Kelly Riedinger Cellulitis Assessment Diagnosis Interference Planning Intervention Rationale Evaluation

Subjective: Client states that he is weak and tired all the time. Client states that he has pain when walking around and that his legs stay swollen and that there are cracks/sores on both feet. Objective Cellulitis with necrosis bilaterally to lower extremities. Edema in left lower extremities and Edema in the right lower extremities. Type II Diabetes

Problem: Risk for impaired skin integrity

Cellulitis is a localised or diffuse inflammation of connective tissue with R/T severe Diabetes inflammation of dermal and AEB subcutaneous Lesions layers of the and sores skin. Cellulitis on can be bilateral caused by lower normal skin extremities flora or by exogenous bacteria and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds,

After 8 hours the client will be taught what a part of his body is at most risk for skin break down. He will also be taught how to do a simplified skin assessment and what to look for if there is a breakdown or change in skin.

For a client with limited mobility, monitor condition of skin covering bony prominences.

Pressure ulcers usually occur over bony prominences, such as the sacrum, coccyx, and heels.

Early assessment and intervention Teach the helps prevent the client skin development of assessment serious problems. and ways to monitor for skin Basic elements of a skin breakdown. assessment are assessment of Monitor skin temperature, conditions at color, moisture, least once a day for color or and intact skin texture Systematic Client will be changes, or inspection can taught what lesions. identify impending to look for Determine problems early and how to whether the inspect his client is Excessive own legs and experiences bathing, will be able loss of especially in hot to sensation or

Nursing student observes the material being taught and made sure it was taught in a simple manner so that it was not to complex for the client. Nursing student will observe the client doing his own simplified skin assessment. Nursing student observes the client in doing a selfinspection of

Kelly Riedinger Cellulitis

Lesions on bilateral lower extremities.

intravenous drug injection or sites of intravenous catheter insertion. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. The mainstay of therapy remains treatment with appropriate antibiotics and recovery periods last from 48 hours to six months.

demonstrate a selfinspection of his lower extremities and be able to report is pain on a scale from 010.

pain.

water, depletes again skin of Limit the moisture and number increases complete baths dryness. The to two or three ability to retain per week, and moisture is alternate them decreased in the with partial skin and starts to baths. Use a diminish amounts tepid water of dermal temperature proteins. (90 and 105 degrees) for bathing.

his lower extremities. Client was able to report his findings and knows to report is there are any new ones. Client also understood the importance of a pain scale and new how to implement it on a scale from 0-10.