Cellulites

A Nursing Case Study Presented to the University of Saint La Salle College of Nursing School Year 2007-2008

In Partial Fulfillment of the Course Requirements in Related Learning Experience

Submitted to: Mr. Norman Verdeflor

Submitted by: Jessil Mei L. Ocdinaria BSN3E

February 26, 2008

Table of Contents Page No. ■ Title Page ■ Table of Contents ■ Introduction ■ Objectives ■ Anatomy and Physiology

i ii 1-4 5 6-9 9-10 11 12-14 15-16 17-18 19-21 22 23-28 29-34 35 36

Definition of Terms

■ Baseline Data ■ Nursing History ■ Health History ■ Assessment ■ Laboratory ■ Pathophysiology ■ Nursing Care Plan ■ Drug Study ■ Health Teaching ■ References

I. Introduction What is cellulites and what are the symptoms of cellulitis? Cellulitis is a spreading bacterial infection of the skin and tissues beneath the skin. Cellulitis usually begins as a small area of tenderness, swelling, and redness. As this red area begins to enlarge, the person may develop a fever—sometimes with chills and sweats—and swollen lymph nodes ("swollen glands") near the area of infected skin. Unlike impetigo, which is a very superficial skin infection, cellulitis refers to an infection also involving the skin's deeper layers: the dermis and subcutaneous tissue. The main bacteria involved in cellulitis are Staphylococcus ("staph"), the same bacteria that cause many cases of impetigo. Occasionally, other bacteria may cause cellulitis as well. Where does cellulitis occur? Cellulitis may occur anywhere on the body, but the leg is the most common site of the infection (particularly in the area of the tibia or shin bone and in the foot), followed by the arm, and then the head and neck areas. In special circumstances, such as following surgery or trauma wounds, cellulitis can develop in the abdomen or chest areas. In cases of morbid obesity, it can also develop in the abdominal area. What does cellulitis look like? The signs of cellulitis include redness, warmth, swelling, and pain in the involved tissues. Any skin wound or ulcer that exhibits these signs may be developing cellulitis. Other forms of noninfected inflammation may mimic cellulitis. People with poor leg circulation, for instance, often develop scaly redness on the shins and ankles; this is called "stasis dermatitis" and is often mistaken for the bacterial infection of cellulites

What are risk factors for cellulitis? Some cases of cellulitis appear in areas where the skin has broken open, such as the skin near ulcers or surgical wounds. Many times, however, cellulitis occurs where there has been no break in the skin at all, such as with chronic leg swelling (edema). People who have diabetes or conditions that compromise the function of the immune system (for example, HIV/AIDS or those receiving chemotherapy or drugs that depress the immune system) are particularly prone to developing cellulitis. Conditions that reduce the circulation of blood in the veins or that reduce circulation of the lymphatic fluid (such as venous insufficiency, obesity, pregnancy, or surgeries) also increase the risk of developing cellulitis. What causes cellulitis? The majority of cases of cellulitis are caused by either staph (Staphylococcus) or strep (Streptococcus) bacteria. Staph (Staphylococcus aureus) is the most common bacteria that causes cellulitis. There is a growing incidence of community-acquired infections due to methicillin-resistant S. aureus (MRSA), a particularly dangerous form of this bacteria that is resistant to many antibiotics and is more difficult to treat. Strep (usually group A or B Streptococcus) is also a common cause of cellulitis. A form of rather superficial cellulitis caused by strep is called erysipelas; it is characterized by spreading hot, bright red circumscribed area on the skin with a sharp raised border. The so-called "flesh-eating bacteria" are, in fact, also a strain of strep that can sometimes rapidly destroy tissues.

Cellulitis can be caused by many other types of bacteria. In children under 6 years of age, H. flu (Hemophilus influenzae) bacteria can cause cellulitis, especially on the face, arms, and upper torso. Cellulitis from a dog or cat bite or scratch may be caused by the Pasteurella multocida bacteria, which has a very short incubation period of only four to 24 hours. Aeromonas hydrophilia, Vibrio vulnificus, and other bacteria are causes of cellulitis that develops after exposure to freshwater or seawater. Pseudomonas aeruginosa is another type of bacteria that can cause cellulitis, typically after a puncture wound. Is cellulitis contagious? Cellulitis is not contagious because it is an infection of the skin's deeper layers (the dermis and subcutaneous tissue), and the skin's top layer (the epidermis) provides a cover over the infection. In this regard, cellulitis is different from impetigo, in which there is a very superficial skin infection that can be contagious. How is cellulitis treated? First, it is crucial for the doctor to distinguish whether or not the inflammation is due to an infection. The history and physical exam can provide clues in this regard, as can sometimes an elevated white blood cell count. A culture for bacteria may also be of value, but in many cases of cellulitis, the concentration of bacteria may be low and cultures fail to demonstrate the causative organism. When it is difficult or impossible to distinguish whether or not the inflammation is due to an infection, doctors sometimes treat with antibiotics just to be sure. If the condition does not respond, it may need to be addressed by different methods dealing with types of inflammation that are not infected. For example, if the inflammation is thought to be due to an autoimmune disorder, treatment may be with a corticosteroid. Antibiotics, such as derivatives of penicillin or other types of antibiotics that are effective against the responsible bacteria, are used to treat cellulitis. If the bacteria turn

out to be resistant to the chosen antibiotics or in patients who are allergic to penicillin, other appropriate antibiotics can be substituted. In many cases, treatment requires the administration of intravenous antibiotics in a hospital setting, since oral antibiotics may not always provide sufficient penetration of the injury to be effective. In certain cases, intravenous antibiotics can be administered at home. In all cases, physicians choose a treatment based upon many factors, including the location and extent of the infection, the type of bacteria causing the infection, and the overall health status of the patient.

II. 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 cellulites b.3) perform competent independent nursing care interventions in order to alleviate any conditions experienced by the client with cellulites b.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

III. Anatomy and Physiology

Epidermis The epidermis is the thin outer layer of skin that contains melanin which gives skin its color and allows for the skin to tan. Carotene, and oxygen-rich hemoglobin also contributes to the color of skin. The epidermis also encompasses the protein keratin which stiffens epidermal tissue to form finger nails. The outermost layer consists of 2530 layers of dead cells. Further levels include: 1. Scaly Cells form the surface of the skin 2. Melanocytes give the skin color 3. Langerhans cells are formed in the bone marrow and work to fight infection It is divided into the following sub-layers: Sub layers Epidermis is divided into the following 5 sublayers or strata: 1. Stratum corneum- is the outermost layer of the epidermis (the outermost layer of the skin). 2. Stratum lucidum- is a thin, clear layer of dead skin cells in the epidermis, and is named for its translucent appearance under a microscope. 3. Stratum granulosum- layer of the epidermis lies between the stratum spinosum, below, and the stratum lucidum, above, in stratified squamous keratinized thick skin of palms and soles. Thin skin, which covers the rest of the body, lacks a definite stratum lucidum and stratum granulosum. 4. Stratum spinosum- is a multi-layered arrangement of cuboidal cells that sits beneath the stratum granulosum. Adjacent cells are joined by desmosomes,

giving them a spiny appearance when the cells shrink during the staining process while the desmosomes hold firm. 5. Stratum germinativum (also called "stratum basale")- is the layer of keratinocytes that lies at the base of the epidermis immediately above the dermis. It consists of a single layer of tall, simple columnar epithelial cells lying on a basement membrane. These cells undergo rapid cell division, mitosis, to replenish the regular loss of skin by shedding from the surface. About 25% of the cells are melanocytes, which produce melanin, which provides pigmentation for skin and hair. Dermis The dermis is the bottom-most, thick inner layer of skin, which comprises blood vessels, connective tissue, nerves, lymph vessels, sweat glands and hair shafts. It has two main layers: 1. Upper Papillary: Contains touch receptors which communicate with the central nervous system and is responsible for the folds of the fingerprints 2. Lower Reticular: Made of dense elastic fibers that house the hair follicles, nerves, and gland Subcutaneous tissue The subcutaneous tissue or subcutis is the layer of tissue directly underlying the cutis. It is mainly composed of adipose tissue. Its physiological function includes insulation and storage of nutrients. Functions of the integumenatry system 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 somewhat as

the body’s first line of defense against infection, temperature change or other challenges to homeostasis. Functions include: • • • • • • Protects the body’s internal living tissues and organs Protects against invasion by infectious organisms Protects the body from dehydration Protects the body against abrupt changes in temperature Helps excrete waste materials through perspiration Acts as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory system) • • • Protects the body against sunburns Generates vitamin D through exposure to ultraviolet light Stores water, fat, and vitamin D

IV. Definition of Terms • Skin (integumentary)- is an organ of the integumentary system made up of a layer of tissues that guard underlying muscles and organs. As the interface with the surroundings, it plays the most important role in protecting against pathogens. • Integumentary system- consists of the skin, hair, nails, the subcutaneous tissue below the skin, and assorted glands. The most obvious function of the integumentary system is the protection that the skin gives to underlying tissues. The skin not only keeps most harmful substances out, but also prevents the loss of fluids. • Cellulites- is an infection of the skin and underlying tissues that can affect any area of the body. It often begins in an area of broken skin, like a cut or scratch, when bacteria invade and spread, causing inflammation, pain, swelling, warmth, and redness.

Staphylococcus aureus- The staph bacteria is the most common if not is one of the highest reported causative agent in the incidence or cases of cellulitis

Streptococcus pyogens- bacteria causing strep throat infections; probable cause of cellulitis.

another

Seizure- sudden attack or spasm, as in epilepsy or a similar disorder. Seizures differ with the type of condition and may consist of loss of consciousness, convulsive jerking of parts of the body, emotional explosions, or periods of mental confusion.

Benign Febrile Seizure- seizure occurring during high temperature rates or increased episodes of fever

Methicillin-Resistant

Staphylococcus Aureus

(MRSA)-

community-acquired

staphylococcus aureus and a particularly dangerous form of this bacteria that is resistant to many antibiotics and is more difficult to treat. • Lesions- wound; area of the skin that is broken, open or infected; may be a trauma or impairment in any area of the skin after an illness, injury or surgery • Benign Febrile Seizures- A convulsion that occurs in association with a rapid increase in body temperature. Febrile seizures are common in infants and young children and, fortunately, are usually of no lasting importance.

V. Baseline Data Name: C. J. Address: Lopez Jaena St., Bacolod City, Brgy. 27 Age: 1 year and 7 months No. of dependents: N. A. Birth date: 12/09/06 Birthplace: Bacolod City Gender: Female Marital Status: N. A. Religion: Roman Catholic Educational Level: N.A. Nationality: Filipino Occupation: N.A. Mother’s Name (guardian): L. D. Date of Admission: February 13, 2008 Admitting physician: Dr. Abaja Time of Admission: 6:30 am

Attending Physician: Dr. Vasquez, Dr. Guiritan Chief Complaints: upward rolling of eyeballs Diagnosis: Cellulites at the Left leg secondary to Benign Febrile Seizure (BFS) VI. Nursing History (Gordon’s Functional Health Pattern) • Health Maintenance-Perception Pattern The client has no noted allergies to foods, drugs/medication or other substances. The mother of the client also stated that she takes her child to the baranggay health center only in cases of fever, colds or if she feels like her child is really not feeling well but does not visit it regularly for check-ups. The client’s mother claimed that she had no idea in terms of the disease prevention and the factors which cause or contribute to the disease and the appropriate treatment regimen for health maintenance and promotion. The mother also claimed that last year her child (client) was also hospitalized because of severe pneumonia and this is her second episode of benign febrile seizure (noted at patient’s health history). The mother of the client also claimed that she does not follow a treatment regimen prior to the clients hospitalization but she claimed that she does her best to comply with the medications needed at present. • Nutrition-Metabolic Pattern The client prior to admission had a good appetite, eating 5-6 times a day including solid and liquid foods. The mother claimed that the client drinks milk in the morning, during lunch time, during snack time at around 3 o’clock in the afternoon, at dinner and before going to sleep. The client also eats rice about half a cup in every meal with any viands including vegetables, fish, meat and poultry products. The client loves to eat fruits including oranges, grapes, apples and banana which is her favorite. She drinks about 4-6 glasses of water each day at different settings. During her hospital stay the client was placed on a soft diet (feb.13-19) and was changed to diet as tolerated. She had a good appetite and was still eating 5-6 times a

day. She was eating rice with vegetables, fish, poultry products, meat and she also ate fruits including oranges, grapes and bananas. Her fluid intake was same as before. She had no difficulty eating or swallowing as well. The client weighed 12 kgs and no weight loss was noted.

Elimination Pattern The client moves usually her bowel once a day in the afternoon or in the evening

with amounts within normal limits and with normal consistency. During her hospital she was not able to defecate upon assessment. In terms of the clients voiding pattern, she voids freely to an amber colored urine of approximately 900-1000 cc/day. Upon assessment the client was able to void freely to an amber colored urine at approx. 240 cc per diaper, fully soaked. No difficulties in terms of her voiding and no abnormalities as to the qualities of urine were noted as well. • Activity and Exercise Pattern Before admission, the client because of her age performed activities of daily living such as eating/drinking, bathing, dressing/grooming, toileting, bed mobility, transferring, ambulating with dependence to her mother or any family member present. She had a high energy level and undertook daily activities without any difficulties and she was physically fit as well. Upon assessment, the client had a high energy level, responsive to any environmental stimuli and performed activities of daily living with aid of her mother. She is capable of rolling to the sides, lying down from a sitting position and sitting up from a lying position. • Sleep and Rest Pattern Prior to admission, the client gets an average of 11-12 hours of sleep a day. She sleeps at around 8-9 o’clock in the evening and wakes up at around 7 or 8 0’clock the next morning. Every afternoon, the client also takes a nap/rest, she sleeps at around 1 o’clock and wakes up 30 mins or an hour after. After sleeping or taking a nap, the

client’s mother claimed that her child(client) looks well rested and feels full of energy as manifested by her enthusiasm. During his hospitalization, the client did not have any sleep pattern disturbances as claimed by her mother. She sleeps at around 8 or 9 o’clock in the evening and wakes up at around 6 or 7 o’clock the next morning. And she also took naps in the afternoon after taking her lunch. • Cognitive-Perception Pattern The client is only one year old and seven months so she is still not capable of reading or answering questions rationally but she had no problems with her eyesight and hearing. She was capable of responding to both verbal and non verbal stimuli appropriate for her age. • Self Perception-Self Concept Pattern The client’s feelings about herself, her body image, self-esteem and emotional state could not be properly assessed in relation to her age. • Role-relationship Pattern The client has six older brothers and sisters five are actually boys and two are girls including her. Her mother is a plain housewife and her father is a jeepney (shopping la salle libertad) driver. They all live together in a shanty bungalow house in a squatter’s area and they only depend on his father’s income for their daily living. The mother of the client claimed that the income which her husband provides for them is really not enough or is not sufficient to meet all their needs or unexpected outcomes or circumstances like the occurrence of health problem/s and illnesses. • Sexuality and Reproductive Pattern She has no problems with her reproductive system before admission and upon assessment. • Coping-Stress Pattern

Based on observation and as claimed by the client’s mother that her child manages stress through playing around, focusing her attention and deviating it from her situation. Upon assessment, the client was very energetic and enthusiastic. • Values and Belief Pattern The client is baptized Roman-Catholic. The client’s mother stated that they go to Sunday masses once in a while if they have the time or if her husband takes a break from his job.

VII. Health History

A. History of Present Illness Patient has been having a non-remittent, erythamous, ulcerating, purulent skin lesions over left leg for months. No meds given, no consultation sought. 2 days prior to admission, mother noted redness of left leg with onset of low grade fever. Paracetamol 5 mL q4h, PRN given with temporary relief. A day PTA, redness on left leg allegedly spread, now warm and tender to touch, still with persistence of fever. Amoxicillin 5 mL TID was given along with PRN doses of Paracetamol without relief of symptoms. A few minutes later PTA, mother woke up to patient having upward rolling of eyeballs, unresponsive to stimulation with stiffening of arms and legs and excessive salivation. B. Past Health History (Prenatal/Natal/Postnatal History) Patient as born FT to 36 year old G7P7 mother with no PNCU, via NSVDNID (home delivery) assisted by a TBA. Patient had good cry and was able to void and pass meconium within 24 hrs. B.1 Childhood Illness/es The child had fever, common colds, and streptococcal infections. B.2.Past Hospitalization

Positive hospitalization (2007) severe pneumonia secondary to benign febrile seizure Second episode of febrile seizure No FDA’s B.3. Serious illnesses/Chronic Illnesses The occurrence febrile seizure and severe pneumonia. B.4. Previous Surgery The client has/had not undergone any previous surgery/ies.

C. Immunization BCG DPT 123 OPV 123 MEASLES HEP B 123

D. Growth and Development At pace with age E. Feeding History Not breastfed since birth Started on milk formula (Bonna) since birth Started on solid foods at 6 months

F. Social/ Personal/ Environmental History Water supply: mineral water (delivered) Flush type toilet Stagnant Canal

Squatter’s area/crowded place

VIII. Assessment February 19, 2008 Tuesday (6am-2pm) shift

A. General Appearance Awake, lying on bed, wearing a loose white blouse with shorts; with fair complexion, with untrimmed nails, combed hair. responsive to verbal and nonverbal stimuli. B. Vital Signs Temperature: 35.5 C Respiratory rate: 32 cpm Pulse rate: 128 bpm Cardiac Rate: 138 bpm C. Integumentary Warm to touch With good skin turgor Afebrile with temperature of 35.5 C Skin peeling at left lower leg

D. Cardiovascular With IVF #3 d5.03 NaCl at KVO rate infusing well at the right dorsal venous arch With strong palpable pulse With PR=128 bpm; Cardiac rate=138 bpm With good capillary refill at 1 sec E. Respiratory Breathes spontaneously to room air at 32 cpm With clear breath sounds auscultated at both lung fields

F. Gastrointestinal Tract On soft diet With good appetite; drank approx. 100 cc of milk With normoactive bowel sounds at 6 cpm G. Genito Urinary Tarct Able to void to an amber-colored urine at approx. 70 cc per diaper H. HEENT Pupils Equally Round Reactive to Light Pale conjunctive I. Musculoskeletal Able to move without difficulty Roll over to the sides Move upper and lower extremities

IX. Laboratory Corazon Locsin Montelibano Memorial Regional Hospital Laboratory Department Bacolod City Patient: Jhong age: 1 year Hospiatl no.01038606 Phsycian: Dr. Vasquez Urinalysis Physical Properties Color Transparency pH Specific Gravity Chemical Test Glucose Protein Cells Straw Slightly hazy 7.0 1.005 g/mL Results Normal values/results Pale to dark yellow / amber Clear 4.5-8.5 1.002-1.035 g/mL Negative Negative Negative Negative Normal Normal renal functioning. Normal Presence of infection. Within normal Normal renal functioning. range Within normal Normal renal functioning. range normal Normal Normal renal functioning. Normal renal functioning. Interpretation Implication Ward: pedia_misc Date of request: 2/13/08

Pus Transitional - squamous - Renal

2-4 /hpf

absent

Normal

Due to/Presence of infection. Dueto/ Presence infection. Presence infection. of of

Few/hpf Dec1/L/hpf

absent absent Absent Absent Absent Absent Absent

Normal Normal Normal Normal Normal Normal Normal

Crystals Amorphousorates None Amorphosphate Uric acid Calcium oxalate Triple PO4 None None None None

Normal renal functioning. Normal renal functioning. Normal renal functioning. Normal renal functioning. Normal renal functioning.

Hematology Complete Blood Count Laboratory/Diagnostic Test Hemoglobin Result 125 g/L Normal Values Female: 110-150 g/L Hematocrit 0.37 L/L Female: 0.37-0.47 L/L WBC count 4.05 Female: 4.0-5.5 x 10(12)/L within normal range within normal range Interpretation within normal range Implication The patient has enough oxygen carrying protein in her blood. No bleeding has occurred. The percentage of red cells in her blood is normal relative to a normal oxygen carrying protein(hemoglobin) . The patient’s defense mechanism against infection, invasion of bacteria, parasites, and tumor cells is maintained. Indicating the body’s response against infection and other foreign bodies.

Differential Count Neutrophils

40%

50-70%

within normal range

Lymphocytes

51%

25-35%

increased

Monocytes

5%

4-8%

Within normal range

Eosinophils

4%

1-5%

Within normal range

Platelet count

276 x 10
9

150-400 x 10 9/L

Within normal range

/L

The patient’s defense against infection is maintained. Indicating the body’s response against bacterial infection. The defense mechanism against infection is increased due to presence/invasion of foreign bodies/ microorganisms. The patient’s body is responding to the bacterial infection. Indicative that the patient has an acute bacterial infection, if increased may indicate chronic infection. The patient’s defense mechanism against infection is maintained. Client inhibits the normal clotting ability. Clotting ability is not impaired and is not at risk for bleeding.

Blood Chemistry II Microworld Examinations Potassium Results 4.82 meq/L Normal values 3.5-5.5 meq/L Interpretation Implication Within the The client has normal normal range potassium levels needed for normal cell functioning. Within the The client has normal sodium normal range levels needed for normal cell functioning and rejuvenation of damage cells.

Sodium

141.60 meq/L

135-14 meq/L

Other Diagnostic Examinations:

Your doctor can diagnose cellulitis by asking a few questions and examining the area of affected skin. Sometimes, especially in younger kids, a blood culture may be done to check for bacteria growth. A positive blood culture means that bacteria from the skin infection have spread into the bloodstream, a condition known as bacteremia. This can potentially lead to septicemia, an infection affecting many systems of the body. x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

X. Pathophysiology
Precipitating Factors: • Environmental factors/contributors: • poor environmental sanitation (presence of flies, mosquito’s, ants and rodents) • improper disposal of waste products • lack of resources to maintain healthy living and hazard free environment • over-crowded settings (they are 9 all in all in the family living in the squatters area) • Economic reasons: • lack of financial resources • Low family income (mother is a plain housewife; father is a jeepney driver with an income of P150-300/day) • • • • Family related: Lack of knowledge with regards to disease prevention and control, health maintenance and treatment regimen Lack of proper attitude towards gaining health control and promoting over-all well being Health status: previous hospitalization for severe pneumonia, previous episode of benign febrile seizure Predisposing Factors: Age: 1 year old and 7 months; low immunity and resistance against infectious diseases

Break in the skin caused by scratched insect bites (probable cause; flies, mosquito’s or ants) in the left lower leg

Bacteria enters the broken skin particularly, staphylococcus aureaus (most common causative agent present in the community/environment)

Bacterial invasion occurs and bacteria secrets an enzyme which results to at first as red, blemished skin

Results to the following Signs and Symptoms
Left lower leg: -Swelling -Warm to touch -Inflammation -High persistent fever--- resulting to seizure -Skin Lesions, Skin peeling

low immunity

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

XI Nursing Care Plan Assessment Nursing diagnosis

Rationale

Desired Outcome

Nursing Intervention

Justification

Evaluation

XII. Drug Study Name of Drug Dosage, Frequency, Route Mechanism of Action Indication Contraindication Adverse Reaction Nursing responsibilities

Name of Drug

Dosage, Frequency, Route

Mechanism of Action

Indication

Contraindication

Adverse Reaction

Nursing responsibilities

Assessment

Nursing diagnosis

Rationale

Desired Outcome

Nursing Intervention

Justification

Evaluation

Name of Drug

Dosage, Frequency, Route

Mechanism of Action

Indication

Contraindication

Adverse Reaction

Nursing responsibilities

Name of Drug

Dosage, Frequency, Route

Mechanism of Action

Indication

Contraindication

Adverse Reaction

Nursing responsibilities