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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Nursing Care Plan for Low Birth Weight - Risk for Infection

Low birth weight babies are babies born with birth weight less than 2500 grams regardless of pregnancy. Birth weight is the weight of a baby who weighed within 1 hour after birth.

The cause of LBW is very complex. LBW can be caused by pregnancy preterm, small for gestational age baby or a combination of both.

Preterm babies are babies born before 37 weeks' gestation. Most preterm infants are not ready to live outside the womb and find it difficult to start breathing, sucking, fight infection and keep the body in order to keep warm.

Low birth weight (LBW) is newborn birth weight less than 2500 grams (up to 2499 grams). Associated with the handling and life expectancy, low birth weight babies are distinguished in:

• Low birth weight 1500-2500 g birth weight.
• Very low birth weight, birth weight less than 1500 grams.
• Extreme low birth weight, birth weight less than 1000 grams.

(Prawirohardjo, 2002)

Immediate complications that can occur in infants of low birth weight among others:

• Hypothermia.
• Hypoglycemia.
• Fluid and electrolyte disturbances.
• Hyperbilirubinemia.
• Respiratory distress syndrome.
• Infection.
• Intravascular hemorrhage.
• Apnea of prematurity.
• Anemia.

Long-term problems that may arise in LBW among others:

• Developmental disorders.
• Impaired growth.
• Visual impairment.
• Hearing disorders.
• Chronic lung disease.
• The increase in the frequency of congenital abnormalities.

Nursing Diagnosis : Risk for infection related to immunological defense ineffective.

Goal: There are no signs of infection.

Expected outcomes:

• Normal temperature.
• No signs of infection.
• Leukocytes 5000-10000.

Nursing Interventions :

• Assess for signs of infection.
• Perform insulation another baby suffering from an infection at the discretion of institutions.
• Before and after handling the baby, do handwashing.
• Make sure all equipment is in contact with the baby clean and sterile.
• Prevent personal transmitted infections for no direct contact with the baby.

Rationale:

• To find early signs of infection.
• Actions taken to minimize the occurrence of infection wider.
• To prevent infection.
• To prevent infection persists in infants.

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Nursing Care Plan for Osteosarcoma - Impaired Physical Mobility

Osteosarcoma is a primary malignant bone tumors are the most common and often fatal and can occur as a secondary metastases from extremity limb in 50% of cases. Usually found on the former site of radiation or more often as a broadcaster in Paget's disease. Osteosarcoma often occurs in men in the age group 10-25 years and the parents who have Paget's disease.

Nursing Diagnosis for Osteosarcoma : Impaired physical mobility related to muskuluskletal damage, pain, and amputation.

Goal: mobillitas physical damage is resolved entirely.

Subjective data: The client said it was difficult to move.
Objective data: The client looks impaired coordination; decreased muscle strength, control and mass.

Expected outcomes:

• The patient stated understanding of individual situations, treatment programs, and security measures,
• The patient seemed to participate in training programs / shows willingness to participate in activities,
• The patient showed technique / behaviors enabling the move action, and
• The patient seemed to maintain coordination and mobility corresponding optimal level.

Intervention:

1. Assess the level of immobilization caused by edema and the patient's perception of immobilization.
R /: The patient will restrict the movement as one of perception (perception are not proportional).

b. Encourage participation in recreational activities (watching TV, reading newspapers, etc.).
R /: Provides the opportunity to expend energy, focus, improve the patient's sense of self control and help in reducing social isolation.

3. Instruct the patient to perform active and passive exercises on the injury or not.
R /: Increases blood flow to the muscles and bones to improve muscle tone, maintain joint mobility, prevent contractures / atrophy and reapsorbsi Ca unused.

4. Assist patients in self-care.
R /: Increases strength and muscle circulation, improve the patient in control of the situation, increasing the willingness of the patient to recover.

5. Provide High-protein diet and High calories, vitamins, and minerals.
R /: Speed up the process of healing, prevent weight loss, because the immobilization usually weight loss.

6. Collaboration with the physiotherapy department.
R /: To determine the exercise program.

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