Hyperthermia related to Cellulitis

Nursing Diagnosis and Interventions for Cellulitis

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.

Intervention :

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.

Imbalanced Nutrition: Less Than Body Requirements related to Low Birth Weight

Nursing Care Plan for Low Birth Weight

Nursing Diagnosis : Imbalanced Nutrition: Less Than Body Requirements related to
  • decrease nutrient deposits,
  • immaturity of enzyme production,
  • weak abdominal muscles,
  • weak reflexes.
Goal: nutrients are met as needed.

Expected outcomes:
  • Babies get the calories and essential nutrients are adequate.
  • Maintain growth and weight gain in a normal curve with weight gain remains, at least 20-30 grams / day.

Interventions :

  • Assess maturity reflex, with regard to feeding (eg, sucking, swallowing, and cough).
  • Auscultation presence of bowel sounds, assess physical status and respiratory status.
  • Assess the weight by measuring body weight every day, then documented in infant growth charts.
  • Monitor the input and output. Calculate the consumption of calories and electrolytes every day.
  • Assess the level of hydration, note fontanelle, skin turgor, urine specific gravity, the condition of the mucous membranes, weight fluctuations.
  • Assess for signs of hypoglycemia; tachypnea and irregular breathing, apnea, lethargy, temperature fluctuations, and diaphoresis. Poor feeding, nervous, crying, high tone, trembling, eyes upside down, and seizure activity.
  • Monitor laboratory tests as indicated: serum glucose, blood urea nitrogen, creatinine, osmolality, serum / urine, urine electrolyte.
  • Give electrolyte supplements as indicated for example calcium gluconate 10%.

Rationale :


  • Determine the appropriate method of feeding for infants.
  • The first infant feeding stable has peristaltic can begin 6-12 hours after birth. If there is respiratory distress, parenteral fluids indicated, and oral fluid had to be postponed.
  • Identifying the risk and the degree of risk to growth patterns. SGA infants with excess extracellular fluid possibility of losing 15% of birth weight. SGA infants may have lost weight in the uterus or decrease fat deposits / glycogen.
  • Provide information about the actual input in conjunction with an approximate adjustment needs to be used in the diet.
  • Increased metabolic needs of SGA infants may increase fluid requirements. Infant state of hyperglycemia can lead to diuresis in infants. Intravenous fluids may be needed to meet increased demand, but must be carefully handled to avoid fluid overload.
  • Because glucose is the main source of fuel for the brain, deficiency can cause permanent damage to the CNS. Hypoglycemia significantly improve the mobility of mortality and severe effects of time dependent on the duration of each episode.

  • Hypoglycemia can occur in the early 3 hours of birth infants SGA when glycogen stores quickly reduced and gluconeogenesis inadequate because of a decrease in deposits of protein drugs and fat.
  • Detecting changes in renal function associated with a decrease in deposits of nutrients and fluid levels due to malnutrition.
  • Metabolic instability in SGA infants / LGA may require supplements to maintain homeostasis.

Risk for Ineffective Thermoregulation related to Low Birth Weight

Nursing Care Plan for Low Birth Weight

Nursing Diagnosis : Risk for Ineffective Thermoregulation

Risk for Ineffective Thermoregulation related to Low Birth Weight
Low birth weight (LBW) is newborn birth weight less than 2500 g (up to 2499 g). Relating to the treatment and life expectancy, low birth weight babies can be divided into:
  • Low birth weight, birth weight 1500 - 2500 g.
  • Very low birth weight, birth weight less than 1500 g.
  • Extreme low birth weight, birth weight less than 1000 g.

Clinical Manifestations

1. Signs and symptoms of preterm infants according Surasmi (2003: 32), among others:
  • Gestational age equal to or less than 37 weeks.
  • Weight loss is equal to or shellfish than 2500 grams.
  • Body length is equal to or less than 46 cm.
  • Nails are not yet past the fingertip length.
  • Limit the forehead and scalp hair ends are unclear.
  • Head circumference is equal to or less than 33 cm.
  • Chest circumference is equal to or less than 30 cm.
  • Lanugo hair is still a lot.
  • Thin subcutaneous fat tissue or less.
  • The ear cartilage growth is not perfect, so it seems not palpable cartilage earlobe.
  • Heel shiny, smooth soles.
  • Genitals: the baby boy pigmentation and scrotal rugae; less, the testes do not descend into the scrotum, to baby girl protruding clitoris, labia minora covered by the labia majora.
  • Weak muscle tone so that the baby is less active and weak movement.
  • Nerve function yet or less mature, resulting in reflex suction, swallowing and cough is still weak or ineffective and weak cries.
  • Mammary gland tissue is still lacking due to the growth of fat tissue is still lacking.
  • Vernix no or less.

2. Signs and symptoms of infants according Surasmi dysmature (2003: 34), among others:
  • Dysmature preterm infants: visible physical symptoms of preterm coupled with growth retardation symptoms.
  • Dysmature term and postterm infants
  • Symptoms of placental insufficiency and duration depending on the time of the baby suffering from a deficit, growth retardation would happen if the deficit lasting (chronic).
  • Stadium baby dismature:
1. First
  • The baby looked thin and relatively longer.
  • Loose skin, dry as a permanent stain is not yet meconium.
2. Second
  • There are signs of the first stage.
  • The green color of the skin of the placenta and umbilical (as meconium mixed), amniotic settles on the skin, umbilicus and placenta due to intrauterine anorexia.
3) Third
  • There is a sign of the third stage.
  • The skin, nails, yellow cord.
  • Found signs of anorexia intrauterine long.

Nursing Diagnosis for : Risk for Ineffective Thermoregulation related to immature CNS (central regulation of residues, reduced lean body mass to surface area, subcutaneous fat loss, inability to feel cold and clammy, poor metabolic reserves).

Goal: Thermoregulation becomes effective in accordance with the development.

Expected outcomes:
Maintaining the skin or axillary temperature (35 - 37,50C).

Nursing Interventions :

  • Assess the temperature with a rectal temperature check at first, then check the temperature of the axilla or use a thermostat with an open base and spreader warm.
  • Place the baby in an incubator or in a warm state.
  • Monitor the temperature control system, spreader warm (keep the upper limit of 98.6 ° F, depending on the size and age of the baby)
  • Assess output and urine specific gravity.
  • Monitor weight gain in a row. If weight gain is inadequate, increase the ambient temperature as indicated.
  • Note the development of tachycardia, redness, diaphoresis, lethargy, apnea or seizure activity.

  • Monitor laboratory tests as indicated (serum glucose, electrolytes and bilirubin levels).
  • Give medications in accordance with the indication.

Rationale :
  • Hypothermia make babies tend to feel stressed because of the cold, the use of fatty deposits can not be updated if there is and decreased sensitivity to increasing CO2 levels or decreased levels of O2.
  • Maintaining a thermoneutral environment, helps prevent stress due to the cold.
  • Hyperthermia with an increased rate of oxygen and glucose metabolism as well as the need for water loss can occur when the ambient temperature is too high.
  • The decline in output and an increase in specific gravity of urine associated with a reduction in renal perfusion during periods of stress because of the cold.
  • The inadequate weight gain despite adequate caloric intake may indicate that the calories are used to maintain the ambient temperature of the body, thus requiring an increase in ambient temperature.
  • Signs of hyperthermia can be continued in brain damage if not resolved.
  • Cold stress increases the need for glucose and oxygen and can lead to problems when a baby has acid base anaerobic metabolism when oxygen levels are not enough available. Increased levels of indirect bilirubin may occur due to the release of fatty acids from brown fat metabolism by fatty acids compete with bilirubin in the bond part in albumin.
  • Helps prevent seizures relating to changes in CNS function induced hyperthermia.
  • Fixing acidosis can occur in hypothermia and hyperthermia.

Nursing Diagnosis and Interventions for Osteosarcoma (osteogenic sarcoma)

Osteosarcoma (osteogenic sarcoma) is a tumor that arises from bone-forming mesenchyme. (Wong. 2003: 616).

The places most often affected are the distal femur, proximal tibia and proximal humerus. The most rare is the pelvis, column, vertebrae, mandible, clavicle, scapula, or bones of the hands and feet. More than 50% of cases occur in the knee area. (Otto.2003: 72).

Clinical manifestations

a. Bone pain.
Bone pain is the most common symptom found in the process of metastasis to bone and is usually the initial symptoms are recognized by the patient. Pain arising from stretching the periosteum and the endosteum nerve stimulation by tumor. The pain can be intermittent and more pronounced at night or while resting.

b. Fractures
The presence of bone metastases can cause bone structure becomes more fragile and at risk for fracture. Sometimes fractures arise before other symptoms. Areas are often fractured long bones in the upper and lower extremities and spine.

c. Emphasis spinal cord
When a process of metastasis to the spine, the spinal cord becomes desperate. Displacement of the spinal cord is not only painful but also parese or numbness in the extremities, micturition disorders, or numbness around the abdomen.

d. Elevation of calcium levels in the blood
This is due to the high release of calcium from bone reserves. Elevation of calcium can cause loss of appetite, nausea, thirst, constipation, fatigue, and even impaired consciousness.

e. other symptoms
When metastasis to the bone marrow, symptoms according to the type of blood cell that is affected. Anemia can occur when on red blood cells. If the white blood cells are affected, the patient DAPT easily infected infeksi.Sedangkan on platelet disorders, can cause bleeding.

Nursing Diagnosis and Interventions for Osteosarcoma (osteogenic sarcoma)

1. Chronic pain related to pathological processes and surgery.
Goal : Pain is reduced / no pain.
  • Give an explanation to the client on how to cope with pain and cause pain.
  • Teach relaxation and distraction techniques.
  • Monitor vital signs
  • Collaboration in providing analgesic.
2. Risk for injury related to pathologic fractures associated with tumors.
Goal: Not the case of injury (injury).
  • Explain to the client on how to cope with and the occurrence of injury.
  • Limit activity.
3. Low Self-Esteem related to the loss of body parts or change roles.
Goal: Improved self-esteem and no complications.
  • Provide motivation to the client.
  • Involves the role of the family.
4. Knowledge deficit related to lack of knowledge about the disease process and treatment programs.
Goal: The client can understand the disease process and treatment programs.
  • Explain to the client about the disease process and treatment programs.
  • Encourage clients to comply with the treatment program.