CELLULITIS

I. INTRODUCTION

Brief Description
Cellulitis is usually caused when bacteria enter a wound or area where there is no skin.
Cellulitis typically presents as a poorly demarcated, warm, erythematous area with
associated edema and tenderness to palpation. It is an acute bacterial infection causing
inflammation of the deep dermis and surrounding subcutaneous tissue. The infection is
without an abscess or purulent discharge. Beta-hemolytic streptococci typically cause
cellulitis, generally group A streptococcus (i.e., Streptococcus pyogenes), followed by
methicillin-sensitive Staphylococcus aureus. Brown BD,Hood Watson KL(2023)

Significance of the study

Recurrent cellulitis is associated with short term and long-term morbidity as well
as significant healthcare costs. Management of underlying predisposing conditions is
crucial to prevent recurrence in addition with evaluation of pharmacological measures,
but specialized and multidisciplinary skills are needed. More efforts are needed to
prevent and treat this underestimated problem.Nurses play a critical role in the
diagnosis and treatment of cellulitis. A thorough medical history and physical exam are
essential for accurate diagnosis. Approximately 30% of patients with cellulitis are
misdiagnosed; cellulitis is commonly mistaken for eczema, lymphoedema, or
lipodermatosclerosis.

Prevalence and Statistics

In nontropical areas, there is a seasonal preference for warmer months due to the
incidence of cellulitis, which is approximately 200 cases per 100,000 patient years. An
estimated 3.7 billion dollars are spent on ambulatory care and 650,000 hospital admissions are
caused by the over 14 million cases that occur in the US each year.

There are no precise statistics or prevalence estimates available for cellulitis in the Philippines.
In nontropical regions like the Philippines, there is a seasonal preference for the warmer
months.
Patient’s Profile

This is the case of patient R, male, married, 70 yrs old and a Roman Catholic. He is a
resident of Bail, Santo Tomas, Launion and currently living with his wife and 3 childrens. He is a
famer. He was admitted on September 9, 2023 at Launion Medical Center with an admitting
diagnosis of T/c Abscess thigh, left; he was later discharged on September 28, 2023. Vital signs
taken as follows; Blood pressure of 130/100, temperature of 38.5, pulse rate of 80 bpm,
respiratory rate of 25 counts per minute, and lastly, with an oxygen saturation of 98%.

Demographic profile

Patient :R
Age : 70 yrs old

Sex : Male

Religion : Roman Catholic

Occupation : Farmer

Address : Bail, Santo Tomas, La Union

Marital Status : Married

Activity Level : Dependent to her guardian (Wife)

Hospital : La Union Medical Center

Room : Surgery Ward

Room number :C
Date of Admission : September 25, 2023

Medical Diagnosis : Abscess, thigh, left with Cellulitis

History of Present Illness

-3 days prior to admission: The patient’s left thigh was injured by accidentally cutting it using
a sickle during their harvest of rice.
-2 days prior to admission: Patient R still went to farm to continue harvesting crops but in pain
in his left thigh
-A day prior to admission; Patient R went home from the farm and complained about the pain
in his left thigh. After 2 hrs he had a fever with a temperature of 38.5, and his wife checked his
injured thigh and saw that there was inflammation and abscess. They went straight to the
nearest hospital and consult OPD

Past Medical History

Patient R has no history of hospitalization, in fact, this is the first time that he was
hospitalized. Furthermore, he denies any drug allergies or undergone any surgery before..

Family History
No known family history connected to his current illness.

Social History
He is socially active. Prior to hospitalization, he loved to be with his kumpare to talk
about anything about life, he was also actively participating in activities of senior citizens
in their barangay.

Psychosocial Developmental Task

Erik Erikson’s Psychosocial Theory

Integrity vs. Despair (Erikson's Eighth Stage):

Integrity vs. despair is the eighth and final stage of Erik Erikson’s stage theory of
psychosocial development. This stage begins at approximately age 65 and ends at death.
Psychologists, counselors, and nurses today use the concepts of Erikson's stages when
providing care for aging patients. Integrity vs. despair involves a retrospective look back on life
and either feeling satisfied that life was well-lived (integrity) or regretting choices and missed
opportunities (despair).

Individuals in late adulthood, around 70 years old, are often in Erikson's stage of Integrity
vs. Despair. The task is to reflect on one's life, find meaning, and come to terms with life
choices. For patient A, a patient with cellulitis, this reflection may include adapting to health
challenges, accepting changes in physical well-being, and finding purpose despite health

Cognitive Theory of Jean Piaget

Assimilation and Accommodation:
Assimilation describes how we interpret new experiences in terms of our current
understanding, so in terms of our current schemas. Accommodation describes how we later
adjust our schemas to better incorporate new experiences.

Patient R, needs to assimilate new information about cellulitis, its treatment, and
potential lifestyle changes. Accommodation involves adjusting their existing knowledge and
behaviors to adapt to the demands of the health condition.

Sigmund Freud’s Psychosexual Theory

Genital Stage (puberty onwards):
Puberty represents the start of the final stage of Freud's psychosexual theory of
personality development, known as the genital stage. It is a time of sexual experimentation
throughout youth, with the goal of successfully settling down in a loving one-on-one relationship
with another person in our twenties. Unlike in the phallic stage, when sexual instinct is aimed
toward self-pleasure, it is now geared toward heterosexual partners' pleasure.

Patient R was able to successfully complete this stage because he had a partner on
whom he could rely and love.

Gordon’s Assessment

Health Maintenance - Health Perception Pattern

Before the hospitalization Patient R viewed health as a state in which he can perform his
work daily, he work as a farmer and with the absence of illness and disease, he considered
himself as a healthy human being, he rarely visits a doctor to have a check up and seek for
medical assistance, he also uses a herbal medicine such as oregano. He drinks alcohol
occasionally. During the Hospitalization, the patient stated that he feels that he is not healthy
anymore due to his condition. He is not able to adjust immediately with the changing
environment from his usual life. He is willing to accept and listen to health teaching and shows
interest to discover easily, he complies with all his medication and orders from the health care
team.

Nutritional-Metabolic Pattern
 The patient has no specific diet, but since he is living on a farm he eats more vegetables
rather than food with cholesterol. He stated also that he just can eat a minimal amount of food
(half rice every meal and he loves coffee. Before Hospitalization he doesn’t take vitamins, but
during hospitalization he takes vitamins prescribed by the doctor such as Vitamin C.

Elimination Pattern
The night before the Hospitalization, he had difficulty urinating. He went back and forth
to the comfort room several times and he said it hurts when he urinates. During the
hospitalization, we inserted an Indwelling foley catheter and he stated that he was relieved.

Activity- Exercise pattern

Before being admitted to the hospital, the patient does all his activities of daily living all
by himself, he is very active in farming, he takes care of all of his crops and pet animals. He
considers walking from their house to the farm as an exercise. However, due to her affected
extremity, he needed some assistance when going to the bathroom, bathing, and changing
clothes.

Sleep-Rest Pattern
Prior to hospitalization, he has difficulty sleeping, he usually sleeps at 12PM and
randomly wakes up from time to time, he wakes up at 6AM usually. But during hospitalization,
he was able to sleep at 9 PM and he woke early because of the medication that he needed to
take.

Cognitive-Perceptual pattern
Before he was hospitalized, his hearing was getting weaker and his vision was getting
blurry. He is still the one who decides when it comes to their family matters.

Self-perception-self-concept pattern
Before the hospitalization, he couldn't really express his feelings about his condition to
his family because he didn’t want to be a burden to anyone. But during the hospitalization, he
felt all the support and care coming from his family that makes him more comfortable despite his
condition.

Role-Relationship pattern
The patient is living with his wife, and three children, but they are now extended family
because his 2 children are now married but still living with them. He works as a farmer and
sometimes he is a part time worker in a construction site, he is able to contribute to their family
expenses and does side hustles. His wife was with her during his hospitalization to assist him.

Sexuality and Reproductive

The patient refused to answer.
 Coping Stress Pattern
He is coping with stress by staying in his farm with the breeze of fresh air, while listening
to the radio. He also loves to play guitar and sing. He said that his wife is her crying shoulder,
he considers his wife as his best friend that he can talk to about everything and rely on. His wife
was with him to take care of him all throughout his admission to the hospital.

Value- Belief Pattern

Patient R is Roman Catholic, he practices their beliefs, such as Holy week, Halloween,
Christmas and Sema Santa. Although he frequently goes to church on Sundays because of
busy schedule. During hospitalization, we asked him if we could render a prayer for him and he
was willing to be offered a prayer at every end of the shift.

II. Normal Anatomy & Physiology

Three layers make up the skin:

The outermost layer of our skin, known as the epidermis, is made up of keratinocytes, or
skin cells, which are the "bricks" that make up the skin barrier.
The purpose of the epidermis is to avoid drying out, monitor the immune system, and shield
the skin from external shocks such as UV rays and pollutants.
The cells that reproduce to replenish the epidermis each month are found in the basal layer,
which is the base of the epidermis. The pigment cells known as melanocytes, which give skin
its distinctive color, are mixed up with the keratinocytes of the epidermis. Sunlight exposure,
which contains UV radiation, activates these cells.
Keratinocytes: five different layers or strata that show the keratinocytes' gradual mutation
1. Stratum Germinativum—the deepest layer—produces new keratinocytes.
2. Stratum Spinosum- 2-4 layer thick, commonly referred to as Pickle cells bec they develop a
spiny appearance as their cell borders interconnect
3. Granular cells make up the stratum granulosum.
4. Stratum Lucidum is primarily limited to the soles and palm.
5. The stratum and cortex are made up of dead keratinized cells.

The dermis, which lies beneath the epidermis, is mostly made up of collagen but also
includes auxiliary structures like sweat glands and hair follicles.

Sebaceous glands are located near hair follicles and create sebum, a mixture of natural
lipids that coat the skin's surface and serve a protective and nourishing function. Sweat glands
help to regulate temperature by evaporating and cooling.

The dermis also contains elastin, a protein that promotes skin suppleness, and fibroblasts,
which are cells that make additional collagen. The purpose of the dermis is temperature
regulation via perspiration secretion to the skin's surface and blood flow modulation to the area.

The subcutis is located beneath the dermis and contains fat and bigger blood veins. The
subcutis serves as a heat insulator as well as a barrier against mechanical damage.
III. Pathophysiology

A. Illustration/Diagram of Pathophysiology

1. Etiology

Usually entering through a skin crack or rupture, Streptococcus species or

Staphylococcus aureus is the causative pathogen causing cellulitis. Having a history of
peripheral vascular disease, having trauma or injury that breaks the skin (skin wounds), being
bitten by insects, animals, or people, having ulcers from certain diseases like diabetes and
vascular disease, using corticosteroid medications or other medications that suppress the
immune system, and having wounds from recent surgery are additional risk factors.

2. Systems and processes involved

The main cause of cellulitis is bacterial infiltration of the skin's barrier, which happens when the
integumentary system is damaged, particularly the subcutaneous tissue. The pathogenicity of
the organism alerts the host defense mechanism, which in turn sets off the immunological
response. Pus accumulation and the start of the inflammatory cascade are the outcomes of the
immunological response, respectively. Pus accumulation destroys the tissues around, causing
holes to open up and an abscess to develop. The signs and symptoms of inflammation, such as
pain, swelling, heat, and redness, are brought on by the inflammatory cascade's advancement
and the body's response to it

3 .Manifestations

The initial onset of fever, chills, sweating, and swelling is often accompanied by localized
redness, warmth, and discomfort. Eventually, the redness may take on a pitting "orange peel"
appearance and may not be consistent, skipping spots. Moreover, painful and swollen regional
lymph nodes are possible.

IV. Diagnostic Tests and Therapeutic Procedure

Blood Test:

A. ABO RH Typing
- It is a method that determines what type of blood the patient has.
B. Complete Blood Count
- It measures different chemical in the blood and for evaluation of possible
infection or hematologic abnormality
C. Blood Chemistry Test
- This is a group of tests to measure different chemicals in the blood. It is used to
measure the body’s fluid balance, electrolyte levels ( such as sodium and
potassium), and kidney function.

Diagnostic Findings:

ABO RH Typing
 ABO GROUP B

RH TYPE POSITIVE

Complete blood count

Examination Result Reference Ranges Differential Result Reference Ranges

count

Hemoglobin 123 (L) Male: 130-180 g/L Sementers 66.0 (H) 55.0- 65.0 %

Hematocrit 42.4 (N) Male: 40-55 vol % Lymphocytes 19.7 (L) 25.0- 4.0 %

RBC Count 4.57 (N) Male: 4.2- 6 x 10^12/L Monocytes 8.6 (H) 3.0- 6.0 %

WBC Count 13.0 (H) Adult: 4-11 x 10^9/L Eosinophils 5.6 (H) 2.0- 4.0%

MCV 92.8 (N) 80-100/L Basophils 0.1 (N) 0.0- 1.0 %

MCH 26.9 (N) 27-31 pg

MCHG 290 (L) 310- 360 g/L

Platelet Count 323 (N) 150-450 x 10^9/L

ULTRASOUND

Interpretation

SOFT TISSUE ULTRASOUND WITH COLOR DOPPLER CORRELATION

High resolution scanning demonstrates a complex mass roughly measuring 8.0 x 5.5 x 2.5cm. in
the medial aspect of the left proximal thigh with associated mild direct sonographic tenderness.
No calcifications seen. No flow noted on Color mapping in this complex mass

IMPRESSION
COMPLEX MASS, PROXIMAL THIGH, LEFT. COULD BE INFLAMMATORY IN NATURE.
NEOPLASTIC PROCESS NOT TOTALLY EXCLUDED.
 Nursing Analysis
management

Vital Signs Regular monitoring of vital signs helps in assessing the severity of the infection
Monitoring and the patient's overall response to treatment. Abnormal vital signs may
indicate systemic involvement requiring immediate attention.

Wound Care Proper wound care is essential for preventing the spread of infection. Nurses
must analyze the wound regularly, assessing for any changes that may indicate
the need for adjustments in the treatment plan.

Fluid and Dehydration can exacerbate cellulitis, so nurses must analyze fluid intake.
Nutrition Nutritional support is crucial for healing, and nurses play a role in assessing and
promoting proper nutrition.

Elevate and Elevation and immobilization help reduce swelling and promote healing. Nurses
Immobilize should analyze the patient's ability to comply with these measures and provide
support and education as needed.

Follow-up and Scheduling follow-up appointments allows nurses to monitor progress and
Monitoring address any emerging issues promptly. Ongoing analysis of the patient's
response to treatment guides adjustments in the care plan.

Pharmacologic Analysis
Interventions

Ketorolac It is indicated for short term management of acute pain that requires
the calibre of pain management offered by opioids

Ampicillin to treat certain infections caused by bacteria, including infections of the

Sulbactam skin, female reproductive organs, and abdomen (stomach area).

Cephalexin treat bacterial infections in various parts of the body. This includes
infections of your airways (chest and lungs), throat, sinuses, ears, skin
and soft tissue, kidneys and bladder.

Acetaminophen to relieve mild to moderate pain from headaches, muscle aches,

menstrual periods, colds and sore throats, toothaches, backaches,
 reactions to vaccinations (shots), and to reduce fever.

Dicloxacillin to treat infections caused by certain types of bacteria. Dicloxacillin is in

a class of medications called penicillins. It works by killing bacteria.

Surgical Intervention

Debridement
Overview

Debridement is a surgical intervention involving the removal of dead or damaged tissue from
wounds to enhance healing and prevent infections. This process is vital in the management of
various conditions, such as chronic wounds, burns, and ulcers. Different debridement methods,
including sharp debridement with surgical instruments, enzymatic debridement using topical
agents, and autolytic debridement facilitated by the body's own enzymes, are employed based
on the nature of the wound. The goal is to promote the growth of healthy tissue, improve blood
circulation, and reduce the risk of complications.

Reference: Baranoski, S., & Ayello, E. A. (2020). Wound care essentials. Lippincott Williams &
Wilkins.

Nursing Responsibilities:
1. Assessment:
● Conduct a thorough assessment of the patient's medical history, including any
underlying conditions that may contribute to cellulitis.
● Assess the affected area, noting the extent of redness, swelling, warmth, and the
presence of any drainage or abscesses.
2. Monitoring Vital Signs:
● Regularly monitor vital signs, including temperature, heart rate, and blood
pressure, to detect any signs of systemic infection.
3. Pain Management:
● Administer prescribed analgesics for pain relief and assess pain levels regularly.
● Elevate the affected limb, if applicable, to help reduce swelling and discomfort.
5. Wound Care:
● Cleanse the affected area with mild soap and water, avoiding harsh or irritating
substances.
● Apply prescribed topical antimicrobial ointments or dressings.
● Monitor the wound for signs of improvement or complications.
6. Antibiotic Administration:
● Administer prescribed antibiotics as ordered, ensuring the patient understands
the importance of completing the full course.
● Monitor for any adverse reactions to antibiotics.
7. Fluid and Nutrition Management:
● Encourage adequate fluid intake to prevent dehydration.
 ● Monitor nutritional status and provide a well-balanced diet to support the body's
healing process.
8. Educating the Patient:
● Provide education on the nature of cellulitis, its causes, and the importance of
adherence to the prescribed treatment plan.
● Instruct the patient on proper wound care, hygiene practices, and signs of
worsening infection.
9.Preventing Complications:
● Educate the patient on signs of complications, such as the spread of infection,
abscess formation, or systemic symptoms like fever.
● Monitor for and address any signs of worsening cellulitis promptly.
10. Infection Control Measures:
● Emphasize the importance of hand hygiene for both the patient and healthcare
providers.
● Implement standard precautions to prevent the spread of infection.
11. Collaboration with the Healthcare Team:
● Collaborate with physicians, wound care specialists, and infectious disease
specialists to ensure a coordinated and comprehensive approach to care.
● Communicate any changes in the patient's condition promptly to the healthcare
team.

Reference: Baranoski, S., & Ayello, E. A. (2020). Wound care essentials. Lippincott Williams &
Wilkins.

Conclusion

Recognizing cellulitis as a unique medical condition necessitates tailored strategies that

prioritize the individual needs and circumstances of each patient.
For patient with cellulitis, personalized care involves clear communication, ensuring they
understand the nature of cellulitis, its causes, and the importance of treatment adherence.
Emphasizing the client's role in their own recovery, including wound care practices and early
symptom recognition, fosters active participation in the healing process.
Considering the specific characteristics of cellulitis in each patient is crucial. This includes
the identification of causative bacteria, understanding the extent of tissue involvement, and
evaluating any underlying health conditions. Tailoring treatment plans based on these factors
ensures a more targeted and efficient approach to managing cellulitis.
The prognosis for cellulitis is significantly influenced by the collaboration between
healthcare providers and clients. Regular communication, ongoing assessment, and shared
decision-making contribute to a more holistic and client-centered care experience. Recognizing
and addressing individual variations in response to treatment, potential complications, and
psycho-social aspects of the condition contribute to a comprehensive and empathetic care
approach.
Recommendation

1. For Nurses and Other Healthcare Providers:

Nurses should receive ongoing education and training on cellulitis, including its causes,
symptoms, and treatment options. Regular training sessions can help them diagnose and
manage cellulitis cases more accurately. To address the complexities of cellulitis cases,
establish multidisciplinary collaboration among healthcare providers. Coordination with
infectious disease specialists, dermatologists, and other relevant professionals may be required
to ensure comprehensive care. Give patients clear and detailed information about cellulitis,
emphasizing the importance of proper wound care, hygiene practices, and early symptom
detection. Ascertain that patients comprehend the prescribed medications and follow-up
procedures. Participate in community outreach programs to raise awareness about cellulitis
prevention methods, early warning signs, and the importance of seeking medical attention as
soon as possible. This may help to reduce the overall incidence.

2. For Nursing Students:

Actively seek clinical exposure to cases involving cellulitis to enhance your understanding
of the condition. Learn to differentiate cellulitis from other skin conditions through hands-on
experiences. Stay updated on the latest developments in cellulitis management and treatment.
Attend seminars, workshops, and webinars to expand your knowledge and skills in
dermatological nursing. Develop effective communication skills to educate patients and their
families about cellulitis. Clear and empathetic communication can positively impact patient
outcomes.

3. For Parents:

Teach children the importance of proper wound care, including cleaning and covering cuts
and scratches. Emphasize the significance of keeping wounds clean to prevent bacterial entry.
Encourage good hygiene practices, such as regular handwashing, to minimize the risk of
bacterial infections. Teach children to avoid sharing personal items that may spread infections.
Instruct parents to seek prompt medical attention if their child exhibits signs of cellulitis, such as
redness, warmth, swelling, and tenderness around a wound.

4. For the Community:

Support and participate in community health education programs focused on cellulitis

prevention. These programs can be conducted by healthcare professionals to raise awareness
and provide practical tips for prevention. Advocate for accessible community clinics or health
centers where individuals can seek timely medical attention for skin infections, including
cellulitis.

5. For Teachers:
 Integrate health education modules into the curriculum to educate students about skin
health, infections, and preventive measures. This can contribute to building a health-conscious
community. Encourage and model good hygiene practices within the school environment.
Reinforce the importance of cleanliness and prompt wound care to prevent the spread of
infections.