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Nursing Care Plan and Diagnosis for Cellulitis Ineffective Tissue Perfusion | Nanda Nursing Interventions and Outcomes Goals

This nursing care plan includes a diagnosis and care plan for nurses with nursing interventions and outcomes for the following conditions: Cellulitis

What are nursing care plans? How do you develop a nursing care plan?

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Nursing Care Plan

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.

Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.

Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

Nursing Care Plan for: Cellulitis

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

Scenario:

A 70 year old male presents to you floor. He was admitted to you from the ER. The patient is alert and oriented times four. He lives alone at home and has a home health nurse that visits him 2 times a week. The patient states he noticed that his right and left legs have started to become extremely red, warm to the touch, and tender when he touches them. He also states that they have started to swell. He reports having pain while walking. On assessment you note that the right and left lower areas of his legs are swollen with 2+ pitting edema and that on palpation the areas feel very warm. The patient winces in pain as your palpate the area. You note as well that the patients feet are cool to the touch and you are unable to palpate a pulse. You use a Doppler to find the dorsalis pedis and post tibial pulses which you document as faint in both the right and left feet. The patient history includes: diabetes, congestive heart failure, peripheral vascular disease, CABG 5 years ago, mitral valve replacement 2 years ago, and hypertension. An ultrasound was performed on the lower extremities to rule out a deep vein thrombosis in the right and left legs. This test came back as negative. Pt VS include: HR 75, BP 140/92, Temperature 99.4, oxygen saturation 96% on room air, pain 4 on 1-10 scale in legs, and RR 15. WBCs 15.3, Blood sugar 257. Blood cultures are pending at this time. The patient is started on IV antibiotics. The patient’s medical diagnosis is Cellulitis.

Nursing Diagnosis:

Ineffective peripheral tissue perfusion related inflammatory response secondary to cellulitis as evidence by faint doppler pulses in the lower extremities and patient’s complaint of pain when walking.

Subjective Data:

The patient states he noticed that his right and left legs have started to become extremely red, warm to the touch, and tender when he touches them. He also states that they have started to swell. He reports having pain while walking.

Objective Data:

A 70 year old male presents to you floor. He was admitted to you from the ER. The patient is alert and oriented times four. He lives alone at home and has a home health nurse that visits him 2 times a week. On assessment you note that the right and left lower areas of his legs are swollen with 2+ pitting edema and that on palpation the areas feel very warm. The patient winces in pain as your palpate the area. You note as well that the patients feet are cool to the touch and you are unable to palpate a pulse. You use a Doppler to find the dorsalis pedis and post tibial pulses which you document as faint in both the right and left feet. The patient history includes: diabetes, congestive heart failure, peripheral vascular disease, CABG 5 years ago, mitral valve replacement 2 years ago, and hypertension. An ultrasound was performed on the lower extremities to rule out a deep vein thrombosis in the right and left legs. This test came back as negative. Pt VS include: HR 75, BP 140/92, Temperature 99.4, oxygen saturation 96% on room air, pain 4 on 1-10 scale in legs, and RR 15. WBCs 15.3, Blood sugar 257. Blood cultures are pending at this time. The patient is started on IV antibiotics. The patient’s medical diagnosis is Cellulitis.

Nursing Outcomes:

-Pt will have dopplerable pulses in lower extremities during hospitalization.-Pt right and left leg will show signs of healing within 48 hours (decrease appearance of redness, swelling, and pain in the affected areas).–Pt will demonstarte how to check his feet and legs for infection and verbalize the importance of doing this often due to his diabetes by discharge.   

Nursing Interventions:

-The nurses will assess the patients doralis pedis and post tibial pulses with the doppler every 4 hours for 24 hours.-The nurse will elevate the patient’s lower extremities on pillows above the heart level to decrease swelling.-The nurse will administered IV antibiotics according to md order.-The nurse will assess the patients lower extremities for signs of healing every shift.

-The nurse will demonstrated and have the patient demonstrate how to check his feet and legs for infection daily by discharge.

 

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