Wednesday, October 19, 2011

Scared of Rashes

So many times, I hear nurses say they hate rash calls. It is because they are afraid of what they cannot see, and I find myself saying, "Let your ears be your eyes".
When you receive a rash call, the first thing you must do is assess if there are associated signs with it. This helps you decide which protocol to use. One of the first questions I ask with a rash is, "Is there a fever?". The questions that follow should determine if the patient is on any medications, presence of itching, and/or has had any new exposures. Common new exposures that cause rashes are new unlaundered clothes; new soaps and laundry detergents; new beauty supplies, including lotions and sunscreen; new pets; new hobbies; and outdoor plant contact. Inflammation should be assessed by asking if the rash is tender to touch.
The location of the rash is easy to determine. Locations are either described as focal, patchy, or diffuse. A focal rash is specific to a specific body part. If the rash is only on a specific body part, it is still considered focal (eg, the hands, cheeks, or lower extremities). A patchy rash is considered on more than one body part but not on all body parts. For example, the rash could be all on exposed body parts only, or only on covered body parts. A diffuse rash covers multiple body parts, usually the entire body.
If a rash cannot be felt, or is not raised, it is said to be macular or consist of macules. If a rash can be felt and is raised, then it is papular or consists of papules. A lesion that contains clear fluid is a vesicle, and a rash that contains cloudy fluid or purulent material is a pustule. Some rashes can be macular and papular, with some areas being palpable and others not.
Describing the color is simple. Just ask the caller the color of the rash. If the do not volunteer an answer, give them the choice of skin colored, pink, red, purple, hypo- or hyper-pigmented.
One of the most important characteristics of a rash that is also the hardest to determine over the phone, and is so important to determine, is if the rash is blanching or non-blanching. If it is non-blanching, it could indicate the presence of blood outside of the blood vessels as occurs with petechiae or purpura. One method to determine this is have the caller apply pressure to the rash with a finger and then quickly remove the finger and look and see if the color changes. The caller needs to be told to look quickly if the rash loses its color then changes back.
The shape of the rash can be described as annular (circular), linear, or irregular. If a rash is confluent, then it covers the entire region without large areas of normal skin. If it is patchy, then areas of normal skin are interspersed with rash areas. A rash with central clearing has normal skin encircled with a rash.
The last characteristic is the appearance of the rash as dry, wet (weeping), scaly or crusted.
It can be overwhelming to attempt to decide which rash protocol to use. You have to consider what other factors are present, not just the rash. Is there a fever? Presence of fever can indicate many childhood illnesses such has Chicken Pox or Hand, Foot and Mouth Disease, but it could also be something indicative of a more serious illness such as Meningitis can also sometimes have the presence of rash.
What is the location of the rash? If it is widespread, is the patient on any new medications, especially antibiotics? If it is a child, have they been exposed to viruses? If it is a localized rash, and all else fails, ask the caller if they have any idea where the rash came from. Of course, you cannot just assume that is the cause without ruling out other possibilities, but often, the caller may know.
Rashes should not scare the triage nurse. They are challenging that is for sure, but keep in mind, it is not the rash that is often the most troubling, but other symptoms that the patient may have will often lead you to determining the protocol to use.