Ana Case Study Copy 2
Ana Case Study Copy 2
NO CONTENT PAGES
1 Introduction 2
2 Patient details 3
3 Presenting complaints 4
Physical assessment
4 Diagnosis
Past medical history
Past surgical history 5-7
Social history
Diet routine
Family History
6 Management in ward
Operation perform
Post op oder 8-9
Endocrine review
Diabetes Educator review
Plan discharge
7 Investigation 10
The patient in this case study is working as cashier at beverage & Food
Ampang .Came to Emergency Department Hospital Canselor Tuanku Muhriz on
10/11/2022 with complaint anterior wall abdomen painful and redness about 5 days
after dislodged insulin pump needle.Before came to Emergency Department patient
went to GP twice and was being given Tablet Paracetamol for analgesic and oral
antibiotic .
In this case study patient did not adhering to their diabetes dietary plan and also not
living in healthy lifestyle. As a heavy smoker 2 box per day and will increase get
complication .
What is a carbuncle?
Abscess large than a boil , usual with one or more openings draining pus on to the
skin. It is usually caused by bacterial infection, most commonly staphylococcus aureus.
This infection is contagious and may spread to other parts of body or to other people.
Pathophysiology
Most carbuncle are caused by the bacteria Staphylococcus aureus ( S aureus ) .A
carbuncle is a cluster of several skin boils ( furuncles ) .The infected mass is filled with
fluid , pus , and dead tissue .Fluid may drain out of the carbuncle , but sometimes the
mass is so deep that it cannot drain on its own.
People who have had diabetes for a long time may have peripheral nerve damage
and reduced blood flow to their extremities ,which
increases the chance for infection.The high sugar levels in
your blood and tissues allow bacteria to grow and allow
infections to develop more quickly.
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PATIENT’S DETAIL
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Presenting complaints
Physical assessment
Patient conscious and alert , GCS 15/15
Able to ambulate well
Hydration fair
Loss of appetite 2/7 days
Chest x-ray - Lung clear
Abdomen soft , no tender ( anterior abdominal swelling , rash over abdomen 2/7
days , fever 2/7 days since 9/11/2022 and complaint painful +++ , pus discharge
from swelling .
Lower limb both –no oedema
No any allergic medications and food
-Vital sign taken BP 132/90 mmhg ,PR 100 bpm, Temperature 37.5 c,
Respiratory rate 20/min, Spo2 99% under room air, dextrostix 12.5mml/L, Pain
score 5/10
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Diagnosis
Right Anterior Abdominal Wall Carbuncle
Allergic - nil
SOSIAL HISTORY
Patient single stayed with friends at Bukit Permai Cheras
Smoker 1-2 box per /day
Denies frequent alcohol intake
Patient had no history for consumption of traditional medication
Patient is not an active patient ,not doing any exercise and had irregular meal
time and always skip main meal.
Working hours started (5pm till 12 midnight)
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FAMILY HISTORY
GRANDFATHER
(TYPE 1 DM ,HPT)
FATHER MOTHER
Grandfather had history of DMT1 and HPT. Patient’s mother and father no medical
history or illness.Patient has three siblings and he is the 2 nd in sibling .His sister and
younger brother has no medical illness.
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DIET ROUTINE PATIENT
Breakfast –patient always skip (weekday and weekend)
Lunch 2pm -3pm) – I cup of rice + fish / chicken +vegetables + ice lemon tea
Dinner (8pm-9pm) – Sandwich 2 pieces + tea ice
Suffer (1am -2am) -2 packed maggie soup + vegetables + egg + tea ice @ 1 cup
coffee.
WARD SURGERY 1
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11/11/2022 at 1am Sent patient to OT for I&D and back from OT at 4 am with
conscious and alert. Wound packed with gauze – not soaked
Post op vital sign:BP 132/78mmhg, HR 80 bpm ,RR 22 /min ,Temp 37.2 c
Spo2 :99% room air , pain score 6/10
OPERATION PERFORM
11/11/2022 Incision and drainage done under GA carbuncle size 8CM X 6CM
incision made over carbuncle.
Wound debridement, hemostasis secured ,normal saline , povidone, hydrogen
peroxide washout done
Povidone packing done tissue culture & sensitivity and swab culture & sensitivity
taken and sent –to trace later
POST OP ODER
Iv Augmentin 1.5gm stat and tds
Tablet Arcoxia 120mg daily
Tablet Paracetamol 1gm qid
Daily dressing with hydrocyn packed
Continue actrapid infusion according sliding scale
Withold insulin pump in ward
Continue ivd 2 paint Normal saline 24hrs
Allow orally as tolerated kiv off ivd
12/11/2022 @ 2pm review by team HPB wound inspection don and not
well healing and having slough ++
Bedside wound debridement done- clean with hydrocyn and pack soaked
hydrocyn
Patient refer Endocrine, diabetic educator and dietition before discharge
ENDOCRINE REVIEW
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Off sliding scale
Monitor dxt QID
S/c Novarapid 16 ii stat and tds
Diabetic Educator to review
To get new appointment endocrine – done @ 09/3/2023
Continue opthalmology appointment on 13/ 4/2023 Prof Ropilah)
DISCHARGE
Patient allow discharge by HPB team
Continue daily dressing with hydrocyn at nearest clinic
TCA KK – to review blood sugar and dressing wound
Continue insulin pump
Continue medications
-Tablet Arcoxia 120 mg daily
-Tablet Augmentin 625 mg tds – 2/52
-Tablet Paracetamol 1gm qid
-Tablet Pantoprazol 40mg daily
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INVESTIGATIONS
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BLOOD GLUCOSE MONITORING
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12.5 12.6 12.5
12
12
10.2
10 9.4
8.6
8
6
4 4
4 3 3 3 3
2 2 2
2
0
6PM 10PM 1 AM 4 AM 5 AM 6 AM 8 AM 1 0 AM 12PM
(10/11/2022) (11/11/2022)
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BLOOD GLUCOSE MONITORING
16
14
12
10
0
6AM 12PM 3PM 6PM 10PM 6AM 12PM 6PM
( 13/11/2022 ) (14/11/2022)
Graph 2 : Basal bolus
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NURSING DIAGNOSIS
1 ) Unstable blood glucose level due to infection and patient not adhering to their
diabetes dietary plan
Subjective data : Patient appears lethargic, exhaustion and polyuria
Objective data: Blood sugar ranges 12.0 mmol/l – 18.0mmol/l during admission till post
op
Goal : Blood glucose level decreased and maintained at normal levels
Nursing interventions
a) Assess and monitor blood glucose level at regular intervals as prescribed
Rational : To ensure that the blood glucose level is within target range – fasting (4.4 -
7.0 mmol/L ) and 2 hours post prandial (4.4 -8.5 mmol/L )
b ) Assess for signs of hypoglycemia or hyperglycemia – polydipsia, blurred vision ,
headache ,fatigue
Rational : To determine the appropriate treatment in maintaining target blood glucose
levels
c ) To explain patient and family on frequent dextrostix checking
Rational : Reduced anxiety also restless feeling to patient and family member
d ) Administer diabetic medication( insulin therapy )as prescribed
Rational : Maintaining normal glucose levels delays the advancement of complications
e) Educate patient on the importance of adhering to a meal plan
Rational : To maintaining stable blood glucose levels
f ) Assess the patient’s current knowledge and understand about the regular treatment
and particularly aerobic exercise
Rational : : Exercise decreases the blood glucose level as the demand for glucose
( energy ) in the cells increases with physical activity
Evaluation : The patient will maintain a blood glucose level of less than 7.8 mmol/L
and A1C below 5.7%
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2 ) Hypoglycemia related to patient not adhire to their diabetes dietry plan
Subjective data : Patient complaint of low appetite , clammy with sweaty , lethargy
Objective data : Dextrostix 3.8 mmol/L
Goal : To replace the insulin in the right amount
Nursing interventions
a) Assess for signs of hypoglycemia
Rational: The patient may feel dizziness ,headache ,hunger
b) Monitor the patient’s blood glucose level
Rational : A change in mental should always alert the nurse to obtain a glucose
c) Assess the sign symptoms and mental status
Rational :The nurse should closely monitor
d) Give a fast acting food or drink , such a orange juice ,honey or candy (15 gm)
Rational : A carbohydrate should be consumed to treat hypoglycemia
e) Educate the patient on the importance of maintaining its patency (using insulin
pump) after discharge
Rational : The needle or tubing in an insulin pump may become occluded which may
increase the patient’s risk DKA
f) Educate the patient on maintaining consistency in food , and the approximate time
interval between meals
Rational : Food intake is appropriate in hypoglycemia to raise blood glucose level
Evaluation: Patient will learn about the proper adherence to treatment and prevent
complication
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3) Risk for developing recurrent infection due to uncontrolled blood glucose
level
Subjective data :Patient verbalized complaint of fever , wound area warm
Objective data : WCC - 17.7
Goal : Patient will not get develop recurrent carbuncle
Nursing interventions
a) Assess vital signs and observe for any sign of infections and inflammation example
warm wound
Rational : Patient may be admitted with infections and ketoacidosis state in diabetic may
increase their risk for infection
b) Educate and teach patient and family how to perform proper hand hygiene
Rational : To maintain patient safety and reduce the risk for cross contamination
c) Maintain aseptic technique for iv insertion procedure administration of medications
Rational : To prevent cross infections
d) Administer prescribed antibiotics if an infection is found
Rational : To immediately treat an infection as healing can be slow for DKA patient
Evaluation: The patient will be able to avoid the development of worsening infection
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4) Pain related to post surgical incision and drainage
Subjective data : Patient complaint of pain at abdominal site
Objective data : Redness, BP 150/95 mmhg , HR : 120bpm , pain score 8/10
Goal : Patient will report relief as evidenced by reduce in pain
Nursing interventions
a) Monitor the patient’s vital sign and characteristics of pain
Rational : To monitor effectiveness of treatment
b) Assess and monitor pain using appropriate pain scale
Rational : Measurement pain score (1-10 )
c) Administer analgesic as prescribed by doctor - tablet Arcoxia 120 mg
Rational :Relief the patient of pain
d) Advise patient deep breathing exercise
Rational: To allow proper O2 supply in the body
e) Advise patient emphasize importance rest periods after every activity example
walking
Rational: Patient will release stress and increase relaxation
Evaluation: Pain relief and patient more comfortable in ward
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5 ) Risk for injury related to reduced visual due to high risk get retinopathy
Subjective data : Patient complaint of reduced visual
Objective data : Vision test done
Goal : Prevent trauma or injury by means doing activities
Nursing interventions
a) Assess the patient degree of visual impairment
Rational : To establish a baseline of visual
b ) Place the bed in the lowest position
Rational :To prevent or minimize injury of the patient
c ) Promote adequate lighting in the patient’s room
Rational :Patient safety and support to patient doing ADLs optimally
d ) Advise patient to wear sunglasses
Rational : To reduce and help protect the eye
e )Advice patient to proper follow up ophthalmology
Rational : Make sure patient get treatment before worsening
f ) Raise side rails on bed as needed
Rational :Prevent patient fall
Evaluation : Patient safety and maintain the ability to perform activities of daily living
without injury
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6) Risk for injury related to viral illness and immunocompromised status ( e.g.
diabetes and RVD )
Subjective data : To prevent injury in future
Objective data : To prevent the spread of infection
Goal : The patient will demonstrate ways to prevent the spread of infection
Nursing interventions
a) Monitor the patient’s vital sign and signs of infection
Rational :To conform the presence of infection
b) Encourage hygiene and explain the importance of proper hand washing
Rational :Hand washing is the single best way to prevent infections
c) Educate the patient about the disease – its transmission, complication, and available
help
Rational Patient can raise confident understanding of importance of sticking to the
guidelines
d) To proper took antiviral medication as prescribed
Rational :To prevent gets infections
Evaluation: Patient understand and know how to do when injury is happen in future
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HEALTH EDUCATION
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3) Diet
Advise patient to took regular meal 3 times per day in same time roughly
everyday , don’t skip or delay meal and avoid snacking
Advice patient to counting carbohydrate every meal and match it with how much
insulin need to take bolus ( patient on pump insulin )
Eat more fiber like vegetables and fresh fruit examples berries , guava , green
apple
Suggest to take food cooked grill bake or steam
Drink more plain water and cut down sugar beverages
Avoid alcoholic – to avoid a slow down complications of diabetes
Educate the patient about the health benefits and importance of exercise in the
management of diabetes -exercise plays role in lowering blood glucose and
reducing cardiovascular risk factor
Use a temporary basal to avoid high and low blood sugars
Know your blood sugar before starting exercise and never take insulin to cover
exercise related snacks
Advice do regular exercise 30 minutes 5 days per week with variety of exercise –
walking , swimming , cycling (150 min/week)
Check blood sugar before during and after exercise to find out hypoglycemia
or hyperglycemia
Carry something sugar to use it if hypoglycemia and bring someone to company
while doing exercise- prevent if anything happen
Wear comfortable sport wear and shoes to prevent injury
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5) Hygiene and wound care
Do dressing as ordered by doctor every day @ twice day at nearest clinic
Make sure take bath 2-3 times / day
Wash hand every time before and after toilet
If wound still not well healing or become worse to see doctor immediately
6) Follow up
Remind patient to come for follow –up endocrine clinic to monitor progress blood
sugar
Eye appointment 1 time per year for eye assessment
Dental appointment every 6 month if needed
To see diabetic educator if any problem or when to get other opinion in whatsApp
call
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8)Health education regarding complications of Diabetes Mellitus
Advise patient to get regular checkups to keep of your heart health
Follow a healthy diet
Aim for a ideal weight
Get active– being physically active makes your body more sensitive to insulin
Manage stress – can raise your blood pressure and can also lead to unhealthy
behaviors such as drinking too much alcohol or overeating
Take medicines as prescribed by your doctor
DIABETIC FOOT
DIABETIC FOOT
DIABETIC FOOT
DIABETIC FOOT
DIABETIC FOOT
DIABETIC FOOT
DIABETIC FOOT
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CONCLUSION AND OUTCOMES
Patient keen to come for regular follow –up with endocrine clinic and
diabetic educator to maintain good blood glucose control . Patient will arrive
ophthalmology clinic to participate in the procedure .
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SUGGESTION
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REFERRANCE
6) https://www.mayoclinic.org/diseases-conditions/boils-and-carbuncles/symptoms-
cause/syc-20353770
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