Necrotizing Fasciitis

Necrotizing Fasciitis Nursing Care Plans Diagnosis and Interventions

Necrotizing Fasciitis NCLEX Review Care Plans

Nursing Study Guide for Necrotizing Fasciitis

Necrotizing Fasciitis is a severe, rapid, and progressive form of inflammation and infection affecting not only the skin, but also deeper down to the subcutaneous, the fascia and muscle.

The condition is rare and is often lethal if not treated effectively. Hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fasciitis, and synergistic necrotizing fasciitis are some of the other names of necrotizing fasciitis.

Necrotizing fasciitis may occur through a variety of complications brought about by surgical or medical conditions.

Its cause may also be unknown and sudden, such as in the case scrotal necrotizing fasciitis.

Signs and Symptoms of Necrotizing Fasciitis

  1. Fever – may appear within 24 hours
  2. Pain and inflammation – as the disease progresses, increasing pain may be felt from the area of onset. The pain may feel worse than expected in relation to the size of the wound.
  3. Redness and warmth around the wound extend beyond the original location
  4. Flu-like symptoms – including diarrhea, nausea, fever, dizziness, and body malaise
  5. More advanced manifestations usually appear after 3-4 days such as:
  6. Presence of purple rash
  7. Large violet blisters, oftentimes filled with foul smelling discharge
  8. Discoloration, peeling, and flakiness – represent the development of gangrene (tissue death)
  9. After 4-5 days, late symptoms may appear:
  10. Hypotension -severe drop in blood pressure
  11. Unconsciousness
  12. Septic shock

Causes and Risk Factors of Necrotizing Fasciitis

The causative agent is often bacterial in origin. It may be aerobic, anaerobic, or mixed.

However, 3 types should be noted as well that hold significant clinical impact and they are:

  1. Type I or multimicrobial (polymicrobial)
  2. Type II or group A streptococcal
  3. Type III gas gangrene (clostridial myonecrosis)

Among these types, Type II is the most common cause of necrotizing fasciitis. Opportunities for its development may come from a variety of ways:

  • Surgical wounds
  • Puncture wounds
  • Burns
  • Minor cuts
  • Insect bites
  • Abrasions

Necrotizing fasciitis may also start idiopathically, without unknown point of origin. Other predisposing factors that may result to its development are certain conditions and lifestyle choices such as:

  • Alcohol abuse
  • Cancer
  • Chicken pox in childhood
  • Liver dysfunction (Cirrhosis, scarring of the liver)
  • Diabetes Mellitus
  • Cardiovascular disease
  • Chronic renal dysfunction/disease
  • Pulmonary disease
  • IV drugs usage (steroids, other meds, substance abuse)

Complications of Necrotizing Fasciitis

If left untreated, necrotizing fasciitis can lead to serious disability, irreversible complications and death.

  1. Sepsis – generalized infection causing systemic changes to the body
  2. Shock – oftentimes septic in origin, with associated cardiovascular compromise and collapse
  3. Organ failure – primarily renal failure
  4. Loss of limb – due to sever tissue damage, amputation may be necessary to avoid further compromise to the patient’s health
  5. Severe scarring – Due to the extensive damage to skin, fat layers, fascia, and muscles
  6. Toxic Shock Syndrome – a toxin-initiated acute and life-threatening condition caused by either streptococcal or staphylococcal species,
  7. Death

Diagnosis of Necrotizing Fasciitis

  • Laboratory Studies
  • Complete blood count – to check for elevated white blood cell counts
  • Serum chemistry studies – due to muscle injuries, electrolytes will be elevated as by-products of destroyed tissue
  • Arterial blood gas testing – to assess for systemic effects of toxins produced by causative agent
  • Urinalysis – to assess baseline data for renal function
  • Blood and tissue culture and gram staining – to detect the causative agent of necrotizing fasciitis and to direct the choice of antibiotic for treatment
  • Imaging studies
  • Ultrasound – to assess for presence of gas in the soft tissues, a clear sign of necrotizing fasciitis
  • CT scan and/or MRI – utilized to assess extent of injury and damage to surrounding structures
  • Finger test – involves sterile technique and the direct palpation of the deep fascia. Absence of bleeding and separation of tissues with minimum resistance is a positive Finger test for necrotizing fasciitis.
  • Biopsy – tissues are sampled for direct microscopic visualization of the presence of the following:
  • Dense infiltration of neutrophils in the fascia and fat layer
  • Necrosis of the fat layer is evident
  • Presence of clusters of bacteria or fungi is visualized when a specialized stain is used for the tissue sample.

Treatment of Necrotizing Fasciitis

  1. Surgical Management – Necrotizing fasciitis is a surgical emergency; hence, surgical management is the top choice for treatment
  2. Surgical debridement – involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and complete removal of dead tissue even beyond the area of necrosis.
  3. Double gloving – this is performed to prevent exposure of staff, rendering wound care, to serious blood infections that may be present in the necrotic tissues.
  4. Dressings – after each debridement, dressings containing silver compounds are helpful in addressing topical and direct antibiotic treatment of the affected tissues.
  5. Soft tissue reconstructions may also be done (e.g. skin grafting), once the patient is clinically stable
  6. Medical management – involves the use of antibiotics and other supportive medications
  7. Antibiotics – used complimentary with surgical management to facilitate complete treatment of Necrotizing fasciitis. Antibiotic of choice could be penicillins, lincosamides, nitroimidazoles, aminoglycosides, carbapenems, or glycopeptides, depending on the causative agent.
  8. Intravenous hydration – utilized to address hypotension and diffused leakage in the capillaries
  9. Nutritional support – either parenteral or enteric to help the patient heal better to the large wounds caused by the condition
  10. Intravenous Immunoglobulin – especially effective to address the toxins released by invading streptococcal organisms
  11. Hyperbaric Oxygen therapy – maybe used for the following reasons:
  12. It is toxic to anaerobic organisms
  13. It improves elimination of bacteria in the wound
  14. It improves better absorption of antibiotics such as aminoglycosides, cephalosporins, etc.

Nursing Care Plans for Necrotizing Fasciitis

Nursing Care Plan 1

Nursing Diagnosis: Infection related to Necrotizing fasciitis as evidenced by positive  tissue biopsy result, temperature of 38.5 degrees Celsius, erythema and pain on the affected site, flu-like symptoms, myalgia, and fatigue

Desired Outcome: The patient will be able to avoid the spread of infection in his/her body as well as the contamination to other people.

InterventionsRationales
Assess vital signs and monitor the signs of infection.To establish baseline observations and check the progress of the infection as the patient receives medical treatment.
Prepare the patient for surgical debridement.It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and complete removal of dead tissue even beyond the area of necrosis.
Ensure that the staff performs double gloving before doing any wound care procedure.This is performed to prevent exposure of staff, rendering wound care, to serious blood infections that may be present in the necrotic tissues.
Place silver-containing dressings on the affected site/s after each debridement,Dressings containing silver compounds are helpful in addressing topical and direct antibiotic treatment of the affected tissues.  
Administer the prescribed antibiotics. To treat the underlying bacterial cause of necrotizing fasciitis.
Inform the patient or caregiver that there is no need to avoid direct social contact. Necrotizing fasciitis is not contagious and is rarely transmissible.  

Nursing Care Plan 2

 Nursing Diagnosis: Hyperthermia related to infective process secondary to necrotizing fasciitis as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

InterventionsRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
Remove excessive clothing, blankets and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotics and anti-pyretic medications.Use the antibiotics to eradicate the bacteria that caused necrotizing fasciitis. Use the anti-pyretic medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 3

Nursing Diagnosis: Fatigue related to body weakness secondary to necrotizing fasciitis as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, lack of appetite, and shortness of breath upon exertion

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionsRationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to dietitian and physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity and improving nutritional intake / appetite.

Other possible nursing diagnoses:

  • Acute Pain
  • Ineffective Tissue Perfusion
  • Imbalanced Nutrition: Less than Body Requirements

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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