Nursing Diagnosis and Nursing Intervention

Acute Pain related to Cellulitis

Nursing Care Plan for Cellulitis

Cellulitis is an infection by Staphylococcus, Streptococcus, or by both of them in the deepest layers of the skin. Bacteria can enter the body through the other parts of the skin of a cut, scratch, or bite. Usually if the skin is infected, affected only the top layer and will disappear on their own with proper care. But in cellulitis, skin tissue becomes infected parts in red, hot, inflamed and painful. Cellulitis usually occurs on the face and lower legs.

While according to Neville, Oral and Maxillofacial Pathology, explains that the term cellulitis used an oedematous deployment of acute inflammation on the surface of the soft tissues and is diffuse. Cellulitis can occur in all places where there is soft tissue and loose connective tissue, especially on the face and neck, because usually in the area of defense against infection is less than perfect.

The main causes of facial cellulitis is Staphylococcus aureus and Streptococcus b- hemolyticus, whereas Staphylococcus epidermidis is a normal inhabitant of the skin and rarely fight infections. Pyoderma predisposing factor is the lack of hygiene, immune deficiencies, and other diseases have been found in the skin.

Cellulitis are not contagious, usually begins as a small, inflamed, pain, swelling, heat, and redness of the skin. When the milking area began to spread, the child will feel pain and discomfort, fever, and can be accompanied by chills and sweating. Swollen lymph nodes in the folds are sometimes found on the nearby skin infections.

Nursing Diagnosis and Interventions :

Acute Pain related to local inflammatory response of subcutaneous tissue.

Goal : The client expressed pain decreased after nursing care.

Expected outcomes :
  • Stable pain scale (0-3).
  • Showed no pain / controlled.
  • Looks relaxed, able to sleep / rest and participate in activities according to ability.
  • Following the recommended pharmacological program.

Intervention :

1. Observation pain scale (0-10), the characteristics of pain, and pain location.
Rational : assist in determining the need for pain management, and program effectiveness.

2. Let the patient take a comfortable position and increase bed rest as indicated.
Rational : to limit the pain.

3. Give a gentle massage.
Rational : increase relaxation / reduce muscle tension.

4. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, guidance imagination, self hypnosis, and breath control.
Rational : increase relaxation, gives a sense of control, and may improve coping skills.

Collaboration

5. Give the medicine before the activity / exercise is planned, according to the instructions.
Rational : increase relaxation, reduce muscle tension / spasm, easy to participate in therapy.

6. Apply ice or a cold pack if necessary.
Rational : the cold can relieve pain and swelling during the acute period.

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