Cellulitis Nursing Care Plan

ASSESSMENT DATA

NURSING DIAGNOSES

PLANNING

INTERVENTION

EVALUATION

OBJECTIVE DATA

Dry and flaky skin

Excoriations

Warmth

Tenderness on the infection site.

SUBJECTIVE DATA

The patient verbalizes itching around the site

1. Infection-related alteration of the body’s inflammatory response as evidenced by dry and flaky skin, excoriations, warmth, and tenderness on the infection site.

1. Patient will remain free of secondary infection.

2. The patient will participate appropriately in the treatment program to counter infection.

3. Patient will restore healthy skin free from any lesions and scarring.

4. Health care workers will observe strict asepsis techniques.

5. Patient will be free from complications arising from cellulitis.

1. Assess the skin for the extent of severity and compromised integrity since the skin is the first-line defense. Therefore, disruption of skin integrity increases the risk of infection and scarring.

2. Assess the patient for any signs of infection such as fever since patients with cellulitis are at high risk for developing other diseases.

3. Apply topical antibiotics such as ammonium lactate 12% topical lotion and diphenhydramine 2% topical cream. Other antibiotics are ceftriaxone 1gram, enoxaparin 40mg, and vancomycin. They help treat infection and prevent the occurrence of further complications.

4. Determine aggravating factors such as allergy to penicillin, take them down, and ensure that all nurses and healthcare workers know the patient’s allergic reaction through detailed documentation.

5. Observe strict asepsis techniques for wound dressing changes, intravenous therapy, wound care, and other invasive procedures on the patient to limit the chances of spreading the infection, thereby preventing further complications.

SHORT TERM GOALS

After 2-3 hours of nursing interventions, the patients cooperate in the treatment plan.

LONG TERM GOALS

After three days, the patient shows improvement to promote disease management, prevent complications, and prevent secondary infection.

2. OBJECTIVE DATA

Edema

Blisters

Excoriations

Erosions

SUBJECTIVE DATA

The patient verbalizes how his skin is damaged.

Impaired skin integrity is related to altered skin defense mechanisms as evidenced by edema, blisters, excoriations, and erosions at the site of infection.

1. The patient will achieve an intact skin structure and integrity with a healthy function.

2. The client will demonstrate prompt wound healing, intact skin, and restore excellent skin integrity.

3. The patient will adhere to the treatment plan and preventive measures to prevent further skin complications.

4. The patient will verbalize an improved skin structure.

5. The patient will practice proper skin hygiene and cleanliness, especially in the affected areas.

1. Assess the client’s skin to identify the severity and affected areas that may require wound dressing and other special care.

2. Obtain a culture of the cellulitis wound to know the exact pathogen causing the infection for antibiotic treatment selection.

3. Apply warm compressors to the site of infection to soothe and promote adequate circulation.

4. Educate the client on proper skin hygiene by maintaining cleanliness in the areas affected.

5. Apply topical ointments and steroid creams since they help in reducing skin inflammation and promote healing. They are applied twice with avoidance of occlusive dressing since it will promote systemic absorption of the steroid.

SHORT TERM GOALS

After 4 hours, the patient demonstrates adherence to the treatment plan and preventive measures such as proper hygiene and cleanliness.

LONG TERM GOALS

After four days, the client demonstrates prompt wound healing to restore intact skin and excellent skin integrity.

After seven days, the patient shows an intact skin structure and integrity to restore healthy skin.

After seven days, the patient verbalizes an improved skin structure.

OBJECTIVE DATA

Unsteady gait

Altered mental status

Maladaptive behavior

SUBJECTIVE DATA

The patient has a history of falling within the past four months.

Risk for falls related to altered mobility secondary to cellulitis and anemia as evidenced by the patient’s history of falling within the past four months, unsteady gait, maladaptive behavior, and altered mental status.

1. Client will be free from falls during his period of hospitalization.

2. Healthcare workers and caregivers will install protective measures necessary to prevent falls and injuries.

3. Client will be able to relate the use of safety measures in preventing falls.

4. Client will identify his selective measures to prevent falls.

5. Nurses will implement appropriate strategies to ensure the client’s safety.

1. Assess risk for falls since this is a standard tool that helps identify contributing factors and the use of mobility devices.

2. Ensure that you provide an identification alert regarding the high risk for falls to help other health care workers and caregivers recognize the need to be cautious when dealing with the patient.

3. Ensure the bed is at the lowest as they help reduce the possibility of sustaining severe injuries.

4. Sustain a neutral behavior by administering fluoxetine to reduce maladaptive behavior and place the patient’s items within his reach to minimize the occurrence of unnecessary falls.

5. Ensure that mobility assistive devices are provided and placed within the patient’s reach to avoid accidental falls.

SHORT TERM GOALS

After 2 hours, the client can relate the use of appropriate safety measures and also identify his selective measures to prevent accidental falls.

After 2-3 hours, nurses will be able to implement the necessary strategies that will ensure the safety of the client.

LONG TERM GOALS

After four days, the client will be free from falls throughout the hospitalization period.