Cellulitis Nursing Diagnosis & Care Plan

Contents: 

• Overview 
• Cellulitis Nursing Diagnosis 
• Cellulitis Care Plans

Pathophysiology: 

• Cellulitis is an infection of the skin (epidermis and dermis) or underlying soft tissues (hypodermis); it can spread rapidly and be life-threatening.
• Bacterial organisms enter a compromised skin barrier and cause infection.
• The most common bacterial organisms are Staphylococcus aureus and group A Streptococcus.
• This condition can occur anywhere but mainly occurs on the lower leg.

Causes:

• Skin Trauma (cuts, puncture, bites, surgery)
• Skin ulcers
• Chronic skin conditions 
• Nail infections 

Signs & Symptoms 

• Erythema/ red streaks 
• Warm/hot to touch 
• Edema (fluid)
• Pain/tenderness
• Fever 
• Blisters (bullae)
• Leaking of yellow fluid or pus
• Skin dimpling (skin assumes thickened appearance similar to an orange peel)

Complications: 

• Sepsis 
• Lymphatic involvement 
• Osteomyelitis 
• Tissue damage
• Gangrene 

Diagnosis: 

• Wound culture/ swab 
• X-ray to rule out possible complications such as osteomyelitis 
• Blood cultures if sepsis and bacteremia is suspected 
• Ultrasound if an abscess is suspected 

• Eron classification system of soft tissue and skin infections (SSTI) to determine the severity of cellulitis infection and possible systemic involvement

• Patients are categorized based on their clinical appearance. 
  • Class 1: no fever and healthy; no systemic toxicity, no comorbidities 
  • Class 2: fever and appears ill; systemic symptoms, stable comorbidities 
  • Class 3: significant toxicity; at least one unstable comorbidity 
  • Class 4: Sepsis; life-threatening condition 

Treatment: 

• Antibiotic treatment 
  • Oral 
  • IV infusion 

Nursing Diagnosis for Cellulitis 

Impaired Skin Integrity r/t compromised defense mechanism of the skin  Acute Pain r/t edematous extremity secondary inflammatory process Ineffective Tissue Perfusion r/t extremity edema  Risk for Vascular Trauma: Risk factor: injury by intravenous antibiotic infusion

Nursing Care Plans for Cellulitis

Impaired Skin Integrity r/t to compromised defense mechanism of the skin 

Expected Outcome: The patient will attain intact skin integrity with a healthy structure and function. 

Screen the patient for risk factors of developing cellulitis.  Risk factors such as a previous history of cellulitis, frequent fungal infections, trauma, chronic skin conditions, obesity, diabetes mellitus type 2, lymphedema, and venous insufficiency need to be considered and included in the treatment plan.

Identify the cause of the skin damage.  Information about the cause of the compromised tissue guides interventions.

Assess the skin condition. Redness, edema, pain, and warmth at the site are signs of inflammation and indicate tissue damage.

Outline the affected area with a marker and date it.  This helps the healthcare team determine if the infection is becoming worse and if antibiotic treatment is effective.

Obtain a wound culture.  Knowing the exact organism helps provide a more targeted antibiotic treatment.

Assess for open lesions and provide skincare as ordered.  Open skin provides an entry for bacteria into the body and possibly into the bloodstream. Providing routine wound care helps reduce the risk of infection and further complications.

Use sterile technique when providing wound care.  This helps lower the risk of infection.

Administer antibiotics as prescribed after obtaining cultures. Treatment will most likely be antibiotic treatment. It can consist of topical, oral, or intravenous antibiotics. Obtaining cultures before treatment increases the detection of the offending microorganism.

Assess the site every four hours.  Infection may get worse and spread within hours. Therefore, frequent assessment ensures early recognition of worsening and promotes early counteraction.

Teach the patient and family signs and symptoms of infection.  Early assessment and intervention help prevent the worsening of a current condition, complications, and possible hospitalization.

Teach the patient about hand hygiene. Hand washing helps reduce the risk of infections by preventing the spread of germs.

Monitor vital signs, especially temperature.  Fever may occur when infectious processes spread from the affected area into the bloodstream. The infection is then systemic, and the patient may be septic.

Acute Pain r/t edematous extremity secondary inflammatory process

Expected Outcome: The patient will report satisfactory pain control at a pain score of 3 or less on a pain scale of 1 to 10. 

Assess pain characteristics. Note  Location  Quality (aching, throbbing, stabbing)  Intensity (pain scale)  Pattern (gradual onset or sudden, consistent pain or intermittent)  Associated factors  Alleviating factors  Aggravating factors  Detailed reports about pain from the patient allow the healthcare team to better target pain management. In addition, the patient’s comorbidities should be considered to cover pain adequately.

Administer pain medication as ordered.  Pain control helps the patient get adequate rest, a state that is much needed for healing.

Use pillows to elevate the affected area.  Often cellulitis is accompanied by swelling, which can cause pain. Elevation of the area may help with reducing edema and pain.

Ineffective Tissue Perfusion r/t extremity edema 

Expected Outcome: The patient will exhibit a return of effective tissue perfusion as evidenced by adequate peripheral pulses and an intact skin condition. 

Assess the patient’s pulses at least every four hours.  Weak and thready pulses may indicate a lack of perfusion. Swelling sometimes can cause the skin and other tissues to tighten and compromise circulation. A doppler may be used when assessing pulses.

Measure the circumference of the extremity at least once per shift and note the severity of edema on a four-point scale.  Worsening of infection may cause an increase in the inflammatory response leading to more swelling. Trending measurements allows for early recognition of deteriorating conditions.

Elevate the affected area.  Elevating the affected area may help decrease swelling.

Apply warm compresses as prescribed.  A warm compress helps soothe the affected area and promote circulation.

Administer medications as prescribed to treat the infection.  Infection often creates inflammatory processes causing swelling at the site. Treating the infection will reduce inflammation and swelling.

Risk for Vascular Trauma: Risk factor: injury by intravenous antibiotic infusion

Risk factors: 

• Type of catheter 
• Inadequate fixture of catheter 
• Infusion rate 
• Type of medication 
• Site (peripheral vs. central line) 

Assess the need for intravenous access and consider the patient’s clinical picture when determining an appropriate access type and site.  Cellulitis infections may require intravenous antibiotics rather than PO antibiotics. The type of access depends on the patient’s condition. Limited access because of deformities, pre-existing conditions such as bleeding, or history of thrombosis plays a vital role.

Teach the patient signs and symptoms of infection.  Early recognition and prompt intervention may contain the severity of complications.

Consider a catheter that is appropriate for the type of fluid and duration of treatment.  Cellulitis often requires long-term antibiotic treatment. A PICC line (peripherally inserted central catheter) is used for long-term IV therapy. This catheter can be managed at home with appropriate instructions, so the patient does not have to be in the hospital during antibiotic treatment.

Monitor for signs of infection at the insertion site. Note  Redness  Warmth  Swelling  Tenderness  Signs of infiltration or extravasation  The patient needs to know the characteristics of infection and phlebitis to promote early reporting and intervention.

More Care Plans:

Risk for Infection

Ineffective Tissue Perfusion

Acute Pain

Disturbed Body Image

DKA Nursing Diagnosis and Care Plan

Ineffective Health Maintenance

References:

2021. [ebook] Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5413991/>

WebMD. 2021. Cellulitis: Symptoms, Causes, Treatments. [online] Available at: <https://www.webmd.com/skin-problems-and-treatments/guide/cellulitis>

Mayo Clinic. 2021. Cellulitis – Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-causes/syc-20370762>