Cellulitis is a bacterial infection of the deeper layers of the skin, usually on the legs, that causes redness, warmth, swelling, and pain. Bacteria often enter through a cut, bite, or crack in the skin. Your priorities are treating the infection, tracking whether the redness is spreading, managing pain, and watching for signs that it is getting worse, such as sepsis.
Each care plan below follows the nursing process (ADPIE).
Impaired Skin Integrity
- Bacterial infection of the skin and tissue below it
- Break in the skin from a wound, bite, or dry cracked skin
- Swelling and inflammation
- Red, warm, swollen area of skin
- Tenderness at the site
- Skin that may look tight or shiny
- Possible blistering or drainage
- Redness stops spreading within 24 to 48 hours of starting antibiotics
- Swelling and warmth decrease within 72 hours
- Skin heals fully without spreading infection or abscess
- Client completes the full antibiotic course
- Outline the red area with a skin marker and note the date and time
- Size, color, warmth, swelling, and drainage each shift
- Temperature, heart rate, and BP
- WBC and blood cultures as ordered
| INTERVENTION | RATIONALE |
|---|---|
| Mark the edges of the redness and compare each shift | This shows clearly whether the infection is spreading or improving. |
| Give antibiotics on time as ordered | On-time doses keep drug levels high enough to kill the bacteria. |
| Elevate the affected limb | Elevation reduces swelling and pain. |
| Report spreading redness, fever, fast heart rate, or low BP right away | These can signal a worsening infection or sepsis. |
| Teach good skin care and how to clean cuts promptly | Healthy skin keeps bacteria out and prevents future infections. |
EVALUATION
- Redness stays within the marked borders and is shrinking
- Swelling and warmth are decreasing
- Vital signs are stable
- Client states how to care for the skin at home
Acute Pain
- Inflammation and swelling of the tissue
- Client reports pain at the site
- Guarding the affected limb
- Grimacing when moving
- Client reports pain at or below their goal within 1 hour of treatment
- Client walks and does daily activities with minimal pain as healing continues
- Pain using the same scale each time
- Effect of pain on movement and sleep
- Response to pain medication
| INTERVENTION | RATIONALE |
|---|---|
| Give pain medication as ordered and recheck pain afterward | Reassessment shows whether the treatment worked. |
| Elevate the limb and support it with pillows | This decreases swelling, which eases pain. |
| Apply cool or warm compresses only as ordered | The right compress can ease discomfort and swelling. |
EVALUATION
- Client reports pain at or below goal
- Client moves the limb with less guarding
Practice this in Head-to-Toe
Assess skin, mark borders, and spot spreading infection before it turns into sepsis.
Play Head-to-ToeQuick answers
Why does the nurse draw a line around the red area in cellulitis?
The line shows the starting borders. If redness moves past the line, the infection is spreading and the provider needs to know.
What finding in a client with cellulitis is most urgent?
Signs of sepsis, such as fever, fast heart rate, low BP, or new confusion, or rapidly spreading redness with severe pain, which can mean a deeper infection.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.