Necrotizing fasciitis, often called the “flesh-eating disease,” is a rare but severe bacterial infection that rapidly destroys soft tissue and fascia. This condition is a medical emergency requiring immediate intervention.
Causes (Related to)
Necrotizing fasciitis can result from various factors compromising the skin’s integrity or immune system function. The following are common causes of necrotizing fasciitis:
- Bacterial invasion through breaks in the skin (cuts, scrapes, burns, insect bites, surgical wounds)
- Compromised immune system (diabetes, cancer, HIV/AIDS, chronic steroid use)
- Intravenous drug use
- Trauma or injury to the skin
- Recent surgery or medical procedures
- Chronic wounds or ulcers
- Obesity
- Peripheral vascular disease
Signs and Symptoms (As evidenced by)
Necrotizing fasciitis can manifest with a variety of signs and symptoms. In a physical assessment, a patient with necrotizing fasciitis may present with one or more of the following:
Subjective: (Patient reports)
- Severe pain that extends beyond the visible affected area
- Pain that seems disproportionate to the visible skin changes
- Flu-like symptoms (fever, chills, fatigue)
- Nausea and vomiting
- Dizziness or weakness
Objective: (Nurse assesses)
- Rapid progression of skin changes (within hours)
- Swelling and redness of the affected area
- Skin discoloration (purple or black areas)
- Blisters or bullae formation
- Crepitus (crackling sensation when touching the skin)
- Foul-smelling discharge from the wound
- Tachycardia
- Hypotension
- Elevated white blood cell count
- Altered mental status or confusion
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for necrotizing fasciitis:
- The patient will show signs of infection control within 24-48 hours of treatment initiation.
- The patient will maintain stable vital signs throughout the treatment course.
- The patient will report decreased pain levels within 24 hours of intervention.
- The patient will demonstrate improved wound healing with no further tissue necrosis.
- The patient will maintain adequate nutrition and hydration status.
- The patient will show no signs of sepsis or systemic complications.
- The patient will verbalize understanding of the condition and treatment plan.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. The following section will cover subjective and objective data related to necrotizing fasciitis.
- Perform a thorough skin assessment.
Carefully examine the affected area and surrounding skin for signs of infection, discoloration, swelling, and tissue necrosis. Early detection of skin changes is crucial for prompt intervention. - Monitor vital signs frequently.
Check temperature, heart rate, blood pressure, and respiratory rate every 1-2 hours or as per facility protocol. Tachycardia, hypotension, and fever may indicate worsening infection or sepsis. - Assess pain levels regularly.
Use a standardized pain scale to evaluate pain intensity and characteristics. Severe pain that extends beyond the visible affected area is a hallmark of necrotizing fasciitis. - Evaluate wound characteristics.
Note the size, depth, color, odor, and any drainage from the wound. Document the progression of skin changes and any new areas of concern. - Assess for signs of systemic involvement.
Monitor for signs of sepsis, such as altered mental status, decreased urine output, or organ dysfunction. Early recognition of systemic complications is vital for timely intervention. - Obtain blood samples for laboratory tests.
Monitor complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and blood cultures. These tests help assess the severity of infection and guide antibiotic therapy.
Nursing Interventions
Nursing interventions and care are essential for the patient’s recovery from necrotizing fasciitis. In the following section, you’ll learn about possible nursing interventions for a patient with this condition.
- Administer broad-spectrum intravenous antibiotics as ordered.
Prompt antibiotic therapy is crucial in combating the infection. Ensure timely administration and monitor for any adverse reactions. - Prepare the patient for and assist with surgical debridement.
Surgical intervention is often necessary to remove necrotic tissue. Explain the procedure to the patient and provide emotional support. - Perform meticulous wound care.
Clean and dress the wound according to facility protocol or surgeon’s orders. Use a sterile technique to prevent further contamination. - Manage pain effectively.
Administer analgesics as prescribed and employ non-pharmacological pain management techniques. Adequate pain control is essential for patient comfort and healing. - Monitor and maintain fluid and electrolyte balance.
Administer IV fluids as ordered and monitor intake and output. Necrotizing fasciitis can lead to significant fluid losses and electrolyte imbalances. - Implement infection control measures.
To prevent the spread of infection, wear proper personal protective equipment (PPE) and follow isolation precautions as needed. - Provide nutritional support.
Collaborate with a dietitian to ensure adequate caloric and protein intake. If oral intake is insufficient, consider enteral or parenteral nutrition. - Prevent pressure injuries.
Implement regular repositioning and use pressure-relieving devices to prevent further skin breakdown.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for necrotizing fasciitis.
Care Plan 1: Impaired Tissue Integrity
Nursing Diagnosis: Impaired Tissue Integrity related to invasive microbial agents secondary to necrotizing fasciitis as evidenced by destruction of skin layers and necrotic tissue.
Related factors/causes:
- Bacterial invasion of soft tissue and fascia
- Compromised immune system
- Poor tissue perfusion
Nursing Interventions and Rationales:
- Perform thorough skin assessments every 2-4 hours.
Rationale: Early detection of changes in skin integrity allows for prompt intervention and prevents further tissue damage. - Prepare and assist with surgical debridement as ordered.
Rationale: Surgical debridement is crucial for removing necrotic tissue and controlling the spread of infection. - Provide meticulous wound care using a sterile technique.
Rationale: Proper wound care promotes healing and prevents further contamination. - Administer prescribed antibiotics as scheduled.
Rationale: Timely antibiotic administration is essential for controlling and preventing infection spread. - Monitor and document wound characteristics, including size, color, odor, and drainage.
Rationale: Tracking wound progression helps evaluate treatment effectiveness and detect any complications early.
Desired Outcomes:
- The patient will demonstrate improved tissue integrity within 72 hours of treatment initiation.
- The patient will show no further progression of tissue necrosis by the end of the first week of treatment.
- The patient’s wound will show signs of granulation tissue formation within two weeks of treatment.
Care Plan 2: Acute Pain
Nursing Diagnosis: Acute Pain related to tissue inflammation and necrosis secondary to necrotizing fasciitis as evidenced by patient’s report of severe pain and grimacing.
Related factors/causes:
- Tissue destruction and inflammation
- Surgical interventions (debridement)
- Frequent dressing changes
Nursing Interventions and Rationales:
- Assess pain levels using a standardized scale every 2-4 hours before and after interventions.
Rationale: Regular pain assessment helps evaluate the effectiveness of pain management strategies and guides adjustments in the treatment plan. - Administer prescribed analgesics as ordered, including opioids if necessary.
Rationale: Proper pain management is crucial for patient comfort and can facilitate healing by reducing stress on the body. - Implement non-pharmacological pain management techniques such as relaxation exercises, distraction, or guided imagery.
Rationale: These techniques can complement pharmacological interventions and provide additional pain relief. - Position the patient comfortably, using pillows or foam wedges to support affected areas.
Rationale: Proper positioning can alleviate pressure on affected areas and reduce pain. - Explain procedures and interventions beforehand to reduce anxiety.
Rationale: Understanding what to expect can help the patient feel more in control and may reduce anxiety-related pain exacerbation.
Desired Outcomes:
- The patient will report pain levels reduced by at least 50% within 24 hours of intervention.
- The patient will demonstrate the use of non-pharmacological pain management techniques by the end of the second day of care.
- The patient will report pain levels of 3 or below on a 0-10 scale by the end of the first week of treatment.
Care Plan 3: Risk for Sepsis
Nursing Diagnosis: Risk for Sepsis related to severe soft tissue infection secondary to necrotizing fasciitis.
Related factors/causes:
- Rapidly progressing bacterial infection
- Extensive tissue damage
- Potential for systemic inflammatory response
Nursing Interventions and Rationales:
- Monitor vital signs, including temperature, heart rate, blood pressure, and respiratory rate, every 1-2 hours.
Rationale: Early detection of changes in vital signs can indicate the onset of sepsis and allow for prompt intervention. - Assess for signs of systemic inflammatory response syndrome (SIRS), such as tachycardia, tachypnea, fever, or leukocytosis.
Rationale: SIRS criteria can help identify the development of sepsis early in its course. - Obtain blood cultures and other laboratory tests as ordered.
Rationale: Blood cultures can identify the causative organism, while other tests, like lactate levels, can indicate tissue perfusion and sepsis severity. - Administer broad-spectrum antibiotics as prescribed and monitor for effectiveness.
Rationale: Prompt and appropriate antibiotic therapy prevents and manages sepsis. - Maintain strict aseptic technique during all procedures and wound care.
Rationale: Preventing further contamination is essential in reducing the risk of sepsis.
Desired Outcomes:
- The patient will maintain stable vital signs within normal limits throughout the treatment course.
- The patient will show no signs of progression to sepsis or septic shock.
- The patient’s laboratory values will remain within normal limits or show improvement within 48-72 hours of treatment initiation.
Care Plan 4: Anxiety
Nursing Diagnosis: Anxiety related to life-threatening illness and uncertain prognosis secondary to necrotizing fasciitis as evidenced by verbalization of fears and increased heart rate.
Related factors/causes:
- The severity of the condition
- Rapid progression of symptoms
- Fear of disability or death
- Lack of knowledge about the disease and treatment process
Nursing Interventions and Rationales:
- Assess the patient’s level of anxiety and understanding of the condition regularly.
Rationale: Understanding the patient’s emotional state and knowledge gaps allows for tailored interventions and education. - Provide clear, honest information about the condition, treatment plan, and prognosis.
Rationale: Accurate information can help reduce uncertainty and give the patient a sense of control. - Encourage the patient to express fears and concerns and listen empathetically.
Rationale: Emotional support can help reduce anxiety and improve the patient’s ability to cope with the situation. - Teach relaxation techniques such as deep breathing exercises or guided imagery.
Rationale: These techniques can help manage anxiety and promote a sense of calm. - Include family members in care discussions and decision-making as appropriate.
Rationale: Family support can be a significant source of comfort for the patient and can help reduce anxiety.
Desired Outcomes:
- The patient will verbalize a reduction in anxiety levels within 48 hours of interventions.
- The patient will demonstrate using at least one relaxation technique by the end of the third day of care.
- The patient will express an understanding of the condition and treatment plan by the end of the first week of care.
Care Plan 5: Risk for Ineffective Peripheral Tissue Perfusion
Nursing Diagnosis: Risk for Ineffective Peripheral Tissue Perfusion related to inflammatory process and potential compartment syndrome secondary to necrotizing fasciitis.
Related factors/causes:
- Tissue edema and inflammation
- Vascular compromise due to infection
- Potential development of compartment syndrome
Nursing Interventions and Rationales:
- Assess peripheral pulses, capillary refill, skin color, and temperature of affected and surrounding areas every 2-4 hours.
Rationale: Regular assessment can detect early signs of compromised tissue perfusion or developing compartment syndrome. - Elevate the affected limb as appropriate to reduce edema.
Rationale: Elevation can help improve venous return and reduce swelling, potentially improving tissue perfusion. - Monitor for signs of compartment syndrome, including severe pain, pallor, paresthesia, and pulselessness.
Rationale: Early detection of compartment syndrome is crucial for timely intervention and prevention of tissue necrosis. - Avoid applying constrictive dressings or devices to the affected area.
Rationale: Constrictive elements can further impair circulation and exacerbate tissue damage. - Collaborate with the healthcare team to consider fasciotomy if compartment syndrome develops.
Rationale: Fasciotomy can relieve pressure and restore blood flow in cases of compartment syndrome.
Desired Outcomes:
- The patient will maintain adequate peripheral tissue perfusion as evidenced by strong peripheral pulses and capillary refill < 3 seconds.
- The patient will show no signs of developing compartment syndrome throughout the treatment.
- Within 72 hours of interventions, the patient will demonstrate improved tissue perfusion, as evidenced by reduced edema and improved skin color.
References
- Stevens, D. L., & Bryant, A. E. (2017). Necrotizing Soft-Tissue Infections. New England Journal of Medicine, 377(23), 2253–2265. https://doi.org/10.1056/NEJMra1600673
- Burnham, J. P., & Kollef, M. H. (2018). Understanding necrotizing soft tissue infections in the intensive care unit. Intensive Care Medicine, 44(11), 1934–1936. https://doi.org/10.1007/s00134-018-5383-6
- Hakkarainen, T. W., Kopari, N. M., Pham, T. N., & Evans, H. L. (2014). Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Current Problems in Surgery, 51(8), 344–362. https://doi.org/10.1067/j.cpsurg.2014.06.001
