Audit of skin changes present in referrals to a specialist lymphoedema service.

An audit of 100 new patients attending a specialist lymphoedema clinic revealed 52% presented with chronic oedema. More than half (58%) of the chronic oedema group presented with skin changes whereas 14% of those with lipoedema, 4% with lymphoedema of the arm, and 8% with lymphoedema of the leg developed skin changes. None of the primary lymphoedema group developed skin changes. Chronic venous disease (CVD) was significantly more prevalent in the chronic oedema group. More patients with bilateral chronic oedema suffered from cellulitis (41%) compared to unilateral (27%). Skin changes, CVD and red leg syndrome (RLS) also occur more often in bilateral leg swelling. Incidence of cellulitis is highest in the chronic oedema group (36.5%), closely followed by the primary lymphoedema group (33.3%). 85% of the patients who were weighed (n=93) were overweight, 39% obese, and 29% morbidly obese. The findings from this audit highlight the importance of skin care training for community nurses managing chronic oedema patients.

Developing a nurse-led 'red legs' service.

As the population ages, more complex care is required to manage multiple comorbidities. In response, a nurse-led service was developed to care for patients with 'red legs'. This chronic inflammatory condition is often misdiagnosed as acute cellulitis and can result in unnecessary hospital admission and inappropriate treatment, with substantial resource and financial implications for trusts. Setting up the service required a multi-agency group to analyse current provision and identify gaps in care. Integrated care pathways were developed to focus on patient experience through referral, diagnostics and treatment. Evaluation showed that much of the prescribed care for patients with red legs could be carried out by patients at home and only a small number required a follow-up appointment. High levels of patient satisfaction were recorded.

Differentiating between red legs and cellulitis and reviewing treatment options.

Red legs (RL) is a chronic inflammatory condition often misdiagnosed as cellulitis. Antibiotic therapy is not required and does not resolve the symptoms. The main causes of RL are chronic dermatological and venous disease, including chronic oedema. Raising awareness of this condition among health professionals could prevent misdiagnosis and unnecessary costly and potentially harmful antibiotic therapy. The aim of this paper is to highlight the differential diagnoses and management of red legs, and the author also includes an example through a case history.

Avoiding admission and facilitating early discharge through OPAT.

Fifteen years ago, only a small minority of hospital inpatients were considered suitable for outpatient parenteral antimicrobial therapy (OPAT) services (Wiselka and Nicholson, 1997). Now, almost 70% of those treated with intravenous (IV) antibiotics as hospital inpatients are considered suitable (Hitchcock et al, 2009). Around 38-53% of those requiring OPAT are able to self-administer (Hills et al, 2012). The demand for IV antimicrobial therapy is increasing and the way it is being delivered is changing. The delivery of IV anti-microbial therapy in the community has the potential to make a huge difference to the way health care is delivered. It can enable people who would once have been admitted to hospital to be treated in the community. It can facilitate early hospital discharge (Nazarko, 2013a). Potentially, there are huge benefits in developing OPAT but there are also risks. People may be subjected to an invasive treatment when it is not necessary; therapy may be continued when it is no longer necessary (Nazarko, 2013b; Conant et al, 2014); and patients may be selected for OPAT who would be best treated in hospital. The key to providing safe and effective care is to work together to maximise benefits and minimise risk (Duncan et al, 2013). This article examines how acute and community services can work together to ensure appropriate selection, treatment and follow-up of patients.

Developing a nurse-led integrated 'red legs' service.

This project was developed to set up a nurse-led service based on the needs of patients diagnosed with 'red legs'. These patients are often wrongly admitted into hospital for treatment of cellulitis. Representatives from the specialties involved in caring for those individuals with red legs were invited to participate with patients to create a stakeholder group whose purpose was to develop integrated care pathways focused on referral criteria, diagnostics and treatment to inform a new nurse-led service. There was a commitment to utilising a number of facilitation techniques and practice-development methods in the progression of the project with the support of the Foundation of Nursing Studies. Much of the prescribed care can be carried out by the patients at home and only 25% patients have required a follow-up appointment within the new service. The service has now been fully commissioned and a secondment opportunity has been developed to lead the new service. Significant savings have been demonstrated and regular revision of the integrated care pathways with all groups, including the patients, will take place.

Uncovering common bacterial skin infections.

The four most common bacterial skin infections are impetigo, erysipelas, cellulitis, and folliculitis. This article summarizes current information about the etiology, clinical presentation, diagnosis, prevention, treatment, and implications for primary care practice needed to effectively diagnose and treat common bacterial skin infections.

A mistaken case of peroneal dislocation.

This article is centred around the similarities and highlights some differences between a sports injury compared with any other injury profile. The authors use a musculoskeletal assessment, diagnosis and management of an injury based on a particular case study. The intention is to highlight how problems may be masqueraded in the history and perception of the injured athlete and how this perception may have complicated the injury and the rehabilitation process. This issue generates a renewed awareness for all primary care nurses and health practitioners who may be involved in treatment pathways for associated injuries related to sports medicine problems. The article gives an insight into peroneal dislocation/subluxation, but primarily focuses on peroneal tendonitis/tendonosis. The management of the injury briefly touches on the associated benefits (and risks) of barefoot running and its role in the prevention of sporting injuries. This article illustrates how the frustration of a chronic injury can lead to the athlete making ill-informed decisions and highlights the need for a thorough assessment and an evidence-based management plan that is negotiated with the athlete.

Diagnosing and managing lower limb cellulitis.

The diagnosis of lower limb cellulitis requires careful and structured assessment. This article looks at the assessment, diagnosis and management of cellulitis, focusing on the lower limb. Assessment should include good skin examination as active skin disease, such as venous stasis eczema and athlete's foot (tinea pedis), is often overlooked as a primary cause of lower limb cellulitis and recurrent episodes.

An evidence-based approach to diagnosis and management of cellulitis.

Community nurses are involved in caring for people who are at risk of cellulitis. The community nurse may be involved in dressing leg ulcers and may refer a patient with suspected cellulitis for appropriate treatment. Community nurses are also increasingly involved in delivery of outpatient antibiotic therapy (OPAT). As the role of the community nurse expands to encompass diagnosis, prescribing, delivery of OPAT and in some cases the decision on when to switch from IV to oral antibiotics, it is essential that the nurse is aware of the evidence base for diagnosis and treatment of lower leg cellulitis. This paper discusses the reasons for the increasing incidence of lower leg cellulitis and explores the evidence base for treatment.

Management of patients with cellulitis of the lower limb.

This article aims to help practitioners develop an understanding of cellulitis of the lower limb. It focuses on the identification of cellulitis, differentiating it from other common conditions, and discusses treatment and management strategies. The article includes information for prevention and early recognition of the condition in an attempt to reduce frequent recurrences.

[Nursing care of a preschool-age child with cellulites induced by phagocyte deficiency].

Phagocyte, the first inflammatory response of the immune system, is an important component of the wound healing process. For children with low immunity who suffer from phagocyte deficiency, even a small wound will result in a rapid response to systemic infection, poor wound healing, and hospitalization for treatment. Such treatments often bring enormous pressure to bear on the child, with serious impacts on his or her psychological well-being as well as on that of the family. This paper applies the concept of preschool-age child development and "TIME" criteria proposed by Dr. Schultz to assess pathological changes in poor healing wounds in order to promote wound healing and shorten necessary hospitalization times. Teaching the primary caregiver (oftentimes the patient's mother) adequate at-home wound dressing skills to reduce re-admission rates is also a main focus of nursing care. This article integrates related articles in the literature with a case analysis by reporting on an individualized nursing intervention for a child with cellulites induced by phagocyte deficiency. It is hoped that recommendations provide a valuable clinical reference for nursing colleagues to care for children suffering from phagocyte deficiency.

Holistic care of a drug-related wound: a case study from a clinic for homeless people.

Homeless people experience greater difficulties than the general population in accessing health care, despite being at greater risk of ill health. This case study describes the benefits of a supportive, accessible homeless health service, and explores the holistic factors involved in the rapid healing of a deep, drug-related wound.

Providing outpatient antibiotic therapy for cellulitis in primary care.

Outpatient parenteral antimicrobial therapy (OPAT) is becoming more widespread. OPAT therapy can be used to treat certain patients who have cellulitis. The decision as to which patients to treat at home must be based on local PCT guidelines--not all patients are suitable for OPAT. OPAT improves patient quality of life by delivering care in the patient's home. This is highly skilled work and the community nurse must have appropriate training and support in order to gain the skills required.

Cellulitis and treatment: a qualitative study of experiences.

Although cellulitis is usually a relatively mild condition, it is potentially life threatening, often necessitating emergency treatment in either the acute or community care settings. The treatment of cellulitis with antibiotics is well established, with effectiveness generally measured against purely biochemical and clinical outcomes (Cox, 2002). Although important, these outcomes are centred purely on the disease process from the medical perspective and little is known about patients' experiences of cellulitis. This qualitative study explores patients' view on the management of community-acquired cellulitis in the secondary healthcare setting. Data were collected through semi-structured groups and individual telephone interviews. Participants were selected through purposive sampling and the Framework Analysis Technique was used to analyse the data. Three superordinate themes emerged: initial presentation/motivation for seeking help; confidence and satisfaction; anxiety and dissatisfaction. Severe pain was almost universally a cause of distress and flu-like symptoms delayed recognition. Health information and communication was generally poor. Participants largely welcomed a move from inpatient to day-patient or outpatient care provided there was adequate information and support. To meet the diverse needs of cellulitis patients, services must be more flexible and tailored to the needs of the individual. Patients are often not told what they can do to prevent recurrence.