16.19 Scabies

Scabies in an infectious skin disorder that is caused by the Sarcoptes scabiei mite. There are three different types of scabies called classic, nodular, and crusted. These types are caused by the same species of mite but have slightly different presentations and occur in different populations. For example, the crusted form of scabies is commonly seen in clients with suppressed immune systems.^[1]

Scabies is commonly seen in children and young adults and is most prevalent in Africa, South America, Australia, and parts of Asia. When seen in these parts of the world, scabies is associated with lower socioeconomic status, poor nutrition, poor hygiene, and homelessness. When seen in industrialized countries, scabies is associated with crowded conditions seen in schools, nursing homes, prisons, or hospitals. A common complication of scabies is a secondary bacterial infection with Streptococcus pyogenes, leading to impetigo. Insomnia can also occur due to the intense itching at night.^[2]

Pathophysiology

Scabies is transmitted by directly contacting the skin of an infected individual or by having contact with a contaminated object. Once on the skin, the mite burrows into the deeper skin layers and lays eggs, leading to the severe itching that is associated with scabies. Oftentimes the presence of mites, their eggs, or their waste products can cause a hypersensitivity reaction. The adult mites will die in 30 to 60 days, and their eggs will hatch in two to three weeks. These eggs will eventually develop into adult mites, and the life cycle of the scabies mite repeats itself.^[3]

Assessment (Recognizing Cues)

Physical Exam

Clients with scabies often have intense itching that is typically worse at night. Upon assessment of the skin, there are often changes that can be visualized, such as white lines that indicate where mites have burrowed down into the skin, as seen in Figure 16.25.^[4] Common areas of mite burrowing are the axilla, between the fingers or toes, wrists, buttocks, or near the umbilicus, waist, genitals, or breasts. If a hypersensitivity reaction occurs, red papules may also be present.^[5]

Common Laboratory and Diagnostic Tests

Scabies is diagnosed clinically based on client history and physical examination of the skin. The diagnosis can be confirmed by taking a skin scraping and viewing it under a microscope for the scabies mite. A dermoscope, or handheld microscope, can also be used for visualizing the skin, or a skin biopsy can also be used to confirm the diagnosis.^[6]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with scabies include symptom management and the prevention of complications. Nursing diagnoses for clients with scabies are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with scabies are as follows^[7]:

• Impaired skin integrity r/t disease process
• Risk for infection r/t risk for secondary bacterial infection
• Disturbed sleep pattern r/t severe itching at night

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with scabies include the following:

• The client will exhibit intact skin following treatment for scabies.
• The client will not exhibit signs of secondary infection such as redness, edema, or discharge during the course of treatment.
• The client will verbalize the ability to sleep eight or more hours a night without waking up due to itching after medical treatment is completed.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical interventions for scabies consist of topical medications like permethrin that kill the scabies mite. There is an oral medication for scabies treatment that has been shown to be effective for clients aged ten years or older, but it is not yet approved for use in the United States.^[8]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with scabies, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^{[9],[10],[11]}

Nursing Assessments

• Assess the client whose main complaint is itching for risk factors for scabies infestation, especially when symptoms are present in other family members.
• Assess the skin to determine the severity of the infestation and assess affected areas for secondary bacterial infection.

Nursing Actions

• Ensure that the hospitalized client with scabies remains isolated from others to prevent the spread of scabies to others. Implement contact transmission-based precautions.
• Administer topical scabies medications as prescribed by the provider.
• Administer antibiotics for secondary bacterial infections as prescribed by the provider.
• Encourage the client to avoid scratching, as this can lead to secondary bacterial infections.

Client Teaching

• Educate the client and their parents/caregivers about the need to also treat any close contacts, even if asymptomatic, to prevent further outbreaks.
• Educate the client that potentially contaminated inanimate objects, such as bedding, clothes, and towels, must also be treated to ensure treatment success. These objects should be washed in hot water and dried on a hot setting to kill the scabies mite. Anything that cannot be washed should be sealed in a plastic bag for three or more days.
• Teach the client and their parents/caregivers that topical medications must be applied to the entire body to treat the scabies infection. This means from the neck down in children and older clients. For infants, the entire body is treated, including the head. Multiple treatments are often required to kill all the mites and eggs.
• Teach the client and their parents/caregivers about the need to not share personal items to prevent the spread of scabies.
• Educate the client and their parents/caregivers about the need to stay home from school or daycare for 24 hours after their initial treatment.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.