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BACTERIAL INFECTIONS-CELLULITIS (Risk Factors (Injury. Any cut, fracture,…

- - - - Patient’s skin remains intact, as evidenced by the absence of redness over bony prominences and capillary refill less than 6 seconds over areas of redness.
    - - Assess the overall condition of the skin.
      - Check on bony prominences such as the sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of head).
      - Evaluate the patient’s awareness of the sensation of pressure
    - - Discourage the patient or caregiver from elevating the head of bed repeatedly. Encourage the use of lifting devices like trapeze or bed linen to move the patient in bed.
      - Encourage the patient to change position every 15 minutes and change chair-bound positions every hour.
      - Encourage the implementation of pressure-relieving devices commensurate with degree of risk for skin impairment
      - Encourage adequate nutrition and hydration
  - - - Patient incorporatess changes into self-concept without negating self-esteem.
      - Patient verbalizes acceptance of self in situation.
      - Patient discusses with family/SO about situation, changes that have occurred.
      - Patient develops realistic goals/plans for the future.
    - - Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.
      - Recognize the normalcy of response to the actual or perceived change in body structure or function.
      - Set limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery.
    - - Assess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs.
      - Assess the perceived impact of change in ADLs, social participation, personal relationships, and occupational activities
      - Assess the result of body image disturbance in relation to the patient’s developmental stage.
      - Evaluate the patient’s verbal remarks about the actual or perceived change in body part or function.