Académique Documents
Professionnel Documents
Culture Documents
Submitted to:
Submitted by:
BSN3E
Page No.
■ Title Page i
■ Table of Contents ii
■ Introduction 1-4
■ Objectives 5
■ Baseline Data 11
■ Assessment 17-18
■ Laboratory 19-21
■ Pathophysiology 22
■ Health Teaching 35
■ References 36
I. Introduction
Cellulitis is a spreading bacterial infection of the skin and tissues beneath the
skin. Cellulitis usually begins as a small area of tenderness, swelling, and redness. As
this red area begins to enlarge, the person may develop a fever—sometimes with chills
and sweats—and swollen lymph nodes ("swollen glands") near the area of infected skin.
infection also involving the skin's deeper layers: the dermis and subcutaneous tissue.
The main bacteria involved in cellulitis are Staphylococcus ("staph"), the same bacteria
that cause many cases of impetigo. Occasionally, other bacteria may cause cellulitis as
well.
Cellulitis may occur anywhere on the body, but the leg is the most common site
of the infection (particularly in the area of the tibia or shin bone and in the foot), followed
by the arm, and then the head and neck areas. In special circumstances, such as
following surgery or trauma wounds, cellulitis can develop in the abdomen or chest
areas. In cases of morbid obesity, it can also develop in the abdominal area.
The signs of cellulitis include redness, warmth, swelling, and pain in the involved
tissues. Any skin wound or ulcer that exhibits these signs may be developing cellulitis.
Other forms of noninfected inflammation may mimic cellulitis. People with poor
leg circulation, for instance, often develop scaly redness on the shins and ankles; this is
called "stasis dermatitis" and is often mistaken for the bacterial infection of cellulites
What are risk factors for cellulitis?
Some cases of cellulitis appear in areas where the skin has broken open, such
as the skin near ulcers or surgical wounds. Many times, however, cellulitis occurs where
there has been no break in the skin at all, such as with chronic leg swelling (edema).
People who have diabetes or conditions that compromise the function of the
immune system (for example, HIV/AIDS or those receiving chemotherapy or drugs that
Conditions that reduce the circulation of blood in the veins or that reduce
by spreading hot, bright red circumscribed area on the skin with a sharp raised border.
The so-called "flesh-eating bacteria" are, in fact, also a strain of strep that can
years of age, H. flu (Hemophilus influenzae) bacteria can cause cellulitis, especially on
the face, arms, and upper torso. Cellulitis from a dog or cat bite or scratch may be
caused by the Pasteurella multocida bacteria, which has a very short incubation period
of only four to 24 hours. Aeromonas hydrophilia, Vibrio vulnificus, and other bacteria are
Pseudomonas aeruginosa is another type of bacteria that can cause cellulitis, typically
Is cellulitis contagious?
(the dermis and subcutaneous tissue), and the skin's top layer (the epidermis) provides
a cover over the infection. In this regard, cellulitis is different from impetigo, in which
First, it is crucial for the doctor to distinguish whether or not the inflammation is
due to an infection. The history and physical exam can provide clues in this regard, as
can sometimes an elevated white blood cell count. A culture for bacteria may also be of
value, but in many cases of cellulitis, the concentration of bacteria may be low and
due to an infection, doctors sometimes treat with antibiotics just to be sure. If the
condition does not respond, it may need to be addressed by different methods dealing
with types of inflammation that are not infected. For example, if the inflammation is
effective against the responsible bacteria, are used to treat cellulitis. If the bacteria turn
out to be resistant to the chosen antibiotics or in patients who are allergic to penicillin,
other appropriate antibiotics can be substituted. In many cases, treatment requires the
not always provide sufficient penetration of the injury to be effective. In certain cases,
In all cases, physicians choose a treatment based upon many factors, including
the location and extent of the infection, the type of bacteria causing the infection, and
A. General Objectives:
After the nursing case study the student nurse will be able to:
valuable judgment
similar conditions
B. Specific Objectives:
After the nursing case study the student nurse will be able to:
cellulites
cellulites
The epidermis is the thin outer layer of skin that contains melanin which gives skin its
color and allows for the skin to tan. Carotene, and oxygen-rich hemoglobin also
contributes to the color of skin. The epidermis also encompasses the protein keratin
which stiffens epidermal tissue to form finger nails. The outermost layer consists of 25-
3. Langerhans cells are formed in the bone marrow and work to fight infection
Sub layers
1. Stratum corneum- is the outermost layer of the epidermis (the outermost layer of
the skin).
2. Stratum lucidum- is a thin, clear layer of dead skin cells in the epidermis, and is
3. Stratum granulosum- layer of the epidermis lies between the stratum spinosum,
below, and the stratum lucidum, above, in stratified squamous keratinized thick
skin of palms and soles. Thin skin, which covers the rest of the body, lacks a
that lies at the base of the epidermis immediately above the dermis. It consists of
membrane. These cells undergo rapid cell division, mitosis, to replenish the
regular loss of skin by shedding from the surface. About 25% of the cells are
melanocytes, which produce melanin, which provides pigmentation for skin and
hair.
Dermis
The dermis is the bottom-most, thick inner layer of skin, which comprises blood vessels,
connective tissue, nerves, lymph vessels, sweat glands and hair shafts. It has two main
layers:
1. Upper Papillary: Contains touch receptors which communicate with the central
2. Lower Reticular: Made of dense elastic fibers that house the hair follicles, nerves,
and gland
Subcutaneous tissue
The subcutaneous tissue or subcutis is the layer of tissue directly underlying the cutis. It
is mainly composed of adipose tissue. Its physiological function includes insulation and
storage of nutrients.
The integumentary system has multiple roles in homeostasis. All body systems work in
the body. The skin has an important job of protecting the body and acts somewhat as
the body’s first line of defense against infection, temperature change or other
• Acts as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory
system)
layer of tissues that guard underlying muscles and organs. As the interface with
pathogens.
• Integumentary system- consists of the skin, hair, nails, the subcutaneous tissue
below the skin, and assorted glands. The most obvious function of the
integumentary system is the protection that the skin gives to underlying tissues.
The skin not only keeps most harmful substances out, but also prevents the loss
of fluids.
• Cellulites- is an infection of the skin and underlying tissues that can affect any
area of the body. It often begins in an area of broken skin, like a cut or scratch,
when bacteria invade and spread, causing inflammation, pain, swelling, warmth,
and redness.
• Staphylococcus aureus- The staph bacteria is the most common if not is one of
differ with the type of condition and may consist of loss of consciousness,
confusion.
• Lesions- wound; area of the skin that is broken, open or infected; may be a
trauma or impairment in any area of the skin after an illness, injury or surgery
increase in body temperature. Febrile seizures are common in infants and young
Name: C. J.
No. of dependents: N. A.
Gender: Female
Marital Status: N. A.
Nationality: Filipino
Occupation: N.A.
Diagnosis: Cellulites at the Left leg secondary to Benign Febrile Seizure (BFS)
The mother of the client also stated that she takes her child to the baranggay health
center only in cases of fever, colds or if she feels like her child is really not feeling well
but does not visit it regularly for check-ups. The client’s mother claimed that she had no
idea in terms of the disease prevention and the factors which cause or contribute to the
disease and the appropriate treatment regimen for health maintenance and promotion.
The mother also claimed that last year her child (client) was also hospitalized because
of severe pneumonia and this is her second episode of benign febrile seizure (noted at
patient’s health history). The mother of the client also claimed that she does not follow a
treatment regimen prior to the clients hospitalization but she claimed that she does her
• Nutrition-Metabolic Pattern
The client prior to admission had a good appetite, eating 5-6 times a day
including solid and liquid foods. The mother claimed that the client drinks milk in the
morning, during lunch time, during snack time at around 3 o’clock in the afternoon, at
dinner and before going to sleep. The client also eats rice about half a cup in every
meal with any viands including vegetables, fish, meat and poultry products. The client
loves to eat fruits including oranges, grapes, apples and banana which is her favorite.
She drinks about 4-6 glasses of water each day at different settings.
During her hospital stay the client was placed on a soft diet (feb.13-19) and was
changed to diet as tolerated. She had a good appetite and was still eating 5-6 times a
day. She was eating rice with vegetables, fish, poultry products, meat and she also ate
fruits including oranges, grapes and bananas. Her fluid intake was same as before. She
had no difficulty eating or swallowing as well. The client weighed 12 kgs and no weight
• Elimination Pattern
The client moves usually her bowel once a day in the afternoon or in the evening
with amounts within normal limits and with normal consistency. During her hospital she
In terms of the clients voiding pattern, she voids freely to an amber colored urine
of approximately 900-1000 cc/day. Upon assessment the client was able to void freely
to an amber colored urine at approx. 240 cc per diaper, fully soaked. No difficulties in
terms of her voiding and no abnormalities as to the qualities of urine were noted as well.
Before admission, the client because of her age performed activities of daily
transferring, ambulating with dependence to her mother or any family member present.
She had a high energy level and undertook daily activities without any difficulties and
Upon assessment, the client had a high energy level, responsive to any
environmental stimuli and performed activities of daily living with aid of her mother. She
is capable of rolling to the sides, lying down from a sitting position and sitting up from a
lying position.
Prior to admission, the client gets an average of 11-12 hours of sleep a day. She
sleeps at around 8-9 o’clock in the evening and wakes up at around 7 or 8 0’clock the
next morning. Every afternoon, the client also takes a nap/rest, she sleeps at around 1
o’clock and wakes up 30 mins or an hour after. After sleeping or taking a nap, the
client’s mother claimed that her child(client) looks well rested and feels full of energy as
During his hospitalization, the client did not have any sleep pattern disturbances
as claimed by her mother. She sleeps at around 8 or 9 o’clock in the evening and wakes
up at around 6 or 7 o’clock the next morning. And she also took naps in the afternoon
• Cognitive-Perception Pattern
The client is only one year old and seven months so she is still not capable of
reading or answering questions rationally but she had no problems with her eyesight
and hearing. She was capable of responding to both verbal and non verbal stimuli
The client’s feelings about herself, her body image, self-esteem and emotional
• Role-relationship Pattern
The client has six older brothers and sisters five are actually boys and two are
girls including her. Her mother is a plain housewife and her father is a jeepney
(shopping la salle libertad) driver. They all live together in a shanty bungalow house in
a squatter’s area and they only depend on his father’s income for their daily living. The
mother of the client claimed that the income which her husband provides for them is
really not enough or is not sufficient to meet all their needs or unexpected outcomes or
She has no problems with her reproductive system before admission and upon
assessment.
• Coping-Stress Pattern
Based on observation and as claimed by the client’s mother that her child
manages stress through playing around, focusing her attention and deviating it from her
situation. Upon assessment, the client was very energetic and enthusiastic.
The client is baptized Roman-Catholic. The client’s mother stated that they go to
Sunday masses once in a while if they have the time or if her husband takes a break
skin lesions over left leg for months. No meds given, no consultation sought.
2 days prior to admission, mother noted redness of left leg with onset of
low grade fever. Paracetamol 5 mL q4h, PRN given with temporary relief.
A day PTA, redness on left leg allegedly spread, now warm and tender to
touch, still with persistence of fever. Amoxicillin 5 mL TID was given along with
A few minutes later PTA, mother woke up to patient having upward rolling of
excessive salivation.
Patient as born FT to 36 year old G7P7 mother with no PNCU, via NSVD-
NID (home delivery) assisted by a TBA. Patient had good cry and was able to
B.2.Past Hospitalization
Positive hospitalization (2007) severe pneumonia secondary
No FDA’s
C. Immunization
BCG
DPT 123
OPV 123
MEASLES
HEP B 123
E. Feeding History
Stagnant Canal
Squatter’s area/crowded place
VIII. Assessment
(6am-2pm) shift
A. General Appearance
Awake, lying on bed, wearing a loose white blouse with shorts; with fair
B. Vital Signs
Temperature: 35.5 C
C. Integumentary
Warm to touch
With IVF #3 d5.03 NaCl at KVO rate infusing well at the right dorsal venous
arch
E. Respiratory
F. Gastrointestinal Tract
On soft diet
H. HEENT
Pale conjunctive
I. Musculoskeletal
Urinalysis
Properties values/results
Cells
Pus 2-4 /hpf absent Normal Due
to/Presence of
infection.
Transitional
- squamous Few/hpf absent Normal Dueto/
Presence of
infection.
- Renal Dec1/L/hpf absent Normal Presence of
infection.
Crystals
Amorphousorates None Absent Normal Normal renal
functioning.
Amorphosphate None Absent Normal Normal renal
functioning.
Uric acid None Absent Normal Normal renal
functioning.
Calcium oxalate None Absent Normal Normal renal
functioning.
Triple PO4 None Absent Normal Normal renal
functioning.
Hematology
Test Values
Hemoglobin 125 g/L Female: within normal The patient has
enough oxygen
110-150 range carrying protein in
her blood. No
g/L bleeding has
occurred.
Hematocrit 0.37 L/L Female: within normal The percentage of
red cells in her
0.37-0.47 range blood is normal
relative to a normal
L/L oxygen carrying
protein(hemoglobin)
.
WBC count 4.05 Female: within normal The patient’s
defense mechanism
4.0-5.5 x range against infection,
invasion of bacteria,
10(12)/L parasites, and
tumor cells is
maintained.
Indicating the
body’s response
against infection
and other foreign
bodies.
Differential Count
Neutrophils 40% 50-70% within normal The patient’s
defense against
range infection is
maintained.
Indicating the
body’s response
against bacterial
infection.
Lymphocytes 51% 25-35% increased The defense
mechanism against
infection is
increased due to
presence/invasion
of foreign bodies/
microorganisms.
Monocytes 5% 4-8% Within normal The patient’s body
is responding to the
range bacterial infection.
Indicative that the
patient has an acute
bacterial infection, if
increased may
indicate chronic
infection.
Eosinophils 4% 1-5% Within normal The patient’s
defense mechanism
range against infection is
maintained.
Platelet count 276 x 10 150-400 x Within normal Client inhibits the
normal clotting
9
/L 10 9/L range ability.
Clotting ability is not
impaired and is not
at risk for bleeding.
Blood Chemistry II
Microworld
of affected skin. Sometimes, especially in younger kids, a blood culture may be done
to check for bacteria growth. A positive blood culture means that bacteria from the skin
infection have spread into the bloodstream, a condition known as bacteremia. This can
x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce
X. Pathophysiology
• Family related:
• Lack of knowledge with regards to
disease prevention and control, health
maintenance and treatment regimen
• Lack of proper attitude towards gaining
health control and promoting over-all
well being
• Health status: previous hospitalization
for severe pneumonia, previous
episode of benign febrile seizure
Break in the skin caused by scratched insect bites (probable cause; flies, mosquito’s or
ants) in the left lower leg
Bacteria enters the broken skin particularly, staphylococcus aureaus (most common
causative agent present in the community/environment)
Bacterial invasion occurs and bacteria secrets an enzyme which results to at first as
red, blemished skin
Medical-Surgical Book
http://www.healthsystem.
http://www.mayoclinic.com/health/cellulitis/
XI Nursing Care Plan
Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation
diagnosis
XII. Drug Study