Cellulitis is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. The skin on the lower legs is most commonly affected, though cellulitis can occur anywhere on the body or face. Cellulitis may affect only the skin’s surface or cellulitis may also affect tissues underlying the skin and can spread to the lymph nodes and bloodstream. Left untreated, the spreading infection may rapidly turn life-threatening.
That’s why it’s important to seek immediate medical attention if cellulitis symptoms occur (Jenkins & Harper, 2011). There are numerous anti-infective medications available, and sometimes a combination of drugs must be given to rid the infection. Regardless, most infections can be controlled and removed. The anti-infective medication highlighted in this paper will be cefazolin better known as Ancef. Cefazolin is a member of the cephalosporins. According to Lilley, Rainforth-Collins, Harrington & Snyder, 2011, “Cephalosporins are semisynthetic antibiotics widely used in clinical practice.
They are structurally and pharmacologically related to the penicillins. Like penicillins, cephalosporins are bactericidal and work by interfering with bacterial cell wall synthesis. They also bind to the same penicillin-binding proteins inside bacteria” (p. 594). Medication Trade Name: Ancef Generic Name: cefazolin Indications and Usage: Upper, lower respiratory tract, urinary tract, skin infections; bone, joint, biliary, genital infections; endocarditis, surgical prophylazis, septicemia (Skidmore, 2011). Adverse Effects:
CNS- headache, dizziness, weakness, paresthesia, fever, chills, seizures (high doses) GI- nausea, vomiting, diarrhea, anorexia, pail, glossitis, bleeding; increased AST, ALT, bilirubin, LDH, alkaline phosphatase; abdominal pain, pseudomembranous colitis GU-proteinuria, vaginitis, pruritis, candidiasis, increased BUN, nephrotoxicity, renal failure HEMA- leukopenia, thrombocytopenia, anemia, neutopenia, lymphocytosis, eosinophilia, pancytopneia, hemolytic anemia INTEG- rash, uticaria, dermatitis RESP- dyspnea SYST- anaphylaxis, serum sickness, superinfection, Stevens-Johnson syndrome (Skidmore, 2011).
Recommended Dosage & Routes: Life-threatening infections- Adult: IM/IV 1-2 g q6hr, max 12 g/day Child > 1 month: IM/IV 100 mg/kg in 3-4 divided doses, max 6 g/day. Mild/moderate infections- Adult: IM/IV 250 mg- 1 g q8hr. Child > 1 month: IM/IV 25-50 mg/kg in 3-4 equal doses. Renal Dose- Adult: IM/IV following loading dose CCr 35-54 mL/min dose q8hr; CCr 10-34 mL/min 50% of dose q18-24hr. Child: IM/IV CCr > 70 mL/min, no dosage adjustment; CCr 40-70 mL/min following loading dose, reduce dose to 7. 5-30 mg/kg q12hr; CCr 20-39mL/min, give 3. 25-12. 5 mg/kg after loading dose q12hr; CCr 5-19 mL/min, 2. 5-10 mg/kg after loading dose q24hr (Skidmore, 2011). Available Forms: Injections 250, 500 mg, 1, 5, 10, 20 g; infusion 500 mg, 1 g/50 ml vial (Skidmore, 2011). Administration Directions: IM route: Reconstitute 250-500 mg of product with 2 mL sterile or bacteriostatic water for injection, or 0. 9% NaCl; reconstitute 1 g of product with 2. 5 mL; give deep in large muscle mass, massage. IV route: Check for irritation extravasation, phlebitis daily, and change site q72hr.
For direct IV dilute in 10 mL of sterile water for injection; give over 5 minutes. For intermittent infusion, dilute reconstituted solution (500 mg or 1 mg) in 50-100 mL D5W, D10W, D5/0. 25% NaCl, D5/0. 45% NaCl, D5/0. 9% NaCl, may be refrigerated up to 96 hours or stored 24 hours at room temperature (Skidmore, 2011). Nursing Implications: As indicated by Skidmore (2011), “Assess patient for previous sensitivity reaction to penicillins or other cephalosporins; cross-sensitivity between penicillins and cephalosporins is common.
Assess patient for signs and symptoms of infection including characteristics of wounds, sputum, urine, stool, WBC > 10,000/mm? , earache, fever; obtain baseline information and during treatment. Obtain culture and sensitivity (C&S) before beginnings product therapy to identify if correct treatment has been initiated. Assess for anaphylaxis: rash, urticaria, pruritis, chills, fever, joint pain, angioedema may occur a few days after therapy begins; epinephrine and resuscitation equipment should be available for anaphylactic reaction.
Identify urine output; if decreasing, notify prescriber (may indicate nephrotoxicity); also check for increased BUN, creatinine. Monitor electrolytes: potassium, sodium, chloride monthly if patient is on long-term therapy. Assess bowel pattern daily; if severe diarrhea occurs, product should be discontinued; may indicate pseudomembranous colitis. Monitor for bleeding: ecchymosis, bleeding gums, hematuria, stool guaiac daily if on long-term therapy. Assess for superinfection: perineal itching, fever, malaise, redness, pain, swelling, drainage, rash, diarrhea, change in cough, sputum.
Syringe compatibilities: Heparin, vit B complex. Syringe incompatibilities- Ascorbic acid injection, cimetidine, lidocaine, vitamins B/C. Y-site compatibilities- Acyclovir, allopurinol, amifostine, atracurium, aztreonam, calcium gluconate, cyclophophamide, diltiazem, enalaprilat, esmolol, famotidine, filgrastim, fluconazole, fludarabine, foscarnet, heparin, labetalol, lidocaine, magnesium sulfate, melphalan, meperidine, midazolam, morphine, multivitamins, ondansetron, pancuronium, perphenazine, regular insulin, sargramostim, tacrolimus, teniposide, theophylline, thiotepa, vecuronium, vitamins B/C.
Y-site incompatibilities- Amiodarone, hetastarch, hydromorphone, idarubicin, vinorelbine tartrate. Additive compatibilities- Aztreonam, clindamycin, famotidine, fluconazole, metronidazole, verapamil. Additive incompatibilities- Amikacin, amobarbital, bleomycin, calcium gluceptate, calcium gluconate, colistimethate, erythromycin, kanamycin, oxytetracycline, pentobarbital, polymyxin B, tetracycline” (p. 194). Patient White/non-Hispanic, female, 52 y/o, ht 5’3”, wt 236. Medical dx- Cellulitis d/t insect bite. Patient presents on floor 3 West. Patient was admitted here from the ER.
The patient is alert and oriented times four. She lives alone at home and has a home health nurse that visits her 2 times a week. The patient state that she noticed that her right and left legs have started to become extremely res, warm to the touch, and tender when she touches them. She also states that they have started to swell. She reports having pain while walking. Patients history includes: diabetes, congestive heart failure, peripheral vascular disease, CABG (coronary artery bypass graft surgery) 5 years ago, mitral valve replacement 2 years ago, and hypertension.
Doctor has ordered: Blood cultures (pending at this time), IV antibiotics cefazolin 500 mg q8hr, and Ultrasound of lower extremities to rule out deep vein thrombosis (this test came back negative). Vitals- HR 75, BP 140/92, Temperature 101. 4, oxygen saturation 96% on room air, pain 4 on 1-10 scale in legs, and RR 15. WBCs 15. 3, blood sugar 257. Nursing Diagnosis Assessment: Objective: On assessment the tight and left lower areas of her legs are swollen with 2+ pitting edema and on palpation the areas feel very warm.
The patient winces in pain as the areas are palpated. Patient’s feet are cool to the touch, however, unable to palpate a pulse. Using a Doppler to find the dorsalis pedis and post tibial pulse, both found, both faint in right and left feet. Subjective: Patient states she noticed that her right and left legs have started to become extremely red, warm to the touch, and tender when she touched them. She also states that they have started to swell. She also reports pain when walking. Diagnosis:
Ineffective peripheral tissue perfusion r/t inflammatory response secondary to cellulitis a/e/b faint doppler pulses in the lower extremities and the patient’s complaint of pain when walking. Plan: Patient with have dopplerable pulses in lower extremities during hospitalization. Patients right and left legs will show signs of healing within 48 hours (decrease appearance of redness, swelling, and pain in the affected areas). Patient will demonstrate how to check her feet and legs for infection and verbalize the importance of doing this often due to her diabetes before discharge.
Patient will verbalize understanding of patient education on antibiotic therapy and the need to complete the entire prescribed dose before discharge. Interventions: The nurses will assess the patient’s dorsalis pedis and post tibial pulses q4hr for 24 hours. The nurses will elevate the patient’s lower extremities on pillows above the heart level to decrease swelling. The nurse will administer IV antibiotic cefazolin 500 mg q8hr according to prescriber order. The nurse will also give proper patient education regarding home antibiotic use.
The nurse will assess the patients’ lower extremities for signs of healing every shift. The nurse will include teaching the patient proper hygiene and precautions with skin wounds as well as ways to prevent recurring cellulitis. The nurse will demonstrate and have the patient demonstrate how to check her feet and legs for infection daily before discharge. Evaluation: Goals met. Patient’s dosalis pedis and post tibial pulses are strong and palpable. Patient is able to verbalize and demonstrate how to check for infection in her lower extremities.
Patient is able to verbalize understanding of proper hygiene and at home antibiotic use. After 2 days of IV antibiotic signs of infection have decreased and patient clearly states “I am feeling better and my legs don’t hurt as bad. I can walk without crying now”. Patient verbalizes need to keep legs elevated with they are swollen. Conclusion The patient has demonstrated a clear understanding of cellulitis. The patient has also demonstrated a clear understanding of ways to prevent cellulitis from occurring. Patient also understands the use of at home antibiotics.
Patient was sent home with a prescription for Cefazolin 500 mg three times a day for 10 days, patient understands the importance of taking medication three times a day as well as completing the entire 10 day regimen. The patient asked numerous questions regarding the disease and all things demonstrated to her, showing interest in working with the health care team to maintain a healthy lifestyle. The patient will be released today, upon which the patient will have brochures and copies of all teaching materials used to educate the patient.
The patient has also been given contact information for the educational staff at this facility. References Jenkins, G. , Kemnitz, C. , & Tortoa, G. (2010). Anatomy and Physiology from Science to Life second edition. Hoboken, NJ: John Wiley & Sons, Inc. Lilley, L. , Rainforth-Collins, S. , Harrington, S. , & Snyder, J. (2011). Pharmacology and the nursing process. (6th ed. ). St. Louis, MO: Mosby Elsevier. Potter, P. A. , & Perry, A. G. (2009). Fundamentals of Nursing seventh edition. St. Louis, MO: Mosby Elsevier. Skidmore, L. (2011). Mosby’s drug guide for nurses. (9th ed. ). St. Louis, MO: Mosby Elsevier. .