Scabies - Nursing Case Study

Pathophysiology

• Primary mechanism: Scabies is caused by the infestation of a mite known as Sarcoptes scabiei var. hominis. The female mite burrows into the skin's stratum corneum, laying eggs which hatch after 3-4 days. The larvae then migrate to the skin surface and mature into adult mites, repeating the cycle.

• Secondary mechanism: The pruritus associated with scabies is due to a hypersensitivity reaction, primarily of type IV, to mite antigens. This reaction usually begins 2-6 weeks after infestation, causing intense itching and skin inflammation.

• Key complication: Continuous scratching can lead to secondary bacterial infections, commonly caused by Staphylococcus aureus or Streptococcus pyogenes. This can result in complications such as impetigo, cellulitis, or post-streptococcal glomerulonephritis.

Patient Profile

Demographics:

45-year-old male, school teacher

History:

• Key past medical history: Eczema, Type 2 diabetes

• Current medications: Metformin, Eczema Cream

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe itching, particularly at night, and skin rash

• Key symptoms: Redness and swelling, blisters, sores from scratching, signs of secondary infection, and visible burrows in the skin

• Vital signs: Elevated body temperature at 100.4°F, heart rate of 98 bpm, blood pressure 130/85 mmHg, respiratory rate of 18 breaths per minute, oxygen saturation 96%

Section 1

Change in Patient Status:

Over the next few days, the patient's condition seems to have deteriorated. He reported increasing discomfort and more intense itching despite the use of prescribed antipruritic medications. His body temperature rose to 101.5°F, indicating potential systemic infection. His blood pressure increased slightly to 135/90 mmHg, possibly due to stress and discomfort, while his heart rate remained stable at 98 bpm. The oxygen saturation remained within normal limits at 96%.

The physical examination revealed that the patient's skin condition had worsened. The rash had spread to new areas, with more pronounced redness, swelling, and visible burrows. Some of the scratches had turned into open sores with signs of pus, suggesting secondary bacterial infection. The patient also reported increased pain around these sores. On further examination, the sores seemed consistent with impetigo, a common complication of scabies, which can be caused by Staphylococcus aureus or Streptococcus pyogenes. This change in patient status would require further diagnostic tests to confirm the diagnosis and guide the modification of the treatment plan.

Section 2

New Diagnostic Results:

The patient’s blood samples were sent to the lab for a complete blood count (CBC) and a culture of the pus from the open sores. The CBC results revealed leukocytosis, with a white blood cell (WBC) count of 18,000/mcL, indicating the likelihood of an ongoing infection. The blood culture was negative, suggesting that the infection was localized and not yet systemic. However, the culture from the open sores tested positive for Staphylococcus aureus, confirming the initial suspicion of impetigo secondary to the scabies infestation.

Change in Patient Status:

Despite the use of topical permethrin and systemic antipruritic medications, the absence of improvement and development of secondary bacterial infection indicate a more complicated scabies infestation, possibly crusted scabies, also known as Norwegian scabies. This form of scabies is more severe and highly contagious, characterized by thick crusts of skin that contain large numbers of scabies mites and eggs. The patient's increased discomfort, persistent fever, and the spread of the rash to new areas of the body despite treatment are suggestive of this diagnosis. This change in patient status necessitates a reassessment of the existing treatment plan and the implementation of more aggressive interventions to control the infestation and treat the secondary bacterial infection.

Section 3

New Complications:

The patient's symptoms begin to intensify, with the itchiness becoming more severe and keeping him awake at night. Despite the use of systemic antipruritics, the patient reports minimal relief. He has also started to complain about a sharp, burning pain in the areas with the crusty sores. On assessment, his temperature spikes to 38.5 degrees Celsius, indicating the persistence of the infection. His blood pressure is also slightly elevated at 135/90 mmHg, likely due to the stress and discomfort he is experiencing.

The patient's skin condition worsens, with the crusts becoming thicker and the rash spreading to cover larger areas of his body, including his neck and face. This progression, along with the presence of open sores with purulent discharge, raises concerns about the risk of further complications, including cellulitis and post-streptococcal glomerulonephritis. The nurse contacts the physician to report the new developments and discuss the need for a more aggressive treatment plan to address the patient's deteriorating condition and prevent further complications.

Section 4

New Diagnostic Results:

Upon consultation with the physician, a skin scraping is immediately ordered to examine the mites under the microscope. The results confirm the presence of scabies mites, eggs, and feces, indicating a severe infestation. The nurse also notes that the patient's blood test results show a high white blood cell count of 14,000 per microliter, suggestive of a bacterial infection. His C-reactive protein (CRP) levels are also elevated at 25 mg/L, which could be indicative of inflammation or infection in the body.

In addition, the patient's urinalysis shows a high number of red blood cells and protein, raising suspicions of post-streptococcal glomerulonephritis. This could be a complication of the untreated skin infection, which might have allowed Group A Streptococcus bacteria to spread to the kidneys. Given these findings, the nurse anticipates the need for further testing to determine the extent of the kidney damage and collaborates with the physician to modify the patient's treatment plan. The new diagnostic results indicate that the patient's condition is more complex than initially thought, requiring careful clinical reasoning and meticulous management to prevent further complications.

Section 5

New Complications:

As the treatment for scabies began, the patient started to show signs of fever with a body temperature spiking to 101.5°F, accompanied by chills and malaise. Upon closer examination, the nurse noticed that the rash had spread to new areas and appeared to be more inflamed, with signs of pus formation suggesting cellulitis. The patient also reported a significant increase in itchiness, particularly during nighttime.

The nurse also noticed that the patient seemed fatigued, with dark circles under his eyes suggesting sleep deprivation - a common side effect of the intense itch caused by scabies. Furthermore, the patient complained of a burning sensation during urination and lower back pain, which could be indicative of kidney involvement. The nurse quickly informs the physician about these new developments. Recognizing the escalating severity of the condition and the potential kidney involvement, the decision is made to commence immediate antibiotic therapy for the skin infection and possible kidney infection. This approach necessitates careful monitoring of the patient's renal function and vital signs, as well as constant evaluation of the skin condition for any signs of improvement or deterioration. The nurse knows that the patient's condition now requires a higher level of care and vigilance to prevent further complications and manage the current symptoms effectively.