Nursing Diagnoses

Nursing Diagnoses related to MRSA

• Impaired Skin Integrity r/t infection.
• Delayed Surgical Recovery r/t infection
• Impaired Tissue Integrity r/t wound, infection
• Risk for Loneliness: Risk factor:  physical isolation
• Risk for Shock: Risk factor: sepsis

	Risk for Loneliness
Actual or Potential	Potential
Risk factor	Physical isolation
Plan/Outcome	Client will (time frame) Maintain one or more meaningful relationship Sustain relationships that allow self-disclosure and demonstrate balance between emotional dependence and independence Participate in personally meaningful activities and interactions, that are ongoing, positive and relevant socially Demonstrate positive use of time alone when socialization is not possible
Nursing interventions	Assess the client’s perception of loneliness.  Use active listening skills.  Establish a therapeutic relationship and spend quality time with the client. Assess the client’s ability and/or inability to meet their physical, psychosocial, spiritual, and financial needs. Explore ways to increase the client’s support system. Encourage the client to develop closeness in at least one relationship.

These nursing diagnoses and interventions come from the Nursing Diagnosis Handbook.  Get your copy today at www.amazon.com!

References

Ackley, B.J., Ladwig, G.B. (2014).  Nursing Diagnosis Handbook: An evidence-based guide to planning care.  Maryland Height, Missouri: Mosby Elsevier.  

Nursing Care

Dear Mrs. MRSA,

My mother-in-law is in the hospital with a MRSA infection.  What can I expect the nursing care to be for her condition?  

Sincerely, 

~Staying Informed in Indiana

Dear Staying,
It is great to hear that you are getting informed about what the nursing staff should be doing to help your mother-in-law as she fights this infection.

• Upon admission to the hospital patients who are suspected to have MRSA are tested for the bacteria.  The CDC does not recommend routine testing for all patients, just those who are suspected to harbor the bacteria.  Suspected individuals would include patients of long-term care facilities, jails, homeless, or persons exhibiting symptoms of MRSA.  

• A culture of the inside of the nose (nares) and another site, usually the groin or underarm, is taken and grown in the laboratory.  If it comes back positive ... 

• MRSA patients will be placed in either a private room, or with patient who also has a MRSA infection, this is call cohorting.  This will ensure that patients who are negative for MRSA do not become colonized/infected.  

All staff and guests will have to wear special personal protective equipment (PPE) when entering the room of a patient with MRSA.  This ensures that not only are staff and guests protecting themselves, but they are also preventing the spread of MRSA to other patients.

Contact Precautions Sign 

Image Source
 http://infectionpreventionuncc.weebly.com/transmission-based-isolation-precautions.html

The correct order for donning and doffing PPE is as follows
When entering the room of MRSA patient

• Sanitize hands
• Put on gown
• Put on gloves

When leaving the room

• Take off gloves
• Take off gown
• Sanitize or wash hands

For more information check out the CDC.

References

The MRSA Interagency Advisory Committee, Connecticut Department of Public Health. (1993).  Guidelines for management of patients with methicillin-resistant staphylococcus aureus in acute care hospitals and long term care facilities.  Retreived from http://www.ct.gov/dph/lib/dph/infectious_diseases/pdf_forms_/mrsa_guidelines[1].pdf.  

Treatment

Dear Mrs. MRSA, 

My husband has been diagnosed with MRSA.  What is the treatment course we can expect?

Sincerely, 

~Stressed in St. Louis 

Dear Stressed, 

• For those people who are colonized with MRSA they can use a special washing powder that will kill the MRSA living on the skin.  Special shampoo is used on the head.  You also apply a cream to the inside of the nose to kill MRSA bacteria there.  This treatment is done for 5 days, and can be done at home.  

• MRSA that is causing an active infection needs to be treated with antibiotics.  Depending on the genetic makeup of the bacteria one is infected with different antibiotics may or may not be successful.  

• The most common antibiotic used to treat MRSA infection is vancomycin.  Other antibiotics that may be used along with vancomycin include rifampin and gentamicin - though this is not always recommended.  

• Skin and Soft Tissue - for an abscess or boil the site will need to be lanced and drained.  However, a more serious and widespread infection like cellulitis will require systemic antibiotics for 5-10 days.  Patients who are sick with other health conditions will probably receive IV vancomycin for 7-14 days.  

• Endocarditis - vancomycin is the recommeded treatment, and certain types of endocarditis require additional antibiotics.  An echocardiogram - sort of like a picture of the heart, is taken.   This helps the provider see the size, shape, and function of the heart.  Valve reconstruction surgery may be indicated for patients with severe damage.  

• Osteomyelitis and joint infection - treatment with vancomycin and possibly rifampin for at least 3 weeks, and possibly longer along with debridement of the bone that is infected.   Debridement is where the health care provider cleans out the dead and infected tissue of a wound so that new, healthy tissue can grow.  

• Blood Infections/ Sepsis - find the original site of infection and treat that, usually with surgical debridement and vancomycin.  

• Pneumonia - drainage of the lungs, along with vancomycin

IV Vancomycin Preparation 

Image Source http://7daypharmacy.net/vancomycin-without-a-prescription.html

The problem with treating MRSA with conventional medical therapies (i.e. antibiotics) is that many times the infection will come back.  If an infection comes back it becomes even harder to treat.  In addition to recurance some patients are allergic to vancomycin.  

As microorganisms evolve to become resistant to antibiotics it is important for the medical community to recognize other treatments for these "superbugs".

Check out this article from BBC News about garlic was used to successfully treat MRSA!  Scientists used a recipe from the Middle Ages to concoct a salve that was 99.9% effective in killing MRSA bacteria in both culture and live mice.  

References 

Lui, C., Bayer, A., Cosgrove, S.E., Daum, R., Fridkin, S.K., Gorwitz, R.J., Kaplan, S.L…. Chambers, H.F.  (2011).  Clinical practice guidelines by the infectious disease society of America for the treatment of methicillin-resistant staphylococcus aureus infection in adults and children.  The Oxford University Press, 1, 1-38.  doi: 10.1093/cid/ciq146

Signs and Symptoms

Dear Mrs. MRSA, 

I am a new nurse and will be starting work at a hospital soon.  I am wondering how I can recognize if my patient has a MRSA infection, and how to recognize when it becomes more serious?

Sincerely, Nursing in Nashville 

Dear Nursing, 

Signs and symptoms of MRSA depend on the location of the infection.  Below I have listed some common sites to watch out for.  

Skin Infection:

MRSA and Skin Infection 

Image Source:
http://www.childrenscolorado.org/wellness-safety/health-library/for-parents/bacterial-viral-infections/mrsa

• Painful, red bump on the skin - looks like an insect bit that develops into a pus filled boil, like a big pimple  

• Sometimes a person will also have a fever.  If you have a fever along with the boil seek medical attention right away.  This could be a sign that the infection has spread to another part of the body.  

• Inflammation of hair follicles - crusty pus filled wounds, sometimes there will not be any pus coming out of the wound but you can feel it deep under the skin - this is called an abscess.  Do not try to bring the pus to the surface.  

• Cellulitis - a deep infection, more serious, underneath the skin, large area of the skin that can get larger as the infection grows.  Red, painful.  

• Other signs that the infection has spread are a general feeling of malaise, chills, swelling of certain areas of the body, muscle ache, dizziness and/or confusion.  

Signs and Symptoms of More Serious forms of MRSA

MRSA + White Blood Cell = Sepsis 

Image Source http://www.webmd.com/a-to-z-guides/ss/slideshow-sepsis-101

• Blood infections/ Sepsis - very high fever, increased heart rate and breathing rate, edema, disorientation, coma.  In addition to the symptoms listed above blood pressure will drop very low, very quickly when the patient is going into septic shock.  

• UTI - pain with urination, frequency and urgency, confusion and changes in mental status especially in older adults, pain in the lower belly or back, malaise

• Pneumonia - mostly seen in young, otherwise healthy patients who were initially sick with the flu or another flu-like disease.  It is very deadly, and must be treated aggressively.  Signs of infection to the lungs would include shortness of breath, very high fever, and bruising easily.  

• Osteomyelitis - extremely painful in the area of infection, you may also see swelling at the area of infection, inability to move the affected area, and general feeling of malaise, high fever. 

For more information about the signs and symptoms of MRSA visit Michelle Moore at Staph Infection Resources.  

References

Rubinstein, E., Kollef, M.H., Nathwani, D. (2008). Pneumonia caused by methicillin-resistant staphylococcus aureus.  Oxford Journals, 46, 378-385.  doi: 10.1086/533594/  

Moore, M. (2015).  MRSA urinary tract infection: risk, facts, symptoms and more.  Retrieved from http://www.staph-infection-resources.com/info/mrsa-uti-infection/  

Davis, C.P., Stoppler, M.C. (2015).  What are the signs and symptoms of a MRSA infection?  Retrieved from http://www.medicinenet.com/mrsa_infection/page4.htm#what_are_the_signs_and_symptoms_of_a_mrsa_infection

Diagnosis

Dear Mrs. MRSA, 

I have a large welt on my left forearm.  It is very painful, and seems to be getting larger by the day.  It looks to me like a spider bite, but I haven't seen any spiders around my house so far this year.  A friend told me it could be MRSA.  How would I find out?

Sincerely, 
Confused in California

Dear Confused,

• To diagnose MRSA a health care provider will swab of the inside of the nose, or take a sample of the boil that appears to be infected with MRSA.  The swab is then applied to a petri dish and grown with nutrients that facilitate the growth of s. aureus.  If it turns out that s. aureus is growing it is then tested to see if it can be killed with antibiotics.  If the s. aureus is not killed with the antibiotics it is diagnosed as MRSA.
• The FDA has approved a new diagnostic test that can have results within about 5 hours.  Instead of a swab of the infected site or the inside of the nose, a blood sample is collected.  The blood is collected in tubes that have special ingredients that will help bacteria grow if it is in fact in the blood.  The blood is then examined under the microscope to see if s. aureus is growing.  The blood test is about 95% accurate, but does result in false positives.  It is a good initial screening tool for providers and hospitals so that appropriate care can be taken that MRSA is not spread to other patients.  Positive blood test results are then confirmed with a nasal screening to rule out false positives.  
• For more information about the progression of complications from MRSA visit MRSASurviors.org.  

MRSA vs a spider bite

Image source http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa

Colonization vs. Infection 

• If you are colonized with MRSA you will not necessarily have any symptoms of disease.  You can be colonized with MRSA on your whole body, or just a part of your body.  You could have MRSA and not even know it unless you had a culture grown in the laboratory.  An active infection progression is quite varied depending on the strain of MRSA you have and the part of your body that is infected.  Like I mentioned before the most common areas to have MRSA infection are on skin and soft tissue and surgical sites.  The most serious kinds of MRSA infection are bloodstream infections leading to sepsis, pneumonia, and osteomyelitis.    
• It is very important that MRSA infections be treated right away so the likelihood of complications will decrease. 

References 

• Sullivan KV, Turner NN, Roundtree SS, McGowan KL.  Rapid detection of methicillin-resistand Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) using the KeyPath MRSA/MSSA blood culture test and the BacT/ALERT system in a pediatric population. Arch Pathol Lab Med.  2013; 13(8):1103-1105. doi: http://dxdoi.org/19.5858.arpa.2012-0422-OA
• Jefferson E.  FDA clears first test to quickly diagnose and distinguish MRSA and MSSA. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm254512.htm.  Updated April 10 2014.  Accessed April 20 2014.  
• MRSA Infection.  MedicineNet website.  http://www.medicinenet.com/mrsa_infection/page7.htm#what_is_the_prognosis_outlook__of_a_mrsa_infection.  Updated February 4 2015.  Accessed April 21 2014.  

Pathophysiology

Dear Mrs. MRSA,

I have tested positive for a MRSA culture of my nose.  Does this mean I am sick?  I feel fine but from what I understand MRSA infection can be pretty bad.  Should I be worried?

Sincerely,

Nosy in Nebraska

Dear Nosy,

You can become colonized with s. aureus by coming in contact with another person who has the infection, or with their things.  Once colonized a break if there is a break in your bodies defenses, be it a break in skin though a cut, surgery, insertion of in-dwelling catheter or ventilator a more serious infection may result. 

Different strains of s. aureus can cause different problems.  For example some forms are good at hiding from the immune system, and others are very good at holding on to tissue or prosthetic devices.  After one has been colonized the bacteria can lay dormant, however if the genes are turned on s. aureus can cause septic shock, scalded skin syndrome, or other diseases by producing toxins and activating the immune system.  However, please note that the different strains of s. aureus do not behave the same.  Some may be more virulent (greater ability to cause infection) while others may be better suited to invade the body and stay there. 

MRSA Culture

Image Source https://www.flickr.com/photos/mediman30/9477953611/

As I mentioned above it really depends on the strain of MRSA one has what the progression of the disease will be.  However, if the s. aureus is resistant to common antibiotics and causes surgical-site infection, pneumonia, or blood stream infection the risk of death is much higher.  It is not well understood if this is because the strain of MRSA is more virulent, or if the patients who become sick were in poor health to begin with. 

One study showed that individuals who were previously colonized with MRSA (such as yourself) actually had better outcomes from blood infections than individuals who become infected without previously being colonized.

Simply being colonized with MRSA doesn't mean you will become sick.  However, if your skin becomes broken like in surgery your medical team will need to take extra care to make sure you do not develop a blood infection.  

Best of luck to you, Nosy!

Next week we will hear from another reader who has tested positive for MRSA.  

References  

Gordon RJ, Lowy FD.  Pathogenesis of Methicillin-Resistant Staphylococcus aureus Infection. Cli Infect Dis. (2008) 46(Supplement 5):S350-S359.doi:10.1086/533591

Epidemiology

Dear Mrs. MRSA, 

My grandmother is moving into a nursing home next month.  I keep hearing about this infection called MRSA that is common in nursing homes.  What is it?  Can I catch it?  What can be done to keep Grandma healthy?

Sincerely, 
Worried in Washington  

Dear Worried,

The good news is that the number of new MRSA infections in the United States are declining.  The number of blood borne MRSA infections - those that can cause the most damage, are declining even more.  Healthcare professionals have learned that better hand cleaning can greatly reduce the number of people of become infected with MRSA.  It is important to practice good hand hygeine when visiting your grandmother, and encourage your family members to do the same.  Choose a facility where the staff gel in and out of the room, wash their hands frequently, and wear protective clothing when visiting rooms where MRSA is present.

What is the distribution in the US?

National Estimated Incidence Rates of Invasive MRSA Infections

Image Source doi:10.1001/jamainternmed.2013.10423

(Washington State has a 22% lower rate of MRSA infections than the national average.)

Are certain parts of the population more affected than others?

• People living in close quarters, such as military, prisons and long-term care facilities, are at a higher risk for contracting MRSA.  Because it can be spread by touching an infected person, or their belongs.  
• People with in-dwelling catheters, central lines, ventilators, or surgery patients have a higher risk of developing complications from MRSA since they are directly exposed to germs.  If your grandmother does need to have one or more of these devices make sure people touching her are using gloves and washing their hands before and after they leave the room.  

What is the mortality and morbidity from this disease?

• It is estimated that 2% of the population carry MRSA in their nose - however, they won’t know it unless they get a lab culture.  
• MRSA is only dangerous if it gets inside the bloodstream.  That is why it is so important for everyone, especially healthcare workers to keep their hands clean, and gloved when working with patients.  
• Deaths related to MRSA have dropped considerably in the United States.  In 2005 about 1100 people died from complications related to MRSA.  In 2011 that number was down to 650 people.  Public health officials attribute this drop in mortality to improvements in hand hygiene as well as greater awareness of the disease.  

Hope that helps clear some things up, Worried.
Next week we will take a question from a reader about how MRSA effects the body (aka pathophysiology).

References
Methicillin-resistant Staphylococcus aureus (MRSA) Infections.  Centers for Disease Control and Prevention website http://www.cdc.gov/mrsa/tracking/index.html.  Updated April 30 2014.  Accessed on April 7 2014.
Dantes R, Mu Y, Belflower R, et al. National Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections, United States, 2011.  JAMA Intern Med.  2013;173(21):1970-1978.  doi:10.1001/jamainternmed.2013.10423.