Protocol for infectious processes?

BonnieSc · Feb 27, 2007

I wish I had our protocols here! I know exactly where they are... hanging on a hook in a very cold, snowbound health center...

We seldom send kids home; the longest the girls stay is eight days at a time; even the counselors in training, who are there multiple weeks, go home every eight days. So yes, we try to treat and let them stay. I haven't had to deal with pink eye, or with impetigo in a camper, but I would first call the parent to see if they wanted the child to stay; then, if they did, do a WHOLE LOT of patient education to keep it from spreading--make sure the kid had plenty of towels, for instance, that s/he wouldn't share--and very importantly, include the counselors in that teaching.

As for vomiting/diarrhea--these are fairly common occurrences here, but usually seem to be caused by dehydration, eating different foods, anxiety, etc, rather than contagious illness, because they clear up quickly (one time occurrences). Kids with either problem stay in the health center until the problem seems to be gone; if a child is really uncomfortable / ill feeling and won't be able to enjoy camp, she goes home. (The parent call usually involves the parent saying "Are you SURE? Can't she just stay?") I've only sent a couple of kids home for illness.

edgwow · Mar 2, 2007

Hey Angie,

The impetego needs to be covered as soon as they come out of the office with a bandaid change 3 X a day. 24 hr. quarentine after trx started. After shower, stall needs to be completely disinfected with 10% bleach solution. Wash cloth used needs to also be bleached. Antibiotic ointment applied with a cotton swab is the most recent trend in treatment, but just because you routinely have it Antibiotic ointment, does not mean that you can give it unless you call and consult with the DR. Even when we(RN's) give Over the counter medications, it is dispensing a medication without a liscence unless you have written permission form the parent or were given a direct order from the DR. We had a policy of no swimming at all until it was completely healed,that would warrent a call home since usually that is an activity that the family would not want the camper to miss ( a week or so), with the option of no lake or pool or pick them up. Usually the camper can go with another group instead of their scheduled water activity. Pink eye needs a doctor visit, since they only need to be on the treatment 24 hours and then resume normal activites. I know of no other way to actually treat pink eye except drops. Vommitting and diarrhea are usually self limiting and they can go back to their group fairly quickly. We keep them on the BRAT diet for a day, and have them eat light for a day. As always dehydration is a problem in the heat with a N/V/D and I would say by the 12th hour or so you need to become concerned, maybe sending out for IV's or if a parent can pick up camper. FYI. many of the campers you see are starting out with a fluid deficit because they are mildly chronically dehydrated,from excess heat, exercise(increasesed resp. rate and insensible respiratory water loss) and even though our bodies adjust,someone with N/V/D has less fluid reserves and may start to perspire less, dry mucous membranes , paler mucous membranes, fever needs to be watched out for, since they will develop a fever from dehydration and fluids and cooling body temperature down are key.

See this website below.

Do not forget a dehydration protocol. You can't just push huge quantities of water for the severly dehydrated since it can cause h2o intoxication. There are replacement volumes on the web. I would look to see what Red Cross standards are. Something like a few ounces of fluid every few minutes, and water with a 1/2 teaspoons of salt. google: fluid replacement in dehydration.

http://www.health.nsw.gov.au/pubs/topics/boils_impetigo_fs.pdf

kcangel, LPN · Mar 2, 2007

can you provide your sources for these treatments? with all of the protocols i'm writing, of course i'm providing the source. here is what i found on doing research:

erceg, l. &. (2001). the basics of camp nursing. martinsville, in: american camping association, inc.

healthcommunities.com. (2007, february 21). fungal infections. retrieved february 28, 2007, from dermatologychannel: http://www.dermatologychannel.net/fungalinfections/

missouri department of health and senior services. (2005, july). prevention and control of communicable diseases. a guide for school administrators, nurses, teachers and child care providers .

the nemours foundation. (2005, october). impetigo. retrieved february 27, 2007, from kidshealth: http://www.kidshealth.org/parent/infections/bacterial_viral/impetigo.html

i am using the missouri dept of health as well as the aap as huge resources. here is what i have written so far for impetigo based on these resources:

ø impetigo is a contagious skin infection caused by either a strep or staph bacteria. it usually starts by scratching the skin with dirty hands. tiny blisters begin then burst and may weep fluid. the blister will crust over and appear like honey or brown sugar. or larger blisters that appear clear then will turn cloudy and are less likely to burst. incubation period 1-10 days.

i. procedure

impetigo - if a camper is suspicious of having impetigo they should be seen by a physician. sometimes a small area can be treated with antibiotic ointment. larger areas may require oral antibiotics. camper needs to practice good hand hygiene and can not share clothes, towels or other personal items with other campers. the missouri dept of health (mdhhs, 2005) recommends exclusion of individual from school until lesions are healed or until 24 hrs after medical treatment as been started. together the nurse and camp director will decide on whether camper should be sent home or allowed to stay with proper treatment.

BonnieSc · Mar 2, 2007

Note that the BRAT diet is not evidence-based. I wouldn't include it in the protocols, personally. Also, my understanding is that it is better to keep impetigo sores uncovered. My camp is extremely dirty (lots of dust) and we often have problems keeping things like sores and open mosquito bites clean; depending on the body part and the injury, we might cover it part of the time.

kcangel, LPN · Mar 2, 2007

That's true, I know the pediatric hospital I work in has phased out the BRATT diet. If they are doing an oral rehydration they use oral eletrolyte solutions. If it's a mild case of vomiting that shows up in the ER they will do an oral challenge with a popsicle. The high sugar content helps with the nausea.

Last summer we had several heat exhaustions show up at camp in the nurses station. We effectively treated them with rest in the A/C and small sips of Gatorade. Worked great. Note that large amounts of gatorade aren't recommended for children.

Our hospital uses evidence based guidelines so I will check to see if they have a protocol.

edgwow · Mar 3, 2007

Wendy,

You are 100% right that it is better to leave the impetego open, but in the environment you are in,camp, how can you leave it open to air and not get dust in it? You can't leave an open sore uncovered and risk exposure from one camper to another except inside your office. Covering it also reminds the camper not to scratch it open as not to irritate it worse with the dirty fingers.

6 summers ago I took care of a heat exhaustion case that I should have sent out in retrospect. After 4 hours, of small sips of various juices, gatorade, she still had not peed. It took her 2 days to recover in my office.

Learned from that one. There are guidelines as to how much fluid and what kind you should give every hour, I just don't know them off the top of my head.

Angie, I am glad you said something about the sugar in the popsicle settling the nausea. Since I have never done ER I was unaware. What a great idea and a reason for them to have popsicles on hand.

At my camp, I use a set of protocols that were purchased by the director on the internet from a company that does the protocols for camps, it lists emergencies and routines, our physician signs them annually and we use them. They are written the same way a pediatricians office does triage, they are like an algorithim.

Neveranurseagain, RN · May 29, 2007

I was working at an extreme sports camp where campers wear elbow pads, helmets and knee pads all day as they skateboard, BMX bike and inline skate. A camper presented with folliculities under his pad that look worse the next morning. You guessed it-he had MRSA. We quarantined every one to cabins, did a skin check on 325 campers (with 2 nurses)as other staff members diluted 50 gallons of bleach with water and mopped/wiped down all surfaces of camp. Got the local hospital out to assist in infection control also. Cleaned dining hall first so after kids were checked for skins rashes they could go eat. No other cases were reported...just had alot of kids calling home that someone had the FLESH EATING BACTERIA and told their parents the camper died (he didn't)....Be sure to have a plan for an alternate infirmary set up...had a N& V (not foodborne) go thru a camp and had 15 kids throwing up for 24 hrs---put them all in same cabin so kids with fx and other problems would not be exposed...

BonnieSc · May 29, 2007

What a nightmare! Thank goodness you weren't the only nurse (though it sounds like you could have used, oh, ten or twelve more)!