Cellulitis is a common bacterial skin infection that manifests as a localized area of redness, swelling, warmth, and pain. This infection occurs when bacteria, often Streptococcus and Staphylococcus, enter through breaks in the skin, such as cuts, abrasions, or surgical incisions. While typically diagnosed through visual inspection, cellulitis requires prompt medical attention and nursing care to prevent complications and ensure effective patient management.
Understanding Nursing Diagnosis Care Plans For Cellulitis is crucial for nurses to provide holistic and patient-centered care. This guide delves into the essential aspects of nursing care for patients with cellulitis, encompassing comprehensive assessments, targeted interventions, and detailed care plans addressing common nursing diagnoses. By utilizing these care plans, nurses can effectively manage patient symptoms, prevent the spread of infection, educate patients on self-care, and promote optimal recovery.
Overview of Cellulitis
Cellulitis arises when bacteria breach the skin’s protective barrier and invade the deeper layers of the dermis and subcutaneous tissue. Several factors can predispose individuals to this infection:
- Skin Trauma: Any disruption to the skin integrity, including cuts, burns, puncture wounds, surgical incisions, tattoos, and piercings, provides an entry point for bacteria.
- Breaks in the Skin: Skin conditions like eczema, psoriasis, athlete’s foot, and even dry, cracked skin can compromise the skin barrier, increasing susceptibility to cellulitis.
- Insect and Animal Bites: Bites can directly introduce bacteria into the skin or create wounds that become infected.
- Intravenous Drug Use: Injection sites can become portals of entry for bacteria, leading to skin and soft tissue infections.
- Underlying Medical Conditions: Conditions such as obesity, lymphedema (chronic swelling), peripheral vascular disease, diabetes mellitus, chronic kidney disease, chronic liver disease, and immunosuppression (e.g., HIV/AIDS) impair circulation, weaken the immune system, or compromise skin integrity, elevating the risk of cellulitis.
- Poor Hygiene: Inadequate hygiene practices, particularly in individuals with risk factors, can contribute to bacterial colonization and infection.
Untreated cellulitis can lead to serious complications, although these are uncommon with prompt antibiotic therapy. Potential complications include:
- Osteomyelitis: Infection of the bone.
- Sepsis: A life-threatening condition arising from the body’s overwhelming response to infection.
- Endocarditis: Infection of the inner lining of the heart chambers and valves.
- Gangrene: Tissue death due to insufficient blood supply.
- Necrotizing Fasciitis: A severe, rapidly progressing infection that destroys deep tissues (“flesh-eating bacteria”).
The Nursing Process for Cellulitis
Nurses play a pivotal role in the care of patients with cellulitis, particularly in inpatient settings. Many patients lack awareness of the condition, its causes, the influence of their existing health problems, and the importance of treatment and skin care. Given the potential for serious complications, vigilant monitoring of vital signs, laboratory results, and symptoms is paramount. The nursing process provides a structured framework for delivering comprehensive care.
Nursing Assessment for Cellulitis
The initial step in nursing care is a thorough nursing assessment, which involves gathering subjective and objective data to understand the patient’s condition comprehensively.
Review of Health History
1. Detailed Inquiry About Skin Trauma: Elicit a detailed history focusing on potential skin injuries or exposures. Ask about:
- Recent Trauma or Injuries: Any cuts, scrapes, punctures, burns, or surgical wounds.
- Insect or Animal Bites: Details of any bites, including the type of animal or insect if known.
- Skin Exposure to Standing Water: Potential exposure to contaminated water sources.
- Travel History: Recent travel to areas with different environmental exposures or infectious disease prevalence.
- New Tattoos or Piercings: Recent procedures performed with potential hygiene concerns.
- Use of Intravenous Drugs: History of IV drug use and injection practices.
2. Identification of Risk Factors: Determine the presence of risk factors that increase susceptibility to cellulitis:
- Overweight or Obesity: Increased skin folds and impaired circulation.
- Chronic Swelling (Lymphedema): Fluid accumulation compromises tissue integrity.
- Immunosuppression: Conditions or medications that weaken the immune system.
3. Review of Medical History: Investigate pre-existing medical conditions that elevate cellulitis risk:
- Diabetes Mellitus: Impaired circulation and immune function.
- Chronic Kidney Disease: Compromised immune system and fluid balance.
- Chronic Liver Disease: Impaired immune function and clotting factors.
- HIV/AIDS: Significant immunosuppression.
- Peripheral Vascular Disease: Poor circulation in the extremities.
4. Assessment of Surgical History and Devices: Explore surgical history and the presence of implanted devices:
- Post-Surgical Complications: Cellulitis as a potential surgical site infection.
- External Orthopedic Pins: Entry points for bacteria.
- Indwelling IV Catheters: Potential infection source at the insertion site.
- Other Surgical Implants: Prosthetics or other foreign materials that can become infected.
Physical Assessment
1. Inspection of Skin Changes: Carefully examine the affected area for the hallmark signs of cellulitis:
- Erythema (Redness): Localized redness that may spread.
- Pain: Tenderness and pain upon palpation or movement.
- Swelling (Edema): Localized swelling and induration.
- Warmth: Increased temperature of the affected skin compared to surrounding tissue.
2. Marking the Area of Infection: Use a skin marker to outline the borders of redness. This technique allows for objective monitoring of infection spread or resolution over time. Document the date and time of marking.
3. Assessment of Lower Extremities: While cellulitis can occur anywhere, it is most common in the lower legs and feet. Assess both lower extremities, noting unilateral or bilateral involvement (cellulitis is rarely bilateral).
4. Monitoring for Systemic Symptoms: Assess for flu-like symptoms, which may indicate a more severe infection or systemic involvement:
- Fever: Elevated body temperature.
- Chills: Shivering and feeling cold.
- Malaise: General feeling of discomfort, illness, or fatigue.
- Lymphadenopathy: Swollen lymph nodes in the groin, axilla, or neck, depending on the cellulitis location.
Diagnostic Procedures
1. Diagnosis by Clinical Inspection: In many cases, cellulitis can be diagnosed clinically based on physical examination, particularly when:
- The infection is localized to a single area.
- Pain is mild to moderate.
- Systemic signs of illness are absent.
- The patient has no significant risk factors for severe illness.
2. Needle Aspiration or Biopsy: These procedures may be considered in specific situations, although results are not always conclusive:
- Needle Aspiration: A small needle is inserted to withdraw fluid for culture and Gram stain.
- Skin Biopsy: A small skin sample is taken for microscopic examination and culture.
- Incision and Drainage (I&D) of Abscess: If an abscess is present, I&D followed by Gram stain and culture of the purulent material is more likely to yield positive results in identifying the causative bacteria.
3. Bloodwork for Systemic Infection: If systemic toxicity is suspected, blood tests are warranted:
- Complete Blood Count (CBC) with Differential: Evaluates white blood cell count (WBC) and differential to assess for leukocytosis (elevated WBC) and neutrophilia, indicating infection.
- Creatinine and Bicarbonate: Assess renal function and electrolyte balance, which can be affected by severe infection.
- Blood Cultures: Identify bloodstream infection (bacteremia).
- Creatine Phosphokinase (CPK): May be elevated in necrotizing fasciitis or severe muscle involvement.
- C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Inflammatory markers that can be elevated in infection.
4. Imaging Studies for Complications: Imaging may be used to evaluate for potential complications:
- Ultrasonography: Detects abscesses and can guide needle aspiration or drainage.
- Computed Tomography (CT) Scans and Magnetic Resonance Imaging (MRI): Used to rule out deeper infections such as necrotizing fasciitis, particularly when clinical suspicion is high.
Nursing Interventions for Cellulitis
Nursing interventions are crucial for promoting patient recovery and preventing complications.
1. Immediate Antibiotic Therapy: Initiate antibiotic treatment promptly as prescribed by the healthcare provider.
- Oral Antibiotics: For mild cellulitis without systemic symptoms, oral antibiotics targeting streptococcal species are typically prescribed.
- Consideration of MRSA: Assess risk factors for Methicillin-resistant Staphylococcus aureus (MRSA) and ensure antibiotic selection covers potential MRSA infection if indicated (e.g., history of MRSA infection, IV drug use, hospitalization, residence in long-term care facility).
2. Intravenous Antibiotics: Intravenous (IV) antibiotics may be necessary for patients with:
- Failed Outpatient Oral Treatment: Lack of improvement with oral antibiotics.
- Systemic Symptoms: Fever, chills, malaise, indicating more severe infection.
- Compromised Immune System: Increased risk of severe or complicated infection.
- Facial Cellulitis: Potential for rapid spread and serious complications.
- Significant Comorbidities: Cardiac, liver, or renal disease, which may complicate treatment and increase risk.
3. Pain and Discomfort Management: Address pain and discomfort associated with cellulitis:
- Warm Compresses: Apply warm, moist compresses to the affected area to promote comfort and circulation.
- Elevation: Elevate the affected extremity to reduce swelling and pain.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Administer NSAIDs (e.g., ibuprofen, naproxen) as prescribed to reduce pain and inflammation.
- Analgesics: For more severe pain, stronger analgesics may be required, as prescribed.
4. Infection Control Measures: Emphasize infection control to prevent secondary infections and spread of bacteria.
- Hand Hygiene: Reinforce the importance of thorough handwashing with soap and water or using an alcohol-based hand sanitizer before and after touching the affected area and after any patient contact.
- Avoid Squeezing or Picking: Instruct patients to avoid squeezing or picking at the cellulitis, which can spread infection and delay healing.
- Proper Wound Care: If there is an open wound, ensure appropriate wound care techniques are followed.
5. Wound Care: Provide wound care as prescribed by the healthcare provider.
- Cleansing: Cleanse the affected area daily with mild soap and water or a prescribed antiseptic solution.
- Dressing: Apply a sterile dressing as ordered. Typically, a dry, sterile dressing is used. If there is drainage, an absorbent dressing may be indicated. Change dressings as needed to keep the wound clean and dry.
6. Skin Care Education: Educate patients on proper skin care to prevent recurrent cellulitis.
- Hygiene: Maintain good hygiene by bathing regularly with mild soap and water.
- Skin Hydration: Keep skin moisturized, especially in dry climates, using lotions or creams to prevent cracking and dryness.
- Foot and Leg Protection: Protect feet and lower legs from injury by wearing appropriate footwear and avoiding walking barefoot, especially outdoors.
- Prompt Treatment of Skin Breaks: Advise patients to promptly clean and cover any cuts, abrasions, insect bites, or other skin breaks with soap and water and a sterile bandage.
- Avoidance of Irritants: Avoid harsh soaps, chemicals, and irritants that can dry or damage the skin.
Nursing Care Plans for Cellulitis
Once nursing diagnoses are identified, nursing care plans provide a roadmap for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of nursing care plans for cellulitis based on common nursing diagnoses.
Deficient Knowledge related to Cellulitis Management
Nursing Diagnosis: Deficient Knowledge regarding cellulitis, its causes, treatment, and prevention.
Related Factors:
- Unfamiliarity with the condition and its management.
- Lack of access to reliable information or healthcare resources.
- Misconceptions about cellulitis and its treatment.
As Evidenced By:
- Recurrent episodes of cellulitis.
- Worsening of cellulitis due to delayed or inadequate treatment.
- Inability to describe proper skin care practices.
- Nonadherence to prescribed treatment regimen or follow-up appointments.
- Poor management of underlying risk factors (e.g., uncontrolled diabetes).
Expected Outcomes:
- Patient will verbalize understanding of cellulitis, its causes, and risk factors.
- Patient will describe proper skin care techniques to prevent cellulitis recurrence.
- Patient will demonstrate adherence to the prescribed treatment plan and follow-up recommendations.
- Patient will identify signs and symptoms of cellulitis requiring medical attention.
Assessment:
- Assess Patient’s Understanding of Cellulitis: Determine the patient’s current knowledge about cellulitis, including causes, symptoms, treatment, and prevention. Identify any misconceptions or knowledge gaps.
- Evaluate Understanding of Risk Factors: Assess the patient’s awareness of their individual risk factors for cellulitis, such as diabetes, obesity, lymphedema, or skin conditions.
- Assess Access to Resources and Support: Determine if the patient has access to healthcare providers, reliable information resources, transportation, and social support to manage their condition.
- Identify Learning Barriers: Assess for any factors that may hinder learning, such as language barriers, cognitive impairments, visual or hearing deficits, or low health literacy.
Interventions:
- Provide Education on Cellulitis: Explain cellulitis in simple terms, covering its bacterial cause, how it develops, common symptoms (redness, swelling, pain, warmth), and potential complications. Use visual aids, pamphlets, or online resources as appropriate.
- Educate on Individual Risk Factors: Discuss the patient’s specific risk factors for cellulitis and explain how these factors increase their susceptibility.
- Teach Proper Skin Care Techniques: Demonstrate and explain proper skin hygiene, including daily washing with mild soap, thorough drying, and moisturizing with appropriate lotions or creams. Emphasize the importance of keeping skin clean and dry, especially in skin folds.
- Instruct on Wound Prevention and Care: Teach patients to prevent skin injuries by wearing protective clothing and footwear, avoiding walking barefoot, and using caution with sharp objects. Explain how to clean and dress minor cuts and abrasions promptly.
- Explain the Importance of Early Treatment: Emphasize the need to seek medical attention promptly at the first signs of cellulitis (redness, swelling, pain, warmth) to prevent complications and ensure timely antibiotic treatment.
- Educate on Medication Regimen: Clearly explain the prescribed antibiotic medication, including dosage, frequency, duration, and potential side effects. Stress the importance of completing the full course of antibiotics, even if symptoms improve.
- Provide Written Instructions and Resources: Give the patient written materials summarizing key information, including skin care guidelines, medication instructions, signs and symptoms to watch for, and contact information for their healthcare provider. Recommend reliable online resources for further information.
- Assess Understanding and Reinforce Teaching: Use teach-back methods to assess the patient’s understanding of the information provided. Answer questions, clarify misconceptions, and reinforce key teaching points as needed.
- Address Barriers to Care: If the patient faces barriers to accessing care or managing their condition, connect them with appropriate resources, such as social workers, patient navigators, or community health programs.
Impaired Physical Mobility related to Cellulitis
Nursing Diagnosis: Impaired Physical Mobility related to pain, swelling, and discomfort from cellulitis.
Related Factors:
- Inflammatory process in the affected limb.
- Edema and tissue swelling.
- Pain and tenderness.
- Underlying obesity, neuropathy, or lymphedema.
- Sedentary lifestyle.
As Evidenced By:
- Altered gait or limping.
- Reluctance to move or bear weight on the affected limb.
- Reports of pain or discomfort with movement.
- Decreased range of motion in the affected joint.
Expected Outcomes:
- Patient will demonstrate improved mobility and comfort in the affected limb.
- Patient will participate in recommended activities and exercises within tolerated limits.
- Patient will utilize assistive devices appropriately to enhance mobility and safety.
- Patient will verbalize strategies to manage pain and improve mobility.
Assessment:
- Assess Baseline Functional Mobility: Evaluate the patient’s mobility level prior to the onset of cellulitis, including their ability to walk, bear weight, and perform activities of daily living (ADLs).
- Assess Pain and Discomfort: Determine the location, intensity, and characteristics of pain in the affected limb. Assess factors that exacerbate or relieve pain.
- Evaluate Range of Motion: Assess the active and passive range of motion of the affected joint(s). Note any limitations due to pain, swelling, or stiffness.
- Monitor Swelling and Inflammation: Assess the extent of swelling, warmth, and redness in the affected limb. Mark the borders of redness to monitor for changes.
- Identify Contributing Factors: Assess for underlying conditions or factors that may contribute to impaired mobility, such as obesity, neuropathy, lymphedema, or sedentary lifestyle.
Interventions:
- Administer Antibiotics as Prescribed: Ensure timely administration of prescribed antibiotics to treat the infection and reduce inflammation and pain.
- Pain Management Strategies:
- Analgesics: Administer prescribed analgesics (NSAIDs, acetaminophen, or opioids if needed) to manage pain effectively. Assess pain relief regularly and adjust medication as needed.
- Warm Compresses: Apply warm compresses to the affected area to soothe pain and promote circulation.
- Elevation: Encourage elevation of the affected limb whenever possible to reduce swelling and pain.
- Promote Rest and Activity Balance: Advise the patient to alternate periods of rest with gentle activity to avoid prolonged immobility and stiffness.
- Encourage Gentle Range of Motion Exercises: Instruct the patient on gentle range of motion exercises for the affected joint(s) to maintain joint mobility and prevent stiffness. Encourage active exercises as tolerated.
- Assistive Devices and Support: Provide assistive devices, such as crutches, walkers, or wheelchairs, as needed to support mobility and prevent falls. Ensure proper fitting and instruction on safe use of assistive devices.
- Promote Safe Ambulation: Assist the patient with ambulation as needed, ensuring a safe environment free of obstacles. Monitor for dizziness or weakness during ambulation.
- Encourage Weight Management and Lifestyle Modifications: If obesity or sedentary lifestyle are contributing factors, encourage weight loss and increased physical activity as appropriate, once the acute infection has resolved.
- Referral to Physical Therapy: Consider referral to physical therapy for a comprehensive mobility assessment and individualized exercise program to improve strength, range of motion, and functional mobility.
Impaired Skin Integrity related to Cellulitis
Nursing Diagnosis: Impaired Skin Integrity related to bacterial infection, inflammation, and edema in cellulitis.
Related Factors:
- Bacterial invasion and infection of the skin.
- Inflammatory response.
- Edema and tissue swelling.
- Potential for abscess formation.
- Poor circulation.
- Skin dryness or breaks in skin integrity.
As Evidenced By:
- Erythema (redness).
- Warmth to touch.
- Swelling and induration.
- Tight, shiny skin appearance.
- Reports of pain, burning, or itching in the affected area.
- Potential for blisters, vesicles, or abscess formation.
- Open wounds or drainage (in some cases).
Expected Outcomes:
- Patient will exhibit improvement in skin integrity with reduced erythema, warmth, and swelling.
- Patient will demonstrate skin healing without the development of blisters, abscesses, or further skin breakdown.
- Patient will report reduced pain, burning, or itching in the affected area.
- Patient will maintain clean, dry, and intact skin.
Assessment:
- Comprehensive Skin Assessment: Thoroughly assess the affected skin area, noting:
- Location and extent of erythema, warmth, swelling, and tenderness.
- Presence of blisters, vesicles, bullae, or abscesses.
- Skin temperature and texture.
- Presence of any open wounds, drainage (color, amount, odor), or necrotic tissue.
- Condition of surrounding skin (hydration, dryness, breaks in integrity).
- Mark the Area of Erythema: Use a skin marker to outline the borders of redness to monitor for spread or resolution. Document the date and time of marking.
- Assess Pain and Sensation: Evaluate the patient’s reports of pain, burning, itching, or altered sensation in the affected area.
- Monitor for Signs of Worsening Infection: Observe for signs of systemic infection (fever, chills, malaise, increased WBC count) or local worsening (increased redness, swelling, pain, purulent drainage, odor).
- Identify Contributing Factors: Assess for factors that may contribute to impaired skin integrity, such as underlying skin conditions (eczema, psoriasis), poor hygiene, pressure, friction, or moisture.
Interventions:
- Maintain Skin Cleanliness and Hygiene:
- Gentle Cleansing: Cleanse the affected area daily with mild soap and water or a prescribed antiseptic solution. Pat skin dry gently. Avoid harsh scrubbing.
- Avoid Irritants: Avoid using harsh soaps, perfumed lotions, or other potential skin irritants.
- Keep Skin Dry: Ensure the affected area is kept clean and dry. Change dressings frequently if drainage is present.
- Wound Care as Prescribed: If open wounds, blisters, or abscesses are present, provide wound care as ordered by the healthcare provider. This may include:
- Dressing Changes: Apply sterile dressings as prescribed. Choose appropriate dressing type based on wound characteristics (e.g., absorbent dressings for drainage, non-adherent dressings for fragile skin).
- Topical Medications: Apply topical antibiotic ointments or creams as ordered.
- Wound Irrigation: Irrigate wounds with prescribed solutions (e.g., sterile saline) if ordered.
- Pain Management: Implement pain management strategies as described in the “Impaired Physical Mobility” care plan, including analgesics, warm compresses, and elevation.
- Prevent Shearing and Friction: If the patient is immobile or at risk for skin breakdown, take measures to prevent shearing and friction:
- Repositioning: Turn and reposition the patient frequently (at least every 2 hours) to relieve pressure on affected areas.
- Pressure-Relieving Devices: Use pressure-reducing mattresses, cushions, or heel protectors as needed.
- Proper Lifting and Transfer Techniques: Use proper body mechanics and lifting aids to avoid dragging or pulling the patient across surfaces.
- Promote Circulation: Encourage measures to improve circulation, such as elevation of the affected limb and avoidance of constrictive clothing.
- Educate Patient on Skin Care: Provide comprehensive education on skin care techniques to prevent further skin breakdown and recurrence of cellulitis, as outlined in the “Deficient Knowledge” care plan.
- Monitor Skin Condition Regularly: Assess skin integrity at least daily, or more frequently as needed, to monitor for changes, signs of worsening infection, or complications. Document findings accurately.
- Consult Wound Care Specialist: If skin integrity is severely compromised, wounds are complex, or healing is delayed, consult a wound care specialist for advanced wound management strategies.
Ineffective Peripheral Tissue Perfusion related to Cellulitis
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to inflammatory process, edema, and potential circulatory compromise associated with cellulitis.
Related Factors:
- Inflammatory process in the affected tissues.
- Edema and swelling compromising blood flow.
- Underlying peripheral vascular disease (PVD), diabetes mellitus, or neuropathy.
- Vasoconstriction due to cold exposure or smoking.
- Sedentary lifestyle.
As Evidenced By:
- Altered skin characteristics (pallor, cyanosis, coolness).
- Diminished or absent peripheral pulses in the affected limb.
- Delayed capillary refill time (>3 seconds).
- Edema.
- Extremity pain or discomfort.
- Paresthesias (numbness, tingling).
- Altered motor function (weakness, paralysis).
- Delayed wound healing in the affected area.
Expected Outcomes:
- Patient will demonstrate adequate peripheral tissue perfusion as evidenced by palpable peripheral pulses, warm and pink skin color, and capillary refill time within normal limits.
- Patient will maintain or improve motor and sensory function in the affected limb.
- Patient will verbalize strategies to improve peripheral blood flow.
- Patient will exhibit timely wound healing if skin breakdown is present.
Assessment:
- Peripheral Vascular Assessment: Perform a comprehensive peripheral vascular assessment of the affected limb and compare findings to the unaffected limb:
- Skin Color and Temperature: Observe skin color (pink, pallor, cyanosis, mottling) and palpate skin temperature (warm, cool, cold).
- Peripheral Pulses: Palpate peripheral pulses (dorsalis pedis, posterior tibial, popliteal, femoral, radial, ulnar) in both limbs and grade pulse strength (0-absent, 1+-thready, 2+-weak, 3+-normal, 4+-bounding).
- Capillary Refill Time: Assess capillary refill time in nail beds of affected and unaffected limbs. Normal is <3 seconds.
- Edema: Assess for edema (location, severity, pitting or non-pitting).
- Sensory Function: Assess sensation to light touch, pinprick, and vibration in the affected limb.
- Motor Function: Assess motor function (muscle strength and range of motion) in the affected limb.
- Assess for Risk Factors: Identify risk factors for impaired tissue perfusion, such as PVD, diabetes, smoking history, hypertension, hyperlipidemia, and sedentary lifestyle.
- Monitor for Signs of Worsening Perfusion: Regularly monitor for changes in skin color, temperature, pulses, capillary refill, pain, sensation, or motor function that may indicate worsening tissue perfusion.
Interventions:
- Elevate Affected Limb: Elevate the affected extremity above heart level whenever possible to promote venous return and reduce edema.
- Apply Warm Compresses (as prescribed): Apply warm compresses to the affected area as prescribed to promote vasodilation and improve circulation. Avoid excessive heat, which can cause burns.
- Encourage Leg Exercises: Encourage the patient to perform leg exercises (ankle pumps, foot circles) as tolerated to promote circulation and prevent venous stasis.
- Promote Hydration: Ensure adequate hydration to maintain blood volume and viscosity, which can improve blood flow.
- Instruct on Measures to Improve Circulation: Educate patients on lifestyle modifications to improve peripheral circulation:
- Smoking Cessation: Emphasize the importance of smoking cessation to improve blood flow and reduce vasoconstriction.
- Avoid Cold Temperatures: Advise patients to avoid prolonged exposure to cold temperatures, which can cause vasoconstriction.
- Regular Exercise: Encourage regular moderate-intensity exercise, such as walking, to promote circulation.
- Proper Foot Care: Instruct patients with diabetes or PVD on meticulous foot care, including daily inspection, washing, drying, and moisturizing feet, and wearing proper footwear.
- Manage Underlying Conditions: Emphasize the importance of managing underlying conditions such as diabetes, hypertension, and hyperlipidemia to improve overall vascular health.
- Utilize Compression Stockings (as prescribed): If prescribed, ensure proper application and use of compression stockings to reduce edema and improve venous return.
- Medication Administration: Administer prescribed medications to improve circulation (e.g., antiplatelet agents, vasodilators) as ordered.
- Monitor Peripheral Perfusion Regularly: Assess peripheral pulses, skin color and temperature, capillary refill, and pain levels at least every shift and more frequently if indicated. Document findings accurately.
- Report Changes in Perfusion: Promptly report any significant changes in peripheral perfusion to the healthcare provider, such as diminished pulses, pallor, coolness, or increased pain, as these may indicate worsening circulatory compromise or complications.
Risk for Infection Spread related to Cellulitis
Nursing Diagnosis: Risk for Infection Spread related to cellulitis and potential for systemic infection or complications.
Related Factors:
- Bacterial skin infection (cellulitis).
- Broken skin barrier.
- Invasive procedures (incision and drainage).
- Insufficient knowledge of infection control measures.
- Underlying conditions compromising immune function (diabetes, immunosuppression).
- Improper antibiotic usage (non-adherence, antibiotic resistance).
- Delayed treatment seeking.
As Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will remain free from signs and symptoms of systemic infection (fever, tachycardia, confusion, sepsis).
- Patient will demonstrate understanding and adherence to infection control measures.
- Patient will complete the full course of prescribed antibiotics as directed.
- Patient will seek prompt medical attention if signs of worsening infection develop.
Assessment:
- Monitor for Systemic Signs of Infection: Assess vital signs (temperature, heart rate, blood pressure, respiratory rate) regularly. Monitor for signs and symptoms of systemic infection, including:
- Fever (>100.4°F or 38°C) or hypothermia (<97°F or 36.1°C).
- Tachycardia (heart rate >100 bpm).
- Tachypnea (respiratory rate >20 breaths/min).
- Hypotension (systolic blood pressure <90 mmHg).
- Confusion, altered mental status.
- Shaking chills.
- Malaise, weakness.
- Monitor Local Signs of Worsening Infection: Assess the cellulitis site regularly for:
- Increased redness, swelling, pain, or warmth.
- Spread of erythema beyond marked borders.
- Purulent drainage, odor.
- Development of blisters, vesicles, bullae, or abscesses.
- Necrotic tissue.
- Review Laboratory Data: Monitor laboratory results, including:
- White blood cell count (WBC) and differential: Elevated WBC (leukocytosis) and neutrophilia may indicate infection.
- C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated inflammatory markers may indicate infection.
- Blood cultures: Obtain blood cultures if systemic infection is suspected.
- Wound cultures: Obtain wound cultures if drainage is present or if directed by the healthcare provider.
- Assess Risk Factors for Infection: Identify risk factors that increase susceptibility to infection spread, such as:
- Immunocompromised status (HIV/AIDS, cancer, transplant recipients, immunosuppressive medications).
- Diabetes mellitus (poorly controlled).
- Peripheral vascular disease.
- Malnutrition.
- Advanced age.
- Presence of invasive devices (IV catheters, surgical drains).
- History of antibiotic-resistant infections (MRSA).
- Non-adherence to prescribed antibiotic therapy.
Interventions:
- Administer Antibiotics as Prescribed: Ensure timely administration of prescribed antibiotics (oral or IV) to treat the cellulitis effectively. Monitor for therapeutic effects and potential side effects.
- Promote Completion of Antibiotic Course: Educate the patient on the importance of completing the full course of antibiotics, even if symptoms improve, to prevent antibiotic resistance and ensure eradication of the infection.
- Infection Control Measures:
- Hand Hygiene: Reinforce strict hand hygiene practices for healthcare providers, patient, and visitors.
- Standard Precautions: Adhere to standard precautions, including use of gloves, gowns, and other personal protective equipment (PPE) as indicated.
- Wound Care Technique: Utilize aseptic technique during wound care and dressing changes to prevent contamination and secondary infection.
- Environmental Control: Maintain a clean patient environment.
- Wound Management: Provide appropriate wound care for any open wounds, blisters, or abscesses, as described in the “Impaired Skin Integrity” care plan.
- Prepare for Incision and Drainage (I&D) if Indicated: If an abscess develops, prepare the patient for I&D procedure as ordered by the healthcare provider. Assist with the procedure and provide post-procedure wound care.
- Patient Education on Signs of Worsening Infection: Educate the patient and family members on the signs and symptoms of worsening infection that require immediate medical attention:
- Increased redness, swelling, pain, or warmth at the cellulitis site.
- Spread of redness.
- Purulent drainage or odor.
- Fever, chills, shaking chills.
- Increased pain, tenderness.
- Confusion, altered mental status.
- Shortness of breath, rapid breathing.
- Encourage Prompt Medical Attention: Instruct the patient to seek immediate medical attention if any signs of worsening infection develop. Provide clear instructions on how to contact their healthcare provider or seek emergency care.
- Monitor for Antibiotic Resistance: Be aware of local antibiotic resistance patterns and consider risk factors for antibiotic-resistant infections (e.g., MRSA). Ensure antibiotic selection is appropriate and guided by culture and sensitivity results when available.
References
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