A model nursing care plan

Necrotizing fasciitis: a model nursing care plan

Carol Bashford

Necrotizing fasciitis (NF) is an infection that can occur following a minor injury or major surgery. An uncommon form of infection in the superficial fascia, NF has been called “the flesh eating disease” (Ruth-Sahd & Pirrung, 1997). Originally termed “hospital gangrene,” NF has become increasingly common in the United States since the late 1980s (Gonzalez, 1998). A diagnosis of NF should be understood by every nurse as a potentially life-threatening infection.

Necrotizing fasciitis has a long history. During the Civil War (United States), a confederate surgeon named Joseph Jones recorded incidents of hospital gangrene. Necrotizing fasciitis has also been called “acute infective gangrene,” “streptococcal toxic shock syndrome,” and “hemolytic streptococcal gangrene.” There are two types of NE Type I involves several bacteria occurring with facultative and anaerobic bacteria. Examples of bacteria cultured from patients are Escherichia coli, Serratia marcescens, Klebsiella pneumoniae, Eikenella corrodens, Saksenaea vasiformis, Neisseria meningitidis, and Haemophilus apnropilus. Type 2 is caused by group A Streptococci occurring independently or combined with Staphylococcus aureus or Staphylococcus epidermis (Gonzalez, 1998; Misago et al., 1996). Early recognition and treatment are imperative to help patients recover and have minimal permanent scars.

Epidemiology

Occurrence of NF is widespread. Healthy as well as immuno-compromised individuals have developed this tissue-destroying infection (Gonzales, 1998). Occurrence in healthy individuals is associated with a history of minor trauma. The incidence of occurrence in male or female gender is 50% (Misago et al., 1996). Necrotizing fasciitis has been documented in wounds on the upper and lower extremities, the abdomen, and the chest. It can be associated with a variety of etiologic factors ranging from minor injury, major trauma, or surgery. A review of the literature identified that NF occurred in minor lacerations, skin abscess, frostbite, open fracture, insect bite, steroid injection, and soft tissue contusion (Gonzalez, 1998; Ruth-Sahd & Pirrung, 1997), minor trauma (Misago et al., 1996), decubitus ulcer (Gavrankapetanovic & Gavrankapetanovic, 1998), idiopathic (Maynor, 1998), and post hysterectomy wound (Loscar et al., 1998).

Lifestyle and/or a compromised immune system increase the risk for developing NE Illicit drug injection places individuals at a significantly higher risk related to nonsterile injection techniques, licking reused needles, or street drug contamination (Gonzalez, 1998). Individuals with altered nutrition-metabolic and/or activity-exercise functional health patterns are also at increased risk. Numerous underlying conditions significantly increase the risk for the occurrence of NF following trauma or any break in the skin. These include: diabetes melitus, acquired immunodeficiency syndrome, major burns, chemotherapy-induced immunodeficiency, neutropenia, prolonged antibiotic therapy, alcoholism, peripheral vascular disease, discoid lupus, multiple myeloma, hypertension, recent perirectal abscess drainage, malnutrition (serum albumin less than 3 gm/dL), and porphyria cutanea tarda. Immunocom-promised individuals have greater mortality and morbidity with this infection (Gonzalez, 1998; Loscar et al., 1998; Misago et al., 1996).

Disease Management

Initially, NF presents similar to many local infections. The wound rapidly develops erythema, edema, and tenderness. The tenderness is usually greater than anticipated by the wound appearance. Nonpitting edema develops past the location of erythema. The presence of nonpitting edema beyond the area of erythema is a classic sign of NE differentiating it from other forms of cellulitis. As the infection continues, indurations develop and the edema may become extreme. Crepitance is usually not present, yet an x-ray of the area will usually reveal the presence of gas within the tissues (Gonzalez, 1998).

After several days, the skin develops a dusky blue coloring, bullae may form and the skin may become hyperesthetic or anesthetic. Fever and elevated white blood cell count may or may not be present. Heart rate will be faster than the patient’s normal. If fever is present, the heart rate will be greater than the 10 beats/degree elevation expected. As the disease progresses, skin necrosis develops and then sloughing of the skin occurs. Fat and fascial necroses occur simultaneously. Reduction of the pain and the presence of numbness can be an indication that the infection has destroyed subcutaneous nerves. The organism continues to spread into adjacent muscles causing immediate or delayed myonecrosis evidenced by an elevated creatinine phosphokinase level (CK) (Ruth-Sahd & Pirrung, 1997). If the wound is opened, the fascia appears gray or grayish green. The exudate is watery thin “dishwater pus” and of significant foul odor in the presence of anaerobic microorganisms (Gonzalez, 1998). Progression of the infection leads to obliterating vascular thromboses. This contributes to occlusion of nutrient vessels in the skin causing ischemic patches, and papular and bullea rashes (Gonzalez, 1998; Misago et al., 1996). Lab findings associated with NF include leukocyte count may or may not be elevated, elevated fibrinogen, FDP-E may or may not be elevated, serum albumin is low normal or decreased, elevated creatinine prosphokinase, and elevated c-reactive protein (Misago et al., 1996). The patient’s condition can rapidly deteriorate into hypoxia, altered level of consciousness, septic shock, disseminated intravascular coagulopathy (DIC), and multisystem organ failure.

Early identification, diagnosis, and aggressive treatment are imperative for the recovery of patients with NE Death and multisystem failure can occur within days of the onset of the infection. Some patients have presented as early as 4 days post injury in septic shock (Misago et al., 1996). The usual treatment is incision, drainage, and removal of all involved tissue, aerobic and anaerobic cultures, and intravenous antibiotics. Multiple debridement interventions are usually needed. Amputation may be needed to prevent the spread of a severe infection. Infection of the elbow or arm can rapidly spread to the shoulder and chest. Necrotizing fasciitis in the chest or abdomen has a 75% mortality rate. Infection in a digit or upper extremity can lead to metastatic abscesses in the major organs, septic shock, and DIC. The disease is known to metastasize to the liver, lungs, spleen, brain, and pericardium (Gonzalez, 1998). It is important for nurses to assess these patients frequently, directing the assessment to the involved tissues, adjacent tissues/organs, laboratory test results, and potential areas for metastasis.

Many wounds are initially treated on an outpatient basis in urgent care centers, clinics, emergency departments, or providers’ offices. In addition, an increasing number of surgeries are being done on an outpatient basis or with overnight observation. Thus, thorough assessment of every wound for early signs of infection is important. Nurses should educate every patient with a wound to immediately report any early sign of infection. Changes in the color of the wound or drainage, new edema, odor, new pain, or slightly larger wound are all noteworthy.

Patients experiencing NF potentially have numerous needs. Skills in assessment, clinical decision making, and critical thinking are the greatest assets for a nurse to promote the patient’s recovery. Systemic support of the patient and management of the wound are needed to promote healing and prevent complications. Collaboration with all members of the health care team is important. Patients should be hospitalized in a private room with contact isolation. A patent IV should be maintained, and the date of the last tetanus immunization should be determined. Treatment will include the administration of intravenous broad-spectrum antibiotics and pain management. Hospitalization, treatment routines, and medications may alter sleep/rest needs and bowel function. Nurses should plan for long, complex dressing changes.

Nursing Plan

The following is a suggested plan of care for situations where the priority is wound management. For the patients experiencing organ failure and/or compromised oxygenation, the priority is activity-exercise health pattern directing patient care to optimize oxygenation and to reduce oxygen needs. Individualizing the care plan promotes continuity and can save nursing time (see Case Study and Figure 1).

Nutrition-Metabolic Health Pattern

Skin Integrity, Impaired (refers to damage to the epidermis or dermis)

Risk for Fluid Volume Deficit or Fluid Vlume Excess

Tissue Integrity, Impaired

Nutrition: Less Than Body Requirements, Altered

Fluid Volume Imbalance, Risk for (Carpenito, 1999; Doenges, Moorhouse, & Geissler, 2000; McCloskey & Bulechek, 2000)

Weigh the patient with NF on admission and weekly. Monitor intake, output, and food intake. Lab values will help determine nutritional status, fluid balance, and progress of the infection. Common tests include WBC, creatinine phosphokinase, BUN, and creatinine since some antibiotics, especially aminoglycosides, can compromise renal function (Whitney & Heitkamper, 1999). Nurses should assess the wound(s) with each dressing change and immediately report any signs of progression of the infection such as increased drainage, odor, tissue erosion, or change in color or bleeding. Use a dedicated skin pencil (kept at the bedside and treated as contaminated upon patient discharge) to mark and date areas of redness and necrosis to help identify progression of the infection. It is important to use strict sterile technique, wear gloves, and wash your hands before and immediately after the dressing change (Ruth-Sahd & Pirrung, 1997).

Patients’ nutritional needs are typically double their usual caloric intake. Some patients may lose their appetite and not eat foods needed for wound healing. These include meat, fish, dairy products, beans, fruits, and vegetables. Assess the patient’s food likes, dislikes, and cultural needs. Nutritional consultation by a dietitian is in order. Changes in the meal plan and selection to meet the patient’s interest and needs will be helpful. Some patients may need enteral or parenteral feeding to meet their significantly increased nutritional needs (Whitney & Heitkemper, 1999). Fatigue and increased nutritional needs put the patient at risk for pressure sores. While in bed and in a chair, ensure that the patient is repositioned at least every 2 hours and monitor for Stage I pressure wounds. Stage I pressure wounds are defined as nonblanchable reddened skin (Kozier, Erb, Berman, & Burke, 2000).

Activity-Exercise Health Pattern

Tissue Perfusion, Altered: Peripheral and/or specific organ system

Self-Care Deficit Syndrome

Mobility, Impaired Physical

Diversional Activity Deficit

Home Maintenance Management, Impaired (Carpenito, 1999; Doenges et al., 2000; McCloskey & Bulechek, 2000)

Some patients may need oxygen for tissue perfusion and wound healing. Patients with extensive infection are treated with hyperbaric oxygen (HBO) therapy to enhance healing or if surgical debridement is contraindicated (Ruth-Sahd & Pirrung, 1997). Patients receiving HBO should be monitored for seizures, chest pain, and cough during HBO. Ambulation at least four times per day and performing activities of daily living will promote circulation, tissue perfusion, and prevent many complications associated with immobility. Assess Sa[O.sub.2] at least every 4 hours. Some patients with this infection may not have the energy or mobility to perform various activities of daily living. Self-care, meal preparation, and shopping for food are important to discuss when planning for discharge. Assess patients for signs of complications, such as altered level of consciousness, petechiae, bleeding, hypoxia, low urine output (output less than intake or hourly output less than 60 cc/hour), tachycardia, hypotension, abnormal breath sounds, altered cognition, and weak peripheral pulses.

Cognitive-Perceptual Health Pattern

Pain

Decisional Conflict

Knowledge Deficit (Carpenito, 1999; Doenges et al., 2000)

Discomfort should be assessed at least every 2 hours while awake. The pain management plan may need to be changed as the patient’s condition changes. Talk with the patient about individual methods of managing discomfort. Complimentary therapies for comfort can be employed. Education is an important factor in pain management. Many people are afraid to take pain medication; and for some it is culturally unacceptable to complain of pain or take pain medications.

A typical pain regimen may be morphine sulfate by patient-controlled analgesia including a PRN dose of morphine sulfate IV that can be given prior to painful dressing changes. Patients with lower extremity or abdominal infection may have their pain managed with an epidural infusion. In settings offering complimentary therapies, daily healing touch therapy is a part of the care plan. Nonpharmacologic interventions, such as imagery, music therapy, distraction, and cold therapies are helpful for some patients.

Self-Perception Health Pattern

Body Image Disturbance (Kozier et al., 2000)

Self-Esteem, Situational Low (McCloskey & Bulechek, 2000)

Some patients experience extreme anxiety and grief over the change in their body’s appearance. Many have life-altering disabilities. Trying to accept and cope with the knowledge that the infection is life threatening and the separation from family associated with hospitalization is difficult. The patient should be encouraged to express feelings. A referral to a psychiatric clinical nurse specialist or mental health professional should be considered.

Role-Relationship Health Pattern

Family Processes, Altered

Role Performance, Altered

Social Isolation (Capenito, 1999; Doenges et al., 2000; McCloskey & Bulechek, 2000)

Nurses should talk with patients about their concerns. Does she have children or adults depending on her? Does she usually check in or assist an aging parent? Is he concerned about a beloved pet at home? There are an increasing number of people who are self-employed. A serious illness such as NF can keep them out of work and without income for a long time and cause financial disaster. Involve the care coordinator, case manager, or social worker in your agency as appropriate early in the patient’s care.

Sleep-Rest Health Pattern

Sleep Pattern Disturbance (Capenito, 1999; McCloskey & Bulechek, 2000)

Hospital routines, anxiety, and trying to sleep in a strange environment and with an intravenous line are several things that can prevent patients from meeting their sleep-rest needs. Plan with the patient and others involved in care for long periods of uninterrupted sleep during the evening and night. Discourage long naps during the day.

Elimination Health Pattern

Constipation

Diarrhea

Risk for Infection (Capenito, 1999; Doenges et al., 2000; McCloskey & Bulechek, 2000)

Altered daily routines, change in food intake, reduced physical activity and medications can cause constipation or diarrhea. Prevention, assessment, and early recognition of problems are important. Monitor and document the client’s intake and output. Altered output or characteristics of the feces or urine may be early signs of a potential complication.

Spiritual-Belief Health Pattern

Spiritual Distress, Risk for (Capenito, 1999; McCloskey & Bulechek, 2000)

There may be a challenge to the patient’s beliefs due to the severity of the illness, altered body appearance and function, and situational barriers to practicing spiritual rituals. There also may be a conflict between the patient’s beliefs and the recommended treatments such as for blood transfusion, surgery, and dietary beliefs versus prescribed diet. Early assessment of spiritual needs, planning, and communication with the patient and family is important.

Health Perception-Health Management Health Pattern

Management of Therapeutic Regimen: Individual ineffective (Capenito, 1999; McCloskey & Bulechek, 2000)

Assess the patient’s understanding of wound care and other needs, especially when planning for wound care after discharge from the hospital. Evaluate the patient’s self-care abilities beginning at admission and ongoing to the day of discharge to determine the patient’s understanding and abilities to care for self after discharge. Patients must be able to care for their wound(s), administer intravenous antibiotics, prepare healthy meals, maintain cleanliness in the home, bathe and dress themselves, obtain needed medications and supplies, and ambulate safely to the bathroom, bedroom, and kitchen. What resources does the patient have for obtaining food, medication, and supplies? Some patients may need to spend the first 2 weeks or more after hospitalization at a progressive care center or with a family member. Today’s society has an increased number of single-parent families and both husband and wife employed outside the home. Thus, the patient may not be able to count on family members to help as needed.

Conclusion

Necrotic fasciitis changes the lives of every affected patient. Some patients have permanent physical and psychological sequelae. Nurses employed in all areas of practice can use their skills in assessment, analysis of the assessment information, critical thinking, decision making, and communication to quickly identify and treat patients as they recover from this life-threatening disease. These patients have complex care needs and are at risk for rapidly developing serious, life-threatening complications. Timely and focused ongoing assessment of the patient is needed to identify signs of NF and complications. With changing patient care delivery models, nurses need to use all their critical thinking and cognitive skills in addition to hands-on skills to help these patients meet their needs as well as all the patients on their assigned caseload.

Figure 1.

Nutrition-Metabolic Health Pattern

Wound Management Nutrition Self Perception-Self

Concept

Assessment Data Assessment Data Assessment Data

Sam’s incision was Sam’s appetite was In addition to Sam

pink and well poor during her and her mother

approximated; serous hospitalization and watching the nurse

drainage saturated after returning home. closely, questioning

one 2 x 2 gauze; no Her mother reported every action and the

odor; tenderness to that Sam needs to be hospital experience,

light touch, reminded to eat, the nurse learned

periwound edema, and barely eats one full that Sam did not want

erythema were meal a day, never to go to work,

present. No excessive snacks, and has shopping, church, or

heat was noted, and minimal energy, school fearing that

she had full range of preferring to rest in someone would see her

motion of all four the recliner most of hand. Sam stated that

digits and hand with day watching TV or she felt like a half

minimal discomfort. reading. Sam stated person. She stated

The discomfort was that food doesn’t that she can’t drive,

controlled by PRN taste good and she cut food, or button

ibupropin 2 to 3 doesn’t feel like her clothes because

times a day and eating. During her of the amputated

sometimes one hospitalization Sam finger. She also

Percocet[R] a day. lost 10 pounds. Lab stated that she was

White blood cell values: BUN 5, total unable to type

count on the day of protein 4.6 g/dl, and reports as quickly as

discharge was 11.1 albumin 2.1 g/dl. prior to the

down from 28.2. amputation, and that

when typing a report

for school, she

became angry at all

the mistakes and how

slow she is now. Sam

stated that she fears

failure in school,

loss of job, and loss

of her desired

career. Sam’s mother

stated that Sam used

to play tennis, jog,

and do aerobics with

friends. But now Sam

refuses to see

friends or leave the

house except for

visits to the

doctor’s office.

Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis

Skin integrity Nutrition: Less than Self-esteem,

impaired R/T body requirements, situational low, R/T

infection and altered, R/T high severe illness, and

amputation of digit metabolic needs and perceived threat to

AEB disarticulation loss of appetite AEB self-concept AEB

amputation of left weight loss of 10 Sam’s illness

index finger, pounds, low albumin, experience, fear

destruction of protein and BUN, behavior, loss of

dermis, wound reported lack of digit, avoiding

tenderness, edema and interest in food and friends, stated fear

erythema. intake less than of loss of job, and

recommended. inability to earn

MBA.

NOC Suggested Outcome NOC Suggested Outcome NOC Suggested Outcome

Demonstrates wound Sam demonstrates Sam expresses

healing: Primary nutritional status: positive

intention, as Food, fluid and self-appraisal,

evidenced by skin nutrient intake as begins to talk with

approximation, evidenced by adequate friends regularly,

resolution of edema, oral intake, and contacts employer

redness, drainage and describes components and school for

white blood cell of nutritionally information about

count within normal adequate diet, returning.

limits. reports adequate

energy levels and

laboratory values are

within normal limits.

NIC Priority NIC Priority NIC Priority

Interventions Interventions Interventions

Incision site care: Collaborate with Sam Assess the degree/

Assess wound and and her mother to severity of perceived

document develop a nutrition threat to her

characteristics of plan to promote self-concept and

wound and periwound wellness. Acknowledge identify coping

tissue with each the values, skills Sam has used.

dressing change interests, and Incorporate normal

developmental phases developmental tasks

Teach Sam signs and of Sam and most young for early adulthood

symptoms to report, adults. Sam and her and teach Sam methods

dressing change mother were given to help her cope with

procedure, method to information on the the change in her

keep wound dry during nutrients and foods appearance and

bath, no lifting or that Sam needed to functionality.

excessive flexion or eat to promote

extension of digits recovery. Food lists Sam’s mother and the

to minimize stress on and sample meal plans nurse regularly

incision, keep were provided to help encouraged Sam to

dressing clean and Sam understand the talk about her

dry at all times. types of food and feelings of the loss

Sam’s dog wanted to amount needed daily. of her finger, her

play with the fluffy Sam was encouraged to appearance, and the

dressing. The weigh herself weekly skills needed for her

dressing resembled and keep a nutrition career goals. Soon

the dog’s favorite diary documenting Sam was able to

ball, so tan-colored food/fluid intake, identify her

Coban was applied to energy level, and strengths, abilities,

anchor and color the activities. She was and control in the

dressing. scheduled for repeat situation. By

lab tests in 2 weeks. contacting her

When friends started employer, Sam learned

visiting Sam’s mother that the Employee

(and eventually Sam) Assistance Program

would set out (EAP) provides

nutritious food which counseling for life

Sam could snack on changes and

without needing to vocational education

use her injured hand. to help her adapt her

typing skills for the

nine fingers. Sam

also contacted the

student services and

disability services

coordinators at the

university for

guidance and

resources for her

recovery and for

educational plans.

Sam was encouraged to

talk with her

friends. Soon Sam met

with her friends at

home and in public

places.

References

Capenito, L.J. (1999). Handbook of nursing diagnosis (8th ed.). Philadelphia: Lippincott Williams and Wilkins.

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C. (2000). Nursing care plans: Guidelines for individualizing patient care (5th ed.). Philadelphia: F.A. Davis Company.

Gavrankapetanovic, I., & Gavrankapetanovic, F. (1998). Necrotizing fasciitis and decubitus ulcers in the ischial area. Medical Archives, 54(2), 113-114.

Gonzalez, M. (1998). Necrotizing fasciitis and gangrene of the upper extremity. Hand Clinics, 14(4), 635-645.

Kozier, B., Erb, G., Berman, A., & Burke, D. (2000). Fundamentals of nursing: Concepts, process and practice (6th ed.). Upper Saddle River, NJ: Prentice Hall.

Loscar, M., Schelling, G., Haller, M., Polasek, J., Stoll, C., Kreimeier, U., Finsterer, U., Steitz, H.O., Baumeister, R., Kimmig, R., Grabein, B., & Briegel, J. (1998). Group A Streptococcal toxic shock syndrome with severe necrotizing fasciitis following hysterectomy — a case report. Intensive Care Medicine, 24(2), 190-193.

Maynor, M. (1998). Necrotizing fasciitis. [Online]. Retrieved April 24, 1999 from http//:www.emedicine.come/emerg.topi c332.htm.

McCloskey, J.C., & Bulechek, G.M. (Eds.) (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis, MO: Mosby, Inc.

Misago, N., Yutaka, N., Seiji, R., Yumiko, G., Tatsuron, T., Maiko, Y., & Hiroma, K. (1996). Necrotizing fasciitis due to group A Streptococci: A clinicopathological study of six patients. The Journal of Dermatology, 23, 876- 882.

Ruth-Sahd, L., & Pirrung, P. (1997). The infection that eats people alive. RN, 60(3), 28-35.

Whitney, J., & Heitkemper, M. (1999). Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds. Heart & Lung, 28(2), 123-133.

Case Study: Not Just Any Hand Wound

Samantha (Sam) is 29-years-old, employed full-time as an administrative associate for a national finance firm and a full-time student at a local university pursuing a Master’s Degree in Business Administration. Sam got a small splinter in the index finger of her left hand while helping her parents clean out their garage. She assumed the splinter would work its way out of her finger and so ignored it. But a day later she noted redness, edema, and tenderness from the end of the finger up to the first joint. She made an appointment to see her family physician. The next day her entire finger was swollen, with the tip becoming a dusky blue color. As soon as her physician saw the grossly swollen, red and blue finger, the physician made arrangements for her to be seen immediately in the emergency room by a hand specialist. Diagnosed with necrotic fasciitis, Sam’s finger was amputated by disarticulation from the hand (metatarsal) immediately in order to stop infection from progressing into her hand. Following surgery, Sam and her family thought that she was healing, so she went home on IV antibiotics. Once home, the wound began to drain. Two additional surgeries on the hand were needed to remove infected tissue and stop progression of the infection. The infection entered the bloodstream and the lungs. Sam was in the ICU for a week and had six hyperbaric treatments.

The home health nurse was sent to Sam’s home with instructions to monitor the intravenous administration of gentamicin sulfate and change the dressing on Sam’s left hand. The home care nurse checked the intravenous piggy-back and was preparing to change the dressing on Sam’s left hand. The nurse noticed that Sam and her mother appeared anxious. They watched the nurse closely and questioned almost every action. Sam reported that at this time she is unable to return work or school. She expressed fear that she may not be able to use the computer competently enough to keep her job and earn the MBA. In talking with Sam and her mother, the nurse realized that this was a classic example of the life-threatening nature of the cellulitis, necrotizing fasciitis.

Carol Bashford, MS, RN, CS, is Assistant Professor of Nursing, Miami University, Hamilton, OH.

Tao Yin, PhD, RN, is Assistant Professor of Nursing, Miami University, Hamilton, OH.

John Pack, MSN, RN,C, is Director, Nursing Resource Center, Miami University, Hamilton, OH.

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