Nursing practice for a patient with sepsis complicated by necrotizing fasciitis and acute kidney injury under multidisciplinary collaboration
多学科协作下1例脓毒血症合并坏死性筋膜炎伴急性肾损伤患者的 护理实践

摘要

目的 总结1例高龄、免疫抑制状态下罹患脓毒血症合并坏死性筋膜炎伴急性肾损伤危重患者的综合护理经验，探讨多学科协作模式下的精细化护理策略及其效果。方法 回顾性分析2024年收治的1例71岁男性患者（基础肾病综合征、长期激素治疗）的临床资料。针对脓毒血症、右下肢坏死性筋膜炎及急性肾损伤等核心问题，在医疗团队主导下，护理重点实施：1)多学科协作管理：联合护理部、骨科、感染科、皮肤科、伤口造口、营养科等，动态评估、制定并执行个体化护理方案；2)创面精细护理：密切观察肢体皮温、周径、动脉搏动及红肿范围变化，对压力性水疱行无菌穿刺抽液与培养，规范应用黄柏液、硫酸镁湿敷及微波照射，后期配合负压引流；3)抗感染与脓毒症监测：精准执行抗生素治疗，严密监测生命体征、炎症指标（WBC、NEU%、hsCRP、IL-6）及意识状态，警惕脓毒症休克；4)肾脏替代与容量管理：严格执行连续性肾脏替代治疗（CRRT）护理，加强导管维护及并发症观察（出血、凝血），严格记录出入量、监测中心静脉压（CVP）及体重，控制液体摄入，防范容量超负荷；5)营养与支持治疗：联合营养科制定并实施肠内肠外营养支持方案，纠正低蛋白血症及电解质紊乱；6)并发症预防：落实基础护理（口腔护理、皮肤护理、翻身拍背）、疼痛评估与管理（NRS评分）、出血观察、预防深静脉血栓（踝泵运动）及压力性损伤等措施。结果 经经过为期4周的综合治疗与精细化护理，患者感染得到有效控制（体温恢复正常，WBC由10.89→9.65×10⁹/L, NEU%由91.6%→ 65.0%, hsCRP由232.14→ 8.45mg/L），右下肢坏死性筋膜炎创面红肿疼痛显著消退，范围明显缩小，肉芽组织生长良好；肾功能改善（尿量由200-400ml/日恢复至约1600ml/日，血肌酐由峰值588.5 umol/L下降至115umol/L）；营养状况好转（白蛋白由19.46 g/L提升至34.5g/L）；未发生严重出血、新发深静脉血栓、压力性损伤等并发症。患者生命体征平稳（P 68次/分，BP 131/81mmHg），精神食欲好转，临床治愈出院。结论 对于高龄、免疫抑制合并脓毒血症、坏死性筋膜炎及急性肾损伤的危重患者，建立高效的多学科协作机制是成功救治的基础。实施以创面精细管理、精准抗感染监护、严格的CRRT与容量调控、个体化营养支持及全方位并发症预防为核心的精细化、系统化护理措施至关重要。护士在其中的专业评估、规范操作、严密观察及团队协调能力是保障患者安全、促进康复的关键因素。

Abstract

Objective To summarize the comprehensive nursing experience of a critically ill patient with sepsis complicated by necrotizing fasciitis and acute kidney injury in an elderly, immunosuppressed state, and to explore the refined nursing strategies and their effects under a multidisciplinary collaboration model.
Methods A retrospective analysis was conducted on the clinical data of a 71-year-old male patient (with underlying nephrotic syndrome and long-term steroid therapy) admitted in 2024. Addressing core issues such as sepsis, right lower limb necrotizing fasciitis, and acute kidney injury, the nursing team implemented the following priorities under the leadership of the medical team: 1) Multidisciplinary collaborative management: Collaborating with the Nursing Department, Orthopedics, Infectious Diseases, Dermatology, Wound Ostomy, and Nutrition Departments to dynamically assess, develop, and implement individualized nursing plans; 2) Detailed wound care: Closely monitoring changes in limb skin temperature, circumference, arterial pulses, and the extent of redness and swelling; performing sterile puncture and aspiration of fluid from pressure blisters followed by culture; applying Huang Bai solution, magnesium sulfate wet compresses, and microwave irradiation in accordance with standardized protocols; and later incorporating negative pressure drainage; 3) Antibiotic therapy and sepsis monitoring: Administer antibiotics precisely, closely monitor vital signs, inflammatory markers (WBC, NEU%, hsCRP, IL-6), and mental status, and be vigilant for sepsis-induced shock; 4) Renal replacement therapy and fluid management: Strictly adhere to continuous renal replacement therapy (CRRT) nursing protocols, reinforce catheter maintenance and monitor for complications (bleeding, coagulation), meticulously record fluid intake and output, monitor central venous pressure (CVP) and weight, control fluid intake, and prevent fluid overload; 5) Nutrition and supportive therapy: Collaborate with the nutrition department to develop and implement enteral and parenteral nutrition support plans to correct hypoalbuminemia and electrolyte imbalances; 6) Complication prevention: Implement basic nursing care (oral care, skin care, turning and back percussion), pain assessment and management (NRS scoring), bleeding monitoring, prevention of deep vein thrombosis (ankle pump exercises), and pressure injury prevention measures.
Results After four weeks of comprehensive treatment and refined nursing care, the patient's infection was effectively controlled (normalized body temperature, WBC from 10.89 to 9.65 × 10⁹/L, NEU% from 91.6% to 65.0%, hsCRP decreased from 232.14 to 8.45 mg/L), the redness, swelling, and pain at the right lower limb necrotizing fasciitis wound significantly subsided, the affected area notably reduced, and granulation tissue grew well; Renal function improved (urine output increased from 200–400 ml/day to approximately 1,600 ml/day, serum creatinine decreased from a peak of 588.5 umol/L to 115 umol/L); Nutritional status improved (albumin increased from 19.46 g/L to 34.5 g/L); no severe bleeding, new deep vein thrombosis, or pressure injuries occurred. The patient's vital signs were stable (heart rate 68 beats/min, blood pressure 131/81 mmHg), mental status and appetite improved, and the patient was discharged in clinical remission.
Conclusion   For critically ill patients with sepsis, necrotizing fasciitis, and acute kidney injury who are elderly and immunocompromised, establishing an efficient multidisciplinary collaboration mechanism is the foundation for successful treatment. Implementing refined and systematic nursing measures centered on meticulous wound management, precise anti-infection monitoring, strict CRRT and volume control, individualized nutritional support, and comprehensive complication prevention is crucial. The professional assessment, standardized procedures, close monitoring, and team coordination capabilities of nurses are key factors in ensuring patient safety and promoting recovery.