- Deficient Knowledge related to unfamiliarity with condition and lack of understanding of treatment as evidenced by recurrent cellulitis and nonadherence with treatment or follow-up
- Impaired Physical Mobility related to inflammatory process and comorbidities (neuropathy, lymphedema, etc.) as evidenced by altered gait and expresses discomfort with movement
- Impaired Skin Integrity related to injury to the skin and inflammation as evidenced by abscess formation and reports of pain, burning, or itching
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective Data: Inaccurate demonstration or teach-back of instructions Inability to recall instructions Exhibiting aggression or irritability regarding teaching follow-up Poor adherence to recommended treatment or worsening medical condition Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to unfamiliarity with condition and lack of understanding of treatment as evidenced by recurrent cellulitis and nonadherence with treatment or follow-up | Patient will demonstrate proper skin care to prevent cellulitis. Patient will identify risk factors contributing to cellulitis. Patient will verbalize signs and symptoms of cellulitis. | 1. Prevent scratching or rubbing. Instruct the patient not to scratch or rub the skin as this causes damage. Have the patient keep their nails cut short to prevent opening the skin. This is especially important for a patient who has numbness to their extremities or who cannot visualize their skin as they may be unaware of the damage they are causing. If the patient cannot cognitively comprehend not scratching, apply gloves or mittens to protect the skin. 2. Educate on the prevention of infection. Handwashing is paramount before touching open areas of the skin. Have the patient demonstrate proper wound care to prevent the introduction of bacteria. 3. Educate on causes and risk factors. Patients with weakened immune systems from HIV/AIDS, diabetes, or cancers will be more susceptible to skin infections. These chronic conditions must be properly managed to prevent secondary infections. 4. Advise on skin care. The skin is the first barrier against the invasion of pathogens. Instruct on basic skin hygiene with bathing and keeping the skin dry from sweat or incontinence. Keep skin moisturized with a lotion or cream as dry, flaky skin is more likely to crack. Patients with diabetes must inspect their feet and lower legs daily for open areas. | Patient demonstrated proper skin care to prevent cellulitis. Patient identified the risk factors contributing to cellulitis. Patient verbalized the signs and symptoms of cellulitis. |
| Subjective Data: Expression of pain and discomfort with movement Refusal to move Objective Data: Limited range of motion Uncoordinated movements Poor balance Inability to turn in bed, transfer, or ambulate Postural instability Gait disturbances Reliance on assistive devices Contractures Decreased muscle strength Inability to follow or complete instructions | Impaired Physical Mobility related to inflammatory process and comorbidities (neuropathy, lymphedema, etc.) as evidenced by altered gait and expresses discomfort with movement | Patient will demonstrate increased mobility with minimal discomfort. Patient will participate in recommended exercise programs such as daily walking | 1. Administer antibiotics as indicated. Antibiotic therapy is necessary to treat cellulitis and will reduce swelling, alleviating pain and discomfort with movement. 2. Utilize assistive devices. In cases of severe cellulitis, wheelchairs or other assistive devices can be utilized to promote movement and transferring. 3. Alternate rest with movement. Depending on the area of cellulitis, the patient may or may not be able to walk independently. Exercise is not usually contraindicated, so the patient can be assisted to ambulate or exercise as tolerated, alternating with periods of rest with the extremity elevated. 4. Premedicate before activity. NSAIDs such as ibuprofen can be administered prior to movement or physical therapy to relieve discomfort and promote adherence. | Patient demonstrated increased mobility with minimal discomfort. Patient participated in recommended exercise programs such as daily walking |
| Subjective Data: Pain Itching Numbness to affected and surrounding skin Objective Data: Changes to skin color (erythema, bruising, blanching) Warmth to skin Swelling to tissues Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to injury to the skin and inflammation as evidenced by abscess formation and reports of pain, burning, or itching | Patient will not experience worsening cellulitis as evidenced by erythema localized to one area. Patient will display skin healing without the formation of blisters or abscesses. | 1. Keep the skin clean and dry. Proper skin care includes washing the skin with warm water and mild soap. The area may or may not be covered with a dressing to prevent further damage. Sometimes the skin will weep and should be wrapped to protect bedding and clothing. 2. Premedicate before wound care. Cellulitis can be painful. Certain wound care techniques such as packing, debridement, and incision and drainage are also painful. General discomfort from swelling and burning can be eased with a cool, damp cloth. 3. Prevent shearing or further irritation. If the patient is immobile or is unable to guard against further skin breakdown take care when turning and repositioning. Ensure the patient is not putting pressure on the area. 4. Elevate the extremity. Swelling can be alleviated by elevating the extremity. Cellulitis often occurs in the lower leg but can affect the arms, face, and other areas. Prop extremities on pillows. | Patient demonstrated increased mobility with minimal discomfort. Patient participated in recommended exercise programs such as daily walking |