Rash, Itching (Pruritus), Anaphylaxis
Also Consider: Abrasion, Bite Wound, Laceration, Puncture Wound, Skin Tear
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Types
Blister, Bulla: fluid-filled, thin wall raised area larger than 5mm.
Vesicle: fluid filled, thin wall raised area smaller than 5mm.
Macule: flat, non-palpable change in skin color smaller than 10mm.
Patch: flat, non-palpable change in skin color larger than 10mm.
Papule: palpable, raised area smaller than 5mm.
Plaque: palpable, raised area larger than 5mm, often from papules coming together.
Wheal: irregularly shaped, elevated area of redness with borders that move over time.
Causes
Common: Dry skin, drug reaction, dermatitis, Shingles (Herpes Zoster), Eczema, Psoriasis
Less common: Scabies, Autoimmune disease, Sepsis, viral infections
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
Not eating or drinking as much as usual
If Pain: exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds
GU: New or worsened incontinence, pain with urination, blood in urine
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)
Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis
Response to any ordered PRN medications
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Acute allergic reaction with hives, pruritus, dyspnea, or anaphylaxis (implement facility anaphylaxis protocol / standing orders)
Notify medical staff & resident representative within the next 16 hours.
Recent onset of pruritic rash, OR
any rash accompanied by other systemic symptoms or occurring after the start of a new medication (notify before next dose is due to be given)
Notify medical staff on the next business day
Recent onset of rash without pruritus or systemic symptoms and no new medications have been started
Notify medical staff at the next regular rounds
Unresolved or recurrent rashes
SBAR Report
Situation: "New rash associated with:" (trouble breathing) (itching) (other acute symptoms)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the rash started, appearance and location(s) of rash, getting worse or staying the same, what treatments have been used.
Abnormal vital signs
History of skin disease
MOLST / Advance Directives
Unrelieved pain
Recent illness, antibiotics, medication changes
General observation of patient condition
Similar symptoms in other patient on unit or in facility
Blood glucose, if elevated
Abnormal findings on lung, cardiovascular, abdomen, GU, neurologic or skin observations.
Assessment: I am concerned about: __________
Recommendations/Requests:
For Anaphylaxis: Epinephrine 1mg/ml (1:1000) 0.3mg IM mid-lateral thigh, repeat every 5-15 minutes as needed. If wheezing, albuterol may also be used. Alert EMS.
Labs: CBC with manual diff, CMP/Chem14
INR if patient is on warfarin
Stop a recently-started medication
Topical medication for itching
If a systemic medication is needed for itching in an elderly patient, use cetirizine 5mg daily instead of diphenhydramine
Disease-specific treatment (shingles, scabies, fungal)
Dermatology consultation
Topical medication for itching
If a systemic medication is needed for itching in an elderly patient, use cetirizine 5mg daily instead of diphenhydramine
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Patients with anaphylaxis who respond promptly to treatment should be observed every 15 minutes for 8 hours.
Update allergy records
Photograph rash as per facility policy
Mark edges of reddened areas to detect future spread.
Monitor vital signs every 8 hrs for 2-3 days
Place on Intake & Output monitoring if systemic symptoms are present
Monitor meal acceptance
Place on 24-hour report
Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)
Implement infection control measures if indicated (scabies, shingles, etc)
Update care plan regarding skin care: avoid traditional soaps, allow skin to dry thoroughly after bathing, apply moisturizers.
Review status and plan of care with designated representative
2025-04-20
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