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Impaired tissue integrity r/t cellulitis

PATIENTS INITIALS: 2012

D.L

AGE: 65

CARE: 03-30-

MEDICAL DIAGNOSIS: Cellulitis. ASSESSMENT DATA FOR NURSING DIAGNOSIS Subjective:

Pt states having extreme pain in her left leg.

Objective:

Redness in both legs.- Skin very sensitive to the touch in leg with cellulitis. Pt. unable to walk, or have leg in dependant position. Unable of tolerating the weight of blanket on her leg due to pain in the infected area. Area of infection covered and wrapped all around with a dressing. Unable to observe the skin under the dressing during the shift.

NURSING DIAGNOSIS COLLABORATIVE PROBLEMS: Impaired tissue integrity R/T inflammatory response secondary to cellulitis in LL leg AEB client being unable to walk, extreme pain and redness in the leg. EXPECTED OUTCOMES WITH INDICATORS:Pt will be free of infection and will be alleviated of its symptoms by the time of discharge.

NURSING INTERVENTIONS 1-Perform frequent skin assessment at a minimum once a day or every shift, ensuring the clients skin is dry and clean.

SCIENTIFIC RATIONALE FOR NURSING INTERVENTIONS Assessment and skin hygiene are two initial defenses for preventing skin breakdown.(Potter&Perry,

REALISTIC EVALUATION Assessment of the skin was done during the shift Left leg with cellulitiswas

2009, p.1304)

wrapped with a dressing. The dressing wasnt changed during the shift. Redness and warmth skin observed in both legs. Swelling not present in any leg. Very painful area and sensitive to the touch was observed in left leg where cellulitis is present.

2- Monitor the impaired tissue for signs of redness, swelling , warmth, pain or other signs of infection.

Systematic inspection can identify impeding problems early.(Ackley, 2006, p.1238) Fever is usually the first and often only sign of infection. Laboratory values provide a global view of the clients immune function and nutritional status to develop an appropriate plan of care for the diagnosis.(Ackley, 2006, p.726) A client with a known history of allergy to a medication needs to avoid exposure to that medication to prevent an allergic reaction.(Potter&Perry, 2009, p.691) When clients are colonized withStaphylococcus or Streptococcus such as in cases ofCellulitis, strict adherence to isolation procedures is necessary.(Ignatavicius &

3- Assess temperature every 4 hr . and checkLab values for WBC, serum albumin,serum protein and cultures.

Temperature an Labvalues were checked and both were under normal levels. Patient revealed being allergic to many medications. Information confirmed upon reviewing of chart.

4- Check patientallergies and administer antibiotic as prescribed. 5- Take extra precautions to minimize spread of pathogenic organisms to other people, using proper hand-washing to prevent crosscontamination.

Contact precautions were maintained all the time when providing care.

Workman, 2002, p.1537)