Methicillin-Resistant Staphylococcus Aureus (MRSA) is a bacterium renowned for causing infections in various parts of the body. What sets MRSA apart is its formidable resistance to many commonly prescribed antibiotics, making treatment a significant challenge. This bacterium can spread rapidly through skin-to-skin contact, especially in community settings, and can lead to severe bloodstream or respiratory infections, particularly within healthcare facilities.
Staphylococcus aureus is a common bacterium, often found harmlessly on the skin or in the nasal passages of about one-third of the population. It only becomes problematic when it breaches the body’s defenses, entering through wounds or areas of compromised skin. Even then, individuals with healthy immune systems may remain asymptomatic. However, the escalating issue of antibiotic resistance, often exacerbated by chronic and unnecessary antibiotic use, has made bacterial infections like MRSA increasingly difficult to treat.
This article delves into the critical aspects of nursing care for patients with MRSA, focusing on the nursing process, assessment, interventions, and tailored care plans to effectively manage this challenging infection.
Nursing Process for MRSA Infection
The cornerstone of managing MRSA infection is the nursing process. Treatment goals are centered on preventing complications, alleviating patient symptoms, and rigorously implementing infection control measures. For localized infections such as furuncles, abscesses, and septic joints, incision and drainage may be the initial treatment. Drug therapy, including antibiotics like clindamycin and tetracyclines, is crucial in combating the infection.
Nurses are at the forefront of preventing MRSA transmission. Strict adherence to contact precautions is paramount in healthcare settings to curb the spread of MRSA. Preventing reinfection is equally vital, necessitating comprehensive patient and family education.
Nursing Assessment for MRSA
The nursing assessment is the foundational step in providing effective care. It involves a thorough collection of physical, psychosocial, emotional, and diagnostic data. Here’s a detailed look at the subjective and objective data pertinent to MRSA.
Review of Health History
1. Evaluate General Symptoms: MRSA infection symptoms are diverse, depending on the infection site. Mild cases often manifest as skin infections like boils, sores, and abscesses. Severe or systemic infections present with:
- Fever
- Body aches
- Dizziness
- Chills
- Confusion
2. Investigate Exposure History: MRSA is highly contagious, spreading through direct contact with infected individuals or animals. It can also persist on surfaces for extended periods. Common contaminated items include:
- Bedding (sheets, pillowcases)
- Clothing
- Medical equipment
- Sporting gear
- Towels
- Door handles
3. Analyze Medical History: Certain pre-existing conditions and factors increase MRSA infection risk:
- Recent Hospitalization
- Intensive Care Unit (ICU) admission
- Antibiotic Usage (especially prolonged or broad-spectrum)
- MRSA Colonization history
- Invasive Procedures (surgeries, catheterizations)
- HIV Infection or other immunocompromising conditions
- Residence in Long-Term Care Facilities
- Presence of Open Wounds or skin breaks
- Hemodialysis treatment
- Discharge with Invasive Devices (central venous catheters, urinary catheters)
4. Identify Specific Risk Factors: Community-Acquired MRSA (CA-MRSA) has distinct risk factors:
- Contact Sports: Sports like wrestling, football, and rugby, involving close skin contact and potential for abrasions, facilitate MRSA transmission.
- Congregated Living Conditions: Overcrowded and unsanitary environments such as prisons, daycare centers, military barracks, and homeless shelters can foster MRSA outbreaks.
- Men who have sex with men (MSM): This population has been observed to have a higher incidence of MRSA infections, possibly due to skin conditions and behaviors that increase exposure.
- HIV Status: Individuals with HIV are more susceptible to MRSA infections due to weakened immune systems and frequent antibiotic use for opportunistic infections.
- Intravenous Drug Use: People who inject drugs are at significantly higher risk of developing MRSA infections, often linked to skin popping and non-sterile injection practices.
Physical Assessment
1. Evaluate Overall Health Status: MRSA can lead to severe invasive infections beyond the skin:
- Osteomyelitis (bone infection)
- Meningitis (infection of brain and spinal cord membranes)
- Pneumonia (lung infection)
- Empyema (pus accumulation in the pleural space)
- Endocarditis (heart valve infection)
2. Skin Inspection: The skin and subcutaneous tissues are the most common sites for MRSA infections. Nurses should meticulously inspect for:
- Cellulitis: Diffuse spreading infection of the skin and subcutaneous tissues, characterized by redness, warmth, swelling, and pain.
- Necrotizing Fasciitis: A severe, rapidly progressing infection that destroys skin and soft tissues, often called “flesh-eating bacteria.”
- Diabetic Foot Ulcers: Open sores on the feet of diabetic patients, which can easily become infected with MRSA.
3. Musculoskeletal Assessment: Staphylococci, including MRSA, are frequent causes of bone and joint infections. Assess for:
- Osteomyelitis: Particularly in the spine and long bones, potentially spreading from a skin infection.
- Septic Arthritis: Infection in natural or prosthetic joints, causing pain, swelling, and reduced mobility.
4. Monitor for Sepsis: Untreated MRSA infections can progress to sepsis, a life-threatening condition. Watch for sepsis indicators:
- High Fever
- Hypotension (low blood pressure)
- Leukopenia (low white blood cell count) or Leukocytosis (high white blood cell count)
- Tachypnea (rapid breathing)
5. Invasive Line Assessment: Patients with central lines, especially in ICUs, are at high risk for Central Line-Associated Bloodstream Infections (CLABSI), often caused by MRSA, which can be fatal. Assess insertion sites for signs of infection.
6. Cardiovascular Status Check: MRSA is a significant cause of bacterial endocarditis. Risk factors include:
- Intravenous Drug Use, particularly leading to right-sided endocarditis.
- Intravenous Catheter Use.
Diagnostic Procedures
1. Culture and Sensitivity Testing: Essential for confirming MRSA infection and guiding antibiotic therapy. Samples may include:
- Blood cultures (for suspected bloodstream infection)
- Sputum (for pneumonia)
- Urine (for urinary tract infection, less common with MRSA but possible)
- Wound Swabs or Aspirates (from skin lesions, abscesses)
2. MRSA Colonization Screening: DNA PCR (Polymerase Chain Reaction) test from nasal swabs is a standard screening tool.
- Positive Result: Indicates colonization, not necessarily active infection.
- Negative Result: Strongly suggests absence of MRSA colonization.
3. Imaging Studies: In cases of suspected S. aureus bacteremia, especially to rule out endocarditis:
- Echocardiography: Non-invasive ultrasound of the heart.
- Transesophageal Echocardiography (TEE): More invasive, providing clearer images of the heart valves.
Nursing Interventions for MRSA
Effective nursing interventions are crucial for patient recovery and preventing MRSA spread.
1. Initiate Empiric Antibiotic Therapy: Begin antibiotic treatment promptly when MRSA infection is confirmed or strongly suspected. Antibiotic selection depends on:
- Type of Infection
- Local Resistance Patterns of S. aureus
- Antibiotic Availability
- Side Effect Profiles
- Patient-Specific Factors (allergies, renal function, etc.)
Intravenous vancomycin is often the first-line treatment for severe MRSA infections in hospitalized patients. Other options include linezolid, daptomycin, and ceftaroline, depending on the clinical scenario and local guidelines.
2. Implement Decolonization Treatment: To reduce MRSA carriage, especially in nares and on skin:
- Nasal Decolonization: Topical mupirocin ointment applied intranasally (though resistance is increasing). Ethyl alcohol intranasal spray (Nozin Nasal Sanitizer) is an alternative.
- Skin Decolonization: Chlorhexidine gluconate (CHG) soap for bathing and skin cleansing.
3. Patient Education on Preventing Transmission:
- Emphasize not sharing personal items like towels, razors, bed linens, and hygiene products, especially for patients with recurrent skin infections.
- Household decolonization may be considered for close contacts, particularly in recurrent cases.
4. Invasive Device Management:
- Removal of Invasive Devices: Central lines and urinary catheters may need to be removed in cases of suspected or confirmed S. aureus bacteremia, especially CLABSI.
- Surgical Removal: Ports and implanted devices might require surgical removal if infected.
5. Surgical Interventions:
- Abscess Drainage: Surgical incision and drainage (I&D) are often necessary for abscesses.
- Removal of Infected Prostheses: Infected joint prostheses or heart valves may require surgical removal and replacement.
6. Wound Care Management:
- Proper Wound Care: Follow prescribed wound care protocols.
- Keep wounds clean, dry, and covered with sterile dressings.
7. Hand Hygiene Education: Reinforce hand hygiene practices for patients and family members:
- Wash hands with soap and water for at least 20 seconds or use alcohol-based hand sanitizer (at least 60% alcohol).
- Key times for hand hygiene: after bandage changes, after contact with infected wounds, after handling soiled items, and before preparing food.
8. Contact Precautions:
- Isolation: Place patients with known or suspected MRSA colonization or infection in a single room.
- Contact Precautions: Implement contact precautions, including wearing gloves and gowns upon room entry and proper disposal of contaminated materials.
9. Treatment Adherence Education:
- Antibiotic Course Completion: Emphasize the importance of completing the entire prescribed antibiotic regimen, even if symptoms improve, to prevent resistance and recurrence.
- Duration: MRSA treatment can last from 5 to 14 days or longer, depending on infection severity and response.
10. Aseptic Technique for Invasive Devices:
- Prevent Hospital-Acquired MRSA: Strict adherence to aseptic techniques when inserting and managing invasive devices (endotracheal tubes, central venous catheters, urinary catheters) is crucial to prevent healthcare-associated infections.
11. Guidance on Seeking Urgent Medical Care:
- When to Seek Help: Instruct patients to contact their healthcare provider if infection symptoms worsen or do not improve within a few days of antibiotic treatment.
- Monitor for Warning Signs: Educate patients to watch for fever, chills, altered mental status, and worsening wound signs (increased redness, swelling, drainage).
MRSA Nursing Care Plans and Diagnoses
Nursing care plans are vital tools for organizing and prioritizing care. They are based on identified nursing diagnoses and guide interventions to achieve patient outcomes. Here are examples of nursing care plans for common MRSA-related nursing diagnoses.
Acute Pain
MRSA skin infections can cause significant acute pain.
Nursing Diagnosis: Acute Pain
Related Factors:
- Skin infection
- Abscess formation
- Inflammation
Evidenced By:
- Patient reports of pain (using pain scale)
- Guarding behavior
- Grimacing
- Distraction behaviors
- Positioning to minimize pain
- Tenderness to touch
- Erythema and Purulent drainage at infection site
Expected Outcomes:
- Patient will report a decrease in pain intensity using a pain scale within a specified timeframe.
- Patient will demonstrate two non-pharmacological strategies to manage pain effectively.
Nursing Assessments:
- Pain Assessment: Regularly assess pain characteristics (location, intensity, quality, aggravating/relieving factors) using a standardized pain scale. Differentiate MRSA pain from other causes like insect bites.
- Identify Potential Pain Causes: Determine factors contributing to pain, such as recent injuries, skin breaks, or surgical procedures.
Nursing Interventions:
- Administer Prescribed Medications: Administer antibiotics to treat the infection and analgesics (e.g., NSAIDs, acetaminophen, or opioids for severe pain as prescribed) for pain relief.
- Wound Care: Perform prescribed wound care to promote healing and reduce inflammation.
- Non-Pharmacological Pain Management: Encourage and implement non-pharmacological pain relief measures such as:
- Cool compresses to the affected area to reduce inflammation and pain.
- Elevation of the affected extremity to decrease swelling and pain.
- Relaxation techniques, distraction, and guided imagery.
- Avoid Irritation: Instruct the patient to avoid touching, picking, or scratching the infected area to prevent further irritation and bacterial spread.
Hyperthermia
Systemic MRSA infection can lead to hyperthermia.
Nursing Diagnosis: Hyperthermia
Related Factors:
- Infection
- Disease process (systemic inflammatory response)
Evidenced By:
- Elevated body temperature above 100.4°F (38.0°C)
- Flushed skin, warm to touch
- Tachycardia
- Tachypnea
- Diaphoresis
- Changes in mental status (in severe cases)
Expected Outcomes:
- Patient will maintain a core body temperature within normal limits.
- Patient will not experience complications of hyperthermia (e.g., seizures, dehydration).
Nursing Assessments:
- Monitor Vital Signs: Regularly assess and monitor temperature, heart rate, respiratory rate, and blood pressure. Fever, tachycardia, and tachypnea can indicate systemic infection and sepsis.
- Review Laboratory Values: Monitor white blood cell count (WBC) and other inflammatory markers, which may be elevated in systemic infection.
Nursing Interventions:
- Cooling Measures: Initiate tepid sponge baths to reduce body temperature.
- Administer Medications: Administer prescribed antipyretics (e.g., acetaminophen, ibuprofen) to reduce fever and antibiotics (e.g., vancomycin) to treat the MRSA infection.
- Promote Fluid Intake: Encourage oral or intravenous fluid intake to prevent dehydration due to fever and increased metabolic rate.
- External Cooling: Use external cooling methods like fans or cooling blankets, being cautious to avoid shivering, which can paradoxically increase body temperature.
Impaired Skin Integrity
MRSA infection often results from and further exacerbates impaired skin integrity.
Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
- Broken skin (abrasions, cuts)
- Traumatized skin
- Surgical incisions
- Insect or animal bites
Evidenced By:
- Open wound, blisters, abscess formation
- Altered skin color (redness, discoloration)
- Altered skin turgor
- Bleeding, purulent drainage
- Non-healing surgical site
Expected Outcomes:
- Patient will demonstrate progressive wound healing, evidenced by reduced erythema, edema, and drainage.
- Patient will maintain or regain skin integrity.
Nursing Assessments:
- Wound Assessment: Assess the location, size, depth, and characteristics of skin impairment. Determine the cause and type of wound. Document wound appearance, stage of healing, drainage (type, color, odor), and dimensions.
- Laboratory Tests: Monitor wound cultures to confirm MRSA infection and guide antibiotic therapy.
- Extent of Impairment: Assess the degree of tissue loss and the clinical appearance of the wound.
Nursing Interventions:
- Wound Cleansing and Dressing: Keep the wound clean and dry. Cleanse as prescribed, and apply sterile dressings.
- Sanitize Linens: Educate the patient and family on laundering bed linens, towels, and clothing in hot water and detergent, avoiding sharing these items.
- Meticulous Wound Care: Emphasize the importance of meticulous hand hygiene before and after wound care. Ensure proper dressing changes and wound coverage to prevent further contamination.
- Prepare for Incision and Drainage (I&D): If an abscess forms, prepare the patient for I&D to remove purulent material.
- Aseptic Technique: In healthcare settings, maintain strict aseptic techniques during procedures and wound care to prevent healthcare-associated MRSA infections.
Ineffective Protection
MRSA infection compromises the body’s protective mechanisms.
Nursing Diagnosis: Ineffective Protection
Related Factors:
- Resistance to S. aureus and antibiotic treatment
- Immunosuppression
- Invasive procedures
- Open wounds
- Extremes of age (very young or elderly)
- Poor nutritional status
- Lack of knowledge about MRSA prevention
Evidenced By:
- Fever, chills
- Weakness, fatigue
- Restlessness, altered mental status
- Cough (if pneumonia is present)
- Immobility
Expected Outcomes:
- Patient will demonstrate measures to enhance protection against infection.
- Patient will not exhibit further signs of worsening infection.
Nursing Assessments:
- Nutritional Status: Assess nutritional status, including weight, serum protein, albumin levels, and muscle mass, as malnutrition impairs immune function.
- Antibiotic History: Inquire about recent antibiotic use, adherence to prescribed regimens, and any history of antibiotic overuse.
- Living Situation: Assess living conditions, particularly crowded environments (group homes, shelters, prisons), which increase MRSA risk.
- Immune Status: Evaluate for immunosuppression due to conditions like HIV, cancer, advanced age, or immunosuppressant medications.
Nursing Interventions:
- Contact Precautions: Implement and maintain contact precautions to prevent MRSA spread.
- Nutritional Support: Encourage intake of protein and calorie-rich foods to support immune function and wound healing.
- Wound Care: Perform meticulous wound care to prevent secondary infections and promote healing.
- Administer Antibiotics: Administer prescribed antibiotic therapy, typically IV vancomycin for severe infections.
- Minimize Invasive Procedures: Avoid unnecessary invasive procedures to reduce the risk of introducing bacteria.
Risk for Infection
Patients with risk factors are vulnerable to MRSA infection.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Prolonged hospitalization
- ICU admission
- Recent antibiotic use
- Invasive procedures
- Immune dysfunction
- Open wounds
Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are focused on prevention.
Expected Outcomes:
- Patient will remain free from MRSA infection.
- Patient will demonstrate understanding and implementation of infection control measures.
Nursing Assessments:
- Monitor for Signs of Infection: Vigilantly observe for signs of infection (redness, warmth, drainage, fever, changes in mental status, hypotension).
- Monitor Laboratory Values: Monitor WBC count, differential count, and culture results for indications of infection.
Nursing Interventions:
- MRSA Screening: Screen high-risk patients (those with history of MRSA, recent hospitalization, invasive devices, or from long-term care facilities) for MRSA colonization upon admission.
- Maintain Asepsis: Adhere to strict aseptic techniques during dressing changes, wound care, catheter care, and IV line management.
- Patient and Family Education: Teach patients and families about infection control measures, emphasizing hand hygiene.
- Antibiotic Stewardship Education: Educate patients about appropriate antibiotic use and the importance of completing prescribed courses to prevent antibiotic resistance.
- Personal Protective Equipment (PPE): Encourage the use of PPE (gloves, gowns) by healthcare providers and visitors when in contact with patients under contact precautions. Ensure proper equipment (thermometer, BP cuff) is dedicated to isolated patients.
By implementing these comprehensive nursing care plans and interventions, nurses play a pivotal role in managing MRSA infections, preventing their spread, and improving patient outcomes.
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