Friday, January 30, 2015

Nursing Care Plan for Cellulitis


Cellulitis is a skin disorder that is characterized by redness, swelling, tenderness and pain in the skin due to inflammation of the connective tissue of the skin caused by a bacterial infection. Infected people generally feel unwell with fever, chills and shaking. It occurs when bacteria like streptococcus and staphylococcus attack injured or damaged skin, such as body piercing, eczema or open wounds. Although the infection can spread to the adjacent skin, this disorder is not contagious because it occurs in the deepest skin layers. This condition can occur any body part, but more often in the arms, lower legs, neck and head area. Can be cured with antibiotics, but it needs to do a skin biopsy to detect bacteria. If left untreated, can cause blood poisoning (sepsis), endocarditis (an infection of the heart valves form) or necrotizing fasciitis (a serious infection of the tissue), where all of this is a medical emergency.


Nursing Care Plan for Cellulitis

Assessment

1. Identity
Name, gender, age, marital status, religion, ethnicity, education, language spoken, occupation, address.

2. History of the disease.

3. The main complaint
Patients usually complain of pain in the wound, sometimes accompanied by fever, chills and malaise.

4. Past medical history.
Asked cause injury to the patient and the disease before it ever like this, is there any allergy owned and history of drug use.

5. History of present illness
There are injuries to specific body parts with characteristic red color, soft, swollen, warm, painful, tense and shiny skin.

6. The family medical history
Usually there is a history in the family of patients suffering from diseases of cellulitis or other skin diseases.

7. The state of emotion psychology
The patient was calm, and emotionally stable.

8. The state of socio-economic
Usually attack on socioeconomic simple.


Physical Examination
1. General condition : Weak
Blood Pressure : decreased (less than 120/80 mmHg).
Pulse : decreased (less than 90 times / min).
Temperature : Increased (more than 37.5 degrees Celsius).
Respiration : Normal.
2. Head : Seen cleanliness, shape, is there any edema or not.
3. Eyes : Not anemic, no jaundice, light reflex (+).
4. Nose : No respiratory lobe.
5. Mouth : Health, not pale.
6. Ear : No wax.
7. Neck : No enlargement of the gland.
8. Heart : Heart rate increased.
9. Extremities : Are there any injuries to the extremities.
10. Integumentary : Early symptoms include redness and tenderness felt in a small area on the skin. Infected skin becomes hot and swollen, and looks like an orange peel peeling (peau d'orange). On the infected skin can be found a small fluid-filled blisters (vesicles) or a large fluid-filled blisters (bullae), which can rupture.

Nursing Diagnosis for Cellulitis
  1. Acute pain related to local inflammatory response of subcutaneous tissue.
  2. Hyperthermia related to the process of infection / inflammation systemic.
  3. Risk for infection related to the presence of skin lesions.
  4. Impaired tissue integrity related to the presence of red lesions.
  5. Impaired physical mobility related to neuromuscular disorders, pain / discomfort, decreased strength and resistance.
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