CELLULITIS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin SHORT TERM: 1. Perform assessment GOAL MET
integrity related to After 4 hours of nursing of wound (stage 1-4)
Objective: Altered circulation intervention the patient and surrounding skin SHORT TERM:
Skin lesion will be able to participate as a baseline and After 4 hours of nursing
Skin redness RATIONALE: in preventative measure document daily or intervention the patient
Swelling Patients who are and treatment. when dressing is was able to participated
blister overweight, paralyzed, changed in preventative measure
with spinal cord injuries, LONG TERM: 2. Provide wound 2-3.Proper wound and treatment.
those who are bedridden The patient will maintain treatment based on care prevents infection
and confined to optimal skin integrity stage and drainage, and other complications, LONG TERM:
wheelchairs, and those within the limits of the using gauze, and also helps speed up The patient maintained
with edema are also at disease, as evidenced by hydrocolloid, foam, the healing process with optimal skin integrity
the highest risk for intact skin. absorptive dressing, less scarring within the limits of the
altered skin integrity. hydrogel disease, as evidenced by
3. Debride and clean intact skin.
wound as ordered
4. Ambulate patient if 4. Ambulating improves
possible blood flow, which in turn
can speed up the process
of wound healing.
5. When pts is in bed, 5. To reduce or relieve
turn every 1-2 hours; the pressure on the area
use all 4 at risk, maintain muscle
sides(lateral, prone, mass and general tissue
dorsal) unless integrity and ensure
contraindicated adequate blood supply to
the at risk area.
6. Do not drag pt 6. Dragging can cause
shear

7. Do not massage skin 7. Rubbing may cause

additional trauma

8. Prevent head of the 8. Because shearing

bed elevation for forces are generated on
more than 30 sacrum, causing
degrees for long mechanical stress
periods

9. Have pt do active 9. To promote

ROM or passive circulation to skin and to
ROM alter weight-bearing

10. Elevate leg to 10. Edema slows oxygen

prevent edema diffusion and metabolic
transport from capillary to
cell

Teach the patient/

significant other to
provide the following:
 Increase calories and  Because tissue are
protein more vulnerable to
 Increase fluid intake necrosis with smaller
Supplement iron and amount of pressure
vitamin c as needed. if the diet is deficit.
  to prevent
Monitor laboratory values dehydration(2600ml
that have as impact on /day if possible)
skin and report  Vitamin C is
abnormalities: HCT/Hbg important for wound
 Teach to call healing, fosters
physician regarding collagen synthesis
sign and symptoms and capillary
of infection or function; Iron
worsening improves oxygen-
carrying capacity of
blood.

 HCT/Hbg bec. low

level compromise
oxygen delivery to
tissue:
 BUN bec. Elevated
levels may indicate
renal disease, which
may affect albumin
 Albumin bec. Low
amount of cause
intestinal edema,
which impels
exchange of
nutrients and waste
products
 Bilirubin bec. Level
may indicate liver
disease, which may
 affect albumin
 Arterial blood gases
bec. It indicate
oxygen available for
tissue.

REF:KIM. J.M, ET al.

Pocket guide to nursing
diagnoses (6th
edition)pp409.

CELLULITIS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for situational low After 2 hours of nursing 1. Use touch during 1. Use touch during After 2 hours of nursing
Objective: self esteem related intervention the patient interactions, if acceptable interactions, if acceptable intervention the patient
Skin lesion to disturbed body image. will verbalize to patient, and maintain to patient, and maintain verbalized understanding
Skin redness understanding of the eye contact. eye contact. of the body changes,
Swelling RATIONALE: body changes, accepting accepting of self in
blister Positive self-esteem of self in situation. 2. Acknowledge situation.
develops when a person difficulties patient may be 2. Validates reality of
feels good and capable of Begin to develop coping experiencing. Give patient's feelings and Developed coping
responding to challenges mechanism to deal information that gives permission to take mechanism to deal
and stressors. effectively with problem counseling is often whatever measures are effectively with problem
Nevertheless, when a necessary and important necessary to cope with
person exhibits mild to a in the adaptation process. what is happening.
remarkable shift in the 3. Develop a therapeutic
view of himself or herself nurse client relationship
such as negativity about through frequent, brief 3. Therapeutic
self, low self-esteem contacts and an accepting relationship promotes
develops. Low self- attitude. Show understanding and can
esteem can reduce the unconditional positive help establish a
quality of a person’s life in regard. Your presence, constructive relationship
many different ways, acceptance, and between the nurse and
including negative conveyance of positive the client.
feelings, fear, relationship regard enhance the
problems, or low client’s feeling self-worth
resilience. This change in
self-esteem is a 4. Use touch during
temporary phase in interactions, if acceptable
response to feeling to patient, and maintain
helpless to control the eye contact. 4. Affirmation of
current situation. 5. Refer for professional individuality and
counseling if indicated acceptance is important
in reducing patient's
feelings of insecurity and
self-doubt.

5. May be necessary to
regain and maintain a
positive psychosocial
structure

REF:KIM. J.M, ET al.

Pocket guide to nursing
diagnoses (6th edition)
ANAPHY:
The skin is composed of 3 layers:
 the Epidermis is the outermost layer and is composed of keratinocytes or skin cells that form the “bricks” of our skin’s barrier.
The functions of the epidermis are protection from environmental insults (like ultraviolet light and toxins), prevention of
dryness, and immune surveillance.
The base of the epidermis is called the basal layer – it contains the cells that replicate in order to replace the epidermis every
month. Mixed in between keratinocytes of the epidermis are pigment cells, called melanocytes, that give skin its characteristic color.
These cells become activated with ultraviolet exposure found in sunlight.
Keratinocytes- 5 distinctive layer or strata that represent progressive mutation of the keratinocytes
1. Stratum Germinativum- produces new keratinocyte(deepest layer)
2. Stratum Spinosum- 2-4 layer thick, commonly referred to as Pickle cells bec they develop a spiny appearance as their
cell boarders interconnect
3. Stratum Granulosum- it consist of granular cell
4. Stratum Lucidum- mostly confined to the palm and soles.
5. Stratum- Corneum-consist of dead keratinized cells.
 Beneath the epidermis is the dermis, composed mostly of collagen but also adjunctive structures like hair follicles and sweat glands.
Sebaceous glands are found next to hair follicles and produce sebum, a combination of natural lipids that coat the skin’s surface
and provide a protective nourishing role. Sweat glands function to help regulate temperature through evaporation and cooling.
Within the dermis also lies a protein, elastin, that provides cutaneous elasticity and fibroblasts, the cells that produce more
collagen. The function of the dermis is temperature regulation though the secretion of sweat to the skin’s surface and the regulation of
blood flow to the area.
 Below the dermis, lies the subcutis which holds fat and larger blood vessels. The subcutis acts as a heat insulator and also provides
protection from mechanical trauma.

Protection against microorganisms, dehydration, ultraviolet light, and mechanical damage; the skin is the first physical barrier that the human body has
against the external environment.
 Sensation of pain, temperature, touch, and deep pressure starts with the skin.

Mobility: The skin allows smooth movement of the body.

Endocrine activity: The skin initiates the biochemical processes involved in Vitamin D production, which is essential for calcium absorption and normal
bone metabolism.
Exocrine activity: This occurs by the release of water, urea, and ammonia. Skin secretes products like sebum, sweat, and pheromones and exerts important
immunologic functions by secreting bioactive substances such as cytokines.
Immunity development against pathogens.
Regulation of Temperature. Skin participates in thermal regulation by conserving or releasing heat and helps maintain the body’s water and homeostatic
balance.

Ref:

Porth, C. M. (2004). Pathophysiology concept of altered health states (7th edition, Vol. 1). Lippinconn Williams & Wilkins.

we further conclude that cellulitis is a any break of the skin that bacteria staphylococcus and streptococcus can cause infection this many factor of immunity/ resistance will
trigger body to responce ----in healing and their is a certain treatment
We found of various appropriate nursing care measures/ medical management and possible surgical management