Nursing Care Plan for Cellulitis

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.