INTRODUCTION:

Infectious diseases are disorders that are caused by microorganisms and spread from one person to another through direct or indirect contact. Skin acts as a barrier between the host and environment. It comprises several layers and is colonized by various micro-organisms that may invade and cause infection of one or more layers.

Necrotizing fasciitis is a fatal clinical syndrome characterized by severe infectious process with progressive necrosis of the subcutaneous tissue, surface fascia, muscles and the skin. It is popularly known as flesh eating disease. It affects both the sexes. More common among older people and is very rare in children.

In 20 to 30% of cases the cause for necrotizing fasciitis cannot be determined. It affects 0.4 to 1.0 person per 100,000 per year¹.

The Necrotizing Fasciitis is a synonym of syndrome Fournier. This syndrome was described by the French urologist Jean Alfred Fournier in nineteenth century as fulminating idiopathic gangrene that rapidly destroys the genitalia, receiving the name of Fournier’s gangrene and being then considered syndrome. The origin of this syndrome arises from the synergism of very virulent aerobic and anaerobic Micro organisms spreading rapidly through the fascia, involving skin and blood vessels from the affected region which causes high mortality rates due to the release of toxins by pathogens in the blood stream, resulting in sepsis and septic shock that may lead to death with in 24 to 96 hours of disease progress^3.

There is difficulty of early diagnosis of this syndrome and its treatment. When the diagnosis is delayed and treatment is not initiated in a timely manner, the process evolves rapidly and may extend through out the body leading to complications such as sepsis, multiple organ failure and death.⁴

A diagnosis and care of a patient with necrotizing fasciitis is a great challenge to all health care professionals as it is not only debilitating to the patient, as well as associated with high mortality rate. The key to overcome this disease is proper planning and understanding between the clinical nurse and the student nurse to individualize treatment plan with proper wound care and hand washing, to meet the needs of patients. Multidisciplinary care is required to achieve the successful results.

Based on the above, the investigators aimed to assess the knowledge of Nursing students, regarding Necrotizing fasciitis.

OBJECTIVES:

1. To assess the knowledge of Nursing students regarding Necrotizing fasciitis.

2. To find out the association between the knowledge of nursing students with regard to Necrotizing fasciitis and their selected variables.

MATERIALS AND METHODS:

The present study was conducted by using quantitative approach with descriptive survey design. The study was carried out among Nursing students at selected college of Nursing, Guntur district, Andhra Pradesh. Eighty-eight Nursing students were selected for the study by using convenient sampling Technique. A structured questionnaire consisting of part – A and part – B was developed and used for collecting the data from the subjects. Part-A contained five items on demographic variables (like Age, year of study, gender, previous knowledge regarding Necrotizing fasciitis and previous experience in caring patients with Necrotizing fasciitis). Part – B consisted of 67 knowledge items on Necrotizing fasciitis. The data collection was done during the month of March 2018, personally by the investigators. The responses of Nursing students were organized and analyzed by using descriptive and inferential statistics.

MAJOR FINDINGS:

Section– I: Findings related to sample characteristics:

The study findings revealed that out of 88 Nursing students, 53(60.23%) were in the age group of 21 to 25 years, 22(25%) were below 21 years, 8(9.09%) were between 26 to 30 years, 5(5.68%) were between 31 to 35 years and none of the students were 36 years and above. When it comes to year of study, 56(63.64%) were studying final year B.Sc (N), 20(22.73%) students were studying I year M.Sc(N) and 12(13.63%) were studying II year MSc(N). Sixty six (75%) were Females and 22(25%) were males. Out of 88, fifty seven (64.77%) did not have previous knowledge regarding Necrotizing fasciitis and 31(35.23%) had previous knowledge regarding Necrotizing fasciitis. Seventy seven (87.5%) students had no experience in caring patient with Necrotizing fasciitis previously and only 11(12.5%) students had experience in caring patients with Necrotizing fasciitis previously.

Section – II: Findings related to knowledge of Nursing students on different aspects of Necrotizing faciitis:

a) Analysis on knowledge of Nursing students on definition of Necrotizing fasciitis:

Fifty one (57.95%) Nursing students knew that “Necrotizing fasciitis means infection of the connective tissue”. Only 21(23.86%) Nursing students knew that “Necrotizing Fasciitis is a kind of rapidly spreading Infection”. Thirty four (38.63%) Nursing students knew that “Any part of the body can get affected with necrotizing fasciitis”. Thirty nine (44.31%) nursing students knew that “Necrotizing fasciitis is also called as flesh eating disease”.

b) Analysis on knowledge of Nursing Students on classification of Necrotizing fasciitis:

Thirty one (35.22%) Nursing students knew that “Myonecrosis is a type of necrotizing fasciitis based on depth of infection”. Negligible (6 i.e., 6.81%) number of nursing students knew that “Ludwig angina is a type of necrotizing fasciitis based on anatomical sites”. Thirteen (14.77%) Nursing students knew that “Type –I is a poly microbial variety of Necrotizing fasciitis”. Only 9(10.22%) Nursing students knew that “Type-I variant is a salt water Necrotizing fasciitis”. Fourteen (15.90%) Nursing students knew that “Perineum is affected in Fournier gangrene”.

c) Analysis on knowledge of Nursing Students on Risk factors of Necrotizing fasciitis:

Thirty five (39.77%) Nursing students knew that “Diabetic patients have the highest possibility of developing necrotizing fasciitis”. Nearly half of the (46%) Nursing students knew that “Diabetic patients are more liable to get Fournier gangrene”.

d) Analysis on knowledge of Nursing students on etiology of Necrotizing Fasciitis:

More than half of the (50 i.e., 56.81%) Nursing students knew that “Necrotizing Fasciitis is caused by aerobic and anaerobic bacteria”. Fourty one (46.59%) Nursing students knew that “Group- A β hemolytic streptococci is the most commonest Bacteria which causes Necrotizing fasciitis”. Only 23(26.13%) Nursing students knew that “Vibrio vulnificus is present in warm sea water and causes Necrotizing fasciitis”. Fifty four (61.36%) Nursing students correctly agreed with the statement that “In most cases of necrotizing fasciitis the non-anaerobic organisms damage tissue areas and causes hypoxia, where the anaerobic bacteria then can thrive and extend the infection”. Twenty one (23.86%) Nursing students knew that “Type-III necrotizing fasciitis is caused by clostridium”. Fifty eight (65.90%) nursing students knew that “IM injections, IV Injections and sometimes sprains without any external injury leads to Necrotizing fasciitis”.

e) Analysis on knowledge of Nursing students on pathophysiology of Necrotizing fasciitis:

Thirty six (40.90%) Nursing students knew that “Multi bacterial symbiosis and synergy is the reason for the rapid and destructive clinical course of Necrotizing fasciitis”. Twenty one Nursing students (23.86%) knew that “Hydrogen, Nitrogen, Hydrogen sulphide and methane are produced in soft tissue infections by aerobic and anaerobic bacteria”. Thirty (34.09%) Nursing students knew that “Fibrous attachments between sub cutaneous tissue and fascia limit spread of infection to hands, feet and scalp”. Only 5(5.68%) Nursing students knew that “Lack of fibrous attachments in trunk and limbs leads to wide spread of infection and tissue destruction”.

Seventy (79.54%) nursing students correctly agreed with the statement that “Majority of Individuals who develop necrotizing fasciitis begin with an existing infection like cellulites, abscess or wound”. Thirty six (40.90%) nursing students correctly disagreed for the statement that “The symptoms of cellulites and Necrotizing fasciitis are totally different from one another”. Thirty nine (44.31%) Nursing students correctly disagreed for the statement that “The pain is restricted only to the affected area”. Half (50i.e.,56.81%) of the Nursing students correctly agreed with the statement that “Appearance of bullae indicates the progression of the infection”. Fourty seven (53.40%) nursing students correctly agreed with the statement that “crackling sensation under the skin is due to the formation of gas in the tissues”. Sixty one (69.31%) nursing students correctly agreed with the statement that “some patients develop septicaemia before the appearance of skin changes”.

Fourty four (50%) nursing students correctly disagreed with the statement that “formation of gas is the main symptom of Type-I Necrotizing fasciitis”. Fourty two (47.72%) Nursing students correctly agreed with the statement that “Bullae formation and rapid progression of the disease with in hours on the extremities are hallmarks of vibrio vulnificus wound infection”. Thirty four (38.63%) Nursing students correctly disagreed with the statement that “Epidermis is the first part to get infected in necrotizing fasciitis”. Twenty eight (31.8%) nursing students correctly disagreed with the statement that “Pain in necrotizing fasciitis is proportional to the degree of skin inflammation”. Only 19(21.59%) nursing students correctly disagreed with statement that “Necrotizing fasciitis presents with patchy discoloration of skin with well-defined margins and lymphangitis”. Fifty (56.81%) nursing students correctly agreed with the statements that “some infected patients with necrotizing fasciitis will experience a patch of anesthesia over the site of erythema”.

f) Analysis on knowledge of Nursing students on disease progression in necrotizing fasciitis:

Twenty eight (31.81%) Nursing students correctly answered that “When a patient with Necrotizing fasciitis has sepsis and rapidly develops multi-organ failure, the condition is called as Hyper acute Necrotizing fasciitis”.

Twenty five (28.40%) Nursing students correctly answered that “When a patient with necrotizing fasciitis shows a very slow progression of Infection for some period of time and suddenly shows deterioration in the condition it is called as sub acute Necrotizing fasciitis”. Only 15(17.04%) Nursing students correctly knew that “The tissue destruction in necrotizing fasciitis takes place with a speed of one inch per hour”.

g) Analysis on knowledge of Nursing students on Diagnosis of Necrotizing fasciitis:

Fourty three (48.86%) nursing students knew that “A diabetic patient with rectal fistula, pain, swelling and scrotal skin change is preliminarily diagnosed as a case of Fournier’s gangrene”. Fifty two (59.09%) Nursing students knew that “A diabetic patient with liver failure and bullae on the skin and a history of exposure to sea water is preliminarily diagnosed as a case of necrotizing fasciitis due to vibrio vulnificus infection”.

For the question about the diagnostic tests used for necrotizing fasciitis, out of 88 nursing students 42(47.75%) opted “MRI”, 13(14.77%) opted “biopsy” and 8(9.09%) opted the “testing of exudates”, which are the correct options. Twenty three (26.13%) nursing students knew correctly that “finger test is nothing but Inserting the index finger in to the layers of fascia”. Twenty one (23.86%) nursing students knew that “when the fascia and dermis are easily separated on insertion of the finger it indicates that finger test is positive for Necrotizing fasciitis”.

h) Analysis on knowledge of nursing students on Treatment of Necrotizing fasciitis:

Fifty three (60.22%) nursing students knew that “Tissue hypoxia limits the efficacy of intravenous antibiotics”. Seventy three (82.95%) nursing students have correctly answered that “early surgical debridement reduces the rate of mortality”. Fourty seven (53.40%) nursing students knew that “Intravenous immunoglobulins are given to treat patients with streptococcal Toxic shock syndrome. Sixty two(70.45%) nursing students answered that “Negative pressure wound therapy (vacuum) dressing is recommended for better wound healing”. Thirty four (38.63%) nursing students knew correctly that “Hyperbaric oxygen Therapy is used to treat a client with anaerobic bacterial infection”. Thirty seven (42.04%) Nursing students knew that “Amputation is not the only choice of treatment in case of necrotizing fasciitis”.

i) Analysis on knowledge of nursing students on prevention of Necrotizing fasciitis:

Sixty five (73.86%) Nursing students knew that “Immediate and effective treatment of any infection prevents necrotizing fasciitis”. Fourty nine (55.68%) nursing students knew that the practices like hand washing, good hygiene can prevent the occurrence of Necrotizing fasciitis”. Fourty five (51.13%) Nursing students knew that “People with liver disease should avoid eating sea foods to avoid necrotizing fasciitis”.

j) Analysis on knowledge of nursing students on prognosis of Necrotizing Fasciitis:

Twenty nine (32.95%) Nursing students knew that “Infection with MRSA have high mortality rate”. Fourty eight (54.54%) nursing students knew that “Necrotizing fasciitis can lead to death of the patient”. Fifty seven (64.77%) Nursing students knew that “The treatment of Necrotizing fasciitis should be initiated within 24 hours for a better prognosis”.

k) Analysis on knowledge of Nursing students on complications of Necrotizing Fasciitis:

Only 15(17.04%) Nursing students knew that Renal failure is a serious complication of necrotizing Fasciitis.

l) Analysis on knowledge of Nursing students on pre-operative care of Necrotizing fasciitis:

Sixty four (72.72%) Nursing students knew that ‘’ top prioriy should be given for pain assessment while caring for a patient with Necrotizing fasciitis”. Fourty four (50%) nursing students knew that “Necrotizing fasciitis is common among Intravenous drug users and alcholics”. Fourty nine (55.68%) nursing students knew that “The pain is out of proportion to the visible symptoms”. Fifty (56.81%) Nursing students knew that ”Elevation of the affected part reduces the pain”. Twenty eight (31.81%) Nursing students knew that” warmth and moist dressing of wound is not prohibited in Necrotizing fasciitis. Fourty six (52.27%) nursing students knew that “Ice packs should not be applied at the wound site”. Fourty five (51.13%) Nursing students knew that ”spontaneous reduction in pain and sensation is not an indication of recovery from the infection”.

m) Analysis on knowledge of Nursing students on Post–operative care of Necrotizing Fasciitis:

Sixty seven (76.13%) Nursing students answered correctly that “The affected part should be elevated after the surgery to reduce the swelling”. Sixty five (73.86%) Nursing students knew that “Post operatively the wound edges should be marked and dated to assess the spread of infection”. Sixty five (73.86%) Nursing students knew that “Psychological support plays an important role in fast recovery of the patient”. Sixty two (70.45%) Nursing students knew that “Intake and output chart should be maintained for all the patients”. Seventy (79.54%) Nursing students answered correctly that “Increased heart rate, Increased B.P, restlessness and anxiety signify greater pain in these patients”

SECTION – III:

Table 1: Mean and Standard Deviation of Nursing Students Based on Their Knowledge Regarding Necrotizing Fasciitis N=88

S. No.	Item	Mean ()	Standard Deviation (SD)
1.	Knowledge regarding Necrotizing fasciitis	30.73	8.06

The mean knowledge score of sample was 30.73 with the standard deviation of 8.06.

Table 2: Frequency and Percentage Distribution of Nursing Students Based on knowledge level Regarding Necrotizing Fasciitis

N=88

Knowledge

Frequency

Percentage

Adequate Knowledge (>76%)

Moderate Knowledge (51-75%)

Inadequate Knowledge (<50%)

32.95%

67.04%

The values in the above table reveal that, majority of students had inadequate knowledge (59 i.e. 67.04%); very negligible number of students had moderate knowledge (29 i.e. 32.95%); none of the students had adequate knowledge.

Table 3: Association Between the Knowledge of Nursing students with Selected Demographic Variables N=88

S. No.	Variables	Chi-Square Calculated Value	Table Value	Degree of freedom
1.	Age	5.64^NS	15.51	8
2.	Year of study	17.16*	9.49	4
3.	Gender	1.7^NS	5.99	2
4.	Previous knowledge regarding Necrotizing Fasciitis	0.43^NS	5.99	2
5.	Previous experience in caring patient with Necrotizing fasciitis	0.24^NS	5.99	2

Note : *Denotes significant at 0.05 level of significance

^NSDenotes not significant at 0.05 level of significance

The Chi-Square values computed between knowledge of Nursing students and their year of study (χ² = 17.16) were found to be significant at 0.05 level of significance. The calculated Chi-Square values between the knowledge of nursing students and their age (χ² = 5.64), gender (χ² = 1.7), previous knowledge (χ² = 0.43) and previous experience (χ² = 0.24) were not significant at 0.05 level of significance.

DISCUSSION:

The present study was conducted to assess knowledge about necrotizing fasciitis among nursing students. The present study consisted majority of the females than males. Similar to this, the results of a study which was conducted by krishnaa keshaav et.al., showed that their study also had majority of females in comparison to males.

In the present study none of the students had adequate knowledge regarding necrotizing fasciitis. Similar to this, a study which was conducted among nursing population by krishnaa keshaav et.al., showed that majority of the nurses were not aware about the condition called necrotizing fasciitis.

Hence, there is a need for educating the nursing students about the necrotizing fasciitis.

CONCLUSIONS:

Majority of nursing students (59 i.e., 67.04%) had inadequate knowledge with regard to Necrotizing fasciitis.

Significant association was there between the knowledge of nursing students on Necrotizing fasciitis and their year of study (χ² = 17.16).

REFERENCES:

1. Krishna et.al., Journal of drug invention today, Awareness about necrotizing fasciitis among student population Vol 10, Issue 11, 2018, 2165-2168

2. http://www.afmr.org/abstracts/2009/SR2009_abstracts/37.cgi

3. Abrahamian FM, Talan DA, Moran GJ. Management of Skin and Soft-Tissue Infections in the Emergency Department. Infect Dis Clin North Am. 2008;22(1):89-116.

4. Shukla A, Sharma A. Clinical study of necrotizing fasciitis and its management. Int Surg J 2017; 4:1964-7.

5. Wilson B. Necrotizing fasciitis. Am Surg 1952; 18:416-31.

Received on 01.06.2019 Modified on 17.07.2019

Int. J. Nur. Edu. and Research. 2019; 7(3):386-390.

DOI: 10.5958/2454-2660.2019.00087.5