CARE STUDY OF A PATIENT WITH

CELLULITIS

BY

ADEGBITE JOHN OLUKOREDE

PRESENTED TO

NIGERIAN ARMY COLLEGE OF NURSING

YABA, LAGOS

IN PARTIAL FULFILMENT OF THE

REQUIREMENT OF NURSING
AND MIDWIFERY COUNCIL OF NIGERIA FOR
THE

AWARD OF REGISTERED NURSING

CERTIFICATE (RN)

FEBRUARY, 2023
 CERTIFICATION

This is to certify that this care study was carried out by

NACON/ND/HND/SET46/006,SN ADEGBITE JOHN OLUKOREDE under the
supervision of SGT CHRISTIAN

SIGNATURE DATE

NAME OF COMMANDANT:LT COL J.O AWUTO

SIGNATURE DATE
 DEDICATION

This care study is dedicated to the Almighty God, for His mercy, kindness,
profound love, and his grace to achieve this work successfully. Also to my
beloved parents and my siblings for their support and encouragement, also to my
mentor for being a man to look up to. Finally to my kind hearted supervisor for his
support and direction during the course of this project.
 ACKNOWLEDGEMENT

My gratitude goes to the Almighty God who is the author and finisher of my faith,
has bestowed upon me the strength, wisdom, knowledge and might to complete
this project.

My profound gratitude goes to my project supervisor SGT Christian for his

immense contribution, guidance and direction at various stages of this write up.

To my beloved parents Mr & Mrs Adegbite Tayo and my siblings for their prayers
and moral support throughout the course, also to my set co-ordinator and entire
students of set 46 and non academic staff whose name could not appear in the
write up.
 TABLE OF CONTENTS

Title page
Certification
Dedication
Acknowledgement
Table of contents

CHAPTER ONE
1.0 Introduction

CHAPTER TWO
2.0 Literature Review
2.1 Anatomy and Physiology of the related organ
2.2 Causes of Cellulitis
2.3 Pathophysiology of Cellulitis
2.4 Clinical Manifestation
2.5 Diagnostic Investigation
2.6 General Management of Hy
2.7 Possible Complication
2.8 Prognosis

CHAPTER THREE
3.0 Patient’s Bio-data
3.1 Admission of the patient
3.2 History Taking
3.2.1 Past medical history
3.2.3 Patient social history
3.2.4 Drug history
3.2.5 History of present illness
3.3 Assessment of patient using Gordon’s eleven functional health pattern
3.4 General Examination
3.5 Medical Management
3.6 Comparative signs and symptoms
3.7 Comparative investigation and result
3.8 Day-to-day Nursing Management
3.9 List of Nursing Diagnosis
3.10 Health Education
3.11 Discharge of patient
3.12 Follow Up of patient
3.13 Drug Review
3.14 Conclusion
3.15 Recommendation
3.16 Nursing care plan

References
Appendices
 CHAPTER ONE
1.0 INTRODUCTION

Cellulitis is a common bacterial skin infection that causes redness, swelling, and
pain in the infected area of the skin. If untreated, it can spread and cause serious
health problems.Good wound care and hygiene are important for preventing
cellulitis.

Different types of bacteria can cause cellulitis, which is an infection of the deeper
layers of the skin. This page focuses on one of the most common causes of
cellulitis: group A Streptococcus (group A strep).

For many people who get cellulitis, experts do not know how the bacteria get into
the body. Sometimes the bacteria get into the body through openings in the skin,
like an injury or surgical wound. In general, people cannot catch cellulitis from
someone else; it is not contagious.

In general, cellulitis appears as a red, swollen, and painful area of skin that is
warm and tender to the touch. The skin may look pitted, like the peel of an orange,
or blisters may appear on the affected skin. Some people may also develop fever
and chills. Cellulitis can appear anywhere on the body, but it is most common on
the feet and legs.Anyone can get cellulitis, but some factors can increase the risk
of getting this infection

Patients presenting with cellulitis often have a recent history of an injury in the
affected area. Cellulitis can develop from neglected minor injuries that have
become infected. The disease generally takes days after the initial injury to
present, but it can progress rapidly in severe cases.

Co-morbid conditions are the most important factors to be looked at when

cellulitis has developed. History of diabetes mellitus, kidney disease, liver disease,
HIV infection, or any other immunodeficient conditions are to be inquired about
and noted in the patient’s history.

History of other skin diseases such as any fungal infections, dermatitis, and venous
insufficiency are to be obtained because they may have served as an entry point
for the pathogen.

Past surgical history is also an important factor in determining the cause of a

patient’s cellulitis. Previous history of any lymph node dissection may be a risk
factor because it points to an underlying condition that predisposes a person to
infection.

The following are risk factors because they allow bacteria to get through the skin:
  Injuries that cause a break in the skin (like cuts, ulcers, bites, puncture
wounds, tattoos, piercings)
 Chronic skin conditions (like athlete’s foot and eczema)
 Chickenpox and shingles
 Injection drug use

Cellulitis is observed most frequently among middle-aged and older adults.

Erysipelas occurs in young children and older adults. The incidence of cellulitis is
about 200 cases per 100,000 patient-yearsand, in nontropical regions, has a
seasonal predilection for warmer months

The vast majority of erysipelas cases are caused by beta-hemolytic

streptococci. One study of nonpurulent cellulitis including 179 patients found
that beta-hemolytic streptococci accounted for 73 percent of cases (diagnosed
by positive blood culture results or serologic testing for anti-streptolysin-O
and anti-DNase-B antibodies) [No etiology was identified in 27 percent of
cases, but the overall clinical response rate to beta-lactam therapy was 96
percent.
Less common causes of cellulitis include Haemophilus influenzae type b
(buccal cellulitis), clostridia and non-spore-forming anaerobes (crepitant
cellulitis), Streptococcus pneumoniae, and Neisseria meningitis. In
immunocompromised patients, the spectrum of potential pathogens is much
broader, and infectious disease consultation is warranted.
 CHAPTER TWO

LITERATURE REVIEW

2.0 PREAMBLE

Cellulitis is a bacterial infection of the skin, which can become serious if not
treated quickly with antibiotics. It often affects the lower leg, but can occur on any
part of the body including the face.

Cellulitis is usually caused by a bacterial infection. Group A streptococcus and

Staphylococcus aureus (staph) are the most common bacteria involved. These
bacteria normally live on a person’s skin without causing any harm, but if skin is
broken they can infect the tissue and cause cellulitis.

The infection usually occurs when bacteria enter the skin through an ulcer, cut,
scratch or insect bite. It can also happen when there is already a skin problem like
eczema, psoriasis, scabies or acne, or after surgery. However, it can occur without
any visible damage to the skin.

2.1. ANATOMY AND PHYSIOLOGY OF THE RELATED ORGANS

Introduction
The skin is the largest organ in the body and has a surface
area of about 1.5–2 m² in adults. In certain areas, it contains accessory structures:
glands, hair and nails. There are two main layers; the epidermis, which covers the
dermis. Between the skin and underlying structures is a subcutaneous layer
composed of areolar tissue and adipose (fat) tissue

LAYERS

EPIDERMIS
This is the most superficial layer and is composed Of stratified keratinised
squamous epithelium. It varies in thickness, being thickest on the palms of the
hands and soles of the feet. There are no blood vessels or nerve endings in the
epidermis, but its deeper layers are bathed in interstitial fluid from the dermis,
which provides oxygen and nutrients, and drains away as lymph.

There are several layers (strata) of cells in the epidermis which extend from the
deepest germinative layer to the most superficial stratum corneum (a thick horny
layer)
Epidermal cells originate in the germinative layer and undergo gradual change as
they progress towards the skin surface. The cells on the surface are flat, thin , non-
nucleated, dead cells, or squames, in which the cytoplasm has been replaced by the
fibrous protein keratin. The surface cells are constantly rubbed off and replaced by
those beneath. Complete replacement of the epidermis takes about a month In
areas where the skin is subject to greater wear and tear, e.g. the palms and fingers
of the hands and soles of the feet, the epidermis is thicker and hairs are absent. In
these areas the dermal papillae are arranged in parallel lines giving the skin
surface a ridged appearance. The pattern of ridges on the fingertips is unique to
every individual and the impression made by them is the ‘fingerprint’

DERMIS
The dermis is tough and elastic. It is formed from connective tissue and the matrix
contains collagen fibres Interlaced with elastic fibres. Rupture of elastic fibres
occurs when the skin is overstretched, resulting in permanent striae, or stretch
marks, that may be found in pregnancy and obesity. Collagen fibres bind water
and give the skin its tensile strength, but as this
ability declines with age, wrinkles develop. Fibroblasts, macrophages and mast
cells are the main cells found in the dermis. Underlying its deepest layer is the
subcutaneous layer containing areolar tissue and varying amounts of adipose (fat)
tissue. The structures in the dermis are:
 blood and lymph vessels
 sensory nerve endings
 sweat glands and their ducts
 hairs, arrector pili muscles and sebaceous glands.

BLOOD AND LYMPH VESSELS

Arterioles form a fine network with capillary branches supplying sweat glands,
sebaceous glands, hair follicles and the dermis. Lymph vessels form a network
throughout the dermis.

SENSORY NERVE ENDINGS

Sensory receptors (specialised nerve endings) sensitive to touch, temperature,
pressure and pain are widely distributed in the dermis. Incoming stimuli activate
different types of sensory receptors. For example, the Pacinian corpuscle is
sensitive to deep pressure. The skin is an important sensory organ through which
individuals receive information about their environment. Nerve impulses,
generated in the sensory receptors in the Dermis, are transmitted to the spinal cord
by sensory nerves.From there impulses are conducted to the sensory area of the
cerebrum where the sensations are perceived

SWEAT GLANDS
These are widely distributed throughout the skin and are most numerous in the
palms of the hands, soles of the feet, axillae and groins. They are formed from
epithelial cells. The bodies of the glands lie coiled in the subcutaneous tissue.
There are two types of sweat gland. Eccrine sweat glands are the more common
type and open onto the skin surface through tiny pores, and the sweat produced
here is a clear, watery fluid important in regulating body temperature. Apocrine
glands open into hair follicles and become active at puberty. They may play a role
in sexual arousal. These glands are found, for example, in the axilla. Bacterial
decomposition of their secretions causes an unpleasant odour.

HAIRS
These grow from hair follicles, downgrowths of epidermal cells into the dermis or
subcutaneous tissue. At the base of the follicle is a cluster of cells called the hair
papilla or bulb. The hair is formed by multiplication of cells of the bulb and as
they are pushed upwards, away from their source of nutrition, the cells die and
become keratinised. The part of the hair above the skin is the shaft and the
reminder, the root shows hair growing through the skin and also desquamation,
which roughens the skin surface; the roughened surface may harbor microbial
growth although many are removed by the constant rubbing off of the topmost
layers.Hair colour is genetically determined and depends on the amount and type
of melanin present. White hair is the result of the replacement of melanin by tiny
air bubbles

ARRECTOR PILI
These are little bundles of smooth muscles fibres attached to the hair follicles.
Contraction makes the hair stand erect and raises the skin around the hair, causing
‘goose flesh’. The muscles are stimulated by sympathetic nerve fibres in response
to fear and cold. Erect hairs trap air, which acts as an insulating layer. This is an
efficient warming mechanism, especially when accompanied by shivering, i.e.
involuntary contraction of skeletal muscles.

SEBACEOUS GLANDS
These consist of secretory epithelial cells derived from the same tissue as the hair
follicles. They secrete an oily antimicrobial substance, sebum, into the hair
follicles and are present in the skin of all parts of the body except the palms of the
hands and the soles of the feet. They are most numerous in the scalp, face, axillae
and groins. In regions of transition from one type of superficial epithelium to
another, such as lips,eyelids, nipple, labia minora and glans penis, there are
sebaceous glands that are independent of hair follicles, secreting sebum directly
onto the surface.Sebum keeps the hair soft and pliable and gives it a shiny
appearance. On the skin it provides some waterproofing and acts as a bactericidal
and fungicidal agent, preventing infection. It also prevents drying and cracking of
skin, especially on exposure to heat and sunlight. The activity of these glands
increases at puberty and is less at the extremes of age, rendering the skin of infants
and older adults prone to the effects of excessive moisture (maceration)

NAILS
Human nails are equivalent to the claws, horns and hooves of animals. Derived
from the same cells as epidermis and hair these are hard, horny keratin plates that
protect the tips of the fingers and toes.The root of the nail is embedded in the skin
and covered by the cuticle, which forms the hemispherical pale area called the
lunula.The nail plate is the exposed part that has grown out from the nail bed, the
germinative zone of the
Epidermis. Finger nails grow more quickly than toe nails and growth is faster
when the environmental temperature is high

FUNCTIONS

Protection:The skin forms a relatively waterproof layer, provided mainly by its

keratinised epithelium, which protects the deeper more delicate structures. As an
important non defence mechanism it acts as a barrier against:

 invasion by micro-organisms
 chemicals
 physical agents, e.g. mild trauma, ultraviolet light
 dehydration
Regulation of body temperature: Body temperature remains fairly constant
around 36.8°C across a wide range of environmental temperatures ensuring that
the optimal range for enzyme activity required for metabolism is maintained. In
health, variations are usually limited to between 0.5 and 0.75°C,
Although it rises slightly in the evening, during exercise and in women just after
ovulation. To maintain this constant temperature, a negative feedback system
regulates the balance between heat produced in the body and heat loss to the
environment

Heat loss: Most heat loss from the body occurs through the skin. Small amounts
are lost in expired air, urine and faeces.
Only heat loss through the skin can be regulated; heat lost by the other routes
cannot be controlled.Heat loss through the skin is affected by the difference
between the body and environmental temperatures, the amount of the body surface
exposed and the type of clothes worn. Air insulates against heat loss when trapped
in layers of clothing and between the skin and clothing. For this reason several
layers of lightweight clothes provide more effective insulation against low
environmental temperatures than one heavy garment

Formation of vitamin D:7-Dehydrocholesterol is a lipid-based substance in the

skin and is converted to vitamin D by sunlight. This vitamin is used with calcium
and phosphate in the formation and maintenance of bones

Cutaneous sensation; Sensory receptors are nerve endings in the dermis that are
sensitive to touch, pressure, temperature or pain. Stimulation generates nerve
impulses in sensory nerves that are transmitted to the cerebral cortex. Some areas
have more sensory receptors than others causing them to be especially sensitive,
e.g. the lips and fingertips.

Absorption:This property is limited but substances that can be

absorbed include:
• some drugs, in transdermal patches, e.g. hormone replacement therapy during the
menopause, nicotine
as an aid to smoking cessation
• some toxic chemicals, e.g. mercury.

Excretion:The skin is a minor excretory organ for some substances including:

• sodium chloride in sweat; excess sweating may lead
to low blood sodium levels (hyponatraemia)
• urea, especially when kidney function is impaired
• aromatic substances

2.2 CAUSES OF CELLULITIS

Staphylococcus and streptococcus bacteria are the most common causes of
cellulitis.

Normal skin has many types of bacteria living on it. When there is a break in the
skin, these bacteria can cause a skin infection.

Risk factors for cellulitis include:

 Cracks or peeling skin between the toes

 History of peripheral vascular disease
 Injury or trauma with a break in the skin (skin wounds)
 Insect bites and stings, animal bites, or human bites
 Ulcers from certain diseases, including diabetes and vascular disease
 Use of corticosteroid medicines or other medicines that suppress the
immune system
 Wound from a recent surgery

2.3 PATHOPHYSIOLOGY OF CELLULITIS

Cellulitis from the activation of the body’s inflammatory response to bacterial

infections
Through breaks and discontinuities in the skin barrier, microorganisms have a
portal of entry into the layers of the skin. The body responds to these microbes as
foreign bodies and their detection initiates an inflammatory response. This
response leads to redness, swelling, pain, and itching of the area involved. A local
infection leads to inflammation of the area involved. With a competent immune
system, the spread of the infection is limited. If the immune system fails to curb
the initial infection, the infection may become systemic by spreading into adjacent
areas. If the infection spreads to the bloodstream, it is called Bacteremia.
Group A streptococcus and staphylococcus are the most common causative agents
of cellulitis. These bacteria are part of the normal flora of the skin but they will
cause infection if the skin is broken. Predisposing conditions for cellulitis include
insect bites, animal bites, pruritic skin rash, recent surgery, athlete's foot, dry
skin, eczema, burns and boils. Another cause may be Hemophilus influenza,
especially in cases of facial infections.
In rare cases, the infection causing cellulitis can spread to the deep layer of tissue
called the fascial lining. Necrotizing fasciitis, also called "flesh-eating disease" by
the media, is an example of a deep-layer infection. It represents an
extreme medical emergency requiring surgical consultation.

2.4 CLINICAL MANIFESTATION

Symptoms of cellulitis include:

  Fever with chills and sweating
 Fatigue
 Pain or tenderness in the affected area
 Skin redness or inflammation that gets bigger as the infection spreads
 Skin sore or rash that starts suddenly, and grows quickly in the first 24
hours
 Tight, glossy, stretched appearance of the skin
 Warm skin in the area of redness
 Muscle aches and joint stiffness from swelling of the tissue over the joint
 Nausea and vomiting

When to see a doctor

It’s important to identify and treat cellulitis early because the condition can spread
rapidly throughout your body.
Seek emergency care if:
 You have a swollen, tender rash or a rash that’s changing rapidly
 You have a fever

2.5 DIAGNOSITIC INVESTIGATION

The health care provider will perform a physical exam. This may reveal:
 Redness, warmth, tenderness, and swelling of the skin
 Possible drainage, if there is a buildup of pus (abscess) with the skin
infection
 Swollen glands (lymph nodes) near the affected area
The provider may mark the edges of the redness with a pen, to see if the redness
goes past the marked border over the next several days.
Tests that may be ordered include:

 Blood culture
 Complete blood count (CBC)
 Culture of any fluid or material inside the affected area
A biopsy may be done if other conditions are suspected

2.6 GENERAL MANAGEMENT OF CELLULITIS

If you are diagnosed with cellulitis, treatment is important. It can prevent cellulitis
from worsening. It can help you avoid serious medical problems like blood
poisoning and severe pain.
To treat cellulitis, doctors prescribe:

Antibiotics: An oral (you take by swallowing) antibiotic can effectively clear

cellulitis.
The type of antibiotic you need and how long you’ll need to take it will vary. Most
people take an antibiotic for 7 to 14 days. If you have a weakened immune system,
you may need to take the antibiotic for longer.

Some people need to take more than one type of antibiotic.Sometimes, the
antibiotic is given through an IV. When this is necessary, a hospital stay is often
prescribed. This can help clear severe cellulitis or cellulitis on the face. Most
people are hospitalized for just over one week.

 Wound care: This is an important part of treating cellulitis. Covering your

skin will help it heal. If you need special wound coverings or dressings,
you’ll be shown how to apply and change them.
 Rest: This can help prevent cellulitis from becoming serious and help your
body heal.
 Elevation: If you have cellulitis in your leg, keeping your leg elevated can
help reduce the swelling and help you heal.

Treatment for another medical condition: If the bacteria got into your body
because you have another skin condition like athlete’s foot, it’s important to treat
that condition, too.

2.6 COMPLICATIONS OF CELLULITIS

These complications or side effects of a cellulitis infection are the most common.
They can occur in people who don’t seek treatment, and they may also occur when
treatment isn’t effective.
Some of these complications are medical emergencies, and you should seek
immediate attention if you show symptoms.

 Septicemia: septicemia occurs when the infection spreads to the

bloodstream. In cases where septicemia isn’t fatal, amputation may be
needed, and chronic pain and fatigue may remain.
 Recurrent cellulitis :A cellulitis treatment that is not properly treated may
return. It may also make complications or side effects more likely in the
future.
 Lymphoedema :The body’s lymph system is responsible for draining
waste products, toxins, and immune cells out of the body. Sometimes,
however, the lymph system can become blocked. This will lead to swelling
and inflammation, a condition known as lymphedema. Treatment will help
reduce symptoms but not fully eliminate them.
 Abscess :An abscess is a pocket of pus, or infected fluid, that develops
under the skin or between layers of skin. It may develop at or near the
injury, cut, or bite. Surgery will be necessary to open the abscess and
properly drain it.
  Gangrene :Gangrene is another name for tissue death. When blood supply
is cut off to tissue, it can die. This is more common on extremities, like the
lower legs. If gangrene is not properly treated, it can spread and become a
medical emergency. An amputation may be required. It can even be fatal.
 Necrotizing fasciitis: Also known as a flesh-eating disease, necrotizing
fasciitis is an infection in the deepest layer of skin. It can spread to your
fascia, or the connective tissue that surrounds your muscles and organs, and
cause tissue death. This infection can be fatal, and it is an extreme
emergency.
 MRSA :Cellulitis is often caused by Staphylococcus, a type of bacteria. A
more serious type of staph bacteria, known as MRSA, can also cause
cellulitis. MRSA is resistant to many of the antibiotics that can treat normal
staph infections.
 Orbital cellulitis :Orbital cellulitis is an infection behind the eyes. It
develops in the fat and muscle that surrounds the eye, and it can limit your
eye movement. It can also cause pain, bulging, and loss of vision. This type
of cellulitis is an emergency and requires immediate medical attention.
 Perianal streptococcal cellulitis: Perianal streptococcal cellulitis is a type
of infection that most commonly occurs in children with strep throat or a
cold. It shows up as a rash around the anus and rectum. Perianal strep is
spread when bacteria from the head and throat makes its way to a child’s
bottom.

2.7 PROGNOSIS
Cellulitis usually subsides within 7-10 days of antibiotic use. Longer treatment
may be needed if the cellulitis is more severe. This may occur if the patient has a
chronic disease or their immune system is not working properly. People with
fungal infections of the feet may have cellulitis that keeps recurring. The cracks in
the skin from the fungal infection allow bacterial entry into the skin.