Herpes zoster (HZ, also called shingles) is a painful condition that produces a maculopapular and vesicular rash. Usually, the rash appears along a single dermatome (band) around one side of the body or face.
In most cases, pain, tingling, burning, or itching occurs a few days before the rash. Next, blisters form, scabbing over in 7 to 10 days. In rare cases, the rash is widespread, resembling varicella zoster (VZ, or chickenpox) rash. Pain can range from mild to severe and may be dull, burning, or gnawing. It may last weeks, months, or even years after the blisters heal. Shingles on the face may impair vision or hearing. (more…)
As full-thickness wounds heal, they begin to fill in from the bottom upward with granulation tissue. At the same time, wound edges contract and pull together, with movement of epithelial tissue toward the center of the wound (contraction). These epithelial cells, arising from either the wound margins or residual dermal epithelial appendages within the wound bed, begin to migrate in leapfrog or train fashion across the wound bed. Horizontal movement stops when cells meet (contact inhibition). The ideal wound edge is attached to and flush with the wound bed, moist and open with the epithelial rim thin, and pale pink to translucent. (more…)
Developing a pressure ulcer can cause the patient pain, lead to social isolation, result in reduced mobility, and can even be fatal. According to the Agency for Healthcare Research and Quality, estimated costs for each pressure ulcer range from $37,800 to $70,000, and the total annual cost of pressure ulcers in the United States is an estimated $11 billion.
Nurses understand their role in preventing pressure ulcers, but what role do patients play in the prevention plan? Nurses need to empower the patient to be an active member in health promotion activities and participate in prevention measures. In this article, I highlight the importance of incorporating pressure ulcer prevention into patient education for high-risk patients as a way to empower patients. Empowered patients can help improve outcomes and reduce overall costs of this hospital-acquired complication. (more…)
One in three patients enters a hospital malnourished. Fight malnutrition by viewing six short videos from the Alliance to Advance Patient Nutrition, including “Rapidly Implement Nutrition Interventions” and “Recognize and Diagnose All Patients at Risk of Malnutrition.” The videos show how to collaborate with the care team to become champions of nutrition and help improve patient outcomes. Watch the videos online or download them for later viewing. (more…)
As a wound care nurse, do you feel the weight of the world on your shoulders when trying to implement a pressure ulcer prevention program? Many staff members think it’s up to the wound care nurse alone to implement the program. However, a successful program requires involvement from all staff and is a 24/7 endeavor. Here’s how to do it. (more…)
Incidence density best measure of pressure-ulcer prevention program
According to the National Pressure Ulcer Advisory Panel (NPUAP), incidence density is the best quality measure of pressure-ulcer prevention programs. Pressure-ulcer incidence density is calculated by dividing the number of inpatients who develop a new pressure ulcer by 1,000 patient days. Using the larger denominator of patient days allows fair comparisons between institutions of all sizes. (more…)
By Tamera L. Brown, MS, RN, ACNS-BC, CWON, and Jessica Kitterman, BSN, RN, CWOCN
Pressure ulcers take a hefty toll in both human and economic terms. They can lengthen patient stays, cause pain and suffering, and increase care costs. The average estimated cost of treating a pressure ulcer is $50,000; this amount may include specialty beds, wound care supplies, nutritional support, and increased staff time to care for wounds. What’s more, national patient safety organizations and insurance payers have deemed pressure ulcers avoidable medical errors and no longer reimburse the cost of caring for pressure ulcers that develop during hospitalization. (more…)
By: Darlene Hanson, MS, RN, Pat Thompson, MS, RN, Diane Langemo, PhD, RN, FAAN, Susan Hunter, MS, RN, and Julie Anderson, PhD, RN, CCRC
Faced with the nursing diagnosis of Impaired skin integrity, we’ve all written care plans that state our goal as “redistributing or reducing pressure.” But how do we do that? Which measures do we take? And how do we know that our interventions have relieved pressure? Do we rely solely on a skin assessment? A patient’s self-assessment of comfort? What if the patient can’t feel pressure relief because of neurologic impairment?
The answers to these questions may be that nurses should use pressure mapping, a tool used by occupational and physical therapists to determine seat-interface pressures and by other healthcare professionals to perform foot assessments. (more…)
Flesh-eating bacteria sounds like the premise of a bad horror movie, but it’s a growing – and potentially fatal – threat to people.
In September 2023, the Centers for Disease Control and Prevention issued a health advisory alerting doctors and public health officials of an increase in flesh-eating bacteria cases that can cause serious wound infections.
There are several types of bacteria that can infect open wounds and cause a rare condition called necrotizing fasciitis. These bacteria do not merely damage the surface of the skin – they release toxins that destroy the underlying tissue, including muscles, nerves and blood vessels. Once the bacteria reach the bloodstream, they gain ready access to additional tissues and organ systems. If left untreated, necrotizing fasciitis can be fatal, sometimes within 48 hours.
The bacterial species group A Streptococcus, or group A strep, is the most common culprit behind necrotizing fasciitis. But the CDC’s latest warning points to an additional suspect, a type of bacteria called Vibrio vulnificus. There are only 150 to 200 cases of Vibrio vulnificus in the U.S. each year, but the mortality rate is high, with 1 in 5 people succumbing to the infection.
How do you catch flesh-eating bacteria?
Vibrio vulnificus primarily lives in warm seawater but can also be found in brackish water – areas where the ocean mixes with freshwater. Most infections in the U.S. occur in the warmer months, between May and October. People who swim, fish or wade in these bodies of water can contract the bacteria through an open wound or sore.
Vibrio vulnificus can also get into seafood harvested from these waters, especially shellfish like oysters. Eating such foods raw or undercooked can lead to food poisoning, and handling them while having an open wound can provide an entry point for the bacteria to cause necrotizing fasciitis. In the U.S., Vibrio vulnificus is a leading cause of seafood-associated fatality.
Why are flesh-eating bacteria infections rising?
Vibrio vulnificus is found in warm coastal waters around the world. In the U.S., this includes southern Gulf Coast states. But rising ocean temperatures due to global warming are creating new habitats for this type of bacteria, which can now be found along the East Coast as far north as New York and Connecticut. A recent study noted that Vibrio vulnificus wound infections increased eightfold between 1988 and 2018 in the eastern U.S.
Climate change is also fueling stronger hurricanes and storm surges, which have been associated with spikes in flesh-eating bacteria infection cases.
Aside from increasing water temperatures, the number of people who are most vulnerable to severe infection, including those with diabetes and those taking medications that suppress immunity, is on the rise.
What are symptoms of necrotizing fasciitis? How is it treated?
Early symptoms of an infected wound include fever, redness, intense pain or swelling at the site of injury. If you have these symptoms, seek medical attention without delay. Necrotizing fasciitis can progress quickly, producing ulcers, blisters, skin discoloration and pus.
Treating flesh-eating bacteria is a race against time. Clinicians administer antibiotics directly into the bloodstream to kill the bacteria. In many cases, damaged tissue needs to be surgically removed to stop the rapid spread of the infection. This sometimes results in amputation of affected limbs.
Researchers are concerned that an increasing number of cases are becoming impossible to treat because Vibrio vulnificus has evolved resistance to certain antibiotics.
People who have a fresh cut, including a new piercing or tattoo, are advised to stay out of water that could be home to Vibrio vulnificus. Otherwise, the wound should be completely covered with a waterproof bandage.
People with an open wound should also avoid handling raw seafood or fish. Wounds that occur while fishing, preparing seafood or swimming should be washed immediately and thoroughly with soap and water.
Anyone can contract necrotizing fasciitis, but people with weakened immune systems are most susceptible to severe disease. This includes people taking immunosuppressive medications or those who have pre-existing conditions such as liver disease, cancer, HIV or diabetes.
It is important to bear in mind that necrotizing fasciitis presently remains very rare. But given its severity, it is beneficial to stay informed.
Debbie King barely gave it a second thought when she scraped her right shin climbing onto her friend’s pontoon for a day of boating in the Gulf of Mexico on Aug. 13.
Even though her friend immediately dressed the slight cut, her shin was red and sore when King awoke the next day. It must be a sunburn, she thought.
But three days later, the red and blistered area had grown. Her doctor took one look and sent King, 72, to the emergency room.
Doctors at HCA Florida Citrus Hospital in Inverness, Florida, rushed King into surgery after recognizing the infection as Vibrio vulnificus, a potentially fatal bacterium that kills healthy tissue around a wound. While King lay on the operating table, the surgeon told her husband she would likely die if they didn’t amputate.
Just four days after the scrape, King lost her leg then spent four days in intensive care.
“The flesh was gone; it was just bone,” she said of her leg.
Cases of V. vulnificus are rare. Between 150 and 200 are reported to the Centers for Disease Control and Prevention every year, with about 20% resulting in death. Most are in states along the Gulf of Mexico, but, in 2019, 7% were on the Pacific Coast. Florida averages about 37 cases and 10 deaths a year.
But a rise in cases nationally and the spread of the disease to states farther north — into coastal communities in states such as Connecticut, New York, and North Carolina — have heightened concerns about the bacterium, which can result in amputations or extensive removal of tissue even in those who survive its infections. And warmer coastal waters caused by climate change, combined with a growing population of older adults, may result in infections doubling by 2060, a study in Scientific Reports warned earlier this year.
“Vibrio distributions are driven in large part by temperature,” said Tracy Mincer, an assistant professor at Florida Atlantic University. “The warmer waters are, the more favorable it is for them.”
The eastern United States has seen an eightfold increase in infections over a 30-year period through 2018 as the geographic range of infections shifted north by about 30 miles a year, according to the study, which was cited in a CDC health advisory last month.
The advisory was intended to make doctors more aware of the bacterium when treating infected wounds exposed to coastal waters. Infections can also arise from eating raw or undercooked seafood, particularly oysters, it warned. That can cause symptoms as common as diarrhea and as serious as bloodstream infections and severe blistered skin lesions.
New York and Connecticut this summer issued health warnings about the risk of infection as well. It’s not the first year either state has recorded cases.
“There’s very few cases but when they happen, they’re devastating,” said Paul A. Gulig, a professor in the Department of Molecular Genetics and Microbiology at the University of Florida College of Medicine.
‘An Accident of Nature’
Vibrio has more than 100 strains, including the bacterium that causes cholera, a disease that causes tens of thousands of deaths worldwide each year.
The V. vulnificus strain likes warm brackish waters close to shorelines where the salinity is not as high as in the open sea. Unlike some other Vibrio strains, it has no mechanism to spread between humans.
It’s found in oysters because the mollusks feed by filtering water, meaning the bacterium can become concentrated in oyster flesh. It can enter humans who swim in salty or brackish waters through the slightest cut in the skin. Infections are treated with antibiotics and, if needed, surgery.
“It’s almost an accident of nature,” Gulig said. “They have all these virulence factors that make them really destructive, but we’re not a part of this bug’s life cycle.”
Once inside the human body, the bacteria thrive.
Scientists don’t believe the bacteria eat flesh, despite how they’re often described. Rather, enzymes and toxins secreted by the bacterium as it multiplies break down the human tissue in the area below the skin, causing necrosis, or death of tissue cells.
The infection spreads like wildfire, Gulig said, making early detection critical.
“If you take a pen and mark where the edge of the redness is and then look at that two or four hours later, the redness would have moved,” Gulig said. “You can almost sit there and watch this spread.”
Researchers have conducted studies on the bacteria, but the small number of cases and deaths make it tough to secure funding, said Gulig. He said he switched his research focus to other areas because of the lack of money.
But growing interest in the bacteria has prompted talk about new research at his university’s Emerging Pathogens Institute.
Examining the bacteria’s genome sequence and comparing it with those of Vibrio strains that don’t attack human flesh could yield insights into potential drugs to interfere with that process, Gulig said.
Shock and Loss
Inside the operating room at HCA Florida Citrus, the only signs of King’s infection were on her shin. The surgeon opened that area and began cutting away a bright red mush of dead flesh.
Hoping to save as much of the leg as possible, the doctor first amputated below her knee.
But the bacteria had spread farther than doctors had hoped. A second amputation, this time 5 inches above the knee, had to be performed.
After surgery, King remained in critical care for four days with sepsis, a reaction to infection that can cause organs to fail.
Her son was there when she awakened. He was the one who told her she had lost her leg, but she was too woozy from medication to take it in.
It wasn’t until she was transferred to a rehab hospital in nearby Brooksville run by Encompass Health that the loss sank in.
A former radiation protection technician, King had always been self-reliant. The idea of needing a wheelchair, of being dependent on others — it felt like she had lost part of her identity.
One morning, she could just not stop crying. “It hit me like a ton of bricks,” she said.
Six different rehab staffers told her she needed to meet with the hospital’s consulting psychologist. She thought she didn’t need help, but she eventually gave in and met with Gerald Todoroff.
In four sessions with King, he said, he worked to redirect her perception of what happened. Amputation is not who you are but what you will learn to deal with, he told her. Your life can be as full as you wish.
“They were magic words that made me feel like a new person,” King said. “They went through me like music.”
Physical therapy moved her forward, too. She learned how to stand longer on her remaining leg, to use her wheelchair, and to maneuver in and out of a car.
Now, back in her Gulf Coast community of Homosassa, those skills have become routine. Her husband, Jim, a former oil company worker and carpenter, built an access ramp out of concrete and pressure-treated wood for their single-story home.
But she is determined to walk with the aid of a prosthetic leg. It’s the motivation for a one-hour regimen of physical therapy she does on her own every day in addition to twice-weekly sessions with a physical therapist.
Recovery still feels like a journey but one marked by progress. She has nicknamed her “stump” Peg. She’s now comfortable sharing before and after pictures of her leg.
And she’s made it her mission to talk about what happened so more people will learn about the danger.
“This is the most horrific thing that can happen to anybody,” she said. “But I’d sit back and think, ‘God put you here for a reason — you’ve got more things to do.’”
What to Know About ‘Flesh-Eating’ Bacterium Vibrio vulnificus
Infection Symptoms:
Diarrhea, often accompanied by stomach cramping, nausea, vomiting, and fever.
Wound infections cause redness, pain, swelling, warmth, discoloration, and discharge. They may spread to the rest of the body and cause fever.
Bloodstream infections cause fever, chills, dangerously low blood pressure, and blistering skin lesions.
To Protect Against Vibrio Infections:
Stay out of saltwater or brackish water if you have a wound or a recent surgery, piercing, or tattoo.
Cover wounds with a waterproof bandage if they could come into contact with seawater or raw or undercooked seafood and its juices.
Wash wounds and cuts thoroughly with soap and water after contact with saltwater, brackish water, raw seafood, or its juices.
Who Is Most at Risk:
Anyone can get a wound infection. People with liver disease, cancer, or diabetes, and those over 40 or with weakened immune systems, are more likely to get an infection and have severe complications.
This article was produced in partnership with the Tampa Bay Times.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
