StudentL 1 Lower Limb Cellulitis University of Washington School of Nursing Nurse- Midwifery Education Program NCLIN 512 Fall 2012 Midwifery Management Process for Common Health Problems 1. Common Health Problem/Condition: Cellulitis is a skin infection that involves erythema, induration and pain that spreads from the dermis to the subcutaneous tissue and may spread to soft tissue (Deignan, 2008). It usually begins with a break in the skin such as a laceration, ulceration, wound or trauma. Cellulitis can be caused by a variety of organisms. Staphylococcus aureus and group A beta- hemolytic streptococci are the most common causes of cellulitis in adults. Staphylococcus aureus is the more common cause of purulent cellulitis (Gunderson, 2011). Beta- hemolytic streptococci more commonly cause erysipelas, a superficial cellulitis with clear raised borders. Cellulitis may occur anywhere in the body but is more common in lower extremities (Baddour, 2012). Cellulitis is one of the most common infections that seen in primary care and inpatient care (Gunderson, 2011). 2. Collection of essential history: The following risk factors should be assessed when diagnosing cellulitis: Risk factors Pregnant White race Venous insufficiency Lymphoedema Peripheral arterial disease Immunosuppression Diabetes Trauma Animal and insect bites Tattoos Ulcers Eczema Athlete s foot (tinea pedis) Burns (Phoenix, Das & Joshi, 2012, p.39) Ask the patient about any events that took place before the cellulitis that could have contributed to one of these risk factors, any skin disorders, breaks in integrity or changes noted. Consider any history of cellulitis, onset, duration, location, alleviating factors, aggravating factors and severity of symptoms. As the infection may cause systemic symptoms such as fever, chills and malaise, ask about these as well (Deignan, 2008). 3. Findings of directed physical assessment: Erythema, induration and pain are the classic signs of cellulitis (Deignan, 2008). Blood cultures, CBC and ESR are not routinely used in young healthy adults (Deignan, 2008; Gunderson, 2011). Needle aspiration and blood culture may be helpful in patients with other underlying diseases where specific antibiotic choice is necessary but it should be noted that cultures have a low yield. CBC may show leukocytosis and ESR may be elevated. Various tests may be considered based on the patient, situation and what differentials need to be ruled out (Gunderson, 2011). Gas shown on plain films is suggestive of necrotizing
StudentL 2 soft tissue infection and CT and MRI may also be used to diagnose necrotizing soft tissue infection if needed. Ultrasound will help diagnose an abscess. 4. Differential diagnoses: Common differential diagnoses for cellulitis with defining characteristics 10 Differential Stasis dermatitis Acute arthritis Pyoderma gangrenosum Hypersensitivity/drug reaction Deep vein thrombosis Necrotising fasciitis Defining characteristics Absence of pain or fever; circumferential; bilateral Involvement of joint; pain on movement Ulcerations on the legs; history of inflammatory bowel disease Exposure to allergen or drug; pruritus; absence of fever; absence of fever or pain Absence of skin changes or fever Severe pain, swelling and fever; rapid progression; pain out of proportion; systemic toxicity; skin crepitus; necrosis; ecchymosis (Phoenix, Das & Joshi, 2012, p.39) Further tests to rule out these diagnoses were discussed in the section above. 5. Diagnosis/Assessment:: Celullitis 6. Treatment/ Management plan: As staphylococcus and streptococcus are the most causative agents of cellulitis, antibiotics effective against these agents should be used (Deignan, 2008). Oral agents should be effective for young healthy individuals. IV antibiotics may be necessary for more extensive cases or cases with more systemic involvement. Due to increasing prevalence resistance strains of Stapholococcus Aureus to beta- lactam antibiotics, there is conflicting opinion regarding treatment of cellulitis (Gunderson, 2011). A RTC study comparing oral beta- lactam and non- beta lactam agents in uncomplicated cellulitis found no difference in treatment efficacy (Madaras- Kelly, Remington, Oliphant, Sloan, Bearden, & 2008). It was noted that non- beta lactam antibiotics were discontinued more often. Suggested approach from The American Journal of Medicine (Gunderson, 2011, p. 1120) Type of Cellulitis Organism Treatment Outpatient non- purulent Treat for streptococci and methicillin- susceptible Cephalexin, dicloxacillin, Outpatient purulent Staphylococcus aureus (MSSA) Treat for community- associated methicillin- resistant Staphylococcus aureus (CA- MRSA) Clindamycin, TMP- SMZ, doxycycline, linezolid Inpatient Treat for MRSA Vancomycin, linezolid, daptomycin, telavancin,
StudentL 3 Treatment recommendation based on specific exposures and risk factors (Phoenix, Das & Joshi, 2012, p.38) Clinical Organism Antibiotic presentation Cat or dog bite Pasteurella multocida Co- amoxiclav; if allergic to penicillin: doxycycline and metronidazole Freshwater Aeromonas Ciprofloxacin exposure hydrophila Saltwater exposure Vibrio vulnificus Doxycycline Necrotising fasciitis Clostridium perfringens Benzylpenicillin, ciprofloxacin, and Butchers and fish handlers Erysipelothrix Penicillin, Ciprofloxacin Duration of therapy has been debated but most authorities recommend 5-10 days of treatment (Gunderson, 2011). The average length of stay for hospitalized patients with cellulitis in the US is 4.5 days. Nonpharmacologic therapies include rest, moist heat and elevating the affected area (Deignan, 2008). Incision and drainage is needed if an abscess forms. If other underlying pathologies are related to the cellulitis, treating those pathologies may help prevent further cellulitis (Baddour, 2012). Compression stockings and diuretic therapy may be indicated when edema is present. 7. Consultation, collaboration or referral: In cases of severe cellulitis where IV therapy or incision and drainage is needed, a referral is appropriate (Deignan, 2008). Cases or periorbital and orbital cellulitis should be referred emergently especially if they restrict eye movement or vision. Also, suspected necrotizing fasciitis or necrotizing cellulitis should be urgently referred as well. Patients with chronic diseases such as diabetes should be referred as they are at risk for more severe complications. 8. Patient education: Discuss the importance of cleaning any skin wounds and avoiding infections (Deignan, 2008). Irrigation and wound dressings should be taught and discussed when appropriate. Discuss the importance of completing the antibiotic therapy. 9. Evaluation & follow- up: For outpatient management it is important to assure that the chosen antibiotic therapy is responding to treatment (Deignan, 2008). As treatment is recommended for 5-10 days, follow- up within this time period would be important. If the cellulitis is not responding to treatment, changing therapy, referral and inpatient management may be appropriate.
StudentL 4 10. Documentation in chart: 11/20/2012 24 yr old white female presenting with left leg swelling and pain Subjective HPI: Patient states that she recently cut herself on her left calf on a branch a week ago. She tried to clean it up but she is afraid that is got infected. She noticed the area getting bigger yesterday and now it is painful. I couldn t wear my skinny jeans because they were too tight and it hurt. She also feels a little chilled, tired and is worried she may be getting the flu. ROS: No pain in joints or puritis. Medical Hx: Exercise induces asthma, no surgeries Ob/Gyn: G1P0010 1 TAB. IUD in placed in Jan 2012. No hx STDs, las pap Jan 2012, no abnormal paps Family hx: Mother with type 2 diabetes Allergies: NKDA Medications: Albuterol inhaler PRN with exercise Social hx:: Lives with friends and works at coffee stand. No tobacco, periodic marijuana. Drinks 2-4 alcoholic beverages every weekend night. Runs 2x a week for 30 min. Objective Vs: BP 122/73, Hr 75, Temp 100.6F, Wt 164lbs, 5 6 Gen: A+Ox4 Skin: Erythematous and swelling on distal area of the left calf from the ankle to mid calf and does not go all the way around the calf. Tender to touch. 3 + pitting edema. Clearly defined area. Wound edges approximated, no purulent drainage. Lungs: CTA bilat no adventitious sounds. Cardio: RRR, no murmurs. Neg homans signs. Assessment Cellulitis Plan Begin Cephalexin 500mg PO QID. May take Tylenol for fever. Marked area with pen to be able to assess changes. Encouraged elevating area and keeping area clean and rest. Try to take breaks at coffee stand and elevate leg. Make sure to have any open areas covered while working. May be helpful to take a day or two off of work. If infection does not go down in the next 3-5 days or symptoms worsen come back.
StudentL 5 References Baddour, L.M. (2012). Cellulitis and erysipelas. In Ed D. J. Sexton, S. L. Kaplan, & E. L. Baron (Eds.) UpToDate. Available from http://www.uptodateonline.com. Deignan, E. M. (2008). Cellulitis. In T.M. Buttaro, J. Trybulski, P.P. Bailey, & J. Sandber- Cook (eds.). Primary Care: A Collaborative Practice (pp. 957-960). St. Louis: Mosby. Hirschmann, J. V. & Raugi, G. J. (2012). Lower limb cellulitis and its mimics Part I. Lower limb cellulitis. Journal of American Academy of Dermatology, doi:10.1016/j.jaad.2012.03.024 Madaras- Kelly, K.J., Remington, R. E., Oliphant, C. M., Sloan, K. L., & Bearden, D. T. (2008). Efficacy of oral beta- lactam versus non- beta- lactam treatment of uncomplicated cellulitis. The American Journal of Medicine, 121(5), p. 419-425. doi:10.1016/j.amjmed.2008.01.028 Phoenix, G., Das, S., & Joshi, M. (2012). Diagnosis and management of cellulitis. British Medical Journal, 345, e4955. doi: 10.1136/bmj.e4955