- 1 -

Cellulitis

- 2 -

20

2556

1
2

- 3 -

(Problem List)
3

- (Personal Social)
5

- (Review of System)
8

- (Physical examination)
9

- (Laboratory)
12

(Temporary problem list)

15

(Sequence of events)
17

(Permanent problem list)

19

Initial Plan

19

Assessment

19

(Plan for diagnosis)

28

- 4 -

(Plan for treatment)

30

(Plan for Nursing

care)

36

(Plan for Health

Education)

48

(Progress Note)
56

(Discharge Planning)
60

(Discharge summary)
63

64

66

65

- 5 -

12

14

.6.

54

HN 37999

164/3 3

17

..

2556

(Chief Complaint)

(Present illness)
5

- 6 -

2
1
1

2 cm

(Past history)
:

:
:
:

- 7 -

:
Paracetamol

:
:

:

(Personal social)

: 6 8

: 3

- 8 -

:
: 1
5-6

: 1

(4-5 )
/: 19
42
1 - 2

60 ml

18 4 10

- 9 -

19 42

1 - 2

60 ml

18

10 23

(History of illness in
neighborhood)

- 10 -

( Family history )

7 5 2

4 1 2 3

70
71

3
1 30

- 11 -

- 12 -

(Review of system)

General:

HEENT

Hair:
Head: ,

Eyes:

Ears:

Nose:

- 13 -

Throat & Neck:

Dermatologic:

Cardiovascular system
Heart and Neck vessel:

Peripheral vascular:

Respiratory

system:

Hemato-lymphatic system :

Gastro intestinal :

- 14 -

Genito-urinary tract :
Urinary:

Genitalia: (
)

Musculoskeletal system:

Neurological system:

Endocrine:

Lymph nodes:

- 15 -

Psycho - social system :

Vital signs

- 16 -

17

2556

Vital signs

T = 37.2 C P =104 / min

mmHg

Body weight

HT = 170 cms.

R = 20 / min

= 70 kgs.

BMI = 25.712 kg / m

BP 110/70

General Appearances: A Thai male 54 years old, looking thin

no respiratory distress, appearing mild weakness, good
consciousness, good orientation and cooperation
Skin: Brown in color, skin surface look

normally, warm to

touch, excessive moisture, smoothness, no lesion, normal skin

turgor, no pitting edema , no rash

Nails: Pink in color, normal shape, no pitting nails, capillary

refill< 2 sec, no clubbing

fingers.

Hair : black Short hair, normal texture and distribution,

no local hair loss, no dandruff .

Head : Symmetrical, normal shape and size, no lesions,

no tenderness.

Face: Symmetrical,

normal shape, no muscle weakness, no

deformity, no tenderness of both frontal and maxillary sinus.

Eyes : Eyebrows and eyelashes present and normal

distribution, no ectropion or entropion of eyelids , no optosis

periorbital and larcrimal paratus are normal, conjunctiva

not

- 17 -

pale, pupil 3 mm RTL BE and good accommodation,

visual acuity of both eyes 6/6, extraocular movement
normal, no nystagmus .

Ears: Pre post auricular lymph node not palpable, Mastoid

not tenderness or swelling , no discharge, both tympanic

membrane intact and normal color, no perforation, good

hearing .

Nose : Symmetrical , no deformity, no rhinorrhea , no

swelling , good smell, no septal deviation or perforation .

Neck: Trachea in midline, neck veins not engorged, thyroid

not enlarged, cervical lymph node not palpable ., sternomastoid
and trapezius muscle no tenderness.

Mouth: dry lips, no cracking or angular stomatitis, buccal

mucosa and gingival pink in color, no oral ulcer, no
lesion, gum no inflammation or bleeding, no lesion,
tongue no lesion and protrudes in midline

Pharynx : Pharynx not injected, no lesion, tonsils not

enlarged and not injected, uvula rises in midline on
pronation, gag reflex present.
Respiratory system

- 18 -

Inspection : AP : lateral diameter 1:2 , normal contour, no

deformity of bone or fracture of ribs, chest wall movement
Rt = Lt , no abnormal retraction and bulging of intercostal
space ,

no mass.

Auscultation; normal breath sounds, no adventitious sound

Palpitation ; no tenderness , Lungs expansion Rt. = Lt, full ,
tactile fremitus equal bilaterally

Percussion; lung field resonance throughout in normal level Rt

= Lt.

Cardiovascular :
Inspection ;no central cyanosis , no clubbing of finger ,
no jugular vein

Palpitation ; No cardiac thrill, PMI at MCL Lt. 5

cms., no heave

th

Auscultation; no murmur .

Percussion pulse ; heart rate 104 / min ; regular rhythm.

Abdomen :
Inspection ; no distention, no scar, normal tympanic on ,
funnel

chest

- 19 -

Auscultation; normal bowel sounds 5-8 /min

Palpitation ; abdominal

soft, no tenderness, no rebound

tenderness, no mass, no hepato-spleenomegaly, no guarding,

no rigidity.

Percussion pulse ; Liver span ~ 9 CM at right midclavicular

line, no shifting dullness, no fluid thrill, no CVA
tenderness.
Back :

normal contour, symmetrical, no deformity of

bone.

Extremities : Arms and legs symmetrical, no deformity,

no lesion , full range of motion , normal movement,

muscle strength intact, motor power grade 5. no edema or

swelling of joint, no tenderness . skin of right legs and
feet swelling , tenderness ,inflammation ,no scope, two
old bleb lesion, fluid discharge.
Genitalia: no examination.
Rectal: no examination.

Neurological:

- 20 -

Cerebral function: Alert consciousness, normal speech and

language , good

orientation.

Cranial nerves: All intact

Moter system: Grade 5 all

Reflex: Deep tendon reflex 2+

Clonus reflex : negative

Babinski Plantar reflex : negative

Stiff neck and kernigs sign: negative

Temporary

problem

list

1.
2. 2

3. ( T 37.8-38.8 c)
4.WBC

44,520

cell /

cu.mm.

- 21 -

17 2556
CBC

( Complete Blood Count )

WBC

44,520

5,000 - 10,000

Hb

cell/cu.mm

cell/cu.mm

10.9 g/dl

10 - 15

g/dl
Hct

34 Vol.%

37 - 47Vol.

%
Plt.count(Cell/

417,000

140,000 -

- 22 -

cu.mm )

440,000

RBC

4.98

4.2-5.4
10

/mm

Neutrophil

90 %

50 - 80%

Lymphocyte

8%

25 - 35%

Eosinophil

1-3%

Monocyte

1%

2 7%

CBC

1. WBC , Neutrophil Leukocytosis

- 23 -

22

8 -

BUN

23 mg %
1.5

0.6 -

Creatinine

1.5 mg %

BUN ,Cr.
Electrolyte

Sodium

135.2

10 - 37

Potassium

3.45

3.5 5. 3

Chloride

101.7

96 - 108

CO2

21.8

22 - 29

93% 7%

electrolyte

electrolyte

(ion)
cation Na , K , Mg , Ca
+

2+

2+,

anion Cl , HCO3 , HPO4 , SO4

-

2-

2-

electrolyte

- 24 -

electrolyte

electrolyte

cation anion

cation
anion

electrolyte

Na , K , Cl HCO3 ,
+

electrolyte
electrolyte

hypokalemia
3.5 mEq/L

(, )

(hyperaldosteronism, ,

Kdepleting diuretics, carbenicillin, sodium

- 25 -

penicillin, amphotericin B),

(malnutrition)

digitalis
21 2556
CBC

( Complete Blood Count )

WBC

27,030

5,000 - 10,000

cell/cu.mm

cell/cu.mm

Hb

11.4 g/dl

10 - 15

Hct

35 .%

37 - 47Vol.

Plt.count(Cell/

442,000

140,000 -

4.98

4.2-5.4

cu.mm )
3

RBC
Neutrophil

82 %

g/dl
%

440,000

10

/mm

50 - 80%

- 26 -

Lymphocyte

8%

25 - 35%

Eosinophil

1-3%

Monocyte

1%

2 7%

CBC

1. WBC , Neutrophil , Plt.count

Leukocytosis

WBC , Neutrophil

21 2556

FBS

75

60-110

mg /dl
BUN

22

8 - 23 mg
/dl

- 27 -

Creatinine

1.5

0.6 - 1.5
mg /dl

Cholesterol

174

<200

Triglyceride

117

35-160

HDL-

26

35-60

125

<150

Cholesterol
LDLCholesterol
FBS

6- 8 hrs

BUN, CR

LIPID PROFILE
cholesterol, Triglyceride
HDL- Cholesterol, LDL- Cholesterol

- 28 -

24 2556
CBC

( Complete Blood Count )

WBC

19,090

5,000 - 10,000

Hb

cell/cu.mm

cell/cu.mm

11.6 g/dl

10 - 15

g/dl
Hct

36 %

37 - 47Vol.

%
Plt.count(Cell/

453,000

cu.mm )

440,000

RBC

140,000 -

5.38

4.2-5.4
10

/mm

Neutrophil

83 %

50 - 80%

Lymphocyte

12 %

25 - 35%

Eosinophil

1-3%

- 29 -

Monocyte

1%

2 7%

CBC

1. WBC , Neutrophil , Plt.count

Leukocytosis

WBC , Neutrophil

28 2556
CBC

( Complete Blood Count )

WBC

10,620

5,000 - 10,000

cell/cu.mm

cell/cu.mm

- 30 -

Hb

11.7 g/dl

10 - 15
g/dl

Hct

37 .%

37 - 47Vol.

Plt.count(Cell/

442,000

140,000 -

5.48

4.2-5.4

cu.mm )
3

RBC

440,000

10

/mm

Neutrophil

79 %

50 - 80%

Lymphocyte

18 %

25 - 35%

Eosinophil

1-3%

Monocyte

2 7%

CBC

1. WBC , Neutrophil , Plt.count

Leukocytosis

WBC , Neutrophil

- 31 -

- 32 -

pyomyositi

(Permeability)

Erysipelas

- 33 -

Tissue inflammation

Histamine

Streptococcus pyogenes, Staphylococcus aureus

Necrotizing

Cellulitis

Elephantiasis

- 34 -

Leptospir

Permanent problem list

1.

Initial

Plan

Subjective Data:
5

2
1
1

2 cm

Objective Data:
leg and feet.

- swelling

and

inflammation

on right

- 35 -

- 2

- WBC
10,000

44,520

cell / cu.mm

(5,000 -

cell / cu.mm )

- 38 C

Assessment

1. Cellulitis
2. Erysipelas
3. Necrotizing

fasciitis

4. Elephantiasis
5. Pyomyositis

1.Cellulitis
Definition

Acute inflammation dermis subcutaneous tissue

bacteria

- 36 -

systemic toxicity lymphagitis

lymphadenopathy
Etiology

- (,

, )
unusual exposures ( )
group A beta-hemolytic Streptococcus (S. pyogenes),
Staphylococcus aureus
-

cellulites

< 3 sinusitis otitis media

Haemophilus influenzae type b, penetrating injury

Pseudomdnas aeruginosa (
gangrenous cellulitis)

gram negative rods, fungus,

group B Streptococcus ()
Pathophysiology

- 37 -

( abscess ulcer)

bacterial

exotoxins local cytokine

systemic reactions
Predisposing factors
-

lymphedema node dissection cancer

(leg ulcer, toe web

intertrigo, and traumatic wound)

-

tinea pedis "athlete's foot"

venous insufficiency saphenous venectomy

lower leg edema

venous and/or lymphatic

coronary artery bypass

-

compromise morbid obesity, heart failure, pregnancy,

filariasis, previous tibial fracture
Clinical
-

features

Local symptoms and signs

tinea pedis lower extremities,

- 38 -

, lymphadenitis regional

lymphadenopathy , abscess formation, blister

warm
and tender lesion
cellulitis
-

Systemic symptoms and signs

, , flu-like symptoms,

alteration of consciousness

cellulitis

Staphylococci Streptococci Skin

lesion
Staph. Strep.
Lymphangitis (
distribution )

Streptococcal cellulitis

Staphylococcal cellulitis
Diagnosis

Streptococcal cellulitis

- 39 -

risk factors recurrence

Investigation

moderate to severe cellulites

.
parenteral ATBs
-

CBC leukocytosis greater than 13,000 WBC/mL

(toxin-mediated leucopenia)
-

( blister abscess

)
o

Systemic toxicity

Unusual exposures,

Recurrent infection

lymphedema,

postvenectomy with tinea pedis

( blister abscess 90 %,
20 %, 4 %)
Treatment

- 40 -

1.
2.

.
-

severe cellulitis

Rapid onset

>38.5 C

o
o

necrotic characteristics
WBC count >13,300/cu.mm

deep rapidly spreading soft tissue

Cellulitis ( orbit

ulcers,

oral antibiotics

infection

intracranial venous sinuses)

lymphoedema

Symptomatic and supportive treatment

- 41 -

1.

2.

3.

wet dressing

Specific treatment

Empiric therapy ( GABHS S. aureus)

Treatment:
* Cloxacillin (Dicloxacillin: absorption ),
*1 gen cephalosporin ( Gram +ve)
st

Cefazolin (1 to 2 g IV Q8h) nafcillin (2 g IV

Q4h) antistaphylococcal penicillins

Penicillin-allergic patients
Clindamycin (600 mg IV Q8h) Vancomycin (1 g

IV Q12h )
-

Oral therapy

Cephalexin (500 mg PO Q6h)

Clindamycin (300 mg PO Q6h) or levofloxacin (500

mg PO once daily)
penicillin

- 42 -

ATBs

Follow up 48h
parenteral

ATBs 10 14

3 5

Recurrent cellulitis 20 50 %

underlying dermatologic diseases tinea

pedis cellulitis lower extremity (

cellulitis )

Complication
-

Abscess formation S. aureus surgical

Toxic shock-like syndrome S. pyogenes

intervention
-

Metastatic infection infective

endocarditis, osteomyelitis, and distant abscess formation

- 43 -

cellulitis

Dermis
subcutaneous tissue
Etiology

(,

Predisposing factors
-

(leg ulcer, toe web

intertrigo, and traumatic
wound)
-

edema

lower leg

- 44 -

Investigation
- CBC
-

- WBC= 44,520 cell/cu.mm

Hemo culture

- Gram stain, Culture

Neutrophil 90 % ,

Lymphocyte28 %

Eosinophill 1 % ,

monocyte

1%

Cellulitis

/cu.mm

WBC 44,520 celll

- 45 -

2.

Erysipelas ()

Erythematous plaque with well defined border

group A streptococcus group C, D

G group B

S. aureus H. influenzae
S. pneumoniae P.
aeruginosa

1.

2.
(peaudorange)
cellulitis cellulitis

- 46 -

vesicle bullae

(annular configuration)

3. (lymphangitis)

erysipelas

nephrotic syndrome

1. CBC leukocytosis

2.

cocci group A
Streptococci

3. ASO anti DNase B

1. erysipelas

- 47 -

2.
3.

abcess

Acute poststreptococcal glomerulonephritis

4.

gangrenous cellulitis

1.

2. Penicillin 100,000 /./

10

- 48 -

- (lymphangitis)

- Dermis
upper subcutaneous tissue

-

erysipelas

- 49 -

Investigation
- CBC
-

- WBC= 44,520

Hemoculture

- Gram stain, Culture

-

Antistreprolysis O (ASO)
anti D nase B

cell/cu.mm

Neutrophil 90 % ,

Lymphocyte28 %

Eosinophill 1 % ,

monocyte

1%

- 50 -

3. Necrotizing

Fasciitis ()

1.

2.

2-3

- 51 -

Investigation
- CBC , Hemoculture
- Gram stain, Culture
- ASO anti DNase B

24

- 125

- 52 -

- 79
4

- 17

9-64%

3-4

1.

- 53 -

2.

3.

4.

5.
2

Figure 1. Vibrio vulnificus is a typical marine vibrio

- a slightly curved bacterium, motile by means of a single polar flagellum. Figure 2. Vibrio cholerae, the
agent of Asiatic or epidemic cholera.

- 54 -

2 - 3

- septic shock

- 55 -

- 79

Anaerobe

Investigation
- CBC

- WBC= 44,520 cell/cu.mm

- Gram stain, Culture

Lymphocyte28 %

- Hemoculture
- ASO
anti D nase B

Neutrophil 90 % ,

Eosinophill 1 % ,

monocyte

1%

-
Fascia

- 56 -

4.

elephantiasis

Lymphatic Filariasis
elephantiasis (subtropic)

120

40 1 3

1 3

Wuchereria

bancrofti Brugia malayi

4-6

Culex (C.

annulirostris, C. itaeniorhynchus, C. quinquefasciatus, and C.

pipiens); Anopheles (A. arabinensis, A. bancroftii, A. farauti,

- 57 -

A. funestus, A. gambiae, A. koliensis, A. melas, A. merus, A.

punctulatus and A. wellcomei); Aedes (A. aegypti, A.

aquasalis, A. bellator, A. cooki, A. darlingi, A. kochi, A.

polynesiensis, A. pseudoscutellaris, A. rotumae, A. scapularis,

and A. vigilax); Mansonia (M. pseudotitillans, M. uniformis);
Coquillettidia (C. juxtamansonia)

80 100 mm 0.24 0.30

mm 40 mm .1 m

microfilariae 244 296 m 7.5 10

m

first-stage larvae

third-stage infective larvae

mosquito's prosbocis
.

- 58 -

ultrasonography

- 59 -

(lymphangitis lymphadenitis)

(spermatic cord)

(epididymis)

W.bancrofti (urticaria)
eosinophils

(microfilariae)

- 60 -

Wuchereria bancrofti

hydrocoele elephantiasis ()

(chyluria)

chyloperitoneum elephantiasis
elephantiasis 95

Brugia malayi

Wuchereria bancrofti

- 61 -

Brugia malayi Wuchereria

bancrofti

- 62 -

Circulating filarial antigen

(CFA) Circulating filarial
antigen (CFA)

X-Ray
tropical eosinophilia
Ultrasound

- 63 -

22.00-02.00 Giemsa

Circulating filarial antigen (CFA)

Wuchereria

bancrofti

- 64 -

1 ivermectin
(150-200 mg/kg PO as single dose; may repeat q2-

3mo), diethylcarbamazine(DEC) and albendazole)

DEC (6 mg/kg per day) 12

bancroftian filariasis 6

brugian filariasis. 2
DEC ( 6-8

mg/kg per day) 2 1

Albendazole 2-3

- 65 -

4-6
6 2
albendazole ivermectin

diethylcarbamazine [DEC]


DEC (6 mg/kg per day x 2 days each month)

- 66 -

(lymphangitis
lymphadenitis)

-
2

(urticaria)

-
- eosinophils

- 2

eosinophils
(microfilariae)

- 67 -

Wuchereria bancrofti

hydrocele
elephantiasis (

(chyluria)

chyloperitoneum

elephantiasis

elephantiasis 95

- 68 -

Brugia malayi

Circulating filarial antigen

(CFA)
Circulatingfilarial
antigen (CFA)
Predisposing factors

-
2

- 69 -

Investigation

22.00-02.00
Giemsa

Circulating filarial

antigen (CFA)

Wuchereria Bancroft

- CBC

- 70 -

5.Pyomyositis

- Pyomyositis

- 71 -

Plan

For

Diagnosis

( Complete

Blood

1. Cellulitis
-

CBC

Count )

leukocytosis
-

cocci group A
Streptococci

- Hemoculture

(Septicemia)

Bacteria gram +

2. Erysipelas
- CBC leukocytosis

- 72 -

cocci group A
Streptococci

- ASO anti D Nase B

Streptococcus
group A Antistreprolysis O

(ASO)
ASO

antibody anti
D nase B,anti hyaluronidase
- Hemoculture

(Septicemia)

Bacteria
gram +

3. Elephantiasis
-

22.00-02.00 Giemsa
-

- 73 -

- Circulating filarial antigen (CFA)

Wuchereria

bancrofti

4. Necrotizing

fasciitis

- CBC leukocytosis

Hemoculture

- Gram stain, Culture

- ASO anti DNase B

5. Pyomyositis

- Radiography
- culture
- MRI

Plan

for

treatment

1. Cellulitis
1.1 Specific treatment

* Cloxacillin (Dicloxacillin: absorption ),

- 74 -

*1 gen cephalosporin ( Gram +ve)

st

Cefazolin (1 to 2 g IV Q8h) nafcillin (2 g IV

Q4h) antistaphylococcal penicillins

Penicillin-allergic patients
Clindamycin (600 mg IV Q8h) Vancomycin (1 g

IV Q12h )
-

Oral therapy

Cephalexin (500 mg PO Q6h)

Clindamycin (300 mg PO Q6h) or levofloxacin (500

Follow up 48h
parenteral

mg PO once daily)
penicillin
ATBs

ATBs 10 14

3 5

- Cloxacillin

1 gm

q 6 hr 7

- 75 -

Dicloxacillin

250mg

1x4

tid ac+hs

Dicloxacillin 3

- Ciprofoxacin
-

Dressing

500 mg 1x2 oral bid ac

wound OD

Record Vital sign 4

1.2 Supportive treatment

-
Supportive treatment

-
1.3 Symptomatic

treatment

wet dressing
2.

Symptomatic treatment

- 76 -

paracetamal

(500) 1-2 tab O prn 6 hrs.( ,

- 77 -

Progess
note

Order

Order for one

day

Date

Date

for

continuation

Order
17

2556

Cellulitis

Bleb

R/O NF

17 /

-Admit

06/56 -0.9 % Nacl

Order
17 /

- Regular

06/56 diet

1000 ml

- Record

- Dressing

Vein KVO

CBC,Bun,Cr,Ele
ctrolyte

Vital sign
wound OD

Medication

-I & D at ER

- Cloxacillin

2 gm
6 hr

v q

-Danzen

1tab oral
tidpc

- 78 -

-para (500)

At17.1

2 tab oral prn

5 .

Hypokalemi

for pain and

fever

LAB K=3.45

K=3.45

-Brufen(400)

mg/dl KCL

mg/dl

1 tab oral tid

20 ml oral stat

pc
.

Progess
note

Order

Order for one

Date

day

Date

Order
S=

O= V/S T

18/6
/56

for

continuation
Order

18/6/
56

-0.9 % Nacl
1000 ml

Vein KVO

- 79 -

37.2 c

right leg
redness

Swelling

A= cellulitis
right leg

nottendernes
s

A= cellulitis
right leg

P = ATB
vein

19/6
/56

19/6
/56

-Caltab (835)
1*2 oral PC

S=

O= V/S T

- 80 -

37.2 c right
leg redness

Swelling

A= cellulitis
right leg

P = ATB
vein

Repeat CBC

Progess
note

Order

Order for one

Date

day

Date

Order
S=

O= V/S T
37. c

Swelling

A= cellulitis
right leg

P = ATB

20/6
/56

CBC

for

continuation
Order

20/6
/56

- 81 -

vein

S=

O= V/S T
37. c

Swelling

Tenderness
at right
Ankle

A= cellulitis
right leg

P = ATB
vein

Repeat CBC

21/6

21/6

/56

/56

Tramal 1*2
oral pc

- 82 -

ATB
7

Progess
note

Order

Order for one

Date

day

Date

Order
S=

O= mild
redness
Not

swelling

Not tender
A= cellulitis
right leg

P =ATB
vein

dressing

22/6
/56

-0.9 % Nacl
1000 ml

Vein KVO

for

continuation
Order

22/6
/56

- 83 -

wound

23/6
/56

0.9 % Nacl
1000 ml

Vein KVO
- CBC,

S=

O= V/S
stable

Swelling
redness

A= cellulitis
right leg

P =ATB

vein ,
Wound

debridement
,

- Bun, Cr,
- FBS,
- Lipidprofile

23/6
/56

Tramal 1*2
oral pc

- 84 -

Order for one

Progess note Date

day

Date

Order
for

continuation
Order
S= 24/6

O= V/S
stable

Swelling
redness

A= cellulitis
right leg

P =ATB
vein

dressing

wound
Repeat CBC

/56

Order
24/6
/56

- 85 -

25/6

25/6

/56

/56

S=

O= V/S
stable

Swelling
redness

A= cellulitis
right leg

P =ATB
vein

Order

Order for one

Progess note Date

day
Order

Date

for

continuation
Order

- 86 -

S= 26/6

/56

26/6
/56

O= V/S
stable

Swelling
redness

A= cellulitis
right leg

P =ATB
vein

Repeat CBC
28/06/56
D/C

27/6
/56

S=

27/6
/56

- 87 -

O= V/S
stable

Right foot
minimal

crust with
necrotizing,
mild

sweeling
redness
around
wound

A= cellulitis
right leg

P =ATB
vein

Order

Order for one

Progess note Date

day

Date

Order
S= 28/6

/56

for

continuation
Order

28/6
/56

- 88 -

O= V/S
stable

Swelling
redness

A= cellulitis
right leg

P =ATB
vein
14

Dressing od

29/6
/56

S=

O= V/S
stable

29/6
/56

- 89 -

Right foot

not sweeling
, not

redness
around
wound

A= cellulitis
right leg

P =ATB
vein

Order

Order for one

Progess note Date

day

Date

Order
S=

O= V/S
stable
no

Swelling

redness

30/6
/56

for

continuation
Order

30/6
/56

- 90 -

A= cellulitis
right leg
P =plan
D/C

D/C
1/7 /
56

S=

O= V/S
stable

Swelling

no

redness

A= cellulitis
right leg

P =D/C

1/7 /
56

- 91 -

Plan for Nursing Care

17 2556
5

54

2
1
1

2 cm

- 92 -

I&D

discharge V/S T = 38
= 100/min R = 24 /min

18 2556

BP= 120/74 mmHg

Discharge

V/S

T = 37.5

P = 90/min

R = 20 /min

BP= 129/90 mmHg

19 2556

- 93 -

Discharge

P = 86/min

R = 20 /min

V/S

T = 37

BP= 129/90 mmHg

17

2556 - 18

2556

1
S;

O;

old bleb 2

38

- 94 -

CBC,

WBC 44,520 cell/cu.mm

Endogenous Pyrogen

Hypothalamus

Prostaglandin

(immune mediated process)

(pain threshold)

somatic visceral

visceral
midline burning)

1.
discharge

- 95 -

2. .

1.

2. 2

Aseptic technique

3.

4.

5.

6. 4

7. cloxacillin(1mg) v 6

8.

- 96 -

9. CBC
10. /

2.

S :

O : T=38 C ,
WBC 44,520 ccmm

Lab

A :

Endogenous Pyrogen

Hypothalamus
Prostaglandin

(immune mediated process)

(pain

- 97 -

threshold)

somatic visceral

visceral midline
burning)

-
-

1.
2.

36.5 37.4

1. 4 .

2. aseptic technique
3. bed rest metabolism

4.
5.

6.

7.

- 98 -

8.

9.
10.

11.

1. 36.8 37.3
2.
3.

4.
5

3 :

S;

- 99 -

O:

1.

2.

1.

2.

- 100 -

3.

1. /

2.

3.

(positive self-talk)

4.

- 101 -

5.

6.

7.

8.

9.

11.



12.

- 102 -

1.

2.
3.

4.
5.

1.
2.

3.
4

S:

O:

K = 3.45 mEq / L

A:

Hyperpolarize resting membrane potential

- 103 -

excitability

( Paralysis )

Transmembrane clectrochemical
gradient

1.

2.

1. ,

2. K = 3.5 5.5 mEq / L

3.
4.

1. Record v/s m 4
, K

- 104 -

2.

3.

4.

- KCL 20 ml oral stat

30 cc./hr

Hyperkalemia

- paracetamal
( 500 mg )2 Tabs prn q- 6 hr

Brufen (400)

1 * 3 pc tramal 1*2 oral pc

5.
6.

1. , 2
2.

Vital signs T = 37

C , P = 88 / , R = 20 /

, BP = 150/80 mmHg

- 105 -

Plan for health education

Cellulitis
1.
2.

3.

4.

5.

Progress Note

1 :

( )
2553

- 106 -

2 :

3 : :

2553

/min

R= 20 /min

V/S : T = 38.5.8 c

BP = 120/74

mmHg

P = 80

- 107 -

1 :

2 :

3 ::

. 53

V/S : T = 37.5 c
BP = 110/70

P = 82

/min

R= 20 /min

mmHg off cloxa

- 108 -

S:

O:

Abdomain palpable Liver enlargement 2 FB below to

right costal margin, Spleen not palpable ,Kidneys not

palpable by Manual, no mass, no hernia , positive

shifting dullness , positive fluid thrill . 39
72.5
1 :

2 :

3 : :

S:

O:

- 109 -

A:

P:

. 53

V/S : T = 37.0 c
/min

BP = 100/70

P = 80

/min

R= 20

mmHg

FFP 2 unit.

S:

O:

38 70.5

1 :

- 110 -

Discharge Planning

()

2 ( secondary prevention )

- 111 -

D -

METHOD (2539)
Diagnosis (D)

Medication ( M )

Environment and economic ( E )

- 112 -

24 2553

Treatment ( T )

- 113 -

Health ( H )

Outpatient

Referal ( O )

out patient Referal

- 114 -

Diet ( D )

(Renal insufficiency)

1. 2 / ,
,

2.

, , ,

, ,

, ,

3.

- 115 -

, ,

,
4.

5.

6.

7.

,,

8.

- 116 -

34 2

29

2553- 11 2553

. 1 30

2553

- Aldactone(100) 1
1

- 117 -

- Lasix ( 40)

1 30 tabs
- B.CO 1
3 -- 90 tabs
- Feso4 1

3 -- 90 tabs
- PPNL

(40) 1

1 30 tabs
-

Dicloxacilline

Ciprofoxacin

ac+hs 20 caps
10 tabs

250mg

1x4 oral

tid

(500) 1x2 oral bid ac

14 Cellulitis c

Cirrhosis

Cellulitis both legs ,

- 118 -

Cirrhosis

renal

impairment , anemia for chronic

disease.

(Holistic care)

- 119 -

1.

2.

. (2545). .
1 . : .

- 120 -

. (2542).

.( 2 ).

.: .

. (2537).
. 1 .:
.

. (2548) . .
1 . :
.

. (2541).

. ( 2). :

. (2548).

562706
.

. (2545). .

1 .

- 121 -

(2540).

( 9). : .

. (2545). .
1 .:
.

. (2533). .
1 .: .

. (2531). .
1.:.

. (2540).
.( 3).

: .

. (2546).

. (2545). .
:

http://WWW.Liver club of Thailand.com

2553

online 2

- 122 -

http://WWW. Thailabonline.com/tomor.htm
2553

online 5

- 123 -

1. Cloxacillin

Staphylococcus aureus , Streptococci

500 mg. 4

500 1000 mg. 6

- 124 -

2.

KCl (Potassium

Chloride)

(Potassium Chloride)

1. Ampule 20 mEq/10 ml 2 mEq/ml

( (High-alert Drug) )

2. KCl /KCl syrup 20 mEq/15 ml

1.33 mEq/ml

3. KCl 500 mg/

(Hypokalemia)

1.

2.
3.

4. (EKG sagging ST
segments, depression T waves Elevated U waves)

- 125 -

1. Renal failure
2. Oliguria Azotemia
3. Anuria

4. Crush syndrome

5. Severe hemolytic reaction

6. Adrenocortical episodica hereditaria
7. Acute dehydration
8. Heat cramps

9. Early postoperative oliguria except during GI drainage

Isstitute for Safe Medication Practice (ISMP)

- (Gastrointestinal ) 10 %

- 126 -

- 1-10 % Bradycardia
- Endocrine & Metabolic system : Hyperkalemia

- 1-10%

- Neuromuscular & skeletal : 1-10 %

/ (Weakness)

- : 1 10 % (Dyspnea)

( 1 %)

, alkalosis, arrythmia, chest pain, heart block,

hypotension, mental confusion, paralysis, paresthesia, phlebitis,

rash, throat pain

/ KCl
(Overdose/Toxicity)

Hyperkalemia

(muscle weakness, paralysis) EKG

Peaked T waves, Flattened P waves, Prolong QRS
complex ventricular arrythemias

- IV admixter 24 .

- 127 -

- Potassium chloride D5W, NSS,

NSS

Dextrose Hypokalemia Insulinmediated movement

- 0.5 - 1 mEq/kg/dose
3mEq/kg/days (IV infusion )

- 5-10 mEq/hr 20 mEq/hr

400 mEq/24 hr

10 mEq/hr cardiac
parameter

Peritoneal line 60mEq/L
Central line 150 mEq/L

- serum potassium 3.5 - 5.0

mEq/L

- EKG 10 mEq/hr Tall

peaked T waves, depression ST

- 128 -

segment, wide QRS complex, absent of P wave,

Venticular tachycardia

- Glucose

-

- pH

- Intake and output

-
BUN Creatinine

1. Kayexalate, Kalimate

20-50 20% sorbital 50%

glucse 50-100 ml 4 .

2.
insulin glucose infusion D-10-W 500 ml + RI 20

unit 1 . 50% glucose 50

cc + RI 20 unit IV stat

- 129 -

3. Sodium bicarbonate 50 mEq 5

Acidosis 10-15

4.
Hemodialysis, Peritonealdialysis

5. 10% Calcium gluconate 10 ml

5 5 EKG

3. Danzen

Serratiopeptidase
Danzen

(sinusitis)

(epididymitis )

- 130 -

serratiopeptidase

1)

2)

(GI disturbance)

- 131 -

30


4.

Tramal

tramadol
tramal

"Grnenthal GmbH"

"" (Tramal) Grnenthal

(Tramadol)

GABAergic, noradrenergic

serotonergic

""

(tramadol hydrochloride)

- 132 -

50 mg. 3

50 mg. 8

Tramadol

, , , ,

, ,

Tramadol

,
,
,

5. Paracetamol

( Acetaminophen )

- 133 -

Aspirin

prostaglandin

Hypothalamus

Endogenous pyrogen

- 1

1-3

12

325 1,000 mg. 4-6 4

- 134 -

gm. / 2 6 gm. /
30

3-4
10 60
11 12

4- 6 .
4- 6

4- 6 .

480 .

9- 11

400 .

6 9

320 .

4 6

240 .

2 4

160 .

1 2

4-6 .
4-6 .

4 6 .

4 12

6 .

120

80 . 4

40 . 4

6 .

- 135 -

10 15
20 25
24

1.
10

2.

3.

5. Brufen

(Nonsteroid

antiimlammatory drugs NSAID)

- 136 -

PKA

Prostaglandin

Prostaglandin

Coumarin

400-800 . 3-4

- 137 -

1.

2.

3.

4.

5.
Dicloxa
(Dicloxacillin)

1. (
)

- 138 -

2. (
)

3.

- 139 -

( unusual bleeding or
bruising )

2-3

- 140 -

( 2

) 2
2

dicumarol , warfarin

tetracyclines

demeclocycline , doxycycline , minocycline , tetracycline

methotrexate

AMCIDIL , DICLEX , DICLOCIL , DICLOCILLIN ,

DICLOSON , DICLOX , DICLOXIA , DITUM ,

DIXOCILLIN , DOROX , MEDICLOX , SERVIDICLOX

- 141 -

12
40 : 125-250 6

40 :

3.1-6.2
1 6

( Capsule ) 250 , 500

( Syrup ) 62.5 5 (
)

( Dry syrup ) 62.5 5 (

)

(15-30 )

- 142 -

CBC ( Complete Blood Count )

CBC

Hct ( Hematocrits )

Hct 30 -40
% 30 %

Hct

Hb ( Hemoglobin )

Hb Hct
Hb 1/3 Hct Hct
30% Hb = 10 gm%

WBC ( White Blood Cell Count )

5000-

10000 cell/ml WBC

- 143 -

Aplastic

Anemia

) WBC

( Differential Count )

Leukemia

Aleukemic Leukemia

Differrential Count

% (
100(%) )

PMN N Neu (polymorphonuclear

cell Neutrophil) 50-60 %

80% WBC

Lymp L (Lymphocyte)

PMN 100%
Lymp

- 144 -

WBC

Lymp
Atypical
Lymphocyte Hct

Eosin E (Eosinophil)

1-2 % 5-10 %

B Basophil, M

Monocyte

Platelets

cell/ml

Adequate
Decrease

- 145 -

Idiopathic Thrombocytopenic Purpura (ITP)

Increase

Essential Thrombocytosis

Decrease Increase

Platelets

RBC Morphology

ASO Anti D Nase B

Streptococcus
group A

Antistreprolysis O (ASO)

ASO

- 146 -

antibody anti
nase B,anti hyaluronidase

1. Charls F. Lacy, Lora L. Armstrong, Morton P. Goldman

and Leonard L. Lance. Drug
Information Handbook. P. 1293-1294. LEXICOMPINC:Ohio,2005-2006
2. Rota M. Doley and Joanne C. Poeggell.Nursing I.V. Drug
handbook.p.564-565. springhouse
Corporation:USA, 1998
3. Adrinene R. Nazareno.Intravenous Medications. P.919922.Mosby:Missouri,2003

- 147 -

4. . .

()
, 163-164.

: , 2547.