TABLE OF CONTENT

TABLE OF CONTENT_______________________________________________________1

CHAPTER ONE____________________________________________________________3

INTRODUCTION_______________________________________________________3

CHAPTER 2_______________________________________________________________6

LITERATURE REVIEW_______________________________________________6

2.1 PREAMBLE______________________________________________________6

2.2 ANATOMY AND PHYSIOLOGY OF THE SKIN________________________7

2.3 IMPORTANT PHYSIOLOGICAL PROCESSES WITHIN THE SKIN._______13

2.4 CAUSES AND ETIOLOGY________________________________________14

2.5 RISK FACTORS_________________________________________________15

2.6 PATHOPHYSIOLOGY____________________________________________16

2.7 STATISTICS & EPIDEMIOLOGY___________________________________17

2.8 CLINICAL MANIFESTATIONS_____________________________________18

2.9 PREVENTION___________________________________________________18

2.10 ASSESSMENT AND DIAGNOSTIC FINDINGS_______________________19

2.11 GENERAL MANAGEMENT______________________________________19

2.11 COMPLICATIONS______________________________________________23
3.1 PATIENT’S BIO DATA____________________________________________25

3.2 ADMISSION OF PATIENT_________________________________________25

3.3 HISTORY TAKING_______________________________________________26

3.4 ASSESSMENT OF PATIENT USING GORDON’S ELEVEN FUNCTIONAL

PATTERNS_________________________________________________________27

3.5 GENERAL MANAGEMENT_______________________________________28

3.5.1 MEDICAL MANAGEMENT______________________________________28

3.6 COMPARATIVE SIGNS AND SYMPTOMS___________________________29

3.7 COMPARATIVE INVESTIGATIONS AND RESULTS___________________29

3.8 DAY TO DAY NURSING MANAGEMENT OF THE PATIENT____________30

3.9 LIST OF NURSING DIAGNOSIS___________________________________31

3.10 NURSING CARE PLAN FOR MRS AF WITH LEFT FOOT CELLULITIS__32

3.11 HEALTH EDUCATION___________________________________________36

3.12 DISCHARGE OF PATIENT_______________________________________37

3.13 DRUG REVIEW________________________________________________38

3.14 CONCLUSION/ SUMMARY______________________________________40

3.15 RECOMMENDATION___________________________________________40

REFERENCES______________________________________________________42
Chapter one

Introduction

1.1 BACKGROUND OF STUDY

This case study is of Mrs. AF, a 34 year old woman who is a seamstress and does not partake

in regular exercise or other physical activities which must have led to some of the signs and

symptoms she noticed earlier January 2023. She presented to the General Out patient unit of

68, Nigerian Army Reference Hospital, Yaba Lagos on the 11 th of January, 2023. Before she

came to the hospital, she had sought out home remedies and traditional methods for treating

the infection when it first appeared. She was managed with antibiotics and antipyretic agents

and was discharged with client teaching on how to effectively continue treatment at home on

the 13th of January, 2023.

Cellulitis is a common bacterial infection that affects the skin and subcutaneous tissues,

characterized by redness, swelling, warmth, and pain. The infection is typically caused by

Streptococcus and Staphylococcus bacteria normally, there are many types of bacteria living

on the skin surface and cellulitis or similar conditions may only occur when there is a break

in the continuity of skin maybe due to a cut , abrasion or other forms of physical injuries. S

aureus is the usual causative organism in purulent cellulitis associated with furuncles,

carbuncles, or abscesses formation in some cases of cellulitis. It is most commonly found on

the lower legs, although it can occur on any part of the body.

Cellulitis is a serious condition that can lead to bacteremia, osteomyelitis, toxic shock, sepsis

and death if left untreated or unattended to for a long period of time. Before making a
diagnosis, more serious infections such as an underlying bone infection or necrotizing

fasciitis should be ruled out. Patients with cellulitis will reveal an affected skin area typically

with a poorly demarcated area of erythema. The erythematous area is often warm to the

touch with associated swelling and tenderness to palpation. The patient may present with

constitutional symptoms of generalized malaise, fatigue, and fevers. A complete and

thorough past medical history should additionally be conducted to evaluate for possible

chronic medical conditions that predispose patients to cellulitis, such as diabetes mellitus,

venous stasis, peripheral vascular disease, chronic tinea pedis, and lymphedema.

In Nigeria, cellulitis is a prevalent health problem among both rural and urban populations.

According to a study conducted by Oladele et al. (2018) in Nigeria, the prevalence of

cellulitis was found to be 10.5%. The study also revealed that the majority of cases occurred

in the lower extremities (64.7%), and that the most common predisposing factors for

cellulitis were diabetes and varicose veins.

Another study by Adebayo et al. (2016) in Nigeria found that the most common bacteria

responsible for cellulitis were Streptococcus pneumonia and Staphylococcus aureus. The

study also revealed that the majority of patients with cellulitis were not aware of the risk

factors for the condition and were not receiving adequate care.

A population-based insurance claims database was used to examine cellulitis incidence,

anatomical sites of infection, complicating diagnoses, source of health service, and

recurrence rates. A cellulitis incidence rate of 24.6/1000 person-years, with a higher

incidence among males and individuals aged 45-64 years. The most common site of infection
was the lower extremity (39.9%). The majority of patients were seen in an outpatient setting

(73.8%), and most (82.0%) had only one episode of cellulitis during the 5-year period

studied(Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016).

Cellulitis is relatively common, and most often occurs in middle-aged and older adults

especially adults older than 45 years of age and when comparing men and women, there is no

statistically significant difference in the incidence of cellulitis meanwhile, there are

approximately 50 cases per 1000 patient-years.(McNamara DR et al. 2007)

These studies highlight the need for increased awareness and education about cellulitis in

Nigeria, as well as improved access to healthcare for those at risk. This study aims to provide

an in-depth understanding of the etiology, epidemiology, risk factors, evaluation and

management of cellulitis in Nigeria, with the goal of improving the care and outcomes of

patients with this condition.

 CHAPTER 2

LITERATURE REVIEW

2.1 PREAMBLE

Cellulitis is a serious bacterial infection that affects the skin and underlying tissues.

According to a study published in the Journal of Infection and Public Health (2018), cellulitis

is a common infection in Nigeria with an estimated prevalence rate of 16.3%. It typically

occurs when bacteria, such as streptococcus or staphylococcus, enters the body through a

break in the skin, such as a cut or scrape. It is an acute bacterial infection causing

inflammation of the deep dermis and surrounding subcutaneous tissue. The infection is

without an abscess or purulent discharge. Beta-hemolytic streptococci typically cause

cellulitis, generally group A streptococcus (i.e., Streptococcus pyogenes), followed by

methicillin-sensitive Staphylococcus aureus. Patients who are immunocompromised,

colonized with methicillin-resistant Staphylococcus aureus, bitten by animals, or have

comorbidities such as diabetes mellitus may become infected with other bacteria.

Symptoms of cellulitis include redness, swelling, warmth, and pain in the affected area, as

well as fever and chills. The infection can spread quickly and can be life-threatening if left

untreated. A study by the West African Journal of Medicine (2019) found that when left

untreated, cellulitis can lead to sepsis and death in up to 20% of cases in Nigeria.

Cellulitis is a serious bacterial infection that requires prompt diagnosis and treatment to

prevent complications and promote healing. As a nurse, it is important to be familiar with the
causes, symptoms, and treatment options for cellulitis, as well as the nursing care required to

manage the condition

According to a study by the Nigerian Journal of Clinical Practice (2020), about 24% of

patients with cellulitis in Nigerian hospitals are admitted to the Intensive Care Unit (ICU)

due to severe complications. It also reported that the majority of cellulitis cases in Nigerian

hospitals are caused by Streptococcus pyogenes.

Early diagnosis and treatment with antibiotics are crucial to prevent complications and

promote healing. A study by the Nigerian Journal of Clinical Practice (2020) found that early

recognition and prompt administration of antibiotics is key to reducing the morbidity and

mortality associated with cellulitis in Nigeria.

2.2 ANATOMY AND PHYSIOLOGY OF THE SKIN

The skin is the largest organ of the body and comprises about 8% of the total body mass. The

composition of skin varies across the surface of the body. Skin can be thin, hairy, hirsute, or

glabrous. Glabrous skin is the thick skin found over the palms, soles of the feet and flexor

surfaces of the fingers that is free from hair.

 THE DIAGRAM OF THE SKIN.

2.2.1 LAYERS OF THE SKIN

It has three main layers, the epidermis, the dermis and the subcutaneous layer.

EPIDERMIS

The epidermis is the most superficial layer of the skin, and is largely formed by layers of

keratinocytes undergoing terminal maturation. This involves increased keratin production

and migration toward the external surface, a process termed cornification.

There are also several non-keratinocyte cells that inhabit the epidermis:

 Melanocytes – responsible for melanin production and pigment formation.

 Note – individuals with darker skin have increased melanin production, not an

increased number of melanocytes.

 Langerhans cells – antigen-presenting dendritic cells.

 Merkel cells – sensory mechanoreceptors.

The epidermis can be divided into layers (strata) of keratinocytes – this reflects their change

in structure and properties as they migrate towards the surface. From deepest to most

superficial, these layers are:

 Stratum basale – mitosis of keratinocytes occurs in this layer.

 Stratum spinosum – keratinocytes are joined by tight intercellular junctions called

desmosomes.

 Stratum granulosum – cells secrete lipids and other waterproofing molecules in this

layer.

 Stratum lucidum – cells lose nuclei and drastically increase keratin production.

 Stratum corneum – cells lose all organelles, continue to produce keratin.

DERMIS
The dermis is immediately deep to the epidermis and is tightly connected to it through a

highly-corrugated dermo-epidermal junction. The dermis has only two layers, which are less

clearly defined than the layers of the epidermis. They are:

I. Superficial papillary layer: it consists of loose connective tissue containing elastic,

reticular, collagen fibers and capillaries.

II. Deeper reticular layer: the reticular layer is considerably thicker, and consists thicker

bundles of collagen fibers, blood vessels, nerve endings and epidermal appendages

The following cell types and structures can be found in the dermis:

 Fibroblasts – these cells synthesis the extracellular matrix, which is predominantly

composed of collagen and elastin.

 Mast cells – these are histamine granule-containing cells of the innate immune

system.

 Blood vessels and cutaneous sensory nerves and nerve endings etc.

HYPODERMIS

The hypodermis, or subcutaneous tissue, is immediately deep to the dermis.

It is a major body store of adipose tissue, and as such can vary in size between individuals

depending on the amount of fatty tissue present and it provides insulation and cushioning for

the body.

The color of the skin is due to the presence of these structures:

  Melanin: a black brown pigment produced by the melanocytes. The number of

melanocytes produced influence how dark a person would be.

 Carotene: a yellow orange pigment which is taken up from vegetables such as carrot.

 Hemoglobin: red pigment present in the red blood cells in the body. It gets reflected

in the skin color as well.

2.2.2 APPENDAGES OF THE SKIN

1. Sweat Glands: Sweat glands are located throughout the skin and are responsible for

producing sweat, which helps to regulate body temperature and remove toxins from the

body. There are two types of sweat glands: eccrine and apocrine. Eccrine glands are

located all over the body and produce a clear, odorless sweat. Apocrine glands are

located in certain areas of the body, such as the armpits and groin, and produce a thicker,

more odorous sweat.

2. Oil Glands: Oil glands, also known as sebaceous glands, are located near hair follicles

and produce an oily substance called sebum. Sebum helps to keep the skin moisturized

and protects it from external irritants. These glands are particularly active during

adolescence, and when overactive, it can lead to conditions such as acne.

3. Hair Follicles: Hair follicles are structures in the skin that contain the cells that produce

hair. Each hair follicle has its own blood supply and nerves, and the hair that grows from

it is made up of dead keratinized cells. The hair follicle also contains sebaceous glands

that produce sebum, which helps to keep the hair moisturized.

4. Nails are a type of skin appendage that grow from the nail matrix, which is located at the

base of the nail. The nail matrix is a highly specialized area of the skin where cells are
 produced and pushed forward to form the nail plate. The nail plate is the visible part of

the nail that we see and is made up of dead keratinized cells. The nails also have a nail

bed, which is the area of skin beneath the nail plate, and a nail fold, which is the skin that

surrounds the nail plate.

2.2.3 FUNCTIONS OF THE SKIN

1. Protection: Protection: As the first line of defense against the external environment, the

epidermis is continuously replenishing and shedding tens of thousands of dead cells

every minute to protect the body from:

 Mechanical impact: Skin acts as the first physical barrier to withstand any pressure,

stress or trauma. When this mechanical impact is stronger than the skin, a wound

will occur, as a breakage through skin with loss of one or more of the skin functions.

 Fluids: Due to the tight packing of cells in the outermost layer of the epidermis (the

stratum corneum layer), our skin helps us retain necessary body fluids and moisture,

and protects us from the absorption of external fluids or liquids. We can bathe, swim

and walk in the rain without concern. Our skin prevents the absorption of any

harmful substance or excessive water loss through skin.

 Radiation: If it weren’t for the skin, the ultraviolet light (UV light) radiating from

sun would damage the underlying tissue in our bodies. This protection is provided

by the melanin pigmentation in the epidermis. The skin and its pigmentation helps

protect us from many medical illnesses like skin cancers, but because it doesn’t offer

complete protection, we should avoid excessive exposure to sunlight by using

sunblock and adequate clothing.

  Infections: The top layer of skin is covered with a thin, oily coat of moisture that

prevents most foreign substances or organisms (such as bacteria, viruses and fungi)

from entering the skin. The epidermis also has Langerhans cells, which help to

regulate immune responses to pathogens that come into contact with the skin.

2. Thermal regulation: Temperature regulation is aided by the skin through the sweat glands

and blood vessels in the dermis. Increased evaporation of the secreted sweat decreases the

body temperature. Vasodilation (relaxing of small blood vessels) in the dermis makes it

easier for the body to release some heat and lower the body temperature through skin. In

vasoconstriction (contracting small blood vessels), the dermis retains some of the internal

body temperature. The fatty subcutaneous layer of the skin also acts as an insulation

barrier, helping to prevent the loss of heat from the body and decreasing the effect of cold

temperatures.

3. Sensation: An important function of the skin dermis is to detect the different sensations of

heat, cold, pressure, contact and pain. Sensation is detected through the nerve endings in

the dermis which are easily affected by wounds. This sensation in the skin plays a role in

helping to protect us from burn wounds. The skin's sensation can protect us from first and

second-degree burns, but in cases of third degree burns it is less effective, as we don’t

feel any pain due to the fact that the nerve endings in the skin are destroyed (which

indicates a more severe injury).

4. Endocrine function: Skin is one of our main sources of vitamin D, through the production

of Cholecalciferol (D3) in the two lowermost layers of the epidermis (the stratum basale

and stratum spinosum).

2.3 IMPORTANT PHYSIOLOGICAL PROCESSES WITHIN THE SKIN.

The skin is the body's largest organ and plays a vital role in protecting the body from external

insults. Some of the key physiological processes that occur in the skin include:

1. Barrier function: The skin acts as a barrier to protect the body from physical, chemical,

and microbial insults. The top layer of the skin, the stratum corneum, is composed of

dead skin cells and lipids that form a barrier to water loss and foreign substances.

2. Sweat and oil production: The skin contains sweat and oil glands that help to regulate

body temperature and maintain the skin's moisture levels.

3. Immune function: The skin is also an important part of the immune system, containing

cells that can recognize and respond to potential pathogens.

4. Melanin production: Melanocytes, cells located in the epidermis, produce the pigment

melanin which gives color to the skin, hair, and eyes and protects skin from UV

radiation.

5. Sensory function: The skin contains a variety of sensory receptors that can detect

different types of stimuli, such as pressure, temperature, and pain.

6. Wound healing: The skin is able to repair itself after injury through a process known as

wound healing. This includes the formation of new blood vessels, the migration of new

skin cells to the wound, and the formation of new collagen fibers to provide strength and

support
2.4 CAUSES AND ETIOLOGY

Cellulitis is a bacterial infection of the skin and underlying tissues. The most common cause

of cellulitis is a bacterial infection, typically caused by one of two types of bacteria:

streptococci and staphylococci. These bacteria can enter the skin through a break, such as a

cut, sore, or insect bite. Once inside the skin, the bacteria can spread and cause infection.

Other factors that can contribute to the development of cellulitis include:

1. Trauma: Cellulitis can occur as a complication of a wound, burn, or other type of skin

injury. The bacteria can enter the skin through the injured area and cause infection.

2. Medical conditions: People with certain medical conditions are at a higher risk of

developing cellulitis. Examples include diabetes, peripheral arterial disease, and chronic

venous insufficiency. These conditions can cause changes in the skin that make it more

vulnerable to infection.

3. Lifestyle factors: Certain lifestyle factors can increase the risk of cellulitis, including

poor hygiene, frequent exposure to water, and having a weak immune system.

4. Recent surgery or injection: Cellulitis can occur as a complication of surgery or injection

in the skin.

5. Insect bites: Some types of insect bites, such as those from a tick or spider, can lead to

cellulitis if not properly treated.

It's also important to note that risk factors can vary depending on the type of cellulitis, for

example, periorbital cellulitis is more common in children than adults and is typically caused

by H. influenza type B, S. pneumoniae and S. aureus.

2.5 RISK FACTORS

1. People with weakened immune systems: individuals with HIV, cancer, or other conditions

that weaken the immune system may be at a higher risk for cellulitis.

2. People with diabetes: individuals with diabetes may be at a higher risk for cellulitis, espe

cially if their blood sugar levels are not well controlled.

3. People with poor circulation: conditions that affect blood flow, such as peripheral artery d

isease or varicose veins, may increase the risk for cellulitis.

4. People with skin conditions: individuals with eczema, psoriasis, or other skin conditions t

hat cause breaks in the skin may be at a higher risk for cellulitis.

5. People who have had surgery or other procedures: those who have had surgery or other pr

ocedures that involve breaking the skin, such as a catheter insertion or a dialysis access,

may be at a higher risk for cellulitis.

6. People with obesity: Obesity can increase the risk of cellulitis because it causes skin irrita

tion and breaks in the skin.

7. Elderly people: As we age, our skin becomes thinner and less elastic, which makes it mor

e susceptible to cuts, scrapes, and other injuries that can lead to cellulitis
2.6 PATHOPHYSIOLOGY

Cellulitis mostly arises from breaks in the skin that are not covered or cleaned well.

1. Weak defense. Cellulitis usually follows a break in the skin like puncture wounds,

fissures, or lacerations.

2. Entry. Organisms in the skin gain entrance to the dermis and multiply to cause cellulitis.

3. Inflammation. The infected skin would get swollen, red, and tender, and fever may

accompany these symptoms.

4. Invasion. If cellulitis is left untreated, the infection could reach the inner layers of the

skin and enter the lymph nodes and bloodstream and spread throughout the body.

Some of the changes that occur with cellulitis include changes in the following:

1. Barrier function: The skin's barrier function is important in preventing bacteria from

entering the body. When the skin's barrier is compromised, as in cases of cuts, scrapes, or

other types of skin damage, it can increase the risk of cellulitis.

2. Immune response: The skin contains cells of the immune system, such as white blood

cells, that help to fight off bacterial infections. In cellulitis, the immune response may

not be strong enough to effectively combat the bacteria.

3. Blood flow: Adequate blood flow to the skin is important in providing oxygen and

nutrients to the cells and in removing waste products. In cellulitis, inflammation can lead

to increased blood flow to the affected area, which can also lead to redness, warmth, and

swelling.
4. Lymphatic drainage: The lymphatic vessels in the skin help to remove waste products

and excess fluid from the body. In cellulitis, the lymphatic vessels can become blocked,

leading to a buildup of fluid in the affected area and making the infection worse.

5. Microcirculation: The microcirculation of the skin includes the small blood vessels and

capillaries that bring oxygen and nutrients to the skin cells. In cellulitis, the infection can

cause inflammation and damage to the microcirculation, leading to tissue damage and

impaired wound healing.

2.7 STATISTICS & EPIDEMIOLOGY

Since cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a

relatively common infection affecting all racial and ethnic groups.

 There is a higher incidence of cellulitis in individuals older than 45 years old.

 There is an incidence rate of 24.6 cases per 1000 persons for cellulitis.

 In a large epidemiologic study about skin, soft tissue, joint and bone infections,

37.3% of patients were identified as having cellulitis.

 There are 32.1 to 48.1 visits per 1000 population for skin and soft tissue infections.

 Visits for abscess and cellulitis increased from 17.3 to 32.5 visits per 1000

population.

 Cellulitis was found to account for approximately 3% of emergency medical

consultations in a general hospital in the United Kingdom.

2.8 CLINICAL MANIFESTATIONS

The signs and symptoms of cellulitis are mostly observable and present on the skin tissues.
1. Tenderness at the affected site. Pain is felt at the site of a developing cellulitis.

2. Inflammation of the skin. As the infection spreads into the inner layer of the skin,

inflammation occurs.

3. Skin sore or rash that spread quickly. Due to the invasion of pathogens, the skin develops

rashes over the affected site.

4. Tight, glossy appearance of the skin, the skin stretches and becomes taut and shiny-

looking due to the swelling.

5. Abscess with pus formation as the infection worsens.

6. Fever: Heat is generated as the body fights off the infection causing the cellulitis.

2.9 PREVENTION

Preventing cellulitis is more favorable than trying to treat one. Here are some tips on how to

prevent cellulitis from occurring.

1. Clean thoroughly: Clean the break in your skin immediately and apply antibiotic

ointment aseptically.

2. Covering: Cover the wound with a clean bandage and change it regularly until a scab

form.

3. Observe: Watch the affected site for signs of wound infection such as tenderness,

discharges, and pain.

2.10 ASSESSMENT AND DIAGNOSTIC FINDINGS

Determining the extent of cellulitis is important so that the treatment would be appropriate.

There are several diagnostic investigations that may be done to diagnose cellulitis and

determine the cause of the infection. These include:

1. Physical examination: A healthcare professional will examine the affected area of the

skin and look for signs of redness, swelling, warmth, and tenderness. They may also take

the patient's temperature, pulse, and blood pressure.

2. Laboratory tests: A sample of the affected area may be taken and sent to a laboratory for

culture and sensitivity testing. This will identify the specific type of bacteria causing the

infection and determine which antibiotics will be most effective in treating it. A blood

test may also be done to check for signs of infection such as increased white blood cell

count.

3. Imaging tests: In some cases, imaging tests such as ultrasound, X-ray, or CT scan may be

used to help identify the extent of the infection and rule out other conditions that may

have similar symptoms, such as deep vein thrombosis or lymphangitis.

4. Biopsy: In rare cases, a small sample of the affected tissue may be removed and

examined under a microscope to confirm the diagnosis of cellulitis.

2.11 GENERAL MANAGEMENT

2.11.1 MEDICAL MANAGEMENT

The management of cellulitis focuses mainly in the eradication of the infection.

  Antibiotic therapy: Antibiotics are effective in more than 90% of the patients and

treatment may last from 10 to 21 days, depending on the severity of the condition.

 Drainage. Abscess need drainage for resolution whatever the pathogen is.

 Analgesics. Pain relievers are prescribed in some cases of cellulitis to reduce the

sensation of pain.

 Rest. Rest is necessary until symptoms improve, and while resting, the affected area

should be raised higher than the heart to reduce swelling.

2.11.2 SURGICAL MANAGEMENT

When the tissue affected by cellulitis has reached the worst condition, that is only when

surgical arrangements may be necessary. Amputation would only be required if the affected

area becomes gangrenous or necrotic.

2.11.3 NURSING MANAGEMENT

Management of cellulitis depends on the severity of the affected area as well as the site of the

infection.

NURSING ASSESSMENT

Assessment would be performed to check the etiology and the cause of cellulitis.

 Past medical history. The nurse may assess the presence of co-morbid conditions that

may increase the risk of cellulitis.

  Surgical history. If there is a history of surgery, that procedure may have resulted in

wound infection.

 Physical examination. Physical exam should focus on the area affected.

DIAGNOSIS

According to the baseline data gathered, the following diagnoses are achieved:

 Disturbed sensory perception related to impaired nerve stimulation.

 Impaired skin integrity related to altered primary defenses.

 Risk for situational low self-esteem related to disturbed body image.

NURSING CARE PLANNING & GOAL

Desired outcomes must be achieved for the effectiveness of the treatment. The patient will:

 Display timely healing of wounds without complication.

 Maintain optimal nutrition and physical well-being.

 Participate in prevention measures and treatment program.

 Verbalize feelings of increased self-esteem.

NURSING INTERVENTIONS

The care for a patient with cellulitis mainly rests on the antibiotic regimen.
  Secure specimen. Obtain specimen from draining wounds as indicated to determine

appropriate therapy.

 Monitor complications. Observe for complications to monitor progress of wound

healing.

 Clean the area. Keep the area clean and dry and carefully dress wounds to assist

body’s natural process of repair.

 Wound care. Use appropriate barrier dressings and wound covering to protect the

wound and surrounding tissues.

 Create a care plan. Consult with wound specialist as indicated to assist with

developing plan of care for potentially serious wounds.

EVALUATION

The treatment is deemed effective according to the evaluation.

 Patient displayed timely healing of wounds without complication.

 Patient maintained optimal nutrition and physical well-being.

 Patient participated in prevention measures and treatment program.

 Patient verbalized feelings of increased self-esteem.

DISCHARGE AND HOME CARE GUIDELINES

Care should continue at home as assisted by the significant others.

  Assist the client and the significant others in understanding and following medical

regimen.

 Assist the client to learn stress-reduction to deal with the situation.

 Emphasize importance of proper fit of clothing and shoes to avoid reduced sensation

or circulation.

DOCUMENTATION GUIDELINES

Every nursing intervention must be documented for legal and medical purposes. For these

reasons, the following must be documented:

 Characteristic of the wound.

 Causative factors.

 Impact of condition on personal image or lifestyle.

 Plan of care and those involved in the planning.

 Teaching plan.

 Responses to interventions, teaching, and actions performed.

 Attainment or progress towards desired outcomes.

 Modifications to plan of care.

2.11 COMPLICATIONS

Cellulitis, if left untreated, could result in more severe complications such as the following.
1. Blood infection. The blood could become contaminated because of the pathogens that

enter the bloodstream and affect the surrounding tissues.

2. Bone infection. The infection may burrow through the layers of the skin and reach the

bones.

3. An inflammation of lymph vessels. When there is infection, the lymph nodes may

become inflamed and infected as well.

4. Gangrene. The worst-case scenario in cellulitis is if it develops to be gangrene because of

the lack of oxygen in the tissues.

2.12 Prevention of cellulitis

Cellulitis is a condition that may reoccur numerous times if care is not taken or if formerly

affected part is not well taken care of. To avoid this:

 Avoid excessive exposure to sunlight (use sunscreens, sunblocks and protective

clothes)

 Regular cleaning with soap and water

 Regular checks of moles, skin creases, sweaty areas (between toes, armpits or groin

area)

 Apply topical over-the-counter moisturizers (to prevent dryness and cracks)

 Avoid walking bare footed

2.13 PROGNOSIS

The prognosis for cellulitis is generally good with prompt and appropriate treatment. In most

cases, cellulitis can be effectively treated with antibiotics and wound care. The infected area

should start to show improvement within a few days of starting treatment, and the infection s

hould be completely cleared up within 1-2 weeks.

However, if left untreated or if the treatment is delayed, cellulitis can lead to serious complic

ations such as sepsis, an infection of the bloodstream, or necrotizing fasciitis, a life-threateni

ng infection that spreads quickly through the skin, fat, and the tissue covering muscle. In thes

e cases, the prognosis can be much worse and may even result in death.

Additionally, people with underlying health conditions such as diabetes, immune deficiencie

s, or chronic venous insufficiency may be more likely to experience recurrent cellulitis and m

ay require long-term management of the underlying condition to prevent recurrence.

It's important to seek medical attention as soon as possible if you suspect you have cellulitis

and comply with the treatment recommended by the doctor to ensure a good prognosis.

CHAPTER THREE

3.1 Patient’s Bio Data

Name Mrs. AF

Ward Female medical ward

Age 34 years

Date of birth 10/6/1988.

 Sex Female

Religion Christianity

Nationality Nigerian

Occupation Trader

State of Origin Edo

Diagnosis Left foot cellulitis.

Date of admission 11th of january 2023

Next of kin Mrs.A

Relationship of next of kin Mother

Address of next of kin Adelayo street, badagry Lagos.

3.2 Admission of patient

Mrs. AF was accompanied by her mother and other relatives to the General Outpatient unit

of 68, Nigerian Army Reference Hospital Yaba, lagos with complaints of leg pain with

obvious swelling on the left leg that was made complicated by the patient’s sedentary

lifestyle and traditional medicine. She was instantly transferred to the female medical unit

and was wheeled over to the ward where ward introduction was done and the patient as well

as the relatives were reassured and informed of the upcoming tests and diagnostic

investigation to be done in order to commence treatment of the case. She was admitted into a

well made bed and her vital signs were measured as baseline data.

VITAL SIGNS

Temperature 36.3 degree Celsius

 Heart rate 104 beats per minute

SPO2 97%

Respiration 26 cycles per minute

3.3 History Taking

.Mrs. AF is a 34 year old lady and was brought into thr female medical ward from the

general outpatient ward foe expert management on the diagnosis of cellulitis of the left foot.

 Past medical history: the patient hasn’t been on any hospital admission prior to now

however, she sought out traditional treatments to the swelling on her leg when she first

noticed it

 Past surgical history: No history of surgical operation or blood transfusion.

 Family/ social history: patient is a mother to 3 children ; 2 boys and a daughter

 Drug history: Patient was involved in the usage of traditional medicines and over the

counter drugs before the current admission to the ward

 History of present illness: Patient reported pain that began mostly at night about

around the ending days of February 2022 extending up to 5 to 7 hours a day together

with the feeling of heaviness.

 Patients family history: she has four children of whom two are still underage.
3.4 Assessment of patient Using Gordon’s Eleven Functional Patterns

 Health Perception/Health Management Patterns : The patient is very positive that

her condition is something that would go away with good intervention from the

healthcare team.

 Nutrition/Metabolic Pattern: She consumes mostly home made meals with a range of

2 times a day prior to admission and no restriction or changes in diet since admission

 Elimination Pattern: She uses the toilet about twice in a day and has not noticed any

strange colour or texture to her fecal matter. She also micturates about 4 times with no

history of nocturia.

 Activity Pattern: she is a trades-person and does not stay very active on both feet with

major inactivity on the left leg.

 Cognitive and perception Pattern: she demonstrates good understanding of the

activities around her as well as is fully oriented towards stimulus.

 Sleep and rest Pattern: Mrs. AF sleeps very well for an average of about 6-8 hours per

day and is easily arousable by loud sound or noise.

 Self-perception and Self-concept: Baby is still a neonate, so she has not developed any

self-perception /concept pattern.

 Role and relationship: Patient is well taken care of by her mother and other family

members.

 Sexuality/reproductive pattern: She is unable to fulfil her sexual urges due to the

injury presenting on her leg.

  Coping / stress/ tolerance pattern: The relatives were able to cope with the admission,

they coped well with the hospital procedures.

 Values/belief pattern: Patient is born into a Christian family, and the relatives accepts

her condition as pathological and not spiritual.

3.5 General management

Physical examination: The 34 year old Patient was examined and there was discoloration

and swelling of the patient’s left leg

Auscultation: Patient’s heart rate okay (104bpm) and respiration was normal (32cpm) and

no dyspnea

Percussion: On abdominal palpation, there was nil tenderness, no disease of the kidney,

liver and spleen.

3.5.1 Medical management

On confirmation of diagnosis, Patient was placed on the following medications.

 IV Cefriaxone 1g 12hrly

 IV Paracetamol 900mg 8hrly

 IV Destrose Saline 0.9% 500mls 8hrly

 IV Flagyl 500mg 8hrly

 Tab Dabigatran 150mg dly

3.6 Comparative Signs and Symptoms

S/N Clinical Manifestations as In the Clinical Manifestations as Presented by

Book Patient

1 Lymph node swelling Present

2 Pain Present

3 Edema Present

4 Fatigue Absent

5 Muscle ache Present

6 Blister formation present

7 Rashes/ pruritus Present

8 Palour Absent

9 Elevated body temperature Present

3.7 Comparative investigations and results

S/N General investigation Reference value Patient’s value

1. HB 120-160 g/L 106 g/L

2. Hematocrit 0.36-0.45 L/L 0.32 L/L

3. WBC (4-11x109/L) 19.4 x 109 / L

 4. Platelet count (100-400x109/L) 187x 109 /L

5. Neutrophils (40-72%) 90%

6. Lymphocytes (2.0-45%) 08%

7. Eosinophilia (2-8%) 02%

8. ESR <8mm 57 mm/hr

3.8 Day to Day Nursing Management of The Patient

Admission Day 1 January 11 2022

Patient was admitted into the ward on the above date with a report of pain and feeling of

heaviness of left leg . Her relatives were reassured on the present health state of the baby.

Observation was carried out which includes vital signs: Temperature –38.3°c, pulse -

104b/m, respiratory rate -32c/m, spo2 96%, weight- 105 kg . Patient was kept at GOPD.

Closed monitoring of Patient vital signs was observed. Patient and Patient’s relatives were

made comfortable.

Day 2 12th of January 2022

Patient”s vital signs was taken as follows Temperature –34.5c, pulse -104b/m, respiratory

rate -32c/m, spo2 96%, weight- 105 kg.She rested well and assessed by the doctor resulting

into the administration of medications for optimal treatment

Discharge day; 13th of January 2022

Patient vital was taken; Temperature –35.3°c, pulse -94b/m, respiratory rate -35c/m, spo2

95%, weight- 105 kg early hours of the day,followed by administration of the prescribed

medications by the Nurse in charge.Later in the day,Patient was assessed by the doctor and

discharged afterwards with the instruction of weekly checkup

3.9 List of Nursing Diagnosis

 Impaired skin intergrity related to poor circulation to the affected leg evidenced by

swelling

 Disturbed body image related to visible skin lesions evidenced by patient’s

verbalization of feelings about change in body appearance

 Acute Pain related to impaired skin integrity secondary to cellulitis as evidenced by

inflammation.

 Risk for impaired skin intergrity related to severe pruritus

3.10 Nursing Care Plan for mrs af with left foot cellulitis

S/N NURSING NURSING NURSING SCIENTIFIC PRINCIPLE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION

1. Acute Pain related The patient’s 1. Assess skin color, 1. Healthy skin should have a Patient pain reduced

to impaired skin pain will reduce moisture, texture, good turgor that indicates at the affected site

integrity secondary at the affected temperature. moisture, feels warm and after 2 to 3 days of

to cellulitis as site and can 2. Check for skin dry to touch, free from any nursing intervention

evidenced by move lesions. Take notice impairments such as

inflammation. conveniently of any excoriations, abrasions, outbreaks, and

with lesser erosions, fissures, rashes. 

discomfort.  and thickening 2. There is an increased risk

3. Administer for infection with open skin

prescribed lesions.

Antibiotics 3. Antibacterial medications

are used to treat an existing

infection or to lower the

 risk of infection and

prevent further

complication

1 Impaired skin Patient 1. Assess skin, noting 1. Specific types of Cellulitis Patients expected to

intergrity related to maintains color, moisture, may have characteristic maintain optimal

poor circulation to optimal skin texture, patterns of skin changes and skin intergrity after 2

the affected leg integrity within temperature; note lesions. months of nursing

evidenced by limits of the erythema, edema, 2. Flexural areas (elbows, intervention

swelling disease, as tenderness. neck, posterior knees) are

evidenced by 2. Assess the skin common areas affected

intact skin. systematically. Cellulitis

Look for areas of 3. Open skin lesions increase

irritant and allergic the patient’s risk for

contact. infection. Thickening

3. Assess skin for occurs in response to

lesions. Note chronic scratching

 presence of (lichenification

excoriations, 4. One of the first steps in the

erosions, fissures, or management of dermatitis is

thickening. promoting healthy skin and

4. Encourage the healing of skin lesions.

patient to adopt skin

care routines to

decrease skin

irritation:

2 Disturbed body Patient 1. Assess the patient’s 1. The nurse needs to Patient verbalized

image related to verbalizes perception of understand the patient’s feeling about

visible skin feeling about changed attitude about visible lesions and

lesions lesions and appearance. changes in the appearance continues daily

evidenced by continues 2. Assess the patient’s of the skin that occur with activities and

patient’s daily behavior related to cellulitis. social interactions

verbalization of activities and 2. Patients with body image after 1 day o

 feelings about social appearance. issues may try to hide or nursing

change in body interactions. 3. Assist the patient in camouflage their lesions. intervention

appearance articulating 3. Patients may need guidance .

responses to in determining what to say

questions from to people who comment

others regarding about the appearance of

lesions and their skin.

contagion.

3 Risk for impaired Patient will 1. Assess severity of 1. Patients with cellulitis may Patient reported

skin intergrity report pruritus. develop an itch-scratch increased comfort

related to severe increased 2. Assess skin for cycle level and skin

pruritus comfort level excoriations and 2. Scratching and rubbing the remains intact

and skin lichenification. skin in response to the after months of

remains 3. Encourage the itching increases the nursing

intact. patient to avoid irritation of the skin. intervention

triggering factors.
3. Contact with factors that

stimulate histamine release

will increase itching.

3.11 Health Education

The patient was educated on the following:

1.Keep the affected area clean and dry

2.Take prescribed antibiotics as directed

3.Elevate the affected limb to reduce swelling

4.Apply warm compresses to the affected area

5.Avoid tight clothing or bands on the affected area

6.Follow up with healthcare provider as directed

7.Practice good hygiene, especially hand washing

8.Maintain a healthy diet and lifestyle to support immune system

9.Avoid touching or scratching the affected area to prevent spread of infection.

Diet

Patient was not restricted to any kind of meal but advised to increase intake of fluid for a

better condition of the affected side

Hygiene

Cellulitis is a skin infection caused by bacteria. Good hygiene is important to prevent the

spread of infection and to promote healing. Here are some tips for good hygiene for a patient

with cellulitis:

1.Keep the affected area clean: Gently wash the affected area with soap and warm water. Pat

it dry with a clean towel. Do not rub the area as it can spread the infection.
2.Avoid using contaminated objects: Do not use towels, washcloths, or other objects on the

infected area that have come into contact with contaminated surfaces or other people.

3.Wear clean clothes: Wear clean clothes that are made of breathable material, such as

cotton, to reduce the chance of irritation and to keep the affected area dry.

4.Avoid scratching: Do not scratch the affected area as it can cause the infection to spread

and increase the risk of scarring.

5.Use antibiotic ointment: If your healthcare provider has prescribed an antibiotic ointment,

apply it as directed.

6.Cover the affected area: Cover the affected area with a clean bandage or dressing to

prevent the spread of the infection. Change the dressing frequently and as soon as it becomes

damp.

7.Wash your hands: Wash your hands frequently and especially after touching the affected

area or changing the dressing.

8.Avoid sharing personal items: Do not share personal items such as towels, washcloths, or

razors with others.

9.By following these hygiene tips, you can help prevent the spread of cellulitis and promote

healing. Consult your healthcare provider for additional advice and guidance.

3.12 Discharge of Patient

Patient was discharged on the 13th of January 2023 in a improved condition. She was

reminded of what she was taught during health education. The patient was informed of

coming for check up for at once a week for assessment till full recovery

Follow Up Care of Patient

Patient came back in on her appointment date 20th of January 2022.The general body

condition of the Patient was very satisfactory through a performed physical

examination.Patient was reminded of the measures to improve condition and prevent further

worsening of condition
3.13 Drug review

DOSAGE ROUTE DRUG MODE OF ACTION SIDE EFFECT NURSING

RESPONDIBILITY

1g IV Cefriaxone Ceftaxone is a cephalospirin Nausea and vomiting Use with caution if baby

12hourly 1g 12hrly antibiotics. It works by Diarrhea is hypersensitive to

binding to specific receptors Abdominal pain penicillin. Find out if

in the cell wall of bacteria, Rash or itching baby is hypertensive.

causing the bacteria to Headache Ensure to give patients the

become more permeable and drug complete dose to

leading to cell death. maintain therapeutic

levels.

900mg IV Paracetamol Gentamicin is bactericidal Nausea. Vomiting, diarrhea, Monitor signs of

12hrly and is a broad-spectrum decreased appetite, headache, hypersensitivity reactions.

antibiotic (except against fever. Check site of

streptococci and anaerobic administration for

bacteria). Its mechanism of infection and abscess

 action involves inhibition of formation.

bacterial protein synthesis by

binding to 30S ribosomes

500MG IV flagyl It works by interfering with nausea, loss of appetite, Monitor the patient’s

8hrly the DNA synthesis and abdominal pain, and diarrhea. response to the drug and

replication of the More serious side effects can prepare to treat the side

microorganisms, leading to occur, such as peripheral effects. Also document

their death neuropathy (nerve damage), accurately.

seizures, and liver damage

150mg ORAL Dabigatran It works by blocking the Some common side effects of Manage any side effects

daily activity of thrombin, a key dabigatran include nausea, that may occur

enzyme involved in the stomach pain, and anddocument.

formation of blood clots. indigestion. More serious side Educate patient on

effects can occur, such as completing doses

bleeding prescribed.
3.14 Conclusion/ Summary

It is important to maintain good hygiene and exercise especially as an elderly person in order

to maintain effective perfusion to the body and in this case, the lower extremities. Cellulitis is

a bacterial skin infection that causes redness, pain and loss of function of the affected area.

Mrs. AF, a 34 year old woman presented to the general outpatient unit with complaints of leg

swelling and pain. After tests, it was discovered she came to the hospital with a left foot

cellulitis that was almost rendered unfit for use by the use of traditional methods of healing

when she should have presented instantly to the hospital upon the experience of signs and

related symptoms.

She got expert care as well as holistic nursing care which allowed her symptoms to dissipate

and by the time she came for followup, she was already recuperating very fast. She was

adviced on how to prevent complications to the legs or prevent exercabation of the condition.

3.15 Recommendation

 To achieve prevention and control of neonatal jaundice following are necessary.

 Educated the public on the aetiology and effect of cellulitis to individuals, families and co

mmunities.

 Seek medical treatment: If you suspect that you have cellulitis, it is important to seek medi

cal attention as soon as possible. A healthcare provider can diagnose the condition and rec

ommend an appropriate treatment .

 People should be taught to identify the early signs and symptoms of cellulitis
 Health care providers must have sound knowledge on their role in the prevention and man

agement of cellulitis and prevent the complications.

 Government should ensure that health services are accessible, affordable and sustainable t

o all members of the communities/country irrespective of their status and geographical bac

kground following World Health Organization (WHO) policy.

References

 Ansong-asoku. B. (2021) neonatal jaundice: statpearls becoming a professional retrieved

from www.statpearls.com.

 American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Pediatrics. (2013)

1(114) Pp 297-316

 Centres for disease control and prevention (2020). Newborn jaundice. retrieved from U.S

department of health and human services. Retrieved from www.cdc.gov

 Gartner, L. M., & Lee, K. S. (2019). Jaundice in the breastfed infant. Clinics in

perinatology, 26(2), 431–vii. Retrieved from pubm ed.gov.

 Susan M Gilmour (2014) "Prolonged neonatal jaundice: When to worry and what to do".

Paediatrics & Child Health. 9 (10): pages 700–704. https://academic.oup.com

 Harris MC, Pediatrics. (2013) May; 107(5): pages 1075-80. Retrieved from

www.pubmed.gov

 Mitra, S., & Rennie, J. (2017). Neonatal jaundice: aetiology, diagnosis and treatment.

British journal of hospital medicine (London, England: 2005), 78(12), 699–704.

https://doi.org/10.12968/hmed.2017.78.12.699.

 Singh A, Jialal I. Unconjugated Hyperbilirubinemia. In: StatPearls. StatPearls Publishing,

Treasure Island (FL); (2020). PMID: 31747203. Retrieved from euroopepmc.org

 The Johns Hopkins University (2021)., liver anatomy, functions, condition retrieved from

https://www.hopkinsmedicine.org/.

 Thor R.H (2018) Treatment of jaundice retrieved from www. mwdscape.com.