MRSA, or Methicillin-Resistant Staphylococcus Aureus, is a bacterium that causes infection to different parts of the body and is challenging to treat as it is resistant to the most commonly-prescribed antibiotics.
MRSA can be spread through skin-to-skin contact in the community but can also cause serious bloodstream or respiratory infections in healthcare settings.
Staphylococcus aureus is a common bacteria found on the skin or in the nose of approximately one-third of the population. The bacteria only becomes concerning when it enters through a wound or compromised area; even then, those with robust immune systems may not have symptoms.
Over time, the chronic and often unnecessary use of antibiotics has led to drug-resistant bacteria, making infections more difficult to treat.
In this article:
Nursing Process
Treatment goals for MRSA infection involve preventing complications, relieving symptoms, and initiating infection control. Incision and drainage may be performed as a primary therapy for furuncles, abscesses, and septic joints. Drug therapy including, clindamycin and tetracyclines, may also be initiated.
Nurses play an important role in preventing the spread of infection. Strict contact precautions must be initiated to prevent the transmission of MRSA in the healthcare setting. Preventing MRSA reinfection is also a priority, and accurate patient education must be provided to both the patient and family members.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to MRSA.
Review of Health History
1. Assess for patient’s general symptoms.
The symptoms of MRSA infection will depend on the area where the infection occurs. It can manifest as skin infections like boils, sores, and abscesses in mild cases. In more severe or systemic cases, symptoms include:
- Fever
- Body aches
- Dizziness
- Chills
- Confusion
2. Elicit a history of exposures.
MRSA is contagious and direct contact with an infected person, or animal can lead to spread. MRSA can live on surfaces and objects for days or even weeks. Some of the most common contaminated items include:
- Bedsheets
- Clothes
- Medical supplies
- Sporting equipment
- Towels
- Doorknobs
3. Review the patient’s medical history.
The following risk factors increase the opportunity of contracting MRSA infection:
- Hospitalization
- ICU admission
- Antibiotic use
- MRSA colonization
- Invasive procedures
- HIV infection
- Admission to a long-term care facility
- Open wounds
- Hemodialysis
- Discharge with invasive devices (such as central venous access lines or an indwelling urinary catheter)
4. Identify the patient’s risk factors.
The risk factors of community-acquired MRSA (CA-MRSA) are:
- Contact sports: MRSA is easily transmitted through skin-to-skin contact, wounds, and scrapes, especially in contact sports like wrestling.
- Living conditions: Living in an unclean or congested environment (such as prisons, child care facilities, and military training camps) can trigger MRSA outbreaks.
- Sexual activity: Men who engage in sexual activity with other men are more likely to develop MRSA infections due to compromised skin.
- Presence of HIV: MRSA infections are common in patients with HIV due to compromised immune systems and the frequent use of antibiotics.
- Illegal drug use: People who inject drugs are over 16 times more likely to develop MRSA infections.
Physical Assessment
1. Assess the patient’s overall health status.
MRSA can result in invasive infections like:
- Osteomyelitis
- Meningitis
- Pneumonia
- Empyema
- Endocarditis
2. Inspect for any changes to the skin.
The skin and subcutaneous tissues are most frequently affected by MRSA-related infections. Cellulitis, necrotizing fasciitis, and diabetic foot ulcers are some skin and soft tissue infections linked to MRSA.
3. Assess the patient’s bones and joints.
The most frequent cause of infections in bones and joints is staphylococci. Spreading from a local infection, MRSA can cause osteomyelitis of the spine and long bones of the upper and lower limbs. MRSA can also lead to septic arthritis in natural and artificial joints.
4. Monitor for sepsis.
If untreated or undertreated, MRSA can worsen into sepsis. Symptoms of sepsis include:
- High fever
- Hypotension
- Leukopenia or leukocytosis
- Tachypnea
5. Assess the status of the invasive lines.
Patients with central lines in intensive care units are at risk for Central Line-Associated Bloodstream Infections (CLABSI), which can be a fatal complication.
6. Check the cardiovascular status.
MRSA is a significant contributor to bacterial endocarditis. Drug use and intravenous catheter use are linked to right-sided MRSA endocarditis.
Diagnostic Procedures
1. Obtain samples for culture and sensitivity.
Clinicians should send blood, sputum, urine, or wound samples suspected to be the source of infection for analysis.
2. Check for MRSA colonization.
A standard diagnostic procedure to screen for MRSA colonization is DNA PCR of MRSA from the nares. A positive result does not necessarily confirm infection, but a negative result rules out infection.
3. Assist with imaging.
Patients suspected of having S. aureus bacteremia should undergo echocardiography or transesophageal echocardiography (TEE) to rule out endocarditis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with MRSA.
Control the Infection
1. Initiate empiric antibiotic treatment.
Administer empiric antibiotics if MRSA infection is confirmed or suspected. The use of empiric antibiotic therapy depends on the following:
- Disease type
- Local S. aureus patterns of resistance
- Medication accessibility
- Side effect profile
- Patient-specific information
IV vancomycin is the drug of choice for MRSA infections in hospitalized patients.
2. Initiate decolonization treatment.
Decolonization of the nares includes topical mupirocin applied intranasally, though this treatment is also becoming resistant, so new medications like ethyl alcohol intranasal spray (Nozin Nasal Sanitizer) are being used. Chlorhexidine gluconate soap is used to decolonize the skin.
3. Educate on not sharing personal items.
Patients with recurrent skin infections should not share towels, bed linens, or hygiene products with other household members. All members of the household may require decolonization treatment.
4. Remove invasive devices.
Suspected or confirmed S. aureus bacteremia may require the removal of central lines and urinary catheters. Surgical removal of ports and implanted devices may or may not be required.
5. Anticipate possible surgery.
Surgery may be needed to drain abscesses or remove an infected joint prosthesis or heart valve.
6. Provide proper wound care.
Perform the prescribed wound care for the patient. Wounds should typically be kept clean and dry and covered with a dry dressing.
7. Instruct on hand hygiene.
Advise the patient and family members to wash their hands with soap and water or rub their hands with alcohol-based solution if soap and water are not available, especially:
- After a bandage change
- Following exposure to an infected wound
- After handling soiled clothing
8. Initiate contact precautions.
Patients colonized or infected with MRSA should be placed in a single room with contact precautions initiated.
9. Teach the patient about treatment adherence.
Depending on the severity of the infection and the patient’s response to treatment, the course of treatment for MRSA may last 5 to 14 days. The patient may be instructed to continue antibiotic therapy once discharged and should be educated to complete the entire regimen, even if symptoms improve.
10. Maintain asepsis in invasive devices.
Nurses and healthcare providers must take great care to prevent MRSA infections from poor disinfection practices that can result in hospital-acquired MRSA in patients with invasive devices like endotracheal tubes, central venous catheters, or urinary catheters.
11. Discuss with the patient when they should seek urgent medical care.
If infection symptoms don’t improve within a few days of taking the prescribed antibiotic, advise the patient to call their healthcare provider. Educate to monitor for symptoms of fever, chills, changes in mental status, or wounds or incisions that are red, swollen, or draining.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for MRSA, 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 MRSA.
Acute Pain
Methicillin-resistant Staphylococcus aureus infections cause acute pain from skin infections appearing as red rashes that quickly worsen. MRSA infections start as swollen, red bumps that may look like spider bites or pimples.
Nursing Diagnosis: Acute Pain
Related to:
- Skin infection
- Abscess formation
- Inflammation
As evidenced by:
- Distraction behavior
- Grimacing
- Guarding behavior
- Positioning to ease pain
- Protective behavior
- Reports intensity using a standardized pain scale
- Tender to touch
- Erythema
- Purulent drainage
Expected outcomes:
- Patient will implement two strategies to reduce pain.
- Patient will report a decrease in pain using a pain scale.
Assessment:
1. Assess pain.
Pain assessment is vital in determining an appropriate treatment regimen. Skin irritation and pain in MRSA are often confused with an insect or animal bite and can be red, swollen, warm to the touch, and painful. If not treated effectively, it may worsen into cellulitis or an abscess.
2. Assess for possible causes.
Determine if the patient was recently injured or had a break in the skin, or underwent a surgical procedure. These are clues that may assist the nurse in considering MRSA infection.
Interventions:
1. Administer medications as ordered.
Medications like antibiotics and analgesics can help clear out infections, promote wound healing, and relieve pain.
2. Encourage wound care.
Proper wound care is essential in preventing the spread of infection and further damage to the tissues.
3. Encourage nonpharmacologic pain approaches.
Nonpharmacologic pain interventions are known to help improve pain symptoms without the side effects of medications. These include cool compresses and elevation of the extremity.
4. Avoid touching the area.
Instruct the patient not to further pick or touch the skin beyond what is required for cleaning as this may further irritate the area and introduce bacteria.
Hyperthermia
Methicillin-resistant Staphylococcus aureus infection that is not promptly treated may become a systemic infection causing hyperthermia, chills, and body aches.
Nursing Diagnosis: Hyperthermia
Related to:
- Infection
- Disease process
As evidenced by:
- Flushed skin
- Skin warm to touch
- Tachycardia
- Tachypnea
- Fever above 100.4 F (38.0 C)
- Diaphoresis
- Changes in mental status
Expected outcomes:
- Patient will maintain core body temperature within expected limits.
- Patient will not experience worsening complications of hyperthermia, such as seizures.
Assessment:
1. Assess and monitor temperature and other vital signs.
Hyperthermia can indicate further infection and other complications in patients with MRSA. A temperature above 100.4 F (38.0 C) is considered a fever. Tachycardia and tachypnea can signal sepsis.
2. Monitor laboratory values.
An elevation in white blood count, along with alterations in vital signs, signals a systemic infection.
Interventions:
1. Initiate a tepid sponge bath.
A tepid sponge bath is an effective cooling intervention that can be delegated to a nursing assistant.
2. Administer appropriate medications as ordered.
The administration of IV antibiotics such as vancomycin is given for severe infections that are caused by MRSA infections. Antipyretics can reduce the temperature for comfort.
3. Encourage fluid intake.
Increased metabolic rate, diuresis, and hyperthermia can cause loss of body fluids. Fluid replacement is essential to prevent dehydration.
4. Encourage external cooling measures.
Cooling measures like a fan or a cooling blanket can reduce the internal body temperature. Ensure not to induce shivering, which causes the opposite effect.
Impaired Skin Integrity
Methicillin-resistant Staphylococcus aureus may result from impaired skin integrity and lead to infection.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Broken, traumatized skin
- Surgical incision
- Insect or animal bite
As evidenced by:
- Abscess formation
- Altered skin color
- Altered turgor
- Bleeding
- Blistering
- Open wound
- Non-healing surgical site
Expected outcomes:
- Patient will regain the integrity of the skin surface.
- Patient will display healing of the skin as evidenced by reduced erythema, swelling, or drainage.
Assessment:
1. Assess the site of skin impairment and determine the cause and the type of wound.
The causative factor of skin impairment must be determined first before appropriate interventions can be implemented.
2. Assess laboratory tests.
Additional testing may be needed to determine and confirm MRSA infection. A swab of the skin/open area can be obtained to assess for MRSA.
3. Assess the degree and extent of skin impairment.
Assessment must include tissue loss, the clinical appearance of the wound, the stage of healing, the presence of drainage, and the measurement of wound dimensions.
Interventions:
1. Keep the wound clean and dry.
Keeping the wound and surrounding skin clean and dry will encourage healing and prevent further skin damage.
2. Sanitize linens.
Bed linens, towels, and any clothing that came into contact with the broken skin should be sanitized in hot water after use and not reused or shared among other family members.
3. Encourage meticulous wound care.
Proper wound care prevents infection and other complications. Always wash hands before performing wound care and after handling soiled bandages. Keep the wound covered so bacteria cannot enter.
4. Prepare for I&D.
Incision and drainage may be necessary if an abscess forms to release purulent drainage.
5. Use aseptic techniques.
In hospital settings, nurses and healthcare workers must take great care to prevent MRSA infections when patients have IV or urinary catheters, as improper disinfection practices can lead to hospital-acquired MRSA.
Ineffective Protection
Resistance to Staphylococcus aureus decreases the ability of the immune system to fight the infection.
Nursing Diagnosis: Ineffective Protection
Related to:
- Resistance to S. aureus
- Invasive procedures
- Poor nutrition
- Open wounds
- Age 65 or older
- Immunosuppression
- Lack of knowledge about MRSA prevention
As evidenced by:
- Fever
- Weakness
- Restlessness
- Cough
- Chills
- Immobility
- Altered mental status
Expected outcomes:
- Patient will not exhibit signs of infection.
- Patient will demonstrate measures to prevent MRSA.
Assessment:
1. Assess nutritional status (i.e., weight, serum protein, albumin levels, muscle mass, etc.)
Anorexia, loss of muscle mass, and nutritional deficiencies affect the patient’s ability to protect against infection.
2. Assess antibiotic use.
MRSA is brought about by poor adherence or overuse of antibiotics. Inquire about the patient’s recent use of antibiotics and the completion of regimens.
3. Assess living situations.
Patients who live in close quarters such as group homes, military barracks, prisons, or any living conditions with high crowding index are more likely to acquire and spread community-acquired MRSA.
4. Assess immunosuppression.
Patients with a weakened immune system (i.e., cancer, advanced age, HIV, etc.) have an increased risk of acquiring MRSA.
Interventions:
1. Initiate contact precautions.
The patient with MRSA is placed on contact precautions to prevent the spread of MRSA to others. This involves placing the patient in a private room and ensuring that all healthcare providers wear appropriate protective equipment, such as gloves and gowns, when entering the room.
2. Encourage intake of protein and calorie-rich foods.
Optimal nutrition supports immune function. A high-calorie, high-protein diet gives the patient more energy and adequate nutrition necessary for cellular repair and wound healing.
3. Perform proper wound care.
If the patient has MRSA-infected wounds, it is essential to properly care for them to prevent worsening infection. Ensure that the wound is cleaned and dressed appropriately and that the patient and their family are educated to wash their hands before and after touching the wound or contaminated items.
4. Administer antibiotic therapy.
Depending on the severity of the MRSA infection, the patient may require antibiotics. IV vancomycin is the treatment of choice for hospitalized patients with MRSA infections.
5. Avoid invasive procedures if possible.
If possible, avoid invasive procedures like catheterization or injections to prevent introducing bacteria into the body.
Risk for Infection
Resistance to some antibiotics causes the patient to become more vulnerable to acquiring methicillin-resistant Staphylococcus aureus.
Nursing Diagnosis: Risk for Infection
Related to:
- Prolonged hospitalization
- ICU admission
- Recent antibiotic use
- Invasive procedures
- Immune dysfunction (i.e., HIV infection)
- Open wounds
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free from infection.
- Patient will demonstrate two effective infection control measures.
Assessment:
1. Observe and report signs of infection.
Redness, warmth, discharge from a wound or incision, and hyperthermia may indicate signs of infections. Meanwhile, changes in mental status, fever, chills, and hypotension suggest sepsis.
2. Monitor laboratory values (i.e., WBC count, differential count, gram stain, culture, polymerase chain reaction).
Increasing WBC and neutrophil counts indicate bacterial infection. S. aureus appears as gram-positive cocci in clusters in gram staining. If cultures are inconclusive, DNA PCR is the gold standard and most sensitive test to identify MRSA.
Interventions:
1. Screen on admission for MRSA.
Patients at risk for MRSA infection (transfer from LTC facility/prison, invasive lines, immunosuppression) or with a history of MRSA should be screened for MRSA via nasal swabbing.
2. Maintain asepsis for dressing changes, wound care, catheter care, and peripheral IV or central line management.
Patients undergoing invasive procedures are at increased risk of MRSA, primarily since S. aureus is transmitted through direct contact with contaminated wounds, devices, or hands. Adherence to aseptic/sterile technique decreases the chances of bacterial spread.
3. Teach the patient and family about infection control measures, especially the importance of hand hygiene.
Along with avoiding infection transmission, hand hygiene is the most important way to protect oneself from harboring bacteria.
4. Teach the patient to take the entire course of antibiotics even if symptoms improve or resolve.
MRSA is caused by an alteration in the bacteria’s molecular biology caused by nonadherence or overuse of antibiotics.
5. Encourage the use of personal protective equipment (PPE).
MRSA is spread through direct contact with infected individuals or contaminated fomites. PPE, such as gowns and gloves, protect against MRSA acquisition and transmission to other patients. Infected patients should be placed in private rooms with their own equipment (i.e., thermometer, BP cuff) that is not shared among other patients.
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