Cellulitis nursing diagnosis

A wound is any skin breakdown or tissue injury that disrupts structural integrity and leads to functional loss. Compromised integrity of the skin, mucous membranes, or organs can result in a wound and infection. Wounds may be acute or chronic as well as closed (under the skin’s surface such as with hematomas) or open due … Cellulitis is a bacterial subcutaneous skin infection. It appears as a reddened, swollen area of the skin and is usually easily diagnosable through inspection. Cellulitis can occur from a simple break in the skin allowing bacteria to enter. Common causes include: Patients are also more at risk for cellulitis when they are overweight, have … Pressure ulcers, also known as decubitus ulcers, pressure injuries, or bedsores are a type of skin breakdown that occurs due to constant pressure causing a lack of blood flow and oxygen which leads to poor tissue perfusion and tissue death. Patients most at risk for developing pressure ulcers are older, bedridden, immobile, and those who …

Pathophysiology: • Cellulitis is an infection of the skin (epidermis and dermis) or underlying soft tissues (hypodermis); it can spread rapidly and be life-threatening. • Bacterial organisms enter a compromised skin barrier and cause infection. • The most common bacterial organisms are Staphylococcus aureus and group A Streptococcus. • This condition can occur anywhere but mainly occurs on the lower leg. Diagnosis: • Wound culture/ swab • X-ray to rule out possible complications such as osteomyelitis • Blood cultures if sepsis and bacteremia is suspected • Ultrasound if an abscess is suspected • Eron classification system of soft tissue and skin infections (SSTI) to determine the severity of cellulitis infection and possible systemic involvement • Patients are categorized based on their clinical appearance. • Class 1: no fever and healthy; no systemic toxicity, no comorbidities • Class 2: fever and appears ill; systemic symptoms, stable comorbidities • Class 3: significant toxicity; at least one unstable comorbidity • Class 4: Sepsis; life-threatening condition Screen the patient for risk factors of developing cellulitis. Risk factors such as a previous history of cellulitis, frequent fungal infections, trauma, chronic skin conditions, obesity, diabetes mellitus type 2, lymphedema, and venous insufficiency need to be considered and included in the treatment plan. Identify the cause of the skin damage. Information about the cause of the compromised tissue guides interventio...

Pathophysiology Cellulitis is a common deep bacterial skin infection that causes redness, swelling, and pain in the affected area of the skin (usually the arms and legs). If untreated, can spread and cause serious health problems. Etiology Cellulitis is usually caused by bacteria that enters into a wound, bruise, burn, surgical cut, bite, or an ulcer. Group A strep (streptococcal) being the most common cause. Desired Outcome Patient will re-establish healthy skin integrity and be free from infection Subjective Data • Pain • Tenderness • Weakness Objective Data • Redness (tends to expand) • Swelling • Warm to the touch • Fever/chills • Red spots • Blisters • Skin dimpling Nursing Interventions and Rationales Nursing Intervention (ADPIE) Rationale Full skin assessment/mark edges with skin marker (note color, swelling, blisters) to determine the severity of cellulitis. Marking the border of cellulitis can determine if it continues to spread and/or if antibiotic therapy is working Antibiotic Therapy/Pain medication Many cellulitis cases are treated with PO antibiotics, but more serious cases may need to be treated in hospital with IV antibiotics NOTE: patient should take full course of antibiotics Pain meds- assess pt’s pain level and give pain medication as needed Elevation of affected extremity elevating the affected extremity helps decrease swelling and speeds up recovery Assess VS/Labs/CT/MRI imaging possible VS- patient can develop a fever Labs- CBC (WBC), Creatinine, CRP...

Cellulitis Cellulitis is usually a superficial infection of the skin (left). But if severe (right) or if left untreated, it can spread into the lymph nodes and bloodstream. Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. The affected skin is swollen and inflamed and is typically painful and warm to the touch. Cellulitis usually affects the lower legs, but it can occur on the face, arms and other areas. The infection happens when a break in the skin allows bacteria to enter. Symptoms Cellulitis usually occurs on one side of the body. Its signs and symptoms may include: • An irritated area of skin that tends to expand • Swelling • Tenderness • Pain • Warmth • Fever • Chills • Spots • Blisters • Skin dimpling When to see a doctor It's important to identify and treat cellulitis early because the condition can spread rapidly throughout your body. Seek emergency care if: • You have a swollen, tender rash or a rash that's changing rapidly • You have a fever See your health care provider, preferably within the same day, if: • You have a rash that's swollen, tender and warm — and it's expanding — but you don't have a fever Causes Cellulitis is caused when bacteria, most commonly streptococcus and staphylococcus, enter through a crack or break in the skin. The incidence of a more serious staphylococcus infection called methicillin-resistant Staphylococcus aureus (MRSA) is increasing. Cellulitis can occur anywhere on the body, but the most common...

The skin is the body’s outermost defense system that keeps pathogens from entering and causing illness. When the skin is compromised due to cuts, abrasions, ulcers, incisions, and wounds, it allows bacteria to enter causing infections. It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity. Causes: (Related to) Internal: • Poor nutritional state ( • • Impaired circulation • • Disease processes ( External: • • Hypothermia • Radiation • Chemicals • Extremes in age • Physical immobilization/bedrest • Paralysis • Surgery • Cognitive impairment • Moisture/secretions • Shearing/friction/pressure Signs and Symptoms (As evidenced by) Subjective: (Patient reports) • • Itching • Numbness to affected and surrounding skin Objective: (Nurse assesses) • Changes to skin color (erythema, bruising, blanching) • Warmth to skin • Swelling to tissues • Observed open areas or breakdown, excoriation Expected Outcomes • Patient will maintain intact skin integrity • Patient will experience timely healing of wounds without complications • Patient will demonstrate effective • Patient will verbalize proper prevention of pressure injuries Nursing Assessment for Impaired Skin Integrity Intervention Rationale Complete skin assessment A thorough head-to-toe skin assessment should be performed on admission, transfer between units, and once per shift to monitor and/or prevent skin breakdown. Braden Skin Assessment The Braden Scale is an eviden...

Cellulitis is a common skin infection that always requires treatment. That’s why it’s important not to ignore the symptoms, such as an irritated or painful rash, skin blisters, swelling, and fever. Early treatment is the best way to prevent potentially serious complications from cellulitis. Cellulitis is a bacterial skin infection. It happens when small cuts or other skin breaks allow bacteria to enter. It causes painful inflammation and swelling and can make your skin feel overly warm. In most cases, cellulitis outbreaks occur on the lower legs. However, your arms, face, and other areas of the body can also be affected. It’s important not to ignore cellulitis symptoms. The condition will not go away on its own, but early treatment can prevent serious complications. If cellulitis is left untreated, the infection can spread to the bloodstream and to the lymph nodes. Once the infection begins to spread, it can quickly become life threatening. Common cellulitis symptoms The early symptoms of cellulitis can present differently in different people. The symptoms and how severe they are can also vary depending on the part of your body that’s affected. General symptoms of cellulitis typically include: • • swelling • an irritated • lines that run outward from the main rash area • pain in the affected area • skin that’s tender to the touch • skin that’s warm to the touch • skin that feels tight or looks glossy • skin dents or dimpling • • headache Severe symptoms of cellulitis Sympt...