CELLULITIS

A Case Study

In partial fulfillment of the course requirement in

Related Learning Experience

Surgical Ward
College of Nursing, St. Anthony College, Calapan City
September 14, 2012

Submitted by:

Dezzan joy S. Arganda

CHAPTER 1 INTRODUCTION
I. Rationale for choosing the case:

We chose this case for the following objectives: II. Learning objectives General Objectives o To acquire familiarity with Cellulitis o To be proficient in the management of patients who suffer from Cellulitis Specific Objectives o Cognitive To learn more about Cellulitis and its complications Identify the clinical and classical signs and symptoms of the condition Discuss the pathophysiology of the condition Review the anatomy and physiology of the organ affected-the cell Identify potential problems of patient o Psychomotor To formulate nursing diagnoses for the patient experiencing the condition To utilize and cultivate nursing skills necessary for the improvement of the clients condition. To monitor and handle the effects of anesthetic medications to the patient Implement holistic nursing care in the care of patient utilizing the nursing process

o Behavioral

To be cautious and conscientious in monitoring the client condition To render ethical principles and respect in taking care of clients with decreased level of consciousness

CHAPTER II CLINICAL SUMMARY

A. GENERAL DATA CATEGORY
Name Unit Assignment Age Birth date Gender Religion Address Civil Status

DEMOGRAPHIC DATA
Mr. C.J. Surgical Ward 30 yrs. Old July 21, 1945 Female Christian Born Again Poblacion III,Victoria, Oriental Mindoro Widowed

Occupation Date of Admission Time of Admission Admitting Physician Admitting Diagnosis

OFW July 24, 2012

Cellulitis

B. CHIEF COMPLAINT
The patient was admitted at the New Oriental Mindoro Provincial Hospital with chief complaint of Pain in the left leg. C. HISTORY OF PRESENT ILLNESS

D. PAST MEDICAL HISTORY

E. PHYSICAL ASSESSMENT Head to Toe Assessment AREA ASSESSED

HAIR

TECHNIQUE USE
Inspection and palpation

NORMAL FINDINGS
>Black >Evenly distributed covers the whole scalp >Smooth >Not so thick or thin >Neither brittle nor dry >Without tenderness, lumps or mass upon palpation >Symmetrical in shape >Symmetric facial movements EYE >Evenly placed and in line with each other >Not protruding PUPIL >Symmetrical in shape CONJUNCTIVA >Pinkish in color >No inflammation >Moist >No ulcer EYE LASHES >Evenly distributed >Symmetrical in shape, with scattered dry cerumen on the outer ear

SIGNIFICANT FINDINGS
Evenly distributed

INTERPRETATION

SKULL and FACE

Inspection and palpation Inspection and palpation

EYES AND VISION

Left eye cannot see clear Right eye is blurred

Muscle weakness

EARS AND HEARING

Inspection and palpation

No discharged found, able to hear well

>Able to hear on both ears clearly >No discharge or lesion upon inspection >No pain/tenderness upon palpation of auricle and mastoid process >Pinna recoils when fold NOSE AND SINUSES Inspection and palpation >In the midline >No discharge >Nares are symmetrical without inflammation and irritation noted >Nose bridge intact, > No tenderness noted on palpation >No bone and cartilage deviation noted on palpation >Tongue is in the midline >Able to move her tongue from side to side and from up to down >Without dentures >Trachea is in the middle >Coordinated movement without discomfort >Presence of carotid pulse >No Jugular venous distention

No discharges found.

MOUTH AND OROPHARYNX NECK

Inspection

No discharges found. Can move freely

Inspection and palpation

UPPER EXTREMITIES SKIN AND NAILS MUSCLE AND STRENGHT LUNGS ANTERIOR CHEST POSTERIOR CHEST >No edema, no lesions >No lumps or mass upon palpation >No contractures >Presence of brachial and radial pulse >Effortless respirations >No adventitious breath sounds present >Normal in size, shape, and color >Without mass, lumps, and tenderness noted >Breast are symmetrical >Normal in size, shape and color.

Inspection and palpation

Inspection, Palpation and Auscultation

>Without lumps, mass and tenderness noted CHEST AND BACK SPINAL Inspection, COLUMN Palpation and LUNGS ANTERIOR CHEST POSTERIOR CHEST ABDOMEN SKIN Inspection, Palpation and Auscultation >Chest symmetric >Spinal column straight >Skin intact >No masses >Effortless respirations >No adventitious breath sounds present >Normal in size, shape, and color >Without mass, lumps, and tenderness noted >Breast are symmetrical >Normal in size, shape and color. >Without lumps, mass and tenderness noted Inspection, Palpation and >symmetric movements caused by respiration >no masses or lesion upon palpation and inspection >Brown complexion >Long and dirty nails >Equal in size and length, symmetrical, no lesions, no masses. > with weakness on both legs; without mass, tenderness, and lumps noted Presence of popliteal and pedal pulse. Inflammation on the left leg

LOWER EXTREMITIES SKIN AND Inspection, TOENAILS Palpation and MUSCLE

Tissue damage

PULSE

F. REVIEW OF SYSTEM LEVEL Integumentary System FINDINGS Skin warm to touch, smooth and with a temperature of 37.3C. inflamed in the left leg. The patient can breathe normally with a respiratory rate of 20 cycles per minute. The patient usually smokes before but had stopped when he got married. He also had pneumonia a year ago and was treated for 5 months. Normal heart sounds and rhythm with a pulse rate of 76 beats per minute and blood pressure of 110/70 mmHg. No history of hypertension, palpitations, angina or cardiovascular disease.

Respiratory System

Cardiovascular System

Gastrointestinal/Digestive/Metabolic Change in consistency of bowel movements, patient defecate only once since he was admitted, no change in appetite Genito-reproductive System Musculoskeletal System Nervous System Normal in urinating Patient cannot walk. GCS of 15

G. GORDONS PATTERNS OF FUNCTIONING

FUNCTIONAL HEALTH PROBLEM

PRIOR TO HOSPITALIZATION The patient sees her health pattern as normal as she suffered from no serious illness before. Whenever she feels pain or something uncommon, she usually takes drugs and consults a physician, but she also believes in herb doctors.

DURING HOSPITALIZATION The patients daugther admits that her husband has illness and believes that wellness will be attained if doctors orders are to be strictly followed. Patient looks thin and restrained on bed because he always want to walk whenever he feels doing it.

ANALYSIS & INTERPRETATION Prior hospitalization the client knows the importance of seeking doctors advice regarding his health problems and issues. During hospitalization, client is not aware of his current health state.

Health perception health management pattern

Nutritional and Metabolic Pattern

The patient eats 3 times a day and he likes eating foods that are a bit salty and he doesnt want sweet foods and he has no allergies on foods and drugs. The patient has a good appetite and was able to eat foods that are being served at the table and he often drinks water. The patient defecate regularly and he usually urinates four to five times a day usually depending on the amount of water he had taken and she also added that his urine is yellow in color and he doesnt feel any difficulty upon urination.

The patients wife stated that he has eaten 3 spoonful of lugaw and drinks cup of water for 5 times a day.

Prior to hospitalization, the patient seems to have a good appetite. During hospitalization, there were limitations on his nutritional and metabolic pattern due to cerebral injury.

Elimination Pattern

The patients wife stated that he has defecated 3 times since he is admitted. She also added that she used 2 suppositories so that he can defecate.

Prior to hospitalization, the patient manifests normal in defecation. Nevertheless, during hospitalization he has a problem defecating since he hasnt eaten much.

Activity and Exercise Pattern

The patient is not practicing typical exercises and he worked as a carpenter at his sister. After his work at the site, he usually does most of the house chores and fix things such as electric fans and alike. The patient usually wakes up at 5:00 am and sleeps at 10:00 pm.

The patients wife stated that her husband likes to walk whenever he wants to.

Prior to hospitalization, the patient can do her daily routine and during hospitalization

Sleep and Rest pattern

The patients wife stated that her husband needs to take sleeping medication in order to sleep for at least 5 hours. She also said that it takes only 2 hours for him to sleep without sleeping medication. The patients wife stated that her husband was anxious and feels discomfort due to his present condition. The patient also cannot communicate well and was not able to make judgments and decisions The patient perception is altered and cannot recognized persons. He also cannot follow instructions and cannot talk benevolently Because of the incident the patient cannot think properly

During hospitalization the patient sleeping pattern was altered and cant sleep without sleeping drug.

Cognitive Pattern

The patient has a good vision, hearing and he was able to smell, taste and touch. He could also communicate appropriately and was able to make judgments and decisions. The patient is a loving and caring father and son. He is also a devoted man to the Lord and as a person full of dreams for his family especially for his children. The patient is a family- oriented person; he is also a loving and caring father, he worked as a carpenter and a devoted Christian

During hospitalization, the patient is anxious and feels discomfort, he also cannot communicate well and was not able to make judgments and decisions During hospitalization the patent is intricate in identifying persons and cannot talk appropriately

Self Perceptual/Self Concern Pattern Role/Relationship Pattern

During hospitalization the patient has an altered thinking process

Sexuality/Reprod uctive Pattern

The patient is sexually active and practicing family planning using contraceptives The patient was able to cope with the stressors of their life by simply having more time to think and finding enough solutions in a calm manner. He always said to his wife whenever they have a problem hindi mo masusulusyonan ang isang problema kapag laging galit ka, kaya calm ka lang The patient and his family seldom go to the church during Sundays. They usually go directly to consult on physicians, but they also believe in herb doctors

The patient is sexually inactive because of his condition The patient cant cope up with the stress around him

Coping/Stress Tolerance Pattern

Prior hospitalization the patient is sexually active and however during hospitalization he became sexually inactive Prior to hospitalization the patient has a good stress coping pattern nevertheless during hospitalization the patient cannot cope up with stress

Values/Belief Pattern

The patients wife stated that their faith in God became even stronger.

Prior to hospitalization, the patient has a strong faith on God and believes that the physicians can cure her illness effectively yet during hospitalization patient cant verbalized his values and beliefs because of his condition.

H. LABORATORY AND DIAGNOSTIC EXAM

Hematology Maria Estrella July 22 2012 EXAMINATION REF. VALUE WBC count 5-10x 109/L Platelet count 150-350x10/l Neutrophil 0.45-0.65 Lymphocytes 0.20-0.35 Hemoglobin M: 140-180g/l F: 120-160g/l Hematocrit M:0.40-0.51 F:0.37-0.47

RESULT 17.0 adequate 0.84 0.16 122 0.37

INTERPRETATION Indicates Infection Indicative of damage or inflammation of tissues Indicative that body is fighting against Viral infection Acute or chronic blood loss lowers the hematocrit and hemoglobin. Acute blood loss can occur from trauma with lacerations, open wounds

BLOOD CHEMISTRY in MA ES Hospital Date 07 22 2012 EXAMINATION REF. VALUE RESULT SGOT up to 40 UI/I 60.0 SGPT Up to 38UI/I 64.3 Urea Nitrogen 7-21mg/dl 21.4

INTERPRETATION AST: High levels Alanine aminotransferase (ALT), formerly called serum glutamate pyruvate transaminase, or SGPT may indicate liver cell damage, hepatitis, heart attack, heart failure, or gall stone and muscle damage Elevated urea nitrogen can also be due to urinary tract obstruction, congestive heart failure or gastrointestinal bleeding. Blood urea nitrogen level may also increase as a result of dehydration, shock, burns or fever. Medications, such as corticosteroids, may increase urea nitrogen levels. In addition, a high protein diet can cause BUN level to increase.

Creatinine Sodium Potassium

0.9-1.5 mg/dl 135-148mmol/l 3.5-5.3mmol/l

0.9

Diagnostic Imaging 30 July 2012 Pateint CJ MALE/30 Dr. Labaguis OMPH Multiple Plain axial CT scan of the head was done
Examination reveals moderate contusions on the left side frontotemporal lobes with associated midline shift to the right (1.0 cm from the Midline) and subfalcine herniation. Minimal (2.0 thick) hyperdense subdural collection seen at the parietal convexity. Minimal hyperdensity with interdigitation seen at the interhemispheric fissure. The right lateral ventricle is mildly dilated Posterior fossa structures and sella are unremarkable Minimal soft-tissue densities seen in both maxillary and ethmoid sinuses There are several linear fractures at the right frontal, right parietal and right temporal region with the latter Extending into the right mastoid with overlying soft-tissue swelling. Minimal tiny comminuted fragments seen at the right temporal fracture with fragment partly embedded in the temporal lobe Both mastoids are sclerotic Small subgaleal hematoma seen at the right parietal region. REMARKS: HEMORRHAGIC CONTUSIONS, LEFT FRONTO TEMPORAL LOBES WITH MODERATE MASS EFECT AS DESCRIBED MINIMAL ACYTE SUBARACHNOID HEMORRHAGE MINIMAL ACUTE SUBDURAL HEMORRHAGE RIGHT PARIETAL CONVEXITY POLY SINUSITIS VERSUS HEMO ANTRUM MULTIPLE FRACTURESS AS DESCRIBED RIGHT FRONTO TEMPORAL BONES SUBGALEAL HEMATOMA, RIGHT PARIETAL REGION

SCLEROTIC MASTOID

July 21 Patient CJ MEGH CT SCAN OF THE BRAIN PROTOCOL: Non contrast axial images of the brain in 5mm and 5mm slice were done. CLINICAL HISTORY: Trauma Findings:
There is small intra parenchymal hemorrhage in the both cerebral hemispheres. The prominent foci are seen in the right basi frontal (0.79)right basi temporal (0.33 cm, 0.63cm and 0.7 cm). right parietal 0.5 cm and left basitemporal region (1.03). Minimal perilesional edema is present. In addition extra axial hemorrhages are evident in the both cerebral convexities with thickest area about 0.79 cm in the right parietal and 1.15 cm in the left basitemporal regions. The subdural hemorrhage along the tentorium is detected. There is buckling of the adjacent parenchyma. Associated minimal subarachanoid hemorrhages in the left basi temporal region are evident. There is effacement of the left sylvian fissure with effacement of the overlying sulci in the left cerebral convexity indicative of edema. Linear fracture in the right frontal bone and right temporal region extending inferiorly into the mastoid branching into two. The anterior limb of the fracture extends into the basitemporal aspect into the sphenoid while the posterior limb extends horizontally in the mastoid into the middle ear. Herper4dnse fluid fills the mastoid, right external auditory canal and middle ear cavity relating to hemoantrum. Scalp swelling is observed in the right parietotemporal area with associated subgaleal hematoma about 1.36 cm. The rests of the cerebral sulci, cisterns, ventricles, and sylvian fissures are not effaced. Midline structures are in place. Mucosal thickening in the maxillary and ethmoid sinuses are present. Sclerotic left mastoid is seen. The rests of the included paranasal sinuses adequately aerated. IMPRESSION: Acute thin subdural hemorrhages in both cerebral convexities (more on the right) and along the falx cerebri with associated minimal subarachnoid hemorrhage in the left temporal region. Associated edema and mass effects are evident. Multiple small intraparenchymal hemorrhage, as described. Linear fracture in the right frontal bone and right temporal region extending inferiorly into the mastoid and middle ear with resultant hemoantrum. Scalp swelling and subgaleal hematoma in the right parietotemporal region. Non specific maxillary and ethmoid mucosal disease.

CHAPTER III. ANATOMY AND PHYSIOLOGY

The CNS consists of the brain and spinal cord, which are located in the dorsal body cavity. The brain is surrounded by the cranium, and the spinal cord is protected by the vertebrae. The brain is continuous with the spinal cord at the foramen magnum. In addition to bone, the CNS is surrounded by connective tissue membranes, called meninges, and by cerebrospinal fluid. Meninges There are three layers of meninges around the brain and spinal cord. The outer layer, the dura mater, is tough white fibrous connective tissue. The middle layer of meninges is arachnoid, which resembles a cobweb in appearance, is a thin layer with numerous threadlike strands that attach it to the innermost layer. The space under the arachnoid, the subarachnoid space, is filled with cerebrospinal fluid and contains blood vessels. The pia mater is the innermost layer of meninges. This thin, delicate membrane is tightly bound to the surface of the brain and spinal cord and cannot be dissected away without damaging the surface.

Brain

It is the part of the central nervous system that is present in the head and protected by the skull, dorsally and laterally. The box that houses the brain within the skull is called the cranium. It has three main regions - the fore brain, the mid brain and the hind brain. The three regions have different parts that have specific functions. Fore Brain It is made up of cerebrum, hypothalamus and thalamus. Cerebrum It is the largest part of the brain and is made up of two hemispheres called the cerebral hemispheres. The two hemispheres are joined together by a thick band of fibres called the corpus callosum. The cerebrum is made up of four distinct lobes - frontal, parietal, temporal and occipetal.

The outer portion of the cerebrum is called the cortex and the inner part is called the medulla. The cortex consists of the cells of the neurons and appears grey in colour. It is also called the grey matter. The medulla consists of the fibres of the neurons and is white. The cortex is highly convoluted which increase the surface area. It is believed that higher the number of convolutions, higher is the intelligence. The cerebrum has sensory areas, association areas and motor areas. The sensory areas receive the messages, the association areas associate this information with the previous and other sensory information and the motor areas are responsible of the action of the voluntary muscles. Cerebrum is responsible for the intelligence, thinking, memory, consciousness and will power. Thalamus It is an area which coordinates the sensory impulses from the various sense organs - eyes, ears and skin and then relays it to the cerebrum. Hypothalamus Hypothalamus, though a small region situated below the thalamus, is an important region of the brain. It receives the taste and smell impulses, coordinates messages from the autonomous nervous system, controls the heart rate, blood pressure, body temperature and peristalsis. It also forms an axis with the pituitary which is the main link between the nervous and the endocrine systems. It also has centres that control mood and emotions. Mid Brain It is a small portion of the brain that serves as a relay centre for sensory information from the ears to the cerebrum. It also controls the reflex movements of the head, neck and eye muscles. It provides a passage for the different neurons going in and coming out of the cerebrum. Hind Brain It consists of cerebellum, pons and medulla oblongata. Cerebellum Cerebellum is like cerebrum. It consists of outer grey cortex and inner white medulla. It is responsible for maintaining the balance while walking, swimming, riding, etc. It is also responsible for precision and fine control of the voluntary movements. For example, we can do actions like eating while talking or listening. One has to concentrate for talking sensibly. However the action of eating, while talking is done automatically. This is controlled by the cerebellum. Pons Pons literally means bridge. It serves as a relay station between the lower cerebellum and spinal cord and higher parts of the brain like the cerebrum and mid brain.

Medulla Oblongata It is a small region of the brain. It is hidden as it is well protected because of its importance. It has the cardiovascular centre and the breathing centre. It also controls activities such as sneezing, coughing, swallowing, salivation and vomiting. The Corpus Callosum This is the neural bridge that connects the two hemispheres to each other, located centrally in brain. The Neocortex The last and most advanced brain to evolve to date is called the Neocortex, neomammalian or rational brain. We share this part of our brain with other higher level mammals like the primates and dolphins, although in humans the neocortex is the largest. It takes up 2/3's of the human brain. This is where we find the brain power to develop language, abstract thought, consciousness and imagination. Let there be no doubt, this is what grants us our status on the food chain and allows us to be human. The Neocortex is divided into two hemispheres, right and left. The right side of the brain controls the left side of the body and vice versa. Also the hemispheres are divided in terms of what kind of thought they process or produce. The right being more concerned with the artistic, spatial and musical. While the left is more concerned with the colder, linear, rational and verbal aspects. Located in the Neocortex are:

Brain Lobes and Their Functions Frontal Lobe The frontal lobe is home to our cognitive thinking, and it is this process that determines and shapes an individual's personality. In human beings, the frontal lobe attains maturity when the individual is around the age of 25. This means that by the time we are 25 years of age, we have achieved a level of cognitive maturity. The frontal lobe is made up of the anterior portion (prefrontal cortex) and the posterior portion, and is divided from the parietal lobe by the central sulcus. The anterior portion is responsible for higher cognitive functions, and the posterior portion consists of the premotor and motor areas, thus, governing voluntary movements. Functions of the frontal lobe include reasoning, planning, organizing thoughts, behavior, sexual urges, emotions, problem-solving, judging, organizing parts of speech, and motor skills (movement). The frontal lobe is extremely vulnerable to injury due to its location, as it is in front of the central cranium. Any damage to this lobe of the brain can lead to one or more of the following problems.

Increased or decreased problem solving ability and creativity Alteration in talking habits Reduced sexual interest or peculiar sexual habits Impaired risk-taking ability Reduced or no sense of taste and/or smell Impaired spontaneity and mental flexibility Increased susceptibility to distractions

Parietal Lobe The parietal lobe is located behind the central sulcus, and above the occipital lobe. It has four anatomical boundaries; the central sulcus, which separates the parietal lobe from the frontal lobe, the parieto-occipital sulcus which separates the parietal and occipital lobes, the lateral sulcus which separates the parietal from the temporal lobe, and the medial longitudinal fissure which divides the two hemispheres (right and left). The parietal lobe is responsible for integrating sensory information from various parts of the body.

The optic nerve passes through the parietal lobe to the occipital lobe. Functions of the parietal lobe include information processing, movement, spatial orientation, speech, visual perception, recognition, perception of stimuli, pain and touch sensation and cognition. Any damage to the parietal lobes results in abnormalities in spatial processing and body image. Mentioned below are the problems that occur after damage to a particular site of the parietal lobe.

Left Parietal Lobe Damage: Any damage to left side of this lobe can cause Gerstmann's syndrome, aphasia (language disorder), and agnosia (abnormal perception of objects). Right Parietal Lobe Damage: Right side damage results in difficulty in making something, impaired personal care skills and impaired drawing ability. Bi-lateral Parietal Lobe Damage: It causes Balint's syndrome which is characterized by impaired visual attention and motor activities.

Occipital Lobe Smallest of all the four lobes, the occipital lobes are located in the rearmost portion of the skull. These are located on the tentorium cerebelli that separates the cerebrum from the cerebellum. This lobe is responsible for visual perception system, as it contains the primary visual cortex. Functions of the occipital lobe include visual reception, visual-spatial processing, movement and color recognition. Disorders of the occipital lobe can cause visual illusions. Because of the location, these lobes are not particularly susceptible to injury, although significant trauma can result in a few problems.

Disruption of the visual-perceptual system Homonomous vision loss

Temporal Lobe There are two temporal lobes, each of which are located on each side of the brain; left and right, at about the level of the ears. The temporal lobes contain the primary auditory cortex, and hence, are responsible for all auditory processing. These lobes also contain the hippocampus, responsible for formation of long-term memory and sorting new information. Functions of both (left and right) temporal lobes include distinguishing and discrimination of smell and sound from other smells and sounds respectively. Between them, they control visual memory (right lobe) and verbal memory (left lobe), and thus, hearing, speech and memory. Effects of temporal lobe damage can again be classified depending on which side of the lobe is affected.

Left Temporal Lobe Damage: It leads to decreased ability to recall audio and visual content, difficulty in recognizing words and remembering verbal material. Right Temporal Lobe damage: Damage to right side of this lobe results in difficulty in recognizing visual content and tonal sequences, recall of previously encountered music or drawings, and reduced inhibition of talking

C. Discharge Planning Medication Instructed the family of the client to strictly follow the doctors prescribed medication Instructed to note for adverse reactions. Asked to watch out for drug hypersensitivity such as rashes and respiratory distress. Exercise Instructed the family of the client to avoid strenuous activities such as work which requires too much movement and lifting heavy things. Gradually resume his normal daily activities but do not strain or do heavy lifting for at least two weeks. Treatment Strictly follow Physicians treatment order. Health teaching Advised the family of the client the importance of strictly following the medication regimen as prescribed by the physician. Advised the family to continuously talk with the patient for verbalization of feelings. Advised family to reorient the patient and to teach the patient to follow instructions. Advised family to present foods that are appealing to the client to enhance his appetite. Give variety of foods. Informed the family not to leave the patient unattended to prevent injuries. Out-patient follow up Informed the family of the client to go back for a follow up check after a week. Diet Advised the family to give the client 6 to 8 glasses of water a day. Advised the family of the client to give foods rich in fiber such as fruits like papaya and pineapple. Give variety of foods

Spiritual counseling Advised the family of the client to continue spiritual preference.