loosely.

Allow some gauze to stick out of the opening.

(*Note) This may be painful the first few times you do it.

This will allow the abscess to drain and heal. *(Visual augmentation):

• Pack gauze loosely in abscess
• Leave gauze inside the abscess and cover with a loose bandage.
• Once a day repeat these steps until wound is completely healed.
• Do NOT let the abscess form a scab over the top.
• It needs to heal from the inside out.
• Teach the patient to do the same once a day at home.
• Give him the supplies he needs.
• If abscess does NOT drain and the center becomes soft, white or yellow (from pus inside), report to your referral doctor.
• He may suggest that you open the abscess, as in chart 4.3.

Chart 4.3 TO OPEN AN ABSCESS

Note: Do this ONLY if your referral doctor agrees.

Equipment/supplies needed:

1. POVIDONE-IODINE (Betadine®) or soap 1% LIDOCAINE (Xylocaine®)
2. 5-10cc syringe
3. 25 gauge needle
4. ALCOHOL wipe
5. sterile gloves
6. sterile scapel blade
7. sterile hemostat
8. sterile gauze bandage

1. Scrub the skin well with POVIDONE-IODINE and water or soap and water.

2. If possible, numb the skin. Inject LIDOCAINE (Xylocaine® 1% solution)

· Inject in a ring around the abscess, about 1cm away from the red edge.

· Do NOT inject any more than the following amount:

Weight Approximate Age Dose:

• Less than 11 lbs. Less than 2 months 1 cc
• 11-21 lbs 2-11 months 2 cc
• 22-31 lbs 1-2 years 4 cc
• 32-44 lbs 3-5 years 6 cc
• 45-59 lbs 6-8 years 8 cc
• 60-89 lbs 9-11 years 12 cc
• 90-109 lbs 12-13 years 16 cc
• 110 lbs or more 14 years or more 20 cc

*More visual augmentation: Numb the skin.

3. Put sterile gloves on.

4. Use a sterile scapel blade to make a cut into the abscess.

Cut across as much of the soft center as possible.

*Another pictoral representation: Open the abscess.

5. If the abscess is large, insert a sterile hemostat.

Spread the hemostat to break up small collections of pus and allow better drainage.

6. Wash, pack, and bandage the abscess, the same as "if abscess drains".

4.4 Plan: IMPETIGO

1. Report to your referral doctor, unless he has signed for you to treat this problem without contacting him.

Always report if patient looks sick or has a fever. While you are waiting to report, follow this plan:

2. Give I.M. shot of benzathine penicillin (Bicillin LA®) Give shot once: (It lasts 3-4 weeks)

Weight Approximate age dose:

• less than 15 lbs less than 4 months consult doctor.
• 15-24 lbs. 4-17 months 300,000 units
• 25-34 lbs. 18 months- 3 years 600,000 units
• 35-49 lbs. 4-6 years 900,000 units
• 50lbs. or more, 7 years or more 1,200,000 units

OR, If patient will not let you give him an injection: Give PENICILLIN V (250 mg./5 ml. suspension or 250 mg. tablets) four times a day for 10 full days:

Weight Approximate age dose:

• Less than 15 lbs. less than 4 mo. 50 mg.(1 cc.)
• 15-24 lbs. 4-17 mo. 75 mg. (1.5cc.)
• 25-34 lbs. 18 mo. thru 3 yrs. 125 mg.(2.5 cc.)
• 35-49 lbs 4-6 yrs 200 mg. (4 cc.)
• 50 lbs or more 7yrs or more 250 g. (1 tablet)

OR if allergic to penicillin: Give ERYTHROMYCIN (200 mg./5 ml. suspension or 250 mg. tablets) four times a day for 10 full days:

Weight Approximate age dose:

• Less than 15 lbs less than 4 months 60 mg. (1.5 cc.)
• 15-24 lbs 4-17 months 80 mg. (2 cc.)
• 25-34 lbs. 18 months-3 years 140 mg.(3.5 cc.)
• 35-49 lbs. 4-6 years 200 mg (5 cc.)
• 50-89 lbs 7-11 yrs. 250 mg. (1 tablet)
• 90 lbs or more 12 yrs or more 500 mg. (2 tablets)

3. Patient education should include the following:

• If taking an antibiotic by mouth, tell paient it is important to take it for 10 full days, to make sure that all of the bacteria are killed.
• Give information

Patient Education:

1. It is important for you to treat impetigo NOW.

• Impetigo can quickly spread to other areas of the body or to other people.
• Impetigo can cause serious kidney problems.

2. Every four hours, if awake, do the following:

• Soak the sores with a warm, wet washcloth to loosen the crusts.
• Wash the sores with soap and warm water.
• Try to remove the crusts.

3. Prevent the spread of impetigo:

• Towels and bedding should be washed before others use them.
• Other people in the home should: Wash well with soap, once a day and see the CHA/P if sores develop.

4. Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems."

5. Recheck as follows:

• Recheck in five days, sooner if patient is feeling worse.
• Examine the skin.
• Often there is an underlying skin problem that may need care, such as eczema.

If infection is NOT getting better, your referral doctor may suggest that you treat for staph bacteria with the same antibiotic used for treating an infected wound (plan 4.2).

4.5 ACNE

1. Report to your referral doctor unless this is a mild case, with just a few blackheads or pimples. While you are waiting to report, follow this plan:

2. Patient education should include information in chart 4.5.

• Chart 4.5 Patient Education: ACNE
• Wash your face and other acne areas well, 3-4 times a day. This will help to remove extra oil that helps to cause acne.
• Wash your scalp often.
• Avoid skin or hair products that are waxy, oily or greasy.
• If you find that certain foods make your acne worse, avoid those foods.
• Special diets, vitamins, or vaccines have NOT been shown to help.
• It is best if you do NOT squeeze blackheads or pimples. Squeezing can spread infection and cause scarring.
• See your CHA/P if you are getting worse instead of better.
• There is other treatment that can help.
• For your mental health: Stay active and healthy in general. Talk to someone who will understand and support you.

3. Recheck as follows:

• Recheck in two weeks, sooner if patient is getting worse. -
• If pateint is NOT getting better, your referral doctor may perscribe one or a combination of medicines, such as: BENZOL PEROXIDE, which helps to kills bacteria living in the skin, OR TRETINOIN (Retin-A®), which helps to remove and prevent blackheads and pimples, OR TETRACYCLINE, ERYTHROMYCIN, or other antibiotic (by mouth or applied to skin) for treatment and prevention of pimples.

4.6 ALLERGIC REACTION

1. If severe allergic reaction with shortness of breath, wheezing, severe swelling, or shock, give emergency care.

Now go to page 8.

2. Report to your referral doctor, unless he has signed for you to treat recurrent allergic reactions without contacting him

Always report if:

- patient had severe allergic reaction or looks sick.

- This is the first time the patient has had this allergic reaction.

- Patient had allergic reaction to a drug. Doctor may suggest giving another drug. While you are waiting to report, follow this plan.

3. Patient education should include following information:

Patient Education:

1. Stay away from what is causing the allergic reaction.

• If you do not know what is causing it, try to find out if you have an allergic reaction after you have a new food or drug (you may never find out).

2. Your doctor may have other more specific suggestions.

3. Tell every health care provider who treats you the name of any drug you are allergic to and what your reaction was.

4. Medicine may include the following: If needed for severe itching or hives: Give DIPHENHYDRAMINE (Benadryl®; 12.5 mg./5 ml. elixir or 25 mg. capsules).

Patient may repeat, if needed, every six hours, as long as he has symptoms:

Weight Approximate age dose:

• Less than 22 lbs. Less than 1 yr. Consult doctor
• 22-44 Lbs. 1-5 yrs. 12.5 mg. (5 cc.)
• 45-89 lbs. 6-11 yrs. 25 mg. (1 capsule)
• 90 lbs or more 12 yrs or more 25-50 mg. (1-2 caps.)

Do NOT give patient an injection of EPINEPHRINE if he has only rash and itching.

EPINEPHRINE is used to treat severe allergic reaction with shortness of breath, severe swelling, or shock (p. 8).

If patient had allergic reaction to PENICILLIN, switch to ERYTHROMYCIN or another antibiotic.

Do not use another "CILLIN" drug, however.

• If allergic to insect sting/bites, patient can prevent future problems.

Insect repellent may help.

• If patient had hives, the next reaction may be severe.

Patient may need to carry his own EPINEPHERINE shot kit with him.

Ask your referral doctor if this is needed.

5. Other plan may include the following:

• Give additional patient education and medicine, as needed. go to "4.17 Plan: General, For Most Skin Problems."
• If your referral doctor agrees, label patient's chart with an allergy warning.
• Include: name of any drug patient is allergic to and what the allergic reaction was, and write this problem on patient's problem list.

6. Recheck in one week, sooner if patient is getting worse.

4.7 CHICKEN POX

1. Report to your referral doctor. While you are waiting to report, follow this plan:
2. Patient education and medicine should include what is in chart 4.7.

Patient Education:

1. Stay at home, away from children, until crusts have fallen off.

2. To prevent itching, and to help dry the blisters, try the following: Apply CALAMINE LOTION to sores that itch, 3-4 times a day.

• For sores around the mouth or genitals, apply wet clothes: Dip cloth in cool water. Apply.
• If possible, change cloth every 5-10 minutes.
• Do this for 10-20 minutes, 4-6 times a day.

3. Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems."

4. Recheck in one week, sooner if patient is feeling worse.

5. Examine sores.

4.8 DANDRUFF

1. Report to your referral doctor only if patient has rash that seems severe or if skin is infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan.

[2] Patient education should include information in chart 4.8.

Chart 4.8 Patient Education: DANDRUFF

1. What is dandruff?

It is dry, flaky skin on the scalp.

Your eyebrows, face, chest,and body creases may be involved; your skin may itch, look pink and greasy.

This is called "seborrheic dermatitis."

On an infant it is called "cradle cap."

It usually goes away within 2-3 months.

On an adult, it may NOT go away, but you can help to keep it under control.

2. It is important to shampoo the scalp. Use a dandruff shampoo, as directed. Usually you should shampoo at least these times: once a days for 2-3 days, until skin is OK. 1-2 times a week, more often as needed to control flaky skin. If other areas of your body are involved, often those areas will be OK if your scalp is treated. 3. See your CHA/P if you are getting worse instead of better. There is other treatment that may help. [3] Recheck as follows: Recheck in one week, sooner ir patient is getting worse. If patient is NOT getting better, if your referral doctor thinks the assessment in seborrheic dermatitis, he may perscribe: a different shampoo or steroid medicine such as HYDROCORTISONE.

4.9 DERMATITIS

1. If irritating chemical is on skin, wash it off with soap and lots of water.

2. Report to your referral doctor, unless he has signed for you to treat recurrent dermatitis without contacting him. Always report if this is the first time patient has ever had dermatitis, the patient looks sick or has fever, rash is severe, skin is infected (getting more tender, warm, red,swollen;pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan.

3. If skin is infected, give and antibiotic. If you can NOT reach a doctor, inn most cases you should follow the plan for impetigo (Plan 4.4).

4. Patient education and medicine should include the following: Give information/medicine in chart 4.9

Chart 4.9 Patient Education: DERMATITIS

1. There may be no cure or treatment that will make this problem go away forever, but there are some things you can do that will help.

2. When skin is wet, dry it; when it is dry, wet it!

• If there are tiny blisters, or if the rash is wet, oozing, you should dry that area.
• Apply wet cloths.
• Dip cloth in cool water.
• If available, use BUROW'S SOLUTION instead of plain water.
• Apply to skin.
• If possible, change cloth every 5-10 minutes.
• Apply for 10-20 minutes, 2-6 times a day.
• CALAMINE LOTION or other treatment may be recommended.
• As your skin is healing, it starts to dry.
• You should keep that area moist.
• Soak the dry area in water.
• Immediately after soaking, apply PETROLEUM JELLY (Vaseline®), BABY OIL, or other medicine prescribed to keep in the moisture.
• Repeat as often as you need to, to keep your skin soft and moist.

3. You may be given a steroid medicine (such as HYDROCORTISONE) to apply as directed. If so, do NOT use on infected skin (pus seen).

4. Prevent irritation and drying by:

• Avoiding most soaps, detergents, and very hot water.
• Also avoid foods clothing, or other things that seem to make it worse.
• If it is necessary to touch these things, use plastic (not rubber) gloves.
• For washing, use plain water. Soap dries the skin. Add soap only if the skin is getting infected.
• Let your skin dry in the air or pat it dry. Do NOT rub it dry with a towel.
• If skin is inflamed (tender, warm, red, swollen): Give HYDROCORTISONE or other steroid cream or ointment prescribed.
• Do NOT give if skin is infected (pus seen).
• Patient should put a small amount on the rash and gently rub it in.
• If the rash is severe, tell patient to cover the area with plastic wrap at bedtime, after putting on the medicine.
• Repeat 3-4 times a day until inflammation is gone (no longer tender, warm, red, swollen).

5. Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems."

6. Recheck as follows:

• in one day if patient looks sick or has fever.
• in 2-3 days if patient is feeling worse.
• in one week

Examine:

1. vital signs:T,P,
2. skin problem.

If patient is NOT getting better, your referal doctor may suggest other treatment, such as stronger steroid medicine (applied to skin or taken by mouth).

4.10 DIAPER RASH

1. Report to your referral doctor, unless he has signed for you to treat this problem without contacting him. Always report if child looks sick or has fever, diaper rash is severe, or skin is infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan.

2. If rash is mainly in exposed areas, treat for urine irritation.

Patient education should include information in chart 4.10[2].

If rash is severe, Give HYDROCORTISONE or other steroid cream or ointment prescribed.

Do NOT use steroid medicine on infected skin (pus seen).

Parent should put a small amount on the rash and gently rub it in.

Repeat 3-4 times a day until inflammation is gone (no longer tender, warm, red, swollen).

[3] If rash is mainly in skin folds, treat for yeast infection.

Patient education should include information in chart 4.10[3].

Check mouth for yeast infection (white patches on mucous membranes).

If present, also treat for thrush (p.228).

Medicine should include something to kill yeast.

Give CLOTRIMAZOLE (Lotrimin®) cream or NYSTATIN (Mycostatin®, Nilstat®) cream.

Parent should first wash and dry the rash well.

Apply cream four times a day and continue for 1 week after rash is gone.

[4] Other plan may include additional patient education and medicine.

Go to "4.17 Plan: General. For Most Skin Problems."

[5] Recheck as follows: -Recheck in three days, sooner if patient is getting worse.

Examine rash.

Chart 4.10[2] Patient education: DIAPER RASH IN EXPOSED AREAS

1. This is probably caused by a damp diaper being next to the skin. Bacteria act on the urine to form ammonia. Ammonia burns the skin.

2. Leave the diaper off for as long as possible.

3. Change the diaper often. If the rash is severe or lasts for a long time, use disposable diapers.

4. With every diaper change, wash with plain water. Do NOT use soap every time unless skin is infected. Soap can dry and irritate the skin.

5. After washing, apply some ointment to keep the urine from touching the skin.

Use PETROLATUM (Vaseline®), A & D OINTMENT, or something similar.

Chart 4.10[3] Patient Education: DIAPER RASH IN SKIN FOLDS

Yeast grows where it is moist, so be sure to keep the genital area dry.

1. Leave the diaper off for as long as possible.

2. Change the diaper often.

3. With every diaper change, wash with plain water.

Do NOT use soap every time unless skin is infected. Soap can irritate the skin.

4. After washing, let skin dry well in the air or pat it dry, and apply medicine to kill yeast, as directed.

5. Avoid plastic pants.

4.11 Plan: Funus. [1] Report to your referral doctor, unless he has signed for you to treat this problem without contacting him. Always report if fungus is on scalp. While you are waiting to report, follow this plan,. [2] Patient eucation should include information in chart 4.11. Chart 4.11 Patient Education: FUNGUS 1. Wash the sores well once a day with soap and water. 2. Fungus grows where it is moist, so be sure to keep the area dry. After washing, dry your skin well and avoid tight-fitting clothes. If you have athlete's foot, wear shoes that let air in and wear cotton socks, changing them at least once a day. 3. If you have fungus of the scalp, clip the hair short near the sores. 4. Prevent the spread of fungus by washing your dirty clothes well in hot water. [3] Medicine should include the following: Give CLOTRIMAZOLE (Lotrimin®, Gyne-Lotrimin®), TOLNAFTATE (Tinactin®), or other fungus medicine perscribed by the doctor. The patient should apply two times a day for at least four weeks, and continue for 1-2 weeks after skin is OK. [4] Recheck as follows: - Recheck in one week, sooner if patient is getting worse. - Examine sores. - If patient is NOT getting better, your referral doctor may think that another medicine is needed, or this may NOT be a fungus infection.

4.12 Plan: Insect Bites [1] If there is an allergic reaction, do the following: - For a severe allergic reaction, with shortness of breath, severe swelling or shock, give emergency care. Now go to page 8. - If it is hives, go to "4.6 Plan: Allergic Reaction." [2] Report to your referral doctor only if problem is severe or if skin is infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan. [3] Patient education and medicine should include what is in chart 4.12. [4] Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems." [5] Recheck only if needed. tell patient to return to clinic in 2-3 days, IF NOT feeling better, sooner if feeling worse. Chart 4.12 Patient Education: INSECT BITES 1. If your skin itches or burns, it may help to apply wet cloths: Dip cloth in cool water. Apply for ten minutes. Repeat as needed. If wet cloths do NOT help enough, ask your CHA/P for some CALAMINE LOTION. Apply to bites that itch, 3-4 times a day. 2. Try to prevent insect bites. Use insect repellent.

4.13 Plan: Lice [1] Report to your referral doctor, unless he has signed for you to treat this problem without contacting him. Always report if skin is infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan. [2] Patient education and medicine should include the following: - Give information/medicine in chart 4.13. - If LINDANE (Gamene®, Kwell®) shampoo is NOT available, use the same medicine used for treating scabies (Chart 4.14). [3] Other plan may include additional patient education and medicine. Go to "4.17 Plan: General., For Most Skin Problems." [4] Recheck as follows: - Recheck in one week. - Examine carefully for lice and nits (eggs). Often the nits stay attached but are dead. - If you still see live lice or new nits (where hair meets the skin), use medicine a second time. Chart 4.13 Patient Education: LICE 1. Use LINDANE (Gamene®, Kwell®) shampoo to kill the lice. Take a bath or shower. Apply 3-4 tablespoons of shampoo, and lather it well for at least four minutes. If you have pubic (genital) lice, apply the shampoo to all of your skin from your chest to your knees. Rinse well, and dry with a towel. 2. After washing off the medicine, when your hair is dry, remove nits (tiny eggs) with a fine-toothed comb or tweezers, if possible. 3. If you have lice on the eyelashes, apply PETROLATUM (Vaseline®) two times a day for eight days, and try to pull the nits (tiny eggs). 4. If you have pubic (genital) lice or body lice, after rinsing off the medicine, put on clean clothes and wash clothing and bedding you have used during the past two weeks. Heat helps kill the lice. Use hot,soapy water, or put hot clothes in dryer for 20 minutes. If this is NOT possible, it may help to hang the clothing and bedding outside for 24-48 hours, especially in below zero temperatures. 5. Every person in the family and sex partners of people with lice should be examined. Those with lice should be treated as soon as possible. 6. Prevent the spread of lice: - treat your combs and brushes. Soak them for one hour in a mixture of water and LINDANE (Gamene®, Kwell®) shampoo or in Lysol® solution, or put them in hot water (near boiling) for 5-10 minutes. -Do NOT share combs or brushes.

4.14 Plan: Scabies[1] Report to your referral doctor unless he has signed for you to treat this problem without contacting him. Always report if rash is severe or skin is infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes). While you are waiting to report, follow this plan. [2] If skin is infected, do the following: First treat with antibiotic as in "4.4 Plan: Impetigo." Do NOT treat patient with medicine for scabies until the infection is healed. [3] Patient education and medicine should include what is in chart 4.14. Chart 4.14 Patient Education: SCABIES 1. For infant of pregnant woman, use CROTAMITON (Eurax®) cream or lotion to kill the scabies mite. Take a bath or shower. Apply a thin layer of medicine to your skin from the neck down. Pay close attention to the areas between the fingers and toes, wrists, elbows, buttocks, and sex organs. Rub in completely. In 24 hours, apply the medicine a second time. Leave the medicine on for 24 hours after the second application.Then wash it of and rinse well. 2. Other patients should use LINDANE (Gamene®, Kwell®) lotion to kill the scabies mite. Take a bath or shower. Dry well, and let the skin cool before applying medicine. Apply a thin layer of medicine to your skin from the neck down. Adults should use up to 1 oz.(half of a 2 oz bottle). Children should use up to half an ounce (one quarter of a two ounce bottle). Pay close attention to the areas between the fingers and toes, wrists, elbows, buttocks, and sex organs. Rub in completely. Leave the medicine on for 8-12 hours. Then wash it off and rinse well. 3. After washing off the medicine, put on clean clothes and wash the clothing and bedding you have used recently. Heat helps to kill scabies. Use hot soapy water, or put in a hot clothes dryer for 20 minutes. If this is NOT possible, it will help to hang the clothing and bedding outside for 24-48 hours, especially in below zero temperatures. 4. Every person in the family and sex partners of people with scabies should be treated at the same time.5. It is normal to continue itching for a while after using the medicine. Do NOT repeat the treatment without checking with you CHA/P first. 6. Prevent the spread of scabies. Keep children with scabies sores home from school until they have washed off the medicine. Bathe as often as possible. [4] Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems." [5] Recheck as follows: - Recheck in one week, sooner if patient is getting worse. - Examine rash. - If itching continues, report to your referral doctor. It may be from continued infection (the doctor may want you to repeat the treatment one time), or an allergic reaction to the scabies mite.

4.15 Plan: Warts [1] Patient education should include information in chart 4.15. Chart 4.15 Patient Education: WARTS 1. Warts are growths that are caused by a virus. 2. A wart should go away without treatment within 1-2 years. 3. If wart is on the bottom of your foot and is painful, it helps to file the wart until it is flat. Repeat, when needed. 4. Your doctor may suggest other treatment, if you are worried about your appearance or, because of their location, warts are spreading a lot (example: on fingertips) or painful (example: on bottom of foot). 5. Other treatment may include applying a wart medicine to dissolve the warts or going to the hospital where special equipment may be used to remove the warts by electricity or freezing. [2] Report to your referral doctor only if warts are large or painful, or if patient wants to have them removed. [3] Recheck as follows: - Recheck only if needed. Tell patient to return to clinnic if warts are getting worse. - Examine warts. - Report to your referral doctor

4.16 Plan: Other or Unknown Skin Problem [1] Report to your referral doctor. There are many kinds of skin problems. First describe the problem to yourself. Next, report exactly what you saw and felt. If you can NOT reach a doctor, follow this plan until you can. [2] Patient education and medicine may include the following: - If skin has tiny blisters, is wet or oozing, patient should dry that area, then apply wet cloths. Dip the cloth in cool water. If severe, it may help to use BUROW'S SOLUTION instead of plain water. Apply to skin. If possible, change cloth every 5-10 minutes. Apply for 10-20 minutes, 2-6 times a day. CALAMINE LOTION or other treatment may be recommended. - If skin is dry, patient should keep that area moist. Soak the area in water. Immediatelyafter soaking, apply PATROLEUM JELLY (Vaseline®), BABY OIL, or medicine prescribed to keep in the moisture. Repeat as often as needed, to keep skin soft and moist. [3] Other plan may include additional patient education and medicine. Go to "4.17 Plan: General, For Most Skin Problems." [4] Recheck as follows: - Recheck at these times: in one day if patient looks sick or has fever, in 2-3 days, sooner if patient is feeling worse, or in one week. - Examine vital signs: t,p, skin problem.

4.17 Plan: General, for Most Skin Problems [1] First follow the specific plan above for assessment. [2] Patient education should include the following: - If needed, get patient education handouts from your referral hospital or other souces. There are many good ones available for skin problems. - Give information that applies in chart 4.17. Chart 4.17 Patient Education: GENERAL CARE A SKIN PROBLEM 1. Activity: Rest in bed if you feel sick or have fever. 2. If your skin itches: - If the skin problem has recently broken out, it may help to apply wet cloths: Dip cloth in cool water. Apply for 10 minutes, 4-6 times a day. - If itching all over the body, it may help to take a CORNSTARCH or OATMEAL bath. Add 1 cup of CORNSTARCH or 2 cups of OATMEAL to a tub of warm water (NOT hot water; body temperature is good). Bathe in this for 10-15 minutes. Repeat if needed, up to 4 times a day. - Avoid scratching, to help prevent infection, spread of infection, and scarring. For a child, keep his fingernails cut short, wash his hands often, and have him wear cotton gloves or socks on his hands, if needed. 3. If an arm or leg is swollen, raise it up higher than the rest of the body. 4. Protect your skin. Avoid things that irritate your skin. If needed, use a sunscreen to prevent sunburn. 5. When your skin is healed, prevent dry skin. Do NOT wash your skin much, unless you have been advised to, for your skin problem. Soap OR water dries out the skin. When you do wash, use plain water on areas that are not dirty, and use soap and water in the body creases,and use a mild soap such as Dove®. After washing, put on PETROLEUM JELLY (Vaseline®) BABY OIL, or other medicine prescribed to keep in the moisture. 6. See your CHA/P if you have danger signs of infection: getting more tender, warm, red, swollen, pus seen. [3] Medicine may include the following: - If skin problem is getting infected (getting more tender, warm, red, swollen; pus seen; enlarged, tender lymph nodes), give and antibiotic. If you can NOT reach a doctor, in most cases you should follow the plan for Imeptigo (Plan 4.4). If there is a lot of pus, follow the plan for Infected Wound (Plan 4.2). If needed for severe itching or hives, give DIPHENHYDRAMINE (Benadryl®; 12.5 mg./5 ml. elixir or 25 mg. capsules). Patient may repeat, if needed, every six hours, as long as he has symptoms. Less than 22 lbs. Less than 1 yr. Consult doctor 22-44 lbs. 1-5 yrs. 12.5 mg. (5 cc.) 45-89 lbs. 6-11 yrs. 25 mg. (1 capsule) 90 lbs. or more 12 yrs or more 25-50 mg.(1-2 caps.) If needed for pain, give ASPRIN or ACETAMINOPHEN (Tylenol®)(p.416). If pain is severe and you can NOT reach a doctor, give ASPRIN or ACETAMINOPHEN with CODEINE (p.416).