Self Care Final (Hess)

Scaly Dermatoses: exclusions

• general dandruff, SD, Psoriasis

• Psoriasis specific

• general dandruff, SD, Psoriasis

  • less than 2 years old

  • worsening, no improvement after 2 weeks of SC

• Psoriasis specific

  • more than 5% BSA

  • face involvement

  • joint pain (psoriatic arthritis)

  • many/large lesions

Scaly Dermatoses: pharm treatments and its MOA

• Selenium Sulfide

• Pyrithione Zinc

• MOA

  • inhibit scalp fungus

  • cytostatic effect

which is good for 1st line? which is more potent?

• 1st line = pyrithione zinc

• potent = selenium sulfide

pyrithione zinc

• strength

• scheduling/use

• ADRs

• counseling

• strength

  • 1 - 2%

• scheduling/use

  • initial/acute = daily to 1 - 2x week

  • controlled = 2 - 3x week (BIW-TIW) for 2 - 4 weeks

  • maintenance = 1x every 1 - 2 weeks

  • wash w/ non-med → zinc 3 - 5mins, rinse

• ADRs

  • CD

  • eye irritation

• counseling

  • leave zinc for 3 - 5 mins

  • avoid contact w/ eyes

  • skin irritation

selenium sulfide

• strength

• scheduling/use

• ADRs

• counseling

• strength

  • 1%

• scheduling/use

  • initial/acute = daily to 1 - 2x a week

  • controlled = 2 - 3x week for 2 - 4 weeks

  • maintenance = 1x every 1 - 2 weeks

  • wash w/ non-med, leave 3 - 5mins, rinse 2 - 3x

• ADRs

  • CD

  • eye irritaion

  • residual oil

  • potential hair color

• counseling

  • same as Pyrithione + rinsing 2 - 3x

diaper dermatitis prevention + treatment

• A

• B

• C

• D

• E

• A

  • air dry

  • diaper off

• B

  • barrier

  • lubricate area, prevent moisture

  • thick layer

  • zinc oxide = strong barrier

  • petrolatum = occlusive

  • talc (carcinogenic), cornstarch → not recommended

• C

  • cleansing

  • change frequently

  • clean w/ soft cloth, warm water

• D

  • change diaper every 2 hrs or immediately

  • disposable

  • not tight-fitting

• E

  • educate hygiene, use/application of pharm, understanding

which is not recommended for diaper dermatitis

topical antibiotics, antifungals, steroids

diaper dermatitis: exclusions

• lesions persist 7+ days or lack of improvement

• s/sx secondary prevention

• outside diaper area

• UTI

• broken skin, blood, vescicles, pus

• comorbid conditions

• s/sx systemic

• chronic, frequent, recurrent sx

• behavioral changes

Diarrhea: exclusions

• less than 6 months, 17.5 lbs

• fever

• blood, mucus, pus

• high volume output, frequency

• vomiting

• dehydration

• abdominal pain, distention, tenderness

• complications

• pregnancy

• chronic

• sx worsen after 48 hrs of onset

• ORS

Diarrhea: Non-pharm

• ORT (Pedialyte)

  • prevent electrolyte loss

• avoid sports drink, sodas, juices, chicken broth

• do not withhold food for 24 hours

Diarrhea: pharm therapy (sx control only)

• not used more than 48 hours

• Loperamide (Imodium A-D)

• Bismuth Subsalicylate (BSS) (Pepto-Bismol)

Loperamide (Imodium A-D)

• mild-mod in pts ≥ 6 years old afebrile, no blood or mucus

• adults (≥12)

  • 4 mg (2 tabs) → 2 mg (1 cap) after each stool

  • max: 8mg/day

• ADR

  • dizziness, constipation

• caution

  • heart warning

Bismuth Subsalicylate (BSS) (Pepto-Bismol)

• mild-mod acute in pts ≥ 12 years old afebrile, no blood, mucus

• tabs: 525 mg q30 - 60 mins PRN

• liquid: 15 - 30 mL q30 - 60 mins PRN

• max: 4200 mg/day

• do not use more than 48 hrs

• ADRs

  • black/tarry stools

  • discoloration tongue

  • tinnitus

• caution

  • do not use in aspirin allergy

  • Reyes Syndrome (do not give to viral infected pts)

  • caution in anticougulant

• separate admin by 2 hrs if taking antibiotics

Otic disorders: referral

• less than 12 years old (cerumen)

• sx of infections

• pain w/ ear discharge

• bleeding/trauma

• typanostomy tubes

• ruptured tympanic membrane

• ear surgery past 6 weeks

• hypersensitivity

• worsen/persist after 4 days of SC

impacted cerumen medication

• Carbamide Peroxide

  • 5 - 10 drops 2x day each ear

  • max 4 days

  • head tilted for 5 mins

water clogged ears medication

• isopropyl alcohol + anhydrous glycerin

  • 4 - 5 drops in each ear

  • remain 1 - 2 mins

  • max: 4 days

Lice: exclusions

• less than 2 months (permethrins Nix)

• less than 2 years (pyrethrins Rid)

• allergies

  • chrysanthemums, pyrethrins

  • ragweed

• conditons

  • secondary infections

  • eyebrow/lid infestations

  • pregnancy/lactating

  • tumors

  • resistance to pediculicides

products for lice

• RID (Synergized pyrethrins)

• NIX (Permethrin 1%)

RID (Pyrethrins)

• active ingredient

• indications

• applications/use

• counseling

• ADRs

• active ingredient

  • pyrethrins + piperonyl butoxide

• indications

  • head, pubic lice

• applications/use

  • apply, leave on for 10 mins

  • rinse hair

  • nit comb

  • repeat 7 - 10 days required

• counseling

  • mandatory repeat treatment

  • nit combing

  • irritation/sx persist after 2nd treatment

• ADRs

  • minimal, mild skin irritation

NIX (Permethrin 1%)

• active ingredient

• indication

• application/use

• counseling

• ADRs

• active ingredient

  • permethrin

• indication

  • head lice

• application/use

  • shampoo, rinse, dry

  • apply, leave on 10 mins

  • rinse

  • nit comb

  • NO REPEAT needed unless live observed 7 - 10 days

• counseling

  • repeat not needed

  • nit comb

  • med attention if irritation/sx persist

• ADRs

  • minimal, mild skin irritation

DSHEA regulation

• dietary supplement health and education act

  • primairy regulatory framework for DS

  • excluded from strict purity and potency standards

  • manufacturer responsible for safety and efficacy

  • no pre-market clinical trials required

  • manufacturers must notify FDA 75 days before marketing new dietary ingredient (NDI)

labeling requirements

• ID statement: DS

• net quantity of contents

• supplement facts panel: nutrients, servings, % daily value

• ingredients list

• manufacturer/distributor info

• directions of use

• botanical products → plant’s scientific name, part used

• labeling claims

  • structure function permitted

  • disclaimer: “not evaluated by FDA. not intended to diagnose, treat, cure, prevent disease

  • health, nutrients content claim → allowed but need FDA approval

adulteration

• composition and safety of product

• presents risk of illness/injury

• imminent hazard

• poisonous ingredients

misbranding

• manufacturer fails to follow required labeling

insomnia: exclusions

• less than 12 years old or over 65 years old

• pregnant/breastfeeding

• frequent nocturnal awakening or early morning awakenings

• chronic sx ≥ 3x/week for at least 3 months

• secondary causes

insomnia: supplements

melatonin → max use 10 days

valerian, chamomile → no benefit

insomnia medication

• antihistamines (Diphenhydramine)

  • for transient, short term insomnia

  • max use 7 - 10 consecutive nights

  • 50 mg diphen HCl; 76 mg diphen citrate

antihistamines

• ADE

• DDIs

• CI

• counseling

• ADE

  • anti-SLUD

  • CNS effects

  • paradoxical excitation - children, elderly, hx mental disorders

  • toxicity - coma, seizures

• DDIs

  • alcohol + CNS depressants

  • CYP2D6 (Metoprolol)

• CI

  • BPH

  • angle closure glaucoma

  • CVD

  • dementia

• counseling

  • avoid alcohol

  • caution in activities

  • hangover effect

  • avoid other AHs

insomnia: recommendations, management

• sleep hygiene

• diphenhydramine 2 - 3 nights if needed

• reassess

• sx resolved → d/c med, continue sleep hygiene

• sx persist → cont diphenhydramine max 7 -10 days before referral

constipation: exclusions

• less than 2 years old

• abdominal pain, distention, cramping

• flatuence

• n/v/d

• anorexia/weight loss

• bloody, dark, tarry

• sx last more than 2 weeks

• sx recur over period of ≥ 3 months

• sx reoccur ≥ 7 days of SC

• daily use of non-rx laxative

• paraplegia/quadriplefia, IBD, colonstomy

fastest onset of action laxatives

• saline (rectal) = 2 - 15 mins

• glycerin suppositories (rectal) = 15 - 30 mins

• stimulant (rectal) = 15 - 60 mins

intermediate onset of action laxatives

• saline (oral) = 0.5 - 6 hrs

• stimulant (oral) = 6 - 10 hrs

slowest onset of action laxatives

• bulk forming = 12 - 72 hrs

• hyperosmotic (PEG 3350) = 12 - 96 hrs

• emollient (stool softeners) = 12 - 72 hrs

bulk forming laxatives

• products

• onset of action

• MOA

• ADR

• counseling

• products

  • Psyllium

  • methylcellulose

  • Polycarbophil

• onset of action

  • slowest (12 - 72 hrs)

• MOA

  • mimics insoluble dietary fiber

• ADR

  • cramping

  • bloating

  • flatuence

• counseling

  • DOC

  • mix/take dose w/ 8oz water

  • separate other meds by at least 2 hrs

hyperosmotic laxatives

• products

• onset of action

• MOA

• ADR

• counseling

• products

  • PEG 3350

• onset of action

  • slowest (12 - 96 hrs)

• MOA

  • draw water into colon via osmosis

  • soften stool

  • increase bowel movements

• ADR

  • bloating

  • abdominal pain

• counseling

  • dissolve 17 g in 4 - 8 oz beverage

  • do not use more than 7 days

emollient laxatives (stool softeners)

• products

• onset of action

• MOA

• counseling

• products

  • Docusate

• onset of action

  • slowest (12 - 72 hrs)

• MOA

  • increase wetting of fecal mass; all mush no push

• counseling

  • take w/ full glass of water

  • do not take with mineral oil

  • recommended for pts on opioids or postpartum

glycerin suppositories

• onset of action

• MOA

• ADR

• counseling

• onset of action

  • fastest (15 - 30 mins)

• MOA

  • local irritant in rectum

  • draws water out of rectum

• ADR

  • minor rectal irritation

• counseling

  • avoid in pts w/ rectal inflammation/ulceration

saline laxatives

• products

• onset of action

• MOA

• ADR

• counseling

• products

  • Mg Hydroxide

  • Mg citrate

• onset of action

  • fastest (rectal) = 2 - 15 mins

  • intermediate (oral) = 0.5 - 6hrs

• MOA

  • non-absorbable ions draw out water into intestines thru osmosis

• ADR

  • cramping

  • dehydrating

  • n/v

  • electrolyte imbalance

• counseling

  • take with 8 oz water

  • take on empty stomach

which saline laxative product is for occasional constipation? acute blowel evacuation?

• mg hydroxide (milk of magnesia) = occasional constipation

• mg citrate, na phosphate = acute bowel evacuation

stimulant laxatives

• products

• onset of action

• MOA

• ADR

• counseling

• products

  • Senna

  • Bisacodyl

• onset of action

  • fastest (rectal) = 15 - 60 mins

  • intermediate (oral) = 6 - 10 hrs

• MOA

  • stimulate colonic myenteric plexus

  • irritate GI lumen

• ADR

  • cramping

  • nausea

• counseling

  • in combo with stool softener for opioid-induced constipation

which stimulant laxative product causes pink/red/orange urine?

Senna

counseling for Bisacodyl

• do not chew/crush tabs

• do not take within 1 hr of antacids, H2RAs, PPIs, milk

Atopic dermatitis: exclusions

• involvement of large area of body, face, or intertriginous areas

• less than 1 year old

• skin infection

atopic dermatitis: non-pharm

• identify/eliminate triggers

• Humidifiers 

• Avoid sudden changes in temp and humidity 

• Short, clean nails

• Cotton sheets and clothing 

• Bathing in lukewarm, hypoallergenic/fragrance free soaps 

• Emollients for moisturizing 

• Diluted bleach bath (BID, recurrent skin infections)

• Wet wrapping

atopic dermatitis: pharm

• Corticosteroids 

  • Anti-inflammatory 

  • Hydrocortisone cream = DOC 

  • Ointment = thickened, dry, scaly skin 

  • BID 

  • Safe for > 2 years old 

  • Risk of tachyphylaxis → use 1x or 2x weekly

  • Avoid when lesions weeping, skin infected cracked, opened, refractory cases

• Antihistamines 

  • Relieve pruritus

  • Topical diphenhydramine often used (not oral)

  • Cooling effect

  • Potential risk of contact dermatitis

T or F: hydrocortisone cream is okay to use for lesions weeping, skin infected, cracked, opened?

F → use ointment version instead of cream

contact dermatitis: exclusions

• < 2 years old 

• Present for > 1 week; chronic 

• > 10% BSA effected (ICD); > 20% BSA effected (ACD)

• Itching, many large vesicle/bullae formation, edema 

• Genitalia, mouth, eyes, nose, anus, face, scalp, neck involvement 

• Secondary infection 

• Failure of self care after 7 days 

• Impairments of ADLs

contact dermatitis: non-pharm

• Wash w/ mild soap

• Clip fingernails 

• Avoid scrubbing or harsh cleaners 

• Wash contaminated clothing 

• Shower (cold or tepid temps)

• Avoid bathing

contact dermatitis: pharm

• bentoquatam

• tecnu

• zanfel

• astringents

• skin protectants

• corticostertoid

Bentoquatam

• use

• application

• counseling

• recommendation

• use

  • prevention

• application

  • apply to clean, dry skin 15 mins before exposure

  • cover exposed areas

  • reapply every 4 hrs

  • wash with soap

• counseling

  • do not apply to open wounds/irritated skin

  • practice good hygiene

• recommendation

  • those entering areas w/ poison ivy, oak, sumac

Tecnu

• use

• application

• counseling

• use

  • prevent rash immediately after exposure

• application

  • apply to exposed skin

  • rub vigorously for 2 mins

  • rinse w/ water or wipe

• counseling

  • most effective used within mins - hrs of exposure

  • effective for 8 hrs

  • reapply PRN

Zanfel

• use

• application

• counseling

• use

  • aim to remove/inactivate urushiol

  • treats rash after appearing, rapid relief

• application

  • wet area

  • dispense product to hands

  • rub + apply + rub for 3 mins

  • rinse

  • repeat if needed

• counseling

  • relief within 30 secs of washing

  • not preventative

astringents

• use

• products

• use

  • barrier, cooling, itch relief

• products

  • Aluminum acetate

  • witch hazel

skin protectants

• use

• products

• use

  • block irritants

  • lock in moisture

  • apply PRN to affected area

• products

  • oatmeal

  • zinc oxide

  • titanium dioxide

  • calamine

corticosteroid

• use

• product

• counseling

• use

  • temporary relief of pruritus, skin irritation, inflammation, rash

  • BID for up to 7 days

• product

  • hydrocortisone 0.5 - 1%

• counseling

  • thin layer

  • do not use more than 7 days

  • avoid long term use

  • wash hands before/after application

pinworm

• medication

• dose

• medication

  • pyrantel pamoate

• dose

  • 11 mg/kg (base) x 1 single oral dose

  • max: 1 g

• may repeat in 2 weeks if sx persist

oral care: exclusions (canker, cold sores)

• lesions present ≥ 14 days, recurring, worsening

• systemic infection

• immunocompromised

• failure of SC after 7 days

fluoride

• use

• types

• use

  • resistance to enamel demineralization

  • remineralization of lesions of enamel

  • interferes w/ bacterial cariogenic process and w/ plaque adherence

• types

  • sodium fluoride

  • sodium monofluorophosphate

  • stannous fluoride

cold sores (HSL): non-pharm

• Wash lesions gently with mild soap and water

• avoid triggers (wear lip sunscreen/SPF)

• wash hands frequently to avoid spreading or autoinoculation

• avoid kissing or sharing utensils/towels while active

cold sores (HSL): pharm

• topical skin protectants

  • 3 - 4x day

  • protection, relieve dryness

• topical oral anesthetics

  • “-caines”, dyclonine, camphor, menthol

  • relief

• Docusanol 10%

  • reduce duration + severity

  • apply at 1st sign, 5x day, up to 10 days

cancer sores: non-pharm

• goog hygiene

• increase nutrients

• avoid spicy foods, sharp foods

• apply ice 10 mins increments

• salt rinse or baking soda paste

cancer sores

• pharm

• counseling

• pharm

  • hydrogen peroxide 1.5%

  • carbamide peroxide 10%

  • topical anesthetics, protectants

  • NSAIDs, APAP

• counseling

  • 3 - 4x day no more than 7 days

  • chronic use → tissue irritation, decalcification

xerostomia (dry mouth): exclusions

• Tooth erosion 

• Candidiasis, gingivitis, periodontitis 

• Reduced denture wearing time 

• Mouth soreness 

• Severe tooth pain 

• fever/swelling 

• Loose teeth, bleeding gums, broken teeth

• Sjogren 

• Salivary gland stones 

• Symptoms severity does not decrease

xerostomia (dry mouth): non-pharm

• Avoid cigs and tobacoos 

• Do not use alcohol containing products 

• Avoid caffeine and hot/spicy foods 

• Limit consumption of sugary, starchy, acidic foods 

• Chew gum w. Xylitol to increase flow of saliva and drink water 

• Use cool list humidifier to moisten air

xerostomia (dry mouth): pharm

• Artificial saliva products w/ fluoride 

  • Relieve discomfort 

  • Mimic natural saliva 

  • Does not stimulate salivary glands 

  • Can be used on PRN

NV: exclusions (children)

• Signs of severe dehydration are present

• The caregiver is unable to manage the children’s N/V

• N/V + 1 of these (summarized):

  • stiff neck

  • < 6 months of age or weight < 17.6 lb

  • Lack of urination in the past 8-12 hours

  • <1 month of age with three large diarrhea stools

  • < 12 weeks of age with fever

  • < 1 year of age with eight diarrhea stools in last 8 hours

  • Severe headache > 2 hours

NV: exclusions (adults - summarized)

• Dehydration

• blood in vomit

• abdominal pain

• stiff neck

NV (motion sickness): product recommendation

• 1st gen AH

  • Dimenhydrinate (Dramamine)

    • 50 - 100 mg every 4 - 6hrs

    • max: 400 mg/day

    • take 30 - 60 min before exposure

  • Diphenhydramine (Benadryl)

    • 25 - 50 mg every 4 - 6 hrs

    • max: 300 mg/day

    • take 30 mins before exposure

  • Meclizine (Bonine)

    • 25 - 50 mg

    • max: 50 mg/day

    • take 1 hr before activity

NV: non-pharm general

• ORS

  • restore electrolytes

  • take 10 mins after last episode of vomiting

  • avoid other fluids before or after ORS

• general

  • eat small meals every 1 - 2hrs

  • avoid hot/humid environments

  • sips of carbonated drinks or fruit juices

  • minimize exposure to strong smells, loud noises, bright lights

  • good ventilation

NV: non-pharm motion sickness

• Sit where motion is lowest (or drive)

• look straight ahead at the horizon

• avoid looking down

• Avoid excessive food, alcohol, and strong odors (food/tobacco) before and during travel