MRSA Nursing Diagnosis & Care Plan

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Written by
Maegan Wagner, BSN, RN, CCM

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.

The symptoms of MRSA infection will depend on the area where the infection occurs. In mild cases, it can manifest as skin infections like boils, sores, and abscesses. In more severe or systemic cases, symptoms include fever, body aches, dizziness, chills, and confusion. 

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 unnecessary use of antibiotics has led to drug-resistant bacteria, making infections more difficult to treat.

To confirm MRSA infection, a swab of the nasal passage or a tissue sample is tested to detect the bacteria.

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. 

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

  • 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:

  • The patient will implement two strategies to reduce pain
  • The 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.

Impaired Skin Integrity

Methicillin-resistant Staphylococcus aureus may result from impaired skin integrity and lead to infection.

Nursing Diagnosis: Impaired Skin Integrity

  • 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:

  • The patient will regain the integrity of the skin surface
  • The 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.

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

  • Infection
  • Disease process

As evidenced by:

Expected outcomes:

  • The patient will maintain core body temperature within expected limits
  • The 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.

References

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Maegan Wagner, BSN, RN, CCM
Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.