Abcess

Cellulitis
Ferdinand Abuan
Kirk Polante
Arminah Reyes
Vangie Tuliao
 Background of the Study

A case of 12 year old boy from Quezon City

Emergency Room admission to general nursing

unit isolation room diagnosed with Facial
Cellulitis to rule-out Mumps vs Abscess,
managed by Dr. X as attending physician.
 Objective
To enhance and learn new information
regarding the said diagnosis.

Additional learning as part of medical

professionals and how to manage the
patient's case.
• Cellulitis is a skin disease that affects the
outer skin and soft tissues underneath. It
is mostly caused by bacterial infections
from the Staphylococci and Streptococci
group. Cellulitis occurs when bacteria
enter a break in the skin and spreads
throughout the skin and into the soft
tissues leading to inflammation. The
most common site of infection is on the
legs.
• An Abscess is a collection of pus that has
built up within the tissue of the body.
Signs and symptoms of abscesses include
redness, pain, warmth, and swelling. The
swelling may feel fluid-filled when
pressed. The area of redness often
extends beyond the swelling.
• Mumps is a contagious disease that is
caused by a virus. It typically starts with a
few days of fever, headache, muscle
aches, tiredness, and loss of appetite.
Then most people will have swelling of
their salivary glands. This is what causes
the puffy cheeks and a tender, swollen
jaw.
Background of the Study
Data and Statistics
SCOPE and
LIMITATION
Scope

Information was gathered from the immediate family

members and patient himself.
Nursing and medical management including laboratory
works, radiology and other examination that lead to the
diagnosis.
Health care instruction and discharge management
including follow-up check-up.
Limitation

This study is limited to a pediatric patient diagnosed

with Facial Cellulitis to rule-out Mumps vs Abscess.
Limited pertinent information's given by the mother
and the patient.
This only includes management done during his
hospital stay.
 Demographic Profile
Name: KJSG
Age: 12
Address: C8 Dil Mauban St. Manresa Quezon
city
Birthday: August 25,2006
Birth Place: Quezon City
Religion: Catholic
Citizenship: Filipino
Chief Complain: Fever for one week
Diagnosis: Cellulitis R/O Mump vs
Abscess
Attending Physician: Dr. X
Date of Admission: August 7, 2019
Time of Admission: 8:47pm
Patients Immunization
Number of doses Age Given
BCG 1 At birth
HEPATITIS B 3-4 3mos
Diphtheria, Pertussis, 5 5yrs
Tetanus (DPT)
Haemophilus influenza 3 n/a
Type(HIB)
Inactivated Polio 3 7mos
Vaccine(IPV/OPV)
Measles,Mumps,Rubella(s 1 15mos
MMR)
Varicella 2 11yrs old
Pneumococcal Conjugate 2 n/a
Vaccine(PCV)
Typhoid 1 n/a
Influenza 2 n/a
PERTINENT
HISTORY
Pertinent History
History of Present Illness
 8 days prior to admission, patient with right swelling in
mandibular area with tenderness; consults a private clinic,
diagnosed with mumps and give Isoprinosine tablet.
 4 days prior to admission, with progress of swelling of
mandibular area, given paracetamol. Noted febrile with
episode 38c.
 3 days prior to admission, consulted at NCH, diagnosis is
mumps, given paracetamol and Mefinamic acid.
 2 days with swelling and pain. For ER Admission.
 1 hour to admission, patients pain worsens and fever is at
40c.
Pertinent History
Past Medical History
> No past medical history
Pertinent History
MEDICATION History
Medication History - given Isoprinosine tablet

Diet and Nutrition

 Weight 44.5
 Height 158.5
 BMI 25.3 – UNDERWEIGHT.
 Diet: Diet as tolerated.
Pertinent History
Sociocultural History
Education Level - Grade 7
Exercise - Loves to play basketball with his
friends
Occupation - none
Substance Abuse - none
Sleep Pattern - 7-9 hours of sleep.
Pertinent History
Family History
Age Occupation Medical History

Father n/a Company High blood

Employee pressure.
Mother n/a Home maker High blood
pressure.
Sibling 1 18yrs old Student none

Sibling 2 12yrs old Student none

Pertinent History
Psychosocial History
Patients parents are well supported on
emotional, spiritual and financial.
First time admitted in the hospital for possible
surgery.
He divert his pain by watching his favorite TV
shows, movies, and playing online games
 COURSE IN THE
WARD/OTHER
CLINICAL UNIT AND
SYSTEM
ASSESSMENT
 Course in other Clinical Unit
• The patient arrived at the Emergency
Department on August 7, 2019 at
around 6:30 PM, accompanied by his
relatives.
• Patient KJSG complained of
mandibular pain and fever, with the
last fever episode at 8:00 AM of
August 3, 2019.
• Vital signs are as follows: Temp: 39.3
°C , PR: 113, RR: 22, BP: 100/70, Pain
scale of 9/10, O2 sat: 98%
Course in the Ward & System Assessment
DAY 1: THERE WILL ALWAYS BE A FIRST TIME…
Clinical Event System Assessment
0813PM ASSESSMENT:
> Diet: Soft Diet for Age > CC: Facial swelling
> IVF: D5 0.3 NaCl 1L X 8 hours > Neuro: GCS 15
> Labs/Diagnostics: CBC, Plate count, CRP > Pain Scale: 9/10
(Titer), Blood Culture of 1 site, Urinalysis > Vital signs:
> Medications: Paracetamol 500mg tablet - BP: 100/70 mmhg
PO every 4 hours as needed for fever of - HR: 113 bpm
greater or equal to 37.8 - RR: 22 bpm
- Temp.: 39.3
1000PM - O2 Sat.: 98%
> Ceftriaxone 2grams IV OD > With 2 episodes of vomiting
Course in the Ward & System Assessment
CONT…….
Clinical Event System Assessment
1005PM
> Mefenamic Acid 500mg tablet NOW

1009PM
> Clindamycin 400mg IV Q6

11237AM
> Paracetamol 300mg IV NOW, then Q4 RTC
Course in the Ward & System Assessment
DAY 2: DAY 1 IS ENOUGH, BUT 2 IS TOO MUCH….
Clinical Event System Assessment
0200AM ASSESSMENT:
> Hook to pulse oximeter and O2 at 2LPM > Neuro: GCS 11
via nasal cannula > Pain Scale: 9/10
> Vital signs:
0500AM - BP: 110/70 mmhg
> Monitor vital signs and neuro vital signs - HR: 108 bpm
Q2 - RR: 26 bpm
> IVF TF: D5 NM 1L X 8 hours - Temp.: 40.2
- O2 Sat.: 99%
1100AM > Had an episode seizure and patient
> D/C O2 and pulse oximeter became aggressive.
> For Serum IgM for mumps tomorrow @
6AM
Course in the Ward & System Assessment
DAY 3: GETTING THERE…..
Clinical Event System Assessment
1125AM ASSESSMENT:
> Diet: Soft Diet for Age > Neuro: GCS 15
> IVF: D5 NM 1L X 82ml/hour 2 cycles > Pain Scale: 7/10
> Vital signs:
- BP: 110/70 mmhg
- HR: 98 bpm
- RR: 22 bpm
- Temp.: 39.2
- O2 Sat.: 97%
> With good appetite upon round
with attending physician.
Course in the Ward & System Assessment
DAY 4: KONTI PA…..
Clinical Event System Assessment
1005AM ASSESSMENT:
> Diet: Soft Diet for Age > Neuro: GCS 15
> May transfer to regular room > Pain Scale: 7/10
> For X-ray of Skull PA view > Vital signs:
> For CBC with PC tomorrow morning - BP: 110/70 mmhg
- HR: 102 bpm
12:12PM - RR: 22 bpm
> IVF TF: D5 NM 1L X 82ml/hour - Temp.: 38.5
- O2 Sat.: 97%
> Noted with cellulitis seen on the
right mandibular area
Course in the Ward & System Assessment
DAY 5: STILL ALIVE AND….
Clinical Event System Assessment
0600AM ASSESSMENT:
> Diet: Soft Diet for Age > Neuro: GCS 15
> IVF TF: D5 NM 1L X 82ml/hour > Pain Scale: 7/10
> Vital signs:
1145AM - BP: 110/70 mmhg
> Refer to Dr. B. Espineda for surgical - HR: 102 bpm
evaluation and management. - RR: 22 bpm
- Temp.: 38.5
1200PM - O2 Sat.: 97%
> IVF TF: D5 NM 1L X 82ml/hour

0200PM
> Monitor vital signs Q4
> Apply warm compress on the affected
site for 3-5 minutes

1100PM
> IVF TF: D5 NM 1L X 82ml/hour
Course in the Ward & System Assessment
DAY 6: READY SET GO…..
Clinical Event System Assessment
0410PM ASSESSMENT:
> Diet: Soft Diet for Age > Neuro: GCS 15
> Referred to Dr. Ortillo-Baytion > Pain Scale: 7/10
for anesthesiology > Vital signs:
> NPO post-midnight - BP: 110/70 mmhg
- HR: 112 bpm
- RR: 22 bpm
- Temp.: 37.6
- O2 Sat.: 99%
> For surgery
Course in the Ward & System Assessment
DAY 7: ISANG LINGGONG PAG-IBIG SA FE….
Clinical Event System Assessment
0645AM ASSESSMENT:
> IVF TF: D5 NM 1L X 82ml/hour > Neuro: GCS 15
> Pain Scale: 7/10
0100PM > Vital signs:
> S/P Incision and Drainage of Right Mandibular - BP: 110/70 mmhg
Abscess - HR: 110 bpm
> Observe aspiration precaution - RR: 22 bpm
> IVF TF: D5 NM 1L X 82ml/hour - Temp.: 37.4
> Meds: - O2 Sat.: 99%
- Ketorolac(Ketomed) 30mg IV Q8 (-) ANST for 3 > No DOB.
doses, then PRN
> Encourage deep breathing exercises
> Suction secretions PRN
> Please relay Wound GS/CS once available.
May transfer back to room

05:30PM
> If wound dressing if fully soaked, please
change the dressing but do not remove the
draining gauge.
OPERATIVE TECHNIQUE COPY:
Course in the Ward & System Assessment
DAY 8: AFTER THE RAIN, THERE WILL ALWAYS
BE A RAINBOW….
Clinical Event System Assessment
1200AM ASSESSMENT:
> IVF TF: D5 NM 1L X 82ml/hour > Neuro: GCS 15
> Pain Scale: 7/10
0341AM > Vital signs:
> May decrease IVF rate to 40ml/hr - BP: 110/70 mmhg
- HR: 110 bpm
1100PM - RR: 24 bpm
> IVF TF: D5 NM 1L X 40ml/hour - Temp.: 36.4
- O2 Sat.: 99%
> Rounds with Dr. B. Espineda.
Not in distress and comfortable.
Course in the Ward & System Assessment
DAY 9: HINDI NAUUBOS ANG UMAGA…
Clinical Event System Assessment
1100AM ASSESSMENT:
> Please follow-up Wound GS/CS results > Neuro: GCS 15
> Please give Mefenamic Acid 500mg > Pain Scale: 4/10
capsule NOW on full stomach > Vital signs:
> IVF to consume and shift to heplock - BP: 110/70 mmhg
> May bathe the patient but do not wet - HR: 96 bpm
the operative site - RR: 24 bpm
- Temp.: 36.4
1230PM - O2 Sat.: 99%
> Continue IV antibiotics until today >Rounds with Dr. B. Espiñeda.
(Ceftriaxone-10PM and Clindamycin-6PM) > Not in distress and comfortable.
> Start Co-Amoxiclav 625mg tablet BID
tomorrow AM
> Mefenamic Acid 50mg capsule Q8 PRN
for severe pain
> IVF rate to KVO and discontinue
> For discharge tomorrow
Course in the Ward & System Assessment
CONT…….
Clinical Event System Assessment
0100PM
> Co-Amoxiclav 625mg tablet BID to
complete for 7 days
> For COD OD
> Follow-up after one week(August 22,
2019 Thurday @ 10AM-12PM)
> Please follow-up CS results and
relatives to be contacted if there will
be change on the antibiotic regimen.
Course in the Ward & System Assessment
DAY 10: UWIAN NA PO….
Clinical Event System Assessment

0645AM ASSESSMENT:
> May go home. > Neuro: GCS 15
> Continue Co-Amoxiclav 625mg tablet > Pain Scale: 2/10
BID to complete 14 days. > Vital signs:
- BP: 110/70 mmhg
- HR: 95 bpm
- RR: 22 bpm
- Temp.: 36.2
- O2 Sat.: 99%
> Patient is apparently well
DIAGNOSTICS
and
TREATMENTS
Laboratory / Diagnostic Test Indication

Complete Blood Count (CBC) > This test is done to check if the patient has developing or
ongoing infection.

CRP (Titer) > This is a blood test marker for inflammation in the
body. Which means that its levels will rise in response to
inflammation.

IgM for Mumps > Is used to measure the amount of IgM antibodies in the
blood to check if the patient is positive to Mumps.

Skull X-Ray > Used to confirm that the swelling is caused by cellulitis.

Urinalysis > Checks for presence of infection in the urine.

Wound G/S and C/S > A medical procedure that determines what
microorganisms in a wound are causing an infection.

Blood C/S > A test that checks for foreign invaders like bacteria, yeast,
and other microorganisms in your blood.
CBC (August 7 and August 11,
2019)
Skull X-Ray
Urinalysis
CRP (Titer)
Blood C/S
IgM for Mumps
Wound G/S and C/S
Medication
Summary of Medication
MEDICATION NAME INDICATION
CEFTRIAXONE > Antibiotic used to treat bacterial
infection
CLINDAMYCIN > Is used to treat a wide variety
of bacterial infection. It is an antibiotic
that works by stopping the growth of
bacteria.
PARACETAMOL > Is a pain reliever and a fever reducer
KETOROLAC > Used for the short-term treatment of
moderate to severe pain . It is usually
used before or after medical procedures
or after surgery.
CO-AMOXICLAV > Infections due to lactamase-producing
strains (where amoxicillin alone is not
appropriate) including respiratory tract,
genitourinary & abdominal infections;
cellulitis, animal bites, severe dental
infection with spreading cellulitis.
NURSING REMARKS
> Avoid mixing ceftriaxone with IV fluids
that have calcium in them (such as
Ringer's solution, Hartmann's solution,
parenteral nutrition-TPN/PPN).
> Given via soluset with PNSS.
> Take this antibiotic at evenly spaced
times. take this medication at the same
time every day.
> Given via soluset with PNSS.
> Given on slow IV push because its
irritating to the vein.
> Given on slow IV push
not be used in patients with or at high risk
of bleeding, asthma or who report
allergic-type reactions after taking aspirin
or other NSAIDs. Caution in patients with
inflammatory bowel diseases.
> May be taken with or without food: Best
taken at the start of meals for better
absorption & to reduce GI discomfort.
CONCEPT
MAP
Relationship
The different boxes are connected by arrow/s.
Arrow signifies relationship or feedback loop link
( )
Double end arrow shows mutual relationship
link
( )
Broken line arrow signifies indirect relationship
( )
Nursing Diagnosis 1
Acute swelling Edema temporary loss of
Acute pain warmth of infected fucntion in involved area
area

Asymmetrical
Nursing Diagnosis 3 wound area Nursing Diagnosis 2
Risk for Elevated WBC 15.84 Altered body
Fever
Infection CRP 12 temperature
Leukocytosis

Chills
Progression of
Treated on IV swelling and ruptured Signs and Symptoms
antibiotics and leaving a small
Malaise
IVF hydrations opening in the skin

12 YEARS OLD
MALE Headache
DX. CELLULITIS VS
ABSCESS OF RIGHT
Risk Factor
MANDIBULLAR AGE: facial Cellulitis
common in children
Medical
management for
Incision and
Drainage

Caused by entry of
bacteria
Post operative Post operative
care care
 Bacteria released
toxins in subcutaneus
tissue

Cellulitis progressed
and spread to
surrounding tissue

And form with abscess

Nursing
Care
Plan
Nursing Care Plan
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Acute pain related Short Term: Independent Short Term:
> Patient verbalized to inflammation of > After 4 hours of > Rest the area, may > After 4 hours of
“ Masakit po yung submandibular nursing provide comfort nursing
panga ko mga area. interventions the interventions the
walong araw na.” patient will report > Apply warm patient reported
minimized compress, may help minimized
Objective data: discomfort of the to reduce the pain discomfort of the
> (+) Swelling of affected area. affected area.
submandibular area
> pain scale of 9/10 Long Term: Dependent GOAL MET!
> (+) Guarding of > After 8 hours of > Administered pain
right cheek intervention medication as
patients pain will be ordered, medication Long Term:
lessened from 9/10 may given as to help > After 8 hours of
to 6/10. lessen the pain. intervention
patients pain is
lessened from 9/10
to 6/10.

GOAL MET!
Nursing Care Plan
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective data: Altered body Short Term: Independent Short Term:
> Patient verbalized temperature related > After 4 hours of > Do tepid sponge > After 4 hours of
“Mainit ang to inflammation of nursing interventions bath nursing interventions
pakiramdam ko.” submandibular area. the patient will > Maintain cold room the patient reported
report minimized temperature minimized discomfort
Objective data: discomfort from hot > Increase oral fluid from hot feeling.
> With latest body feeling. for flushing of toxin.
temperature of 38.4. > Check and regulate GOAL MET!
> Patient is warm to Long Term: iv fluid.
touch. > After 8 hours of > Do plenty of rest.
intervention patients Long Term:
body temperature Dependent > After 8 hours of
will decrease from Give anti-pyretic intervention patients
38.4 to 37. medication as body temperature
needed for fever as decreased from 38.4
ordered. to 37.8.

PARTIALLY MET.
Nursing Care Plan
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Objective data: Risk for Infection related Short Term: Independent GOALS
> Status post incision and to incision and drainage. > After 4 hours of nursing > Assessed vital signs every 4 Short Term:
drainage interventions the patient hours. Change in vital signs > After 4 hours of nursing
> No presence of infection will remain free of especially body temp. can be interventions the patient
infection. an indication of starting remained free of infection,
Objective data: infection as evidenced by normal
Vital Signs: Long Term: > Maintained aseptic vital signs and absence of
T-36.7 > After 8 hours of technique on every signs and symptoms of
RR-17 intervention will present procedure done to the infection.
CR-72 no signs of infection will patient. Aseptic technique
BP-100/60 be noted from the helps reduce transfer of GOAL MET!
O2 sat- 96-98% Acute pain related to inflammation of
patient. microorganism to the patient.
Practiced handwashing every Long Term:
submandibular area. before and after contact to > After 8 hours of
the patient. Hand washing is intervention no signs of
a very effective way to infection noted from the
reduce acquiring and patient.
transferring bacteria.
GOAL MET!
Dependent
> Given antibiotic accordingly
per doctor’s order.
antibiotic is given after
surgeries as prophylaxis
DISCHARGE
Plan
Discharge Planning
Area of Focus Instruction(s)
Medication > Co-Amoxiclav 625mg/ tab give 1 tablet every
12hours (8am-8pm) until August 28,2019(It is a
combination antibiotic used for bacterial infections. It
contains amoxicillin (an antibiotic from the penicillin
group of medicines) mixed with clavulanic acid. The
clavulanic acid stops bacteria from breaking down
amoxicillin, allowing the antibiotic to work better.)
Exercise > Stretching exercises Place the tip of your
tongue on the roof of your mouth. Open your
mouth as wide as you comfortably can, and
hold for 5-10 seconds. Place the tip of your
tongue on the roof of your mouth. Glide your
lower jaw out as far as it will go and then back
in as far as it will go.
Treatment > Advised patient and patients parents to
change wound dressing twice daily using
aseptic technique.
> Advised patient to complete the antibiotic
regimen as ordered.
Health Teaching > Advised patient to do proper oral
hygiene using a soft toothbrush.
> Encourage patient to eat or drink
soft cold foods to avoid bleeding.
Outpatient > Patient may follow up with doctor
on the said date or 1week after
discharge from the hospital.
Diet > Soft cold diet
> Getting adequate fluids particularly
water, it is important to help your
body fight off the cellulitis infection.
 Summary,
Conclusion
Recommendation
SUMMARY
> The proponents were able to define abscess cellulitis
mandibular, identify its signs and symptoms, and explain its
pathophysiology. Enumerated some of the laboratory and
diagnostic exams used to assess the patient prior to surgery
which are CBC, skull x –ray, clotting time, bleeding time. This
study identified the medications used and its indication in
relation to the patient’s case: Co- Amoxiclav , Paracetamol,
Ketorolac, Clindamycin. This also recognized the surgical
interventions applied which is the incision and drainage of
submandibular abscess, right. Made nursing care plans and
created health instructions in discharging the patient.
 Conclusion
The study therefore concludes
that incision and drainage is
not just a simple disease that
can be easily cured by self-
medications because if not
treated properly and reoccur
in multiple times it can lead to
serious complications and end
up in abscess cellulitis at all
through surgery. We should be
aware on our diets that can
damage our senses.
Recommendation
The proponents recommend that
patient should know how to manage
his surgical wound properly and that
he should be aware of any signs and
symptoms of complications post
operatively. This study recommends
that the patient should be more
careful on his lifestyle because he is
more susceptible now from acquiring
infections due to incision and
drainage which is one of the bodies’
lines of defense against
microorganisms.