Quality and Safety

Education in Nursing
(QSEN)
A Case Study
Maddie McWilliams, Alyssa ONeill, Courtney Thompson
Methodist University
 (S) Situation

37 year old male, presenting with necrotizing fasciitis of

the right (R) forearm.
Past Medical History: IV drug use, recreational marijuana
use, alcohol dependency
Hospitalized for debridement of the R forearm
 Necrotizing Fasciitis
Necrotizing fasciitis (NF) is a skin
infection specifically involving the
subcutaneous structures and deep
fascia.
There is a high mortality rate due
to a rapidly progressing infection
that can lead to septic shock.
Four types exist depending on
microbiological findings with Type
1 (polymicrobial) being most
(Misiakos, et al., 2014)
common.

(Misiakos, et al., 201

 Necrotizing Fasciitis, continued.

Skin necrosis
with bullae in
addition to
Fourniers
gangrene with
erythema and
edema in the
perineal and (a)Necrotising fasciitis leg, after initial
gluteal regions debridement
(Misiakos, et al., (b)after application of meshed split
2014). skin graft
(Sadasivan, Maroju,
Balasubramaniam, 2014)
 (B) Background
Neuro/HEENT/Psych/Pain: Alert and oriented x 3. Appears stated age. Engaged
in conversation, but uncooperative. Normocephalic configuration. No lumps,
lesions or tenderness. Hair normal texture, evenly distributed, slightly greasy.
EOM intact and equal. PERRLA. Red reflex bilaterally. Slightly off-white sclera,
pink conjunctiva; moist with no redness or swelling noted. No lumps, lesions or
tenderness of auricles. No drainage or excess cerumen. Tympanic membranes
intact, pearly-gray bilaterally. Nasal septum midline. No nasal flaring noted.
Nares symmetric. Turbinates pink, free of swelling or lesions. Nasal mucosa
moist, mild drainage; no bleeding, perforations or lesions noted. Lips pink and
dry. No dental implants noted. Teeth yellow-tinged. Mucosa and gums slightly
brown and moist. Tongue pink and midline. Uvula midline. Consistent pain
reporting of 8-10 on a 10 point scale despite pain medication.
Cardiorespiratory: Temperature 98.2 F (oral), Pulse 75 bpm, Respiratory Rate 16
breaths/min, Blood Pressure 175/88 mmHg (L leg, sitting), O2 98% (room air); No
adventitious sounds noted. Rate, rhythm, and depth WNL. S1 and S2 RRR. No S3
or S4 noted. No murmurs noted.
 (B) Background, continued.
GI/GU: Bowel sounds normal x 4 quadrants. Clear, yellow urine. Unmeasured
I/O. Bowel movements regular, once per day, not visualized. Consumes 75% of
breakfast and lunch tray, drinks soda or sweet tea brought from significant
other.
Musculoskeletal/Skin: Self-ambulates. Multiple tattoos covering most of
extremities. Large surgical open incision to R forearm, 203mm long, 76mm
wide at center.
Lab Work: WBC 8.2, RBC 3.77 (L), Hgb 10.9 (L), Hct 31.4 (L), MCV 83.3,
MCH 28.9, MCHC 34.7, Plts 278, RDWSD 41.8, RDWCV 13.8, MPV 9.3, NRBC
0.0, NRCAB 0.00, Na 143, K 4.3, Cl 111 (H), CO2 25, BUN 16, Cr 6.59 (H),
Glucose 101, Ca 8.0 (L), GFR 10
Lines/tests: 22 gauge to L antecubital fossa, PICC placement in upper L chest,
PCA and Sodium Chloride 0.45% IV 75mL/hr over 13.25hr; CT Upper
Extremity w/ Contract (R): No osseous destruction; extensive soft tissue
edema most pronounced within the posterior aspect of the forearm where this
is confluent edema; no loculated fluid collection identified; edema extends
deep to the underlying muscular fascia, likely indicating associated fasciitis;
 (A) Assessment

Debridement has been successful, patient is

healing appropriately, but does not have adequate
pain management.
Impaired skin integrity related to skin infection as
evidenced by recent wound debridement
 (R) Recommendation
Intervention: Encourage the patient to report any signs of recurrent
infection or temperature; Have patient demonstrate understanding of
need for routine dressing changes and maintenance of clean
dressings; Keep area clean and dry, encourage patient to eliminate
touching and scratching the infected area to decrease the chance of
spreading infections; Elevate affected extremity to reduce edema;
Coordinate with wound care specialist to apply dry, sterile dressings
(Wittman-Price, et al., 2013).
Rationale: Appropriate use of dressings may promote moist wound. Use of
semiocclusive film dressings or hydrocolloid barrier wafers mechanically
protect and properly humidify wounds that are epidermal or dermal
(Carpenito, 2014).
(R) Recommendation, continued.
Intervention: Assess patients perception of pain, attitude toward
pain, effect of mediations to decrease pain; Perform comprehensive
assessment of pain, noting location, duration, severity using a 0-10
scale; Administer pain medications as prescribed and evaluate
effectiveness; Administer pain medications prior to dressing changes
(Wittman-Price, et al., 2013).
Rationale: Pain management should be aggressive and individualized to
eliminate any unnecessary pain with drugs administered on a regular
schedule rather than PRN. Management of pain prior to a painful
procedure can decrease the amount of analgesia needed and the effects
of anxiety and fear, which will escalate the pain experience (Carpenito,
2014).
(R) Recommendation, continued.
Intervention: Counsel patient to eliminate the spread of infection to
other areas of the body by maintaining clean dressings; Counsel
patient not to share towels, washcloths, clothing with other members
of the family; Discuss the need for good nutritional intake and
balanced meals; Discuss the risks of recreational drug use (Wittman-
Price, et al., 2013).
Rationale: To prevent transmission of infection, the mode of transmission
must be known. The disease of addiction prevents individuals from
learning adaptive social and other coping skills (Carpenito, 2014).
 The Diagnosis
What is Necrotizing Fasciitis?
Necrotizing fasciitis is a serious soft tissue infection that has the possibility of becoming lethal due to a
rapid progression with the risk of becoming septic (Misiakos, et al., 2014).
NF can vary from erythema, swelling, and tenderness to skin ischemia with blisters and bullae. If a
patient does not get treatment, they can become critically ill with severe septic shock and multi-organ
dysfunction (Misiakos, et al., 2014).
Patient presented with erythema and swelling to his R forearm and was diagnosed with NF after a CT of
his upper extremity with contrast.
Who gets Necrotizing Fasciitis? Why?
The development of NF can be as a result of compromised integrity of skin or mucous membranes,
diabetes arteriopathy, alcoholism, obesity, immunosuppression, malnutrition, renal failure and increased
age (Sadasivan, Maroju, Balasubramaniam, 2014).
Patient obtained NF after drinking at a bar with a friend and engaging in IV drug use. With a history of
both alcoholism and IV drug use, the patient was susceptible for a systemic infection.
 Safety and the Diagnosis
Inpatient
Practice Medical Asepsis to decrease spread of infection (Wilkinson, 2016).
Maintain clean hands
Maintain a clean environment
Prevent the transmission of pathogens through appropriate precautions and through the use of personal
protective equipment

Community
Educate the patient on causes of infection transmission
Counsel patient not to share towels, washcloths, clothing with other members of the family (Wittman-Price, et al., 2013).

Patient-Specific
Discuss the risks of recreational drug use (Wittman-Price, et al., 2013).
 Lessons Learned
One thing learned
Second thing learned
Third thing learned
 Any
Questions?
 References
Carpenito, Lynda Juall. (2014). Nursing Care Plans: Transitional Patient &
Family Centered Care.
Philadelphia, PA: Lippincott Williams & Wilkins.
Misiakos, E.P., Bagias, G., Patapis, P., Sotiropoulos, D., Kanavidis, P.,
Machairas, A. (2014). Frontiers in
Surgery, 1 (36), 1-10.
Patient EMR and physical assessment.
Sadasivan, J., Maroju, N. K., & Balasubramaniam, A. (2014). Necrotizing
Fasciitis. Indian Journal of
Plastic Surgery, 46 (3), 472-478.
Wilkinson, J. M. (2016).Fundamentals of nursing. 3rd ed. Philadelphia, PA: F.
A. Davis.
Wittmann-Price, R. A., Thompson, B. R., Sutton, S. M., Eskew, S. R. (2013).