Cellulitis is a bacterial skin infection. It appears as a reddened, swollen area and is usually easily diagnosable through inspection. Cellulitis can occur from a simple break in the skin, allowing bacteria to enter.
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Overview
Common causes include:
- Injury to the skin (cuts, burns, puncture wounds)
- Insect/animal bites
- Skin conditions (eczema, chickenpox, shingles)
- IV drug use
- Infected surgical incisions
- Poor hygiene practices when getting a tattoo or piercing
Patients are more at risk for cellulitis when they are overweight, have chronic swelling (lymphedema), or have other conditions affecting circulation, such as peripheral vascular disease.
Antibiotics are needed to treat cellulitis. Complications are uncommon, though they can be severe, resulting in osteomyelitis, sepsis, endocarditis, gangrene, and necrotizing fasciitis.
Nursing Process
Cellulitis is a common condition nurses will become familiar with in the inpatient setting. Patients often require education about this condition if they lack an understanding of potential causes, how their comorbidities influence skin infections, and why treatment and skin care is so important. Cellulitis can become life-threatening if complications develop, so the nurse must monitor vital signs, lab work, and symptoms.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a cellulitis.
Review of Health History
1. Ask the patient about the details regarding skin trauma.
Obtain a thorough medical history, particularly concerning the patient’s skin abnormalities and the inciting event. Ask about the following:
- Travel history
- Recent trauma or injuries
- Use of intravenous drugs
- Animal or insect bite
- Skin exposure to standing water
- A new tattoo or piercing
2. Determine risk factors.
Patients are more at risk for cellulitis if the following apply:
- Overweight status
- Chronic swelling (lymphedema)
- Immunosuppression
3. Review the patient’s medical history.
Review the patient’s medical history for comorbid conditions that may raise the risk for cellulitis, which include:
- Diabetes mellitus
- Chronic kidney disease
- Chronic liver disease
- HIV/AIDS
- Peripheral vascular disease
4. Assess the patient’s surgical history.
Cellulitis can be a post-surgical complication. Also, note that cellulitis can occur due to the presence of devices or foreign objects, such as:
- External orthopedic pins
- Indwelling IV catheters
- Other surgical instruments
Physical Assessment
1. Inspect the skin changes.
Carefully inspect the affected area for the four symptoms associated with cellulitis:
- Erythema
- Pain
- Swelling
- Warmth
2. Mark the area to monitor the spread of infection.
The nurse can use a pen to mark the edges of redness to monitor for the spread of infection past the marked border to determine improvement or worsening.
3. Assess the lower extremities.
Although cellulitis can occur anywhere on the body, it typically affects the lower limbs, rarely bilaterally.
4. Monitor for flu-like symptoms.
Flu symptoms such as fever, chills, and malaise may be present if the infection is severe.
Diagnostic Procedures
1. Diagnose through inspection.
As long as the patient meets the following criteria, further testing is not required for diagnosis:
- Infection limited to one area
- Mild pain
- No systemic signs of illness
- No risk factors for severe illness
2. Prepare for needle aspiration or biopsy.
Needle aspiration or biopsy can be performed, though results are not always valuable. Gram stain and culture after incision and drainage of an abscess yields positive results in most cases.
3. Perform bloodwork if systemic infection is present.
Patients with cellulitis who exhibit signs of systemic toxicity should receive additional bloodwork, including:
- Complete blood count (CBC) with differential
- Creatinine
- Bicarbonate
- Blood cultures
- Creatine phosphokinase
- C-reactive protein (CRP)
4. Consider imaging for complications.
Ultrasonography may be utilized to detect abscesses and guide aspiration. CT scans and MRIs can rule out necrotizing fasciitis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a cellulits.
1. Initiate antibiotic treatment immediately.
Oral antibiotics directed against streptococcal species should be administered to patients with mild cellulitis without systemic illness symptoms. Consider the risk of Methicillin-resistant Staphylococcus aureus (MRSA) with antibiotic therapy.
2. Consider IV antibiotics.
Patients who meet the following criteria may require IV antibiotics:
- Failed outpatient treatment
- Compromised immune system
- Facial cellulitis
- Cardiac, liver, or renal comorbidities
3. Manage pain and discomfort.
Cellulitis may be painful, and the nurse can offer interventions such as a warm compress and elevation to reduce swelling. NSAIDs can be administered to reduce pain and inflammation.
4. Prevent further infection.
Emphasize infection control precautions. Cellulitis is not contagious, but hand hygiene is paramount. Highlight the importance of handwashing before and after touching the affected area. Refrain from squeezing or picking the area.
5. Provide wound care.
Dress the wound per the healthcare provider’s orders. This usually includes cleansing the area daily and applying a dry dressing.
6. Emphasize skin care.
Hygiene is crucial to preventing recurrent cellulitis. Instruct on keeping the skin clean and dry, applying moisturizer to dry skin to prevent cracking, protecting the feet and lower legs, and promptly treating and covering any open areas.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for cellulitis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for cellulitis.
Deficient Knowledge
Cellulitis is preventable and can be easily managed if identified early with prompt treatment.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with condition
- Lack of access to care
- Lack of understanding of treatment
As evidenced by:
- Worsening of condition
- Recurrent cellulitis
- Inability to perform skin care
- Nonadherence with treatment or follow-up
- Poor management of other risk factors
Expected Outcomes:
- 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.
Assessment:
1. Assess how the cellulitis started.
Patients are often unaware of how easily cellulitis can occur. An animal bite, insect sting, or small cut can become cellulitis. The patient may attempt to self-treat at home not realizing the need for antibiotics.
2. Assess health history.
Patients with diabetes and neuropathy may not feel when their skin has been cut. The swelling and redness may not be evident until it has become severe. Patients who cannot care for themselves (paraplegia, dementia, brain injury) may not be aware of skin breakdown or cannot assess their skin themselves.
3. Assess access to care and support.
Assess if the patient isn’t able to seek treatment due to a lack of accessible providers, transportation issues, or financial barriers. If cellulitis is a recurrent issue identify a caregiver or family member that can accept the teaching and manage the care and follow-up of the patient.
Interventions:
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.
Impaired Physical Mobility
Cellulitis can cause swelling and pain, inhibiting physical mobility and increasing the risk of falls and injuries.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Inflammatory process
- Edema
- Pain
- Obesity
- Comorbidities (neuropathy, lymphedema, etc.)
- Sedentary lifestyle
As evidenced by:
- Altered gait
- Reluctance to exercise
- Expresses discomfort with movement
- Decreased range of motion
Expected outcomes:
- Patient will demonstrate increased mobility with minimal discomfort.
- Patient will participate in recommended exercise programs such as daily walking.
Assessment:
1. Assess the patient’s baseline functional mobility.
Understanding the patient’s functional level of mobility prior to cellulitis can help plan appropriate interventions and treatment to improve symptoms.
2. Assess and monitor the extent of inflammation and swelling.
Cellulitis is often painful or tender due to swelling and warmth to the area. Underlying complications such as abscesses can further exacerbate discomfort and limit the patient’s ability and willingness to initiate movement.
Interventions:
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.
Impaired Skin Integrity
Cellulitis causes redness and swelling to the skin that can worsen into blisters and abscesses if untreated.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Injury to the skin
- Inflammation
- Edema
- Poor circulation
As evidenced by:
- Erythema
- Warmth
- Swelling
- Tight, shiny skin
- Abscess formation
- Reports of pain, burning, or itching
Expected outcomes:
- 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.
Assessment:
1. Assess the skin.
Cellulitis presents as redness and swelling initially. Assess for any open areas, drainage, and the condition of surrounding skin.
2. Mark the area of erythema.
Using a skin marker, outline the area of redness. This is the best way to assess if redness is continuing to spread.
3. Monitor wounds.
If an open area has already occurred, measure the size, color of the wound, any drainage, and if an odor is present. Document accurately to allow for ongoing assessment.
Interventions:
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.
Ineffective Tissue Perfusion
Conditions such as peripheral vascular disease, diabetes, and neuropathy complicate cellulitis by causing poor circulation and healing.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Inflammatory process
- Circulatory compromise
- Peripheral neuropathy
- Vascular disorders
- Diabetes mellitus
- Insufficient knowledge of conditions
- Sedentary lifestyle
As evidenced by:
- Absent or diminished pulses
- Altered motor function
- Altered skin characteristics
- Paresthesias
- Pallor
- Edema
- Extremity pain
- Delayed peripheral wound healing
Expected outcomes:
- Patient will demonstrate adequate tissue perfusion as evidenced by strong peripheral pulses, skin color within the patient’s ethnicity, and uncompromised mobility and function.
- Patient will verbalize strategies to improve peripheral blood flow.
Assessment:
1. Monitor skin characteristics.
Cellulitis typically causes erythema. If the skin appears pale, purple, or blackened, these are signs of impaired perfusion that require immediate intervention.
2. Assess for underlying conditions.
Chronic conditions such as diabetes, peripheral vascular disease (PVD), and lymphedema can complicate cellulitis and increase the risk of ineffective perfusion.
3. Assess and monitor the capillary refill time of the affected extremity.
Nail beds normally return to a pinkish color within 1-2 seconds after compression. If tissue perfusion is compromised, capillary refill time will be prolonged.
Interventions:
1. Elevate the affected body part.
Elevating the affected body part can help decrease swelling and promote tissue perfusion.
2. Encourage the patient to apply warm compresses as prescribed.
Warm compresses can help soothe cellulitis and promote circulation and tissue perfusion in the affected area.
3. Utilize compression stockings.
Encourage patients to wear compression stockings, especially if they experience chronic edema, as controlling swelling has been shown to reduce the recurrence of cellulitis.
4. Instruct on measures to improve circulation.
Patients with comorbidities such as diabetes, PVD, and neuropathy should follow these recommendations to improve peripheral perfusion and reduce the incidence of cellulitis:
- Avoid freezing temperatures that cause vasoconstriction
- Adhere to daily foot care and inspections
- Participate in walking or other exercise to promote circulation
- Stop smoking to improve blood flow
Risk For Infection
Untreated cellulitis can advance to systemic infections and can be life-threatening.
Nursing Diagnosis: Risk For Infection
Related to:
- Decreased immune function
- Improper antibiotic usage
- Broken skin barrier
- Improper hygiene practices
- Chronic diseases
- Malnutrition
- Delayed treatment
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will not experience signs of systemic infection (fever, tachycardia, confusion).
- Patient will take antibiotics as prescribed until completion.
Assessment:
1. Assess for worsening infection.
Life-threatening infections can result from cellulitis such as osteomyelitis, sepsis, and gangrene. The nurse should monitor closely for systemic signs of infection.
2. Monitor lab work.
It will be expected for the WBC and CRP to be elevated. Monitor for these values trending up as infection worsens. Blood cultures or needle aspiration may be ordered to pinpoint a specific pathogen.
3. Assess for contributing conditions.
Chronic conditions such as diabetes or a suppressed immune system can complicate an infectious process as well as predispose the patient to worsening infection.
Interventions:
1. Instruct on oral antibiotic use.
Oral antibiotics are the usual course for uncomplicated cellulitis. Instruct the patient to take all of their medication, even if the cellulitis has significantly improved or resolved. If the condition does not improve after a few days, have the patient contact their provider for a change in treatment.
2. Administer IV antibiotics.
Some patients will require hospitalization and IV antibiotics. The usual pathogen is either streptococci or staphylococcus and the antibiotic prescribed should address this.
3. Prepare for I&D.
Once abscess formation occurs, it must be drained as antibiotic therapy alone will not treat it. The nurse can assist the provider with bedside incision & drainage by preparing a sterile field with all medication and equipment. The nurse should premedicate the patient as this can be a painful procedure.
4. Teach the patient about signs of infection.
If the patient is treating cellulitis at home or has recently undergone surgical intervention, the nurse should educate on worsening signs of infection. Encourage the patient to monitor the skin for worsening redness or swelling along with any discoloration or drainage. If they experience fever or changes in breathing or LOC, they should seek immediate treatment.
References
- Brown, B. D., & Hood Watson, K. L. (2023, August 7). Cellulitis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved January 2024, from https://www.ncbi.nlm.nih.gov/books/NBK549770/
- Cellulitis. (2020, May 29). CDC. Retrieved April 27, 2022, from https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html
- Cellulitis – Symptoms and causes. (2020, February 6). Mayo Clinic. Retrieved April 27, 2022, from https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-causes/syc-20370762
- Cellulitis. (2022, May 6). Mayo Clinic. Retrieved January 2024, from https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-causes/syc-20370762
- Cellulitis: Symptoms, causes, treatment & recovery. (2022, April 18). Cleveland Clinic. Retrieved January 2024, from https://my.clevelandclinic.org/health/diseases/15071-cellulitis
- Herchline, T. E., & Stuart, M. (2019, June 14). Cellulitis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved April 27, 2022, from https://emedicine.medscape.com/article/214222-overview
- Herchline, T. E. (2022, April 26). Cellulitis workup: Approach considerations, moderate to severe cases and systemic symptoms, ultrasonography, CT scanning, and MRI. Diseases & Conditions – Medscape Reference. Retrieved January 2024, from https://emedicine.medscape.com/article/214222-workup#c9
- Pastorino A, Tavarez MM. Incision and Drainage. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556072/