DOW UNIVERSITY OF

HEALTH SCIENCES

HEALTH ASSESSMENT

INDIVIDUAL PRESENTAION
Of
H.A
CLIENT DIAGNOSED WITH

A 60 Year old lady with cellulitis.

BY
Farheen Sadruddin Datoo
Dated:-Jan 10,2012
Faculty:Mam Rubina
Programme:BScN Generic Year II Sem
III

OBJECTIVES
At the end of this presentation students
will be able to:
Define Cellulitis
Discuss its causes, symptoms &
pathophysiology.
Describe Patients profile
Identify its chief complaints
Illustrate its review of systems and health
examination.

Objectives of the Study

General Objective
This case study is designed for the student
nurses to become practiced, well-informed
and mannered in delivering holistic care
and a guide to physical examination for
patients diagnosed with Cellulitis.

Definition
Cellulitis is a skin infection that
develops as a result of bacterial
entry via breaches in the skin barrier.
Manifests as erythema, edema, and
warmth.
Predisposing factors include
disruption to the skin barrier as a
result of trauma, inflammation,
preexisting skin infection (ie tinea
pedis), and edema.

Causes
Cellulitis occurs when one or more
types of bacteria enter through a crack
or break in your skin.
The two most common types of
bacteria that are causes of cellulitis are
streptococcus and staphylococcus. The
incidence of a more serious
staphylococcus infection called
methicillin-resistant Staphylococcus
aureus (MRSA) is increasing.

Cont
Although cellulitis can occur anywhere
on your body, the most common
location is the lower leg. Bacteria is
most likely to enter disrupted areas of
skin, such as where you've had recent
surgery, cuts, puncture wounds, an
ulcer, athlete's foot or dermatitis.

Cont..
Certain types of insect or spider bites
also can transmit the bacteria that
start the infection. Areas of dry, flaky
skin also can be an entry point for
bacteria, as can swollen skin

Possible signs and symptoms of

cellulitis include:

Redness
Swelling
Tenderness
Pain
Warmth
Fever

Incubation
Cellulitiscandevelop inas little as
24hours orcan take days to
develop.

PATIENT HEALTH
HISTORY/PATIENT PROFILE

A. Biographic Data
Name: Shafique Begum.
Age:
60 years old.
MR no:
2668.
Date of Admission: Dec 18, 2012.
Ward and Bed no: Female medical ward,
bed no 2
Attending Physician: Dr. Manzar.
Attending Staf:
Staf Farzana.

B.MEDICAL DIAGNOSIS

Abscess with Cellulites at right leg.

C. Chief Complaint

Infected Wound at Right Leg.

Swelling at the Right leg.

NURSING

ASSESSMENT

Chief Complaint:
Infected Wound at Right Leg

History of Present Illness:

Four days onset of pustule like
lesions on the right leg which later
become enlarged and erythematous
with tenderness and local swelling.
Past Medical History:
Asthma.

E. Family History of Illness

In their family there is no history of
diseases or illness. But her husband stated
that his brother had an history of
hypertension.

G. Social Data
Mrs shafique begum is a 60 year old lady.
She lives with her family and has two
married children.
In her spare timings she usually do
stitching and read religious books.

H. Psychosocial Data
No hallucinations and delusions.
During admission she was aware that
shes in the hospital.
Obtunded LOC.
Able to recall past and recent events.

REVIEW OF SYSTEMS AND

PHYSICAL ASSESSMENT

A. General Appearance
Weight:
70 kg
Height:
5 feet 3 inches
Level of Consciousness: Obtunded
Body Build:
Endomorphic
Posture and Gait: Unable to stand and
walk

LEVEL OF CONSCIOUSNESS
AND HYGIENE
The patient was awake, lying on bed in supine position but
is less sharp or dull , but not in distress. She looks
according to age and is calm and engaging. One can see
that she is well nourished and practices good hygiene, a
well groomed personality.
The patient was responsive to verbal and nonverbal stimuli.

VITAL SIGNS

Temp=36.5C
P=79/min
R=22/min
BP=120/80 mm of Hg

General Physical Assessment

SKIN: The patients skins moisture is dry due to dehydration. The texture is
rough due to aging and signs of dehydration.
HEAD:
The patients head was round and in proportion w/ the body. Hair
color is white and has no dandruff and lice. The patients general
appearance of face indicates a feeling of weakness.
NECK and SHOULDERS: The veins and clavicle are visible. The shoulders
are asymmetrical. The neck muscles are weak.
EYES: The patients eyes are symmetrical to the ears. She manifested a
blurred vision due to aging. Pale conjunctivae was noted. Sunken eyes
was observed. The eyes appeared dry due to dehydration.

EARS:The clients ear manifested a good hearing balance. There were

no discharges noted.
NOSE:
The clients nasal septum is intact and in the midline. There
were no discharges noted. Airs move freely as the client breathes
through the nose.
MOUTH and THROAT: The clients mouth has presence of lesions due
to frequent vomiting. The lips were dry due to dehydration. The throat
was functioning well. Dentures present. There is a black discoloration
in the enamel.
CHEST: The chest is symmetric. The skin was sagged. The thorax is
elliptical.
ABDOMEN: The skin of the abdomen is unblemished and uniform in
color. Symmetric abdominal contour flattened and rounded. Audible
bowel sounds. Symmetric movements cause by respiration. No
tenderness noted. Clicks & gurgles sounds were 6 times per minute.!

EXTREMITIES: The fingers in both hands and feet are complete.

In lower extremities ,the has so many scars and lesions.
In lower Extremities: Swelling erythema.

Body Part

Technique

Assessed

Used

Skin

Actual Finding

Interpretation

Inspection

Pt Skin color was fair and even

Normal

Palpation

Skin was dry, poor skin turgour

Due
dehydraion

to

Body Part

Technique

Assessed

Used

HEENT

Head
Inspection
Palpation

Actual Finding

Normocephalic
Evenly distributed hair, no
dandruf or Seborrhea
dermatitis
lesions.

Interpretation

Normal
Normal
Normal

Sinuses non-tender
Normal
Normal

Eyes
Inspection
Symmetrical eyelids
Clear and moist conjuctiva
Anicteric sclera
Nearsightness
-PERRLA
-visual fields normal

Normal
Signs of
Aging
Normal

Body Part

Technique

Assessed

Used

Ears

Nose

Inspection

Palpation

Inspection

Actual Finding

Interpretation

No discharge
Non tender
No presence of mass or
nodules

Normal
Normal
Normal
Normal

Symmetrical nasal folds

Nasal septum at midline
Mucosa is moist, pinkish,
intact and no discharge

Normal
Normal
Normal
Normal
Normal

Palpation

Non tender sinuses

Body Part

Technique Used

Actual Finding

Interpretation

Assessed
Mouth,
Pharynx
and Neck

Mouth
Inspection

Pharynx
Inspection
Neck
Inspection
Palpation

Lips pinkish and dry

Tongue at midline
Gums and mucosa pink
Presence of dentures
Uvula at midline
Tonsils not inflamed
Neck symmetrical with full
ROM
Trachea at midline
Lymph nodes non tender

Normal
Normal
Normal
Aging
(decalcification
)
Normal
Normal
Normal
Normal
Normal
Normal

Body Part

Technique

Assessed

Used

Pulmonary

Inspection

Symmetric

Palpation

Symmetrical lung expansion

Symmetrical tactile fremitus

Auscultation

Actual Finding

Clear lung sounds

No adventitious breath
sounds

Interpretation

Normal
Normal
Normal
Normal
Normal
Normal
Normal

Body Part

Technique

Assessed

Used

Cardiovascu Auscultation
lar

Abdomen

Inspection

Auscultation

Actual Finding

S1 & S2 best heard at 5th ICS

MCL
No murmurs or heaves heard.
Flat and symmetrical
No lesions
Click o gurgles heard at 6
times per minutes.

Interpretation

Normal
Normal
Normal
Normal

Normal

Normal
Normal

Percussion

Tympanic over LLQ

Dull at RUQ, LUQ and RLQ

Palpation

No tenderness

Body Part

Technique

Assessed

Used

Extremities

Inspection

Skin dry
Skin intact
Nails convex curved
Pink nail beds

Palpation

Normal capillary refill

Skin cool to touch
Muscles with slight atrophy
muscle strength weakness
Difficulty in standing &
walking

Genitourinar
y
Inspection
Motor
Sensory

Actual Finding

Pt refusal, as per patient

statement genitourinary
system was normal. No
problem associated with it.
100% intact
Cranial nerves responsive

Interpretation
Due to
dehydration
Normal
Normal
Normal
1 sec
Aging process
Normal
Infection

Normal
Normal

REFERENCES
http://www.mayoclinic.com/health/cel
lulitis
Habif TP, ed.Clinical Dermatology.
5th ed. Philadelphia, Pa: Mosby
Elsevier; 2009; chap9.