Sunday, July 16, 2006

Targeting cellulitis

Targeting cellulitis

Nursing Dec 2002

Deborah E. Roy; Nancy A. Stotts

Find out how to help a patient who gets this nasty inflammatory condition.

FOUR DAYS AGO, Eric LeMay, 34, cut his right thigh while working on his car. Now he comes to the emergency department complaining of pain at the site. The wound is approximately 1 1/2 inches (3.8 cm) long with 2 1/2 inches (6.4 cm) of swelling and redness all around it. The physician who evaluates him diagnoses cellulitis and admits him to the hospital.

Cellulitis is a rapidly spreading acute inflammation with infection of the skin and subcutaneous tissue, usually caused by bacteria. It can progress to tissue death and systemic infection, so the patient needs immediate treatment and close monitoring. In this article, we'll explain how cellulitis develops, how it's treated, and what you can do to help Mr. LeMay.

Common culprits: Strep, staph, and Haemophilus

Although it can develop in and under the skin anywhere, cellulitis most often affects the extremities. The classic signs are erythema, edema, and pain.

Cellulitis can develop in apparently normal skin, but its usually associated with a break in skin integrity. The most common causes in adults are group A streptococci and Staphylococcus aureus;
H. influenzae Type B is more common in children.

The following conditions increase the risk:

* venous insufficiency or stasis
* thrombophlebitis
* diabetes
* lymphedema
* surgery
* malnutrition
* substance abuse
* presence of another infection
* compromised immune function due to human immunodeficiency virus (HIV), treatment with steroids or cancer chemotherapy, or autoimmune diseases, such as lupus erythematosus.

How the immune system responds

Tissue injury precipitates most cases of cellulitis. Initially, cells at the injury site release chemicals that call in white blood cells (WBCs), dilate the blood vessels, and increase capillary permeability. The WBCs engulf and digest bacteria and debris and, as they die, their digested debris is released and forms pus. Fibrin passes from the blood to the involved tissue to wall off the injury and limit the spread of infection.

The larger the bacterial load at the site, the larger the affected area and the greater the patients immune response to combat infection. In many cases, the immune response alone resolves cellulitis, but if the bacterial load is large enough or the strain is very virulent, it may not be adequate and he'll need antibiotic therapy In some cases, a painful abscess forms-a sac of pus walled off by fibroblasts and collagen and a rich medium for bacteria. Incision and drainage (IUD) of the abscess will relieve pain and aid healing.

Identifying and responding to the problem.

The diagnosis of cellulitis is based on the patients clinical signs and history.

He may need a WBC count drawn to screen for infection and blood cultures if bacteremia is suspected. When drainage, an open wound, or another obvious portal of entry is present, a culture and Gram's stain usually determine the causative organism and appropriate antibiotic therapy. Occasionally, X-ray, ultrasound, computed tomography, or magnetic resonance imaging is used to determine the extent of inflammation and to identify abscess formation.

To care for Mr. LeMay, administer drug therapy and supportive measures.

Administer antibiotics. Therapy will depend on the identified or suspected organism. Penicillins (nafcillin, oxacillin), cephalosporins (cephalexin), vancomycin, and aminoglycosides (gentamicin) are common choices. If cultures identify a specific pathogen, make sure the prescribed antibiotic is effective against it. Administer intravenous (LV) and oral doses as soon as possible and at the prescribed times to maintain steady blood levels.

Monitor his progress. Regularly assess Mr. LeMay for improvement or worsening cellulitis-every 4 hours at first, then twice a day as he improves. Outline the area of redness and swelling with a skin marker so you can see whether the inflammation is spreading or shrinking. After each assessment, document the size, shape, color, and temperature of the wound and surrounding tissue. Describe the type of drainage, if present, and whether the patient reports pain; also indicate the date and time. If the area of erythema increases or he develops fever, chills, drainage, or more pain, document your findings and notify the primary care provider.

Change dressings.

Mr. LeMay develops an abscess, and his primary care provider performs IUD, withdrawing about 10 ml of pus. He leaves the wound open to heal by secondary intention.

Change the dressing two or three times daily with a wet-to-- moist sterile dressing to keep the wound open and to wick away exudate. Fluff the dressing and fill the space loosely (packing in too much could cause ischemia and delay healing). Don't let the gauze in the wound dry out; besides being painful, removing dry gauze would disturb new granulation tissue, cause bleeding, and inhibit healing. If it dries before you can change it, slightly moisten it with sterile 0.9% sodium chloride solution to loosen it before removal.

After changing the dressing, document your observations of tissue in the wound base, the surrounding skin, and the old dressing. Also chart the type of new dressing and the time you applied it.

Provide pain relief. The pain of cellulitis may spring from inflammation or the I&D procedure. As ordered, administer oral analgesics such as acetaminophen with oxycodone for pain and a nonsteroidal anti-inflammatory drug to decrease inflammation. Provide IN analgesics or extra doses as ordered; for example, before an I&D procedure or dressing change and for breakthrough pain.

Assess Mr. LeMay's pain using a standard numeric pain-rating scale ranging from 0 (no pain) to 10 (worst pain imaginable). Using the same scale each time, document his pain rating whenever you take his vital signs, before you administer an analgesic, and an hour afterward. Adjust his medication or dosage to maintain his pain rating at a level he's targeted.

Apply local treatments. Elevate the site, if possible. Apply warm compresses to improve blood flow and delivery of oxygen and immune components to ease pain and swelling.

Maximize nutrition and hydration. Mr. LeMay needs good nutrition for tissue repair and to fight infection. Even a well-nourished patient needs plenty of calories and extra protein, carbohydrates, essential fats, and micronutrients (such as vitamins A, B, C, and D) to heal. If you suspect he's malnourished, arrange a nutritional consult.

Adequate hydration is also critical for cell function and to remove bacteria and their by-products from tissues. Carefully evaluate your patient's intake and output and assess him for dry mucous membranes, decreased urine output, and orthostatic hypotension. Unless he must restrict fluids because of a renal or cardiac problem, have him drink eight glasses of fluid a day.

Looking forward to full recovery

After 3 days, Mr. LeMay is ready to go home. You teach him about his medications and review the method for changing his wound dressings, which he'll do twice a day until he sees his primary care provider. With the appropriate medical treatments and your timely care, he's looking forward to a full recovery and should soon return to his normal activities.

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