It is Friday, and Mr. Adams is seen in your Nurse Sick Call after submitting a sick call request that stated he had “water bumps” all over his right leg that were getting worse. They are also very itchy. He is afraid that he has caught a flesh-eating bacteria. When he arrived in the clinic you see that he has wrapped toilet paper all around his right shin/lower leg. It appeared that the toilet paper was wet in some areas and had what looked like dry yellowish areas of past exudate. What other information do you need from Mr. Adams?
subjective
When did the bumps first appear and have they changed/worsened since then?
They came around Tuesday night (3 days ago) and they have gotten “watery” but have not spread. They are more itchy now than they were before, but he thinks it is because all he is doing is thinking about them being a serious disease.
What did you do on Tuesday? Anything unusual?
Mr. Adams tells you that it was a regular work day for him. You ask what he does for a job and he replies that he is on outside detail on the road crew.
What have you done, if anything, to take care of the rash?
Mr. Adams tells you that when they started “oozing”, he used the only thing he had, toilet paper, as a bandage, and every day he has been putting another layer on (as the paper gets soaked through). He has not showered since Tuesday. The men in the pod who know about the rash are staying away from him because they believe that he is contagious. He had asked the officer to send him to medical on Wednesday morning, but she said that the nurse was not in the office when she called, so it would be better that he dropped a sick call slip, which he did and then he went to work. He has been covering the leg with the toilet paper and his uniform so more people don’t see and so that he can continue to work.
You ask Mr. Adams if he has any allergies to anything, and also if this has ever happened before.
Mr. Adams discloses no allergies, and at first, states that this has never happened before. When you ask him if he ever got anything like this as a child, he replied that one summer he went to a camp, and he did have some rash when there, but cannot remember what it was. He lives in the city and does not usually go to the country.
Finally, you ask him specifically what he did at work on Tuesday.
Mr. Adams replies that he had to cut the weeds on the side of Highway 36. He did go into the woods a bit because it was cooler there. There were lots of plants he did not know, including one with clusters of three shiny leaves. Yes, he thinks that he did pick some with his hands to get it out of the way. Yes they make the workers wear gloves. He cannot remember for sure, but he thinks his right leg was itchy and so he rubbed it with his gloved hand.
objective
What will you do next?
Complete your physical examination.
Vital signs are as follows:
122/82 – 72-16-98%-98.6℉
You have to remove the toilet paper to assess the lesions. As you try to “unravel” it, there is clearly areas of the paper sticking to the lesions/leg. How do you remove the toilet paper? Using sterile water, try to disintegrate the areas where the dried exudate is sticking.
Why not use water from the sink?
You have not yet seen what is underneath the toilet paper, and so it is better to use sterile water in case there are areas of skin breakdown into which you could be introducing bacteria (although, yes, he has not showered since Tuesday and yes, he has continued to work outside….).
The lesions
You get the toilet paper off, and you find a leg like the one pictured above. Lesions are in various stages, some vesicles, some broken with clear, yellowish fluid, and some areas are just weeping that same fluid. You complete your assessment by auscultating Mr. Adams’ lungs and heart, and completing an abdominal assessment.
Mr. Adams does not have any additional abnormalities, but what might you find with patients with this condition?
Patients may have face and/or eye involvement, as individuals will typically rub their face and eyes without even realizing it and contaminate that skin. Patients may have involvement of the general area, especially males who may use their hands while urinating. Others may have severe reactions to the causative agent, and have breathing issues that include wheezing and stridor, and even anaphylaxis (typically when first exposed, usually not 3 days later).
Assessment
Mr. Adams suffers from Impaired Skin Integrity related to open, weeping lesions on his right leg. He has a Risk for Infection related to these open lesions.
plan
If Mr. Adams had come in and the involvement on his leg was minimal, your Nursing Guideline/Protocol* for Skin could have been used, if you had one. However, he has a large area of involvement and so a provider must be contacted. Report is given based upon your thorough assessment of Mr. Adams’ condition, and the provider orders a tapering dose of prednisone and calamine lotion. She diagnoses Mr. Adams with poison ivy dermatitis. She also asks you to schedule Mr. Adams to be seen in Provider clinic on Monday.
You conduct patient education with Mr. Adams.
Patient education
Is poison ivy contagious?
Poison ivy rashes are not contagious. The rash from poison ivy exposure only occurs if you are exposed to the plant oil – urushiol oil. A poison ivy rash will not “spread” to other persons or other areas of the body, unless other areas of the skin become exposed to more urushiol oil; an example is if the urushiol oil is still under the fingernails and you touch/scratch another area of the body, you most likely will have a rash develop in that area as well. Note that urushiol oil can stay on surfaces/clothing/tools until they are cleaned, so continued exposure and rash may occur, which will make the patient think that the rash is “spreading”.
Medications
You must review the mechanisms of action and reason for prescribing the medications that are prescribed. Prednisone is a steroid to help with the symptoms of itching and swelling. Antihistamines do not help with the itching from poison ivy reaction. Calamine lotion may help relieve the itching as well. You must also discuss any potential interactions with other medication the patient may be prescribed.
Wound Care
Keep area clean and dry, use calamine lotion, do NOT wrap in toilet paper. Because of the large area of involvement and the weeping of the lesions, you will be placed on daily wound care to check the leg and redress it with a loose gauze dressing. Exposure to the air will not cause a problem for the lesions if that occurs.
Signs and Symptoms to report immediately
Have the officer contact healthcare staff immediately if you notice changes like bright redness to the affected skin, swelling, exudate that is thicker and pus-like, or you feel like you have a fever. If the rash suddenly changes in lesion type, or spreads to another area of your body, also let healthcare staff know immediately. Sometimes open areas of skin can become infected with bacteria, and that would necessitate antibiotics be prescribed for you.
You make the appointment for Mr. Adams to see the provider on Monday, and you schedule him for nursing wound care daily. You have administered his first dose of prednisone while he was in clinic. You make sure that Mr. Adams understands his instructions by asking him to explain it (back) to you before he leaves the exam room. Finally, you document all in Mr. Adams’ health record, including his comprehension of the patient eduction.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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