Cellulitis is an infection of the skin caused by bacteria. Cellulitis can be caused by bacteria and organisms that are normally present in the skin. Cellulitis usually happens when there is a disturbance that causes the previously exposed skin, such as cuts, burns, insect bites or surgical wound. Cellulitis can occur anywhere in the body, but the most common parts affected by cellulitis is a skin on the face and legs. Cellulitis can only attack the upper skin, but if not treated and the more severe infections, can spread to the blood vessels and lymph nodes.
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).
In the infected skin can be found a small fluid-filled blisters (vesicles) or a large fluid-filled blisters (bullae), which can rupture.
Because of the infection spreading to a wider area, the nearby lymph nodes to swell and soft palpable. Lymph nodes in the groin enlarged due to infection in the leg, underarm lymph nodes enlarged due to infection in the arm.
Patients may experience fever, chills, increased heart rate, headache and low blood pressure. Sometimes these symptoms occur several hours before other symptoms appear on the skin. But in some cases these symptoms did not exist. Sometimes it can arise abscess, as a result of cellulitis.
Nursing Diagnosis and Interventions for Cellulitis
Hyperthermia related to the process of infection / inflammation systemic.
Goal : The client indicates a decrease in body temperature after nursing care.
Expected outcomes :
- Vital signs within normal limits.
- No fever.
- Intake - output balance.
1. Observation blood pressure body temperature, respiratory rate and pulse.
Rational : indicates the status of the body circulation.
2. Monitor intake and output every 8 hours.
Rational : shows the hydration status.
3. Encourage a lot of drinking in the absence of contraindications.
Rational : replace body fluids lost due to an increase in the rate of metabolism.
4. Maintain adequate ventilation in the room.
5. Give a warm compress.
Rationale: helps lower body temperature.
6. Use a thin clothes and absorb sweat.
Rational : provide comfort and speed up the process of decline in body temperature.
7. Instruct the client to the total bedrest.
Rational : excessive activity can increase the body's metabolism so that the temperature is increasing.
8. Maintain IV fluids according to the program.
Rational : to support and expand the volume of circulation, especially if inadequate oral input.
9. Give antipyretic therapy as recommended by your doctor.
Rationale: helps reduce fever and response hypermetabolism, lowering fluid loss invisible.