INFESTATION

 It can be a parasitic attack or subsistence on the skin and/or its appendages, as by

insects, mites, or ticks; sometimes used to denote parasitic invasion of the organs and
tissues, as by helminths.
 The term is also sometimes applied to large internal parasites such as intestinal worms,
but this is more usually referred to as INFECTION.
 It is also used in parasitology to pertain to ectoparasitism.
 Ectoparasitism is a form of parasitism wherein the parasite lives outside the body of the
host. The parasite is referred to in particular as an ectoparasite. In ectoparasitism, the
host-parasite relationship is non-mutual. Many of the endoparasitic relationships do not
lead to much harm to the host compared with that in endoparasitism. Nevertheless,
there are ectoparasites that serve as carriers of disease. For instance, the
mosquito, Aedes aegypti, may carry dengue virus, which can cause dengue. The
mosquito is an example of an ectoparasite since it benefits from its host, e.g. human, by
feeding on the blood of the latter. Other examples of ectoparasitism are ticks, lice,
and leech that feed externally from the skin of their host.

SCABIES

• Infestation of the skin by the itch mite Sarcoptes scabiei found in people living in
substandard hygienic conditions
• From Latin word: Scabere – “to scratch”
• “Seven-year itch”/ “The Itch”
 • Sarcoptes scabiei
• Upon infesting a human host,
• 1) The adult female burrows into the skin, where she deposits 2-3 eggs
per day.  
• 2) They hatch as larvae in 3-4 days. 
• 3) The 6-legged larvae migrate to the skin surface and then burrow into
molting pouches (these are shorter and smaller than the adult burrows).
• 4)The larvae molt, turning into 8-legged nymphs.  This form molts a
second time into slightly larger nymphs, before a final molt into adult
mites. 
•  5) Adult mites then mate when the male penetrates the molting pouch
of the female
 Mating occurs only once, as that one event leaves the female fertile for the rest of her
life (1-2months). 

Manifestations
 Intense pruritus (itching)
 Superficial burrow (a short S-shaped track that indicates the mite's movement
under the skin)
 Secondary lesions
• Symptoms appears 4 weeks from contract
• Symptoms are most likely to develop:
• Between the fingers and on the palm side of the wrists.
• On the outside surfaces of the elbows and in the armpits.
• Around the waistline and navel.
• On the buttocks.
• Around the nipples, bra line, and the sides of the breasts (in women).
• On the genitals (in men).
• Increased itching that occurs at night
• In babies and small children, itching and skin irritation may also occur:
• Around or on the scalp, neck, and face.
• On the palms of the hands and soles of the feet
• Often the first symptom noticed in a baby is in these areas and is a series of tiny
sores that are like blisters (vesicles).

Diagnosis
• Scabies Scraping
• Observe the characteristic burrows of the mites causing scabies.
• A sterilized needle can be used to explore the pearly bump at the end of
a burrow, remove its contents, and place it on a slide to be examined.
• The mite itself may then be identified under a microscope.
Treatment:
o -Warm soapy bath or shower to remove the scaling debris from the crusts and dried
thoroughly
o -Lindane (Kwell), Crotamiton (Eurax) or 5% permethrin (Elimite) are scabicides
o -Scabicides are applied to the entire skin from the neck down and left for 12-24 hrs the
washed thoroughly
o -Repeat treatment after 1 week

Pharmacologic Management
• Permethrin 5% cream (Elimite)
• Lindane 1% cream or lotion
• Ivermectin pill (Stromectol)
• Malathion 0.5% lotion (Ovide)
• Benzyl benzoate lotion
• Crotamiton lotion or cream (Eurax)
• Sulfur-based lotions, creams, or soaps

Nursing Intervention

 Wear clean clothing and sleep between freshly laundered bed linens
 All beddings and clothing should be washed in hot water and dried in hot dryer
 Pruritus may persist for several weeks due to hypersensitivity
 Advise client not to apply more scabicides because it will cause more irritation
 Advise clients not to take frequent showers because it dries up the skin
 May administer oral corticosteroids such as diphenhydramine (Benadryl), or
Hydroxyzine (Iterax) as ordered to healp control pruritus
 All close contacts and family members should be treated simultaneously to eliminate
mites

Prognosis
• The prognosis for complete recovery from scabies infestation is excellent.
• In patients with weak immune systems, the biggest danger is that the areas of
skin involved with scabies will become secondarily infected with bacteria.

Prevention
• If a person is known to have scabies, they should not have close skin-to-skin contact
with others until they have been treated.
• If one member of a household has scabies, all other household members, sexual
partners, and close contacts should be treated simultaneously.
• Clothing, towels, and bedding from an affected person should be washed in hot water
and dried in a dryer.
• If an article cannot be washed this way, it can be stored away from human contact for
three days to eliminate mites.
 • In the hospital, staff should use gloves and gowns when treating patients who have a
suspicious rash and itching.

DERMATOPHYTES

Dermatophytes are a group of fungus that commonly causes skin disease in animals and
humans. It originate from soil-dwelling keratinophilic organisms, but only a few species still
reside primarily in the niche and mostly have become adapted to people or animals. There are
approximately 40 species dermatophytes, which generally are in three genera-Microsporum,
Trichophyton and Epidermophyton. Both Microsporum and Trichophyton cause
dermatophytosis in humans and animals.
Dermatophytes cause dermatophytosis commonly known as ring worm.
Dermatophytosis is a contagious infection. It is also an inflammatory reaction in the host of the
superficial tissues such as the epidermis, hair, and nails.
Types of Dermatophytosis
 Tinea pedis (athlete's foot): fungal infection of the feet
 Tinea unguium: fungal infection of the fingernails and toenails, and the nail bed
 Tinea corporis: fungal infection of the arms, legs, and trunk
 Tinea cruris (jock itch): fungal infection of the groin area
 Tinea manuum: fungal infection of the hands and palm area
 Tinea capitis: fungal infection of the scalp and hair
 Tinea faciei (face fungus): fungal infection of the face
 Tinea barbae: fungal infestation of facial hair

INCIDENCE
Since dermatophytes are found worldwide, infections by these fungi are extremely
common. Infections occur more in males than in females, as the predominantly female
hormone, progesterone, inhibits the growth of dermatophyte fungi.
Risk factors
 Diabetes mellitus
 Immunocompromise (e.g., HIV)
 Poor circulation, peripheral arterial disease
 Maceration of skin (e.g., in athletes)


Causative agent of dermatophytosis – dermatophytes (Microsporum, Trichophyton,

and Epidermophyton)

Incubation period - The incubation period in humans is usually 1 to

2 weeks
Mode of transmission - Dermatophytes are spread by direct contact
from other people (anthropophilic organisms),
animals (zoophilic organisms), and soil (geophilic
 organisms), as well as indirectly from fomites

Period of communicability of ringworm or tinea - Active lesions shed infective material

continuously. The fungus persists on
contaminated materials for as long as skin cells or
animal hair harbour viable spores. This means it
can spread on contact to other parts of your
body, or to other people, even when you're being
treated. The tendency for fungus to recur in
many adults, especially on the feet and toenails,
is a genetic condition.

Manifestations There are no pathognomonic sign for this

infection but Erythematous plaques, Pruritus, nail
discolouration and onycholysis are the most
common clinical features

Reservoir for dermatophytosis/ringworm or tinea are:

 tinea capitis – humans and animals, including dogs, cats and cattle
 tinea corporis – humans, soil and animals, including cattle, kittens, puppies, guinea pigs,
mice and horses
 tinea pedis/cruris – humans
 tinea unguium – humans and, rarely, animals or soil.

CAUSES
1. From a person who has ringworm.

People can get ringworm after contact with someone who has the infection. To avoid
spreading the infection, people with ringworm shouldn’t share clothing, towels, combs, or
other personal items with other people. Those that cause dermatophytosis may be also spread
by using exercise machines that have not been disinfected after use.
2. From an animal that has ringworm.

People can get ringworm after touching an animal that has ringworm. Many different
kinds of animals can spread ringworm to people, including dogs and cats, especially kittens and
puppies. Other animals, like cows, goats, pigs, and horses can also spread ringworm to people.
3. From the environment.

The fungi that cause ringworm can live on surfaces, thrive in moist, in warm areas,
particularly in damp areas like locker rooms and public showers, tanning beds, swimming pools.
For that reason, it’s a good idea not to walk barefoot in these places.
4. Accidentally infected from the soil
 It’s possible that these fungi may live for an extended period as spores in soil. Humans
and animals can contract ringworm after direct contact with this soil. This includes the activities
like planting, gardening or playing outside.
Transmission
Dermatophytes are transmitted by direct contact with an infected host (human or
animal)[3] or by direct or indirect contact with infected shed skin or hair in fomites such as
clothing, combs, hair brushes, theatre seats, caps, furniture, bed linens, shoes, socks, towels,
hotel rugs, sauna, bathhouse, and locker room floors. Also, transmission may occur from soil-
to-skin contact. Depending on the species the organism may be viable in the environment for
up to 15 months.
While even healthy individuals may become infected,[8] there is an increased
susceptibility to infection when there is a preexisting injury to the skin such as scars, burns,
excessive temperature and humidity. Adaptation to growth on humans by most geophilic
species resulted in diminished loss of sporulation, sexuality, and other soil-associated
characteristics.

SYMPTOMS
Dermatophytosis/Ringworm can affect skin on almost any part of the body as well as
fingernails and toenails. The symptoms of ringworm often depend on which part of the body is
infected, but they generally include:
 Itchy skin
 Ring-shaped rash
 Red, scaly, cracked skin
 Hair loss on the affected area

Symptoms of ringworm by location on the body:

 Feet (tinea pedis or “athlete’s foot”): The symptoms of ringworm on the feet include
red, swollen, peeling, itchy skin between the toes (especially between the pinky toe and
the one next to it). The sole and heel of the foot may also be affected. In severe cases,
the skin on the feet can blister.
 Scalp (tinea capitis): Ringworm on the scalp usually looks like a scaly, itchy, red, circular
bald spot. The bald spot can grow in size and multiple spots might develop if the
infection spreads. Ringworm on the scalp is more common in children than it is in
adults.
 Groin (tinea cruris or “jock itch”): Ringworm on the groin looks like scaly, itchy, red
spots, usually on the inner sides of the skin folds of the thigh.
 Beard (tinea barbae): Symptoms of ringworm on the beard include scaly, itchy, red spots
on the cheeks, chin, and upper neck. The spots might become crusted over or filled with
pus, and the affected hair might fall out.

Diagnosis:
  Fungal culture – CONFIRMATORY TEST. A fungal culture may be performed to confirm
the diagnosis of tinea infection or dermatophytosis and to identify the pathogenic
species. Common media include dermatophyte test medium, Mycosel, or mycobiotic
agar. A fungal culture might also be referred to as a “fungal smear.” It can be used to
test various areas of the body, including:
 blood
 skin
 mucosal surfaces, such as wounds or the genital region
 nail
 Potassium hydroxide (KOH) microscopy. A potassium hydroxide preparation or KOH
prep, is a quick, inexpensive fungal test to differentiate dermatophytes and Candida
albicans symptoms from other skin disorders like psoriasis and eczema. cells are
obtained from the affected area, placed on a slide with a solution consisting of
potassium hydroxide, and examined under a microscope to look for signs of a fungus. A
KOH test can confirm the presence of fungi, including dermatophytes.
 Wood lamp exam (ultraviolet light). A Wood lamp examination is a test that uses
ultraviolet (UV) light to look at the skin closely. A Wood's lamp is a light that uses long
wave ultraviolet light. When an area of scalp that is infected with tinea (a type of
ringworm fungus) is viewed under a Wood's light, the fungus may glow
 dermoscopy (trichoscopy). This is a method of hair and scalp evaluation and is used for
diagnosing hair and scalp diseases. Where in it will see if there are abnormal changes in
the scalp caused by the existence of dermatophytosis.

COMPLICATIONS
The main complication is secondary bacterial infection. Alopecia is also one complication
of tinea capitis and pain and difficulty with shoes can result from onychomycosis.

MANAGEMENT
The treatment for ringworm depends on its location on the body and how serious the
infection is. Some forms of ringworm can be treated with non-prescription (“over-the-counter”)
medications, but other forms of ringworm need treatment with prescription antifungal
medication.
 Terbinafine inhibits the growth of dermatophytes of all genera and is the main drug of
choice for the treatment of dermatophytoses, especially with chronic conditions.

Ringworm on the skin like athlete’s foot (tinea pedis) and jock itch (tinea cruris) can
usually be treated with non-prescription antifungal creams, lotions, or powders applied to the
skin for 2 to 4 weeks. There are many non-prescription products available to treat ringworm,
including:
  Clotrimazole (Lotrimin, Mycelex) - often the first-line drug used in the treatment of
tinea cruris. It is a broad-spectrum antifungal agent that inhibits yeast growth by
altering cell membrane permeability, causing the death of fungal cells
 Miconazole (Aloe Vesta Antifungal, Azolen, Baza Antifungal, Carrington Antifungal, Critic
Aid Clear, Cruex Prescription Strength, DermaFungal, Desenex, Fungoid Tincture,
Micaderm, Micatin, Micro-Guard, Miranel, Mitrazol, Podactin, Remedy Antifungal,
Secura Antifungal)
 Terbinafine (Lamisil)
 Ketoconazole (Xolegel)

For non-prescription creams, lotions, or powders, follow the directions on the package
label. Contact your healthcare provider if your infection doesn’t go away or gets worse.
Ringworm on the scalp (tinea capitis) usually needs to be treated with prescription antifungal
medication taken by mouth for 1 to 3 months. Creams, lotions, or powders don’t work for
ringworm on the scalp. Prescription antifungal medications used to treat ringworm on the scalp
include:
 Griseofulvin (Grifulvin V, Gris-PEG) - is still the drug of choice for the treatment of tinea
capitis of the Microsporum type.
 Terbinafine
 Itraconazole (Onmel, Sporanox)
 Fluconazole (Diflucan)

Prevention
How can I prevent ringworm?
 Keep your skin clean and dry.
 Wear shoes that allow air to circulate freely around your feet.
 Don’t walk barefoot in areas like locker rooms or public showers.
 Clip your fingernails and toenails short and keep them clean.
 Change your socks and underwear at least once a day.
 Don’t share clothing, towels, sheets, or other personal items with someone who has
ringworm.
 Wash your hands with soap and running water after playing with pets. If you suspect
that your pet has ringworm, take it to see a veterinarian. If your pet has ringworm,
follow the steps below to prevent spreading the infection.
 If you’re an athlete involved in close contact sports, shower immediately after your
practice session or match, and keep all of your sports gear and uniform clean. Don’t
share sports gear (helmet, etc.) with other players,
 ASCARIASIS

• Otherwise known as roundworm infestation, ascaridiasis

• A helminthic infection of the small intestines generally associated with few or no
symptoms
• Characterized by an early pulmonary invasion from larval migration and a later more
prolonged intestinal phase

MANIFESTATIONS
• Bloody sputum
• Cough
• Low-grade fever
• Passing worms in stool
• Shortness of breath
• Skin rash
• Stomach pain
• Vomiting worms
• Wheezing
• Worms exiting through the nose or mouth

DIAGNOSIS
• Abdominal x-ray
 • Complete blood count (increased eosinophils)
• Stool ova and parasites exam
• History of passing out adult worms
• Vomits a worm

COMPLICATION
• Bowel obstruction by bolus of worms
• Airway obstruction
• Loeffler’s pneumonia
• Appendicitis

MANAGEMENT
• Administration of anti-parasitic medications: -‘dazole’ family (mebendazole,
albendazole)

TRICHINOSIS

Trichinosis, also known as trichinellosis, is a foodborne parasitic infection caused by a species of

roundworm called Trichinella. ou can contract trichinosis if you eat raw or undercooked meat from an
animal infected with Trichinella. The most common offending agent for humans is pork meat. The
roundworm begins its life cycle in the intestines and then lodges itself in the muscles, causing pain and
discomfort.

According to the Centers for Disease Control and PreventionTrusted Source, approximately 10,000 cases
of trichinosis are diagnosed every year around the world. Trichinosis is fairly rare in the United States
since there are strict laws for meat processing and animal feed. In fact, an average of only 400
trichinosis cases are reported each year in the United States. The disease is most commonly seen in rural
areas.

Causative Agent
 Trichinellosis (trichinosis) is caused by nematodes (roundworms) of the genus Trichinella. In
addition to the classical agent T. spiralis (found worldwide in many carnivorous and omnivorous
animals), several other species of Trichinella are now recognized, including T. pseudospiralis
(mammals and birds worldwide), T. nativa (Arctic bears), T. nelsoni (African predators and
scavengers), T. britovi (carnivores of Europe and western Asia), and T. papuae (wild and
domestic pigs of Papua New Guinea and Thailand). Trichinella zimbabwensis is found in
crocodiles in Africa but to date there are no known associations of this species with human
disease.

Incubation Period
 Systemic symptoms usually appear about 8 – 15 days after ingestion of infected meat; this varies
from 5 – 45 days depending on the number of parasites involved. GI symptoms may appear
within a few days.

Mode of Transmission
  Humans can contract trichinosis when they eat raw or undercooked meat of an animal infected
with Trichinella larvae. After the parasites are ingested, the acid in the stomach dissolves the
cyst, which is the protective capsule surrounding the larvae. When the hard covering of the cyst
is dissolved, the larvae enter the intestine, where they mature into adult worms and reproduce.
The female worms then release their larvae into the bloodstream, allowing them to migrate
through the blood vessels and into the muscles. Once they’re in the muscles, the worms
encapsulate into the muscle tissues, where they can live for an extended period.

Period of Communicability
 Not transmitted person to person; animal hosts may remain infective for months and meat from
these animals remains infective until the larvae are killed by sufficient cooking or irradiation.

MANIFESTATION
 During the first week after ingesting infected meat, the person may be asymptomatic or
experience abdominal discomfort, nausea, vomiting and or diarrhea. One to several weeks later,
as larvae migrate into tissues, fever, myalgia, periorbital edema, urticarial rash, and conjunctival
and subungual hemorrhages may develop. Cardiac and neurological complications may appear
in the third to sixth week.

MANAGEMENT
 Administration of anti-parasitic medications: -‘dazole’ family (mebendazole,
albendazole)

Diagnostic/Laboratory Procedures
 Diagnosis is based on clinical presentation and epidemiological evidence and can be confirmed
by blood tests and skeletal muscle biopsy. Skeletal muscle biopsy taken more than 10 days after
infection (most often positive after the fourth or fifth week of infection) frequently provides
conclusive evidence of infection. Serum antibody titres rarely become positive before the
second week of illness; testing paired acute and convalescent serum specimens usually is
diagnostic.

Management
 Specific treatment is under the direction of the attending health care provider. Albendazole or
mebendazole are effective in the intestinal stage and the muscular stage. Corticosteroids are
indicated only in severe cases to alleviate symptoms of inflammatory reaction when the CNS or
heart is involved; however they delay elimination of adult worms from the intestine. In rare
 cases where infected meat is known to have been consumed, prompt administration of
anthelminthis treatment may prevent development of symptoms.

HOOKWORM

• disorder is caused by infestation with the roundworms Necator

americanus, Ancylostoma duodenale
• SYNONYMS: Ancyclostomiasis, uncinariasis, necatoriasis

Manifestations
• Anemia
• Hyporprotenemia
• Retarded in mental as well as physical development
• Severe acute pulmonary and GI reactions

MANAGEMENT
• Administration of antihelminthics
• Supportive management

DEFINITION
Hookworm is an intestinal parasite of humans. The larvae and adult worms live in the small
intestine can cause intestinal disease. The two main species of hookworm infecting humans
are Ancylostoma duodenale and Necator americanus. Hookworm infection is acquired through
skin exposure to larvae in soil contaminated by human feces (see the image below). Soil
becomes infectious about 9 days after contamination and remains so for weeks, depending on
conditions.
Ancylostoma duodenale- are anthropophilic human hookworms transmitted from infected soil
and transmitted via contact with domesticated animals, such as dogs and cats which are the
definitive host of these species
Necator americanus- is a species of hookworm that infests humans as well as other animals
such as cats and dogs. However, humans are its most common definitive host. The species is
referred to as the New World hookworm of humans. Similar to other hookworms such
as Ancylostoma duodenale, the species belongs to phylum Nematoda. Both Ancylostoma
duodenale and Necator americanus attach to the intestinal wall of their host and suck blood.
Thus, their presence in the intestines causes diarrhea, anorexia, and iron-deficiency anaemia.
They are also similar in morphology although Necator americanus is smaller than Ancylostoma
duodenale. 

INCIDENCE
Human infection with A duodenale or N americanus is estimated to affect approximately 472
million people worldwide. These parasites drain the equivalent of all the blood from
approximately 1.5 million people every day.

MODE OF TRANSMISSION
Hookworm eggs are passed in the feces of an infected person. If an infected person
defecates outside (near bushes, in a garden, or field) or if the feces from an infected person are
used as fertilizer, eggs are deposited on soil. They can then mature and hatch, releasing larvae
(immature worms). The larvae mature into a form that can penetrate the skin of humans.
Hookworm infection is transmitted primarily by walking barefoot on contaminated soil.
One kind of hookworm (Ancylostoma duodenale)can also be transmitted through the ingestion
of larvae.

RISK FACTORS

 those who live in warm, tropical, or subtropical areas

 people who spend time in areas where there is poor sanitation management and
hygiene, especially if walking barefoot or with skin-to-soil contact

 those who are pregnant or of childbearing age

 young children who have contact with contaminated soil or sandboxes

 workers who have contact with contaminated soil, especially farmers, plumbers,
electricians, and exterminators

 people who sunbathe on contaminated sand

The risk increases in areas where people use “night soil” or fertilizer made from human feces

SIGNS AND SYMPTOMS

People with a hookworm infection may show some of the following symptoms:

 a skin rash in one area that is typically red, raised, and itchy

 weight loss

 loss of appetite
  breathing complications, such as wheezing and a cough

 fever

 stomach pain

 diarrhea

 extreme tiredness and weakness

 iron deficiency anemia or malnutrition

 physical and thought development problems in children due to severe anemia

 heart failure and widespread tissue swelling as a result of severe anemia

DIAGNOSTIC
 Examination of a stool sample
 Blood tests to check for anemia and iron deficiency

Hookworm infection is diagnosed by identifying hookworm eggs in a sample of stool. Stool

should be examined within several hours after defecation.

Eosinophilia is often present in people infected with hookworms. Eosinophilia is a higher than
normal number of eosinophils, which are a type of disease-fighting white blood cell that play
an important role in the body's response to allergic reactions, asthma, and infection with
parasitic worms (helminths). During the 5 to 9 weeks between penetration of larvae and
appearance of eggs in the stool, eosinophilia may be the only laboratory abnormality.
Hookworm infection is an important diagnostic consideration in people who have a blood
count done that shows eosinophilia, especially if they are immigrants or travelers returning
from endemic regions where sanitation is poor.
Blood tests for anemia and iron deficiency are also done.

PREVENTION

Hookworm infection prevention involves the following:

 Using sanitary toilet facilities

 Preventing the skin from directly contacting the soil (for example, by wearing
shoes and using a tarp or other barrier when seated on the ground)

 Treating dogs and cats for hookworm to prevent them from spreading animal
hookworms to people
In areas where human hookworm infection is common, public health officials sometimes
periodically treat people who are likely to be infected with hookworms and other
roundworms that are spread through contaminated soil (such as Ascaris and whipworm) with
a single dose of albendazole. This treatment helps prevent complications of these infections

MEDICAL MANAGEMENT

Most cases of classic hookworm disease can be managed on an outpatient basis with
anthelmintic and iron therapy, complemented by an appropriate diet.

 Iron therapy. Patients with anemia and malnutrition may require both iron
supplements and nutritional support (including folate supplementation).
 Antihelmintics. For patients with cutaneous larva migrans who have minimal
symptoms, specific anthelmintic treatment may be unnecessary.
 Blood transfusions. Blood transfusion is indicated in rare cases of acute severe
gastrointestinal (GI) hemorrhage; in patients with chronic anemia, blood transfusions
(ie, packed red blood cells [RBCs]) should be administered slowly and are usually
followed by a diuretic to prevent rapid fluid overload.

Pharmacologic Management

Antihelmintics are the drug of choice for hookworm infections.

 Anthelmintics. Anthelmintic drugs effective against hookworms include

benzimidazoles (eg, albendazole, mebendazole) and pyrantel pamoate; the Centers
for Disease Control and Prevention (CDC) continues to recommend a 400-mg single
dose of albendazole on its Website (July 26, 2018), but notes that albendazole is still
not FDA approved for the treatment of hookworm infection.

Nursing Management

 Reduce or diminish pain. Provide rest periods to promote relief, sleep, and

relaxation; acknowledge reports of pain immediately; get rid of additional sources of
discomfort, and determine the appropriate pain relief method.
 Improve tissue perfusion. Submit patient to diagnostic tests as indicated; administer
blood transfusion as indicated.
 Protect skin integrity. Monitor site of impaired tissue integrity at least once daily for
color changes, redness, swelling, warmth, pain, or other signs of infection; provide
 skin care as needed; keep a sterile dressing technique during wound care; clip the
patient’s nails as necessary; and teach patient and significant others about proper
handwashing, wound cleansing, dressing changes, and application of topical
medications.
 Enforce knowledge about the disease and its treatment. Determine priority of
learning needs within the overall care plan; render physical comfort for the patient;
grant a calm and peaceful environment without interruption; include the patient in
creating the teaching plan; help the patient in integrating information into daily life;
and provide clear, thorough, and understandable explanations and demonstrations.