A Case Study on CELLULITIS

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Objectives

A. General Objectives:After the nursing case study the student nurse will be able to:

a.1) discriminate the essential information’s that would be vital in dealing with related situations which calls for valuable judgment a.2) practice the knowledge learned in rendering effective independent nursing care to future exposures to clients with similar conditions

a.3) accept willingly the importance of comprehending the information being presented in order to have the fundamentals in dealing with related potential cases.

B. Specific Objectives:After the nursing case study the student nurse will be able to:

b.1)identify what is cellulites and its different types in relation to its causative agents

b.2) conform to the appropriate ways of dealing clients with cellulitesb.3) perform competent independent nursing care interventions in

order to alleviate any conditions experienced by the client with cellulitesb.4) demonstrate appreciation for the significance of understanding

the anatomy and physiology of the affected area/system relative to the disease and the disease process

b.5) appraise the importance compliance to the treatment regimen for the said condition.

Hospital #: 62363-2010 Medical Record #: 53533

Name of Patient: ITUM, MARCEKLINO BALICOAL Gender: Male Age: 58Y3YM1

Birthplace: Cagayan de Oro City Weight: 142lbs.

Birthdate: October 10, 1952

Address: Prk.7 Tipanoy , Iligan City Lanao Del Norte

Health Insurance: PhilHealth Civil Status: Married Religion: Roman Catholic Primary Language: Bisaya

Date Admitted: 01-10-11 Time: 7:00 am

Admitting Physician: Dr. Jamel Omar Norden MD

Attending Physician: Dr. Richito Sarmiento MD

P A T I E N T ’ S P R O F I L E

Admit patient to ROD under the management of Dr. Richito Sarmiento

Secure consent TPR with BP q 4 Low salt, low fat diet Start venocolysis with Plain NSS at 29

gtts./min LABS: CBC,UA,CREATININE,FBS,SGPT,URIC

ACID,UTZ MEDS: I&O q shift

Doctors Orders

Chief Complaint: Infected Wound at Right Leg

History of Present Illness:Four days onset of pustule like lesions on the

right leg which later become enlarged and erythematous with tenderness and local swelling.

Past Medical History: Hypertension Family History: Smoking Final Diagnosis

Abscess with Cellulites at right leg.

N U R S I N G A S S E S S M E N T

G.I • Abdominal falt and rounded • Bowel sounds active and continent flatus • (-) nausea /emesis • (+) gag reflex • Diet: DAT Chest and Lungs:• (-) crackles, • (-) wheezing • RR: 20 bpm • Airway not obstructed• Unlabored effort• Breath sounds clear at all lobes• (-) cough CV:• apical pulse: 74 bpm • Radial pulse: 72 bpm, norrmal and bounding• (+) edema at right leg • Capillary refill: < 3 seconds

P H Y S I C A L A S S E S S M E NT

INTEGUMENTARY :• Appearance: warm and intact; • (+)4x4 lesion at right leg with ulceration; • (+) sanguineous discharges• (+) localized swelling • (+) tenderness • Dressing intact • IV site patent • IV solution: Plain NSS GU: • Bladder not distended when palpated • (-) FBC • Voiding: continent • (-) penile discharges VITAL SIGNS:• BP: 140/90 MMHG, RR: 20 BPM, PR: 94 BPM, TEMP: 37.8 C

Diagnostics and Laboratory Results

ULTRASOUND RESULT 01/18/11

• Normal size kidneys with suggestive changes of parenchymal disease.

Ultrasonically normal urinary bladder

No ascites

Physical • Color: yellow• Transparency: slightly hazy • Ph: 6.5 • Specific gravity: 1.005 Chemical • (-) Albumin • (-) Glucose • Glucose testing: 5.80 • Creatinine: 75 • Uric acid: 299 • SGPT: 19

Urinalysis

SPECIMEN: WOUND DISCHARGE

GROWTH OF ENTEROBACTER sakazakii

Sensitive to: Resistent to:Ceftazidine Clindamycin Imipenem AmpicillinTazopactam LinezolidCiprofloxacinMoxifloxacin

CULTURE AND SENSITIVITY TEST

Interpretation:

Hematocrit- (0.33) Increases: dehydration, polycythemia

vera Decreases: anemia, hemorrhage Hemoglobin- (112) Increases: polycythemia vera Decreases: anemia, hemorrhage WBC- (10.0) Increases: acute infection, leukemia decreases: aplastic anemia

Cellulitis is a local soft-tissue inflammatory reaction secondary to bacterial invasion of the skin. Generally characterised by erythema, swelling, pain and hardening. Cellulitis may be acute, sub-acute or chronic. Trauma may be a predisposing cause, but hematogenous and lymphatic dissemination can be the cause of its sudden appearance in previously normal skin. The most common bacteria causing cellulitis are staphylococci or streptococci.

Cellulitis

The most common type of cellulitis is Cellulitis of the extremities. Other types:

Breast Cellulitis Breast cellulitis is a bacterial skin infection that occurs on the breast. skin

affected by cellulitis will commonly be red, swollen, and warm and painful to the touch. Breast cellulitis is treated with antibiotics.

Facial Cellulitis Facial cellulitis is a bacterial skin infection that occurs on the face. Leg Cellulitis is a condition characterized by redness, warmth, swelling, and painOrbital Cellulitis Orbital cellulitis is an infection that can lead to permanent vision

problems. Perianal Cellulitis Perianal cellulitis is a bacterial infection that occurs around the anal

orifice. Periorbital Cellulitis Periorbital cellulitis is a bacterial infection that occurs around the eyelid.

Types:

Causes of Cellulitis

Cellulitis is caused by a type of bacteria entering the skin, usually by way of a cut, abrasion, or break in the skin. This break does not need to be visible. Group A Streptococcus and Staphylococcus are the most common of these bacteria, which are part of the normal flora of the skin, but normally cause no actual infection while on the skin's outer surface.

Predisposing conditions for cellulitis include; insect or spider bite blistering animal bite tattoos pruritic (itchy) skin rash, recent surgery athlete's foot, dry skin, eczema injecting drugs (especially subcutaneous or intramuscular injection or

where an attempted IV injection "misses" or blows the vein), pregnancy, diabetes and morbid obesity burns and boils

Diabetes Neuropathic limb Sepsis Chronic ulcer Osteomyelitis Bursitis Immunocompromised – eg. Steroid use, cirrhosis Impaired wound healing Non-blanching rash History of water contact Bites Traumatic crush injury

Predisposing factors

Signs and Symptoms

pain or tenderness erythema that blanches on palpation, swelling to the involved area and local

warmth Cellulitis caused from infection tends to be

reproducibly tender in the reddened area. Systemic involvement with fever, and leukocytosis is common.

scaly redness on the shins and ankles

Diagnostic Tests: Appearance of the skin/presence of signs and

symptoms blood tests, a wound culture or other tests to help rule

out a blood clot deep in the veins of the legs ultrasound will be used to make sure there is not a

blood clot in a deep vein. A CT scan or an MRI may also be done to rule out

other problems FBC – Signs of sepsis Prolonged inflammation despite medical intervention Neutropenia X-RAY affected limb if fracture/ foreign body or

osteomyelitis is suspected (chronic history or diabetic)

Bone infection (osteomyelitis) Inflammation of the lymph vessels (

lymphangitis) Sepsis, shock Tissue death (gangrene) Blood poisoning Abscess Facial cellulitis and meningitis

Complications

Anatomy and Physiology

The Epidermis

The epidermis, as its name suggests, is the outermost layer of the skin. It is comprised of four separate layers of epithelial tissue. The outermost layer of the epidermis is the stratum corneum. It is approximately 20-30 cells thick. The cells here are completely keratinized and dead, and this is what gives the skin its waterproof quality. The next two layers, the stratum granulosum and the stratum lucidum, are siimilar in that they represent an intermediate stage of keratinization. The cell here are not fully keratinized yet, but as the growth of the skin pushes them outward, they will increasingly move towards that state. The deepest layer of the epidermis is the stratum germinativum. The cells here are mitotically active-- that is, they are alive and reproducing. This is where the growth of skin takes place.

Parts and it’s Functions

The Dermis

The dermis is the second layer of skin, directly beneath the epidermis. Unlike the epidermis, the dermis has its own blood supply. Because of the presence of this blood supply, more complex structures are able to exist here. Sweat glands are present to collect water and various wastes from the bloodstream, and excrete them through pores in the epidermis. The dermis is also the site of hair roots, and it is here where the growth of hair takes place. By the time hair reaches the environment outside of the skin, it is completely dead. The dermis also contains dense connective tissue, made of collagen fibers, which gives the skin much of its elasticity and strength.

The Subcutaneous Layer

Beneath the dermis lies the final layer of skin, the subcutaneous layer. The most notable structures here are the large groupings of adipose tissue. The main function of the subcutaneous layer is therefore to provide a cushion for the delicate organs lying beneath the skin. It also functions to insulate the body to maintain body temperature.

The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. The skin has an important job of protecting the body and acts as the body’s first line of defense against infection, temperature change, and other challenges to homeostasis. Functions include:

Protect the body’s internal living tissues and organs Protect against invasion by infectious organisms Protect the body from dehydration Protect the body against abrupt changes in temperature,

maintain homeostasis Help excrete waste materials through perspiration Act as a receptor for touch, pressure, pain, heat, and cold (see

Somatosensory system) Protect the body against sunburns Generate vitamin D through exposure to ultraviolet light Store water, fat, glucose, and vitamin D

The intent of cellulitis treatment is to decrease the severity of the infection, speed up recovery, relieve pain and other symptoms, heal the skin, and prevent the infection from coming back.

Antibiotics are usually used to treat cellulitis. If the infection is limited to a small area, has not spread to the bloodstream or lymph system, and you don't have any other medical problems, antibiotics you take by mouth (oral) are effective. If the infection is more widespread, or if you're having a slow recovery on oral antibiotics, antibiotics may be used intravenously (IV) or by injection.

For cellulitis of the leg or arm, treatment also includes elevating the limb to reduce swelling.

Medical Management

Medications used to treat cellulitisThe extent of the infection and its location

help determine what type of antibiotic is used.

Oral antibiotics include penicillin or a similar medication such as dicloxacillin. For people who are allergic to penicillin, a cephalosporin, erythromycin, or vancomycin can be used.

Topical antibiotics including mupirocin may be used for children with cellulitis in the area around the anus.3

Intravenous antibiotics may include nafcillin, levofloxacin, or cephalosporin

Nursing Interventions

skin Integrity Cellulitis makes skin susceptible to other damage,

including bed sores. Even if there are no open sores from the infection, the swelling can weaken the skin and lead to problems.. Interventions include avoiding friction against the infected area, turning the patient regularly and keeping the area dry.

Pain · Severe cellulitis can be very painful, especially if it

has spread throughout the system. Ask the patient to describe the type and intensity of the pain and monitor the effect of pain medication. If the medication isn't helping, contact the patient's doctor to determine if a higher dose needs to be given. Regularly assess vital signs, as pain can increase heart rate and blood pressure.

Activity The patient's tolerance for activity can be affected by cellulitis. The related

factor may include pain, fatigue due to medication or general weakness as expressed by the patient. For example, "activity intolerance related to side effects of medication as manifested by patient saying she feels weak." Encourage the patient to engage in as much physical activity as she feels possible, help her perform range of motion exercises and allow for adequate periods of rest and relaxation.

Fever Fever is a common symptom of cellulitis and could be expressed as

"hyperthermia related to bacterial infection." The evidence may include elevated heart rate, flushing, warm skin or excessive sweating. Since fever can lead to dehydration, it is important to make sure your patient gets plenty of fluids. Fever can also be the cause of a diagnosis, such as "risk for deficient fluid volume." In this case, interventions would involve keeping the patient free of fever by administering doctor-prescribed fever reducers and monitoring vital signs.

Knowledge Deficit Cellulitis may be prevented by taking simple precautions, especially with

wounds. These include cleaning the wound, applying antibiotic cream, keeping it covered and watching for signs of infection.

Preventing a recurrence of cellulitis Good hygiene and good wound care lower the risk of

cellulitis. Any wounds should be cleaned and dressed appropriately. Changing bandages daily or when they become wet or dirty will reduce the risk of contracting cellulitis. Medical advice should be sought for any wounds which are deep, dirty or if there is concern about retained foreign bodies.

Cellulitis tends to recur in people with certain medical conditions that can lead to skin breakdown, such as edema (fluid buildup), fungal or bacterial infections, diabetes, or peripheral arterial disease.

Apply support stockings in patients with edema Application of good skin hygiene to reduce or eliminate

recurrence of cellulitis.

use of antifungal medications in recurring skin fungal infections to help reduce condition

Adinistering preventive antibiotics as ordered to help high risk patients.

Promoting Fluid Intake and Maintaining Nutrition◦ Encourage fluids (2L/day minimum with

electrolytes and calories).◦ Administer intravenous fluids and nutrients, if

necessary. Adhere to proper nutritional intake with foods rich in vitamins, minerals and protein to hasten wound healing.

◦ Instruct on cause of Cellulitis and management of symptoms.

◦ Explain treatments in simple manner and using appropriate language.

◦ Repeat instructions and explanations as needed

Teaching Patients Self-Care

Instruct the patient to: follow doctor's instructions for taking medication and for skin

care. Take all of medication as prescribed. Proper skin care skin. Any measure that prevents injury to skin

will help to prevent cellulitis. Elevate affected leg or arm to reduce swelling. Apply warm compresses to the affected area. Use pain relievers as needed. Use support stockings to prevent fluid buildup. Take steps to treat or prevent fungal infections, such as

athlete's foot. If athlete's foot is hard to treat or recurs, ask primary health care provider about oral antifungal medications

Take care of feet, especially in patients having diabetes or other conditions that may increase the risk of infection.

Avoid touching possible sources of infection, such as ill family members and their belongings; raw fish, meat, or poultry; or soil, particularly when you have an area of broken skin.

Follow up visits.

Outlook (Prognosis)

It is possible to be cured with 7 - 10 days of treatment. Cellulitis may be more severe in people with chronic diseases and those who are more prone to infection because their immune system is not working properly (immunosuppressed).

People with fungal infections of the feet may have cellulitis that keeps coming back. The cracks in the skin offer an opening for bacteria to get inside.

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the condition may recur. Relapses can be far more serious than the first attack.

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

Drink lots of fluids, especially water and proper nutirional intake. Liquids will keep patient from becoming dehydrated and foods that are nutritionally dense promotes wound healing and recovery.

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. It’s important to have the doctor monitor his progress.

Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Give supportive treatment. Protection from infection. Application of proper hand washing and placement of

soiled and used articles must be observed. Practicing good hygiene, cleaning of articles and home equipments and environmental sanitation must be put in mind in order to prevent bacterial growth and spread of infectious agents.

Discharge Plan

References:   Nursing Care Plan 7th Edition   Nursing Diagnosis Handbook   Medical-Surgical Book   Encarta Encyclopedia 2007   http://www.healthsystem.   http://www.mayoclinic.com/health/cellulitis/