INDEX

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

8 Blood glucose monitoring pre& post op 11

Graf sliding
9 Blood glucose monitoring bolus 12
Graf bolus
10 Nursing diagnosis 13-18
11 Health education 19-22
12 Conclusion and outcomes 23
13 Suggestion 24
14 Reference 25
INTRODUCTION

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

Name: Lim Jia Hui

I/c No: 960611-56-5739
MRN: M751986
Age: 26 years
Race: Chinese
Gender: Male
Occupation: Cashier (Food & Beverage)
Height: 165cm
Weight : 50kg
BMI: 18.4KG/M (under weight)
Waist circumference: 85cm
Date of admission: 10/11/2022 (5B- Surgery 1)
Date of discharged: 14/11/2022
Address : 27 Jalan Bukit Permai , 2/2 Taman Bukit Permai 2 ,56100 Kuala Lumpur

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Presenting complaints

Patient complaints swelling abdominal area about 5 days , Initially erythematous at

middle site. Also self visited (GP) on Monday 07/11/2022 ,doctor given antibiotic and
analgesic.but symptoms did not resolved and claimed denied fever .After 2-3 days
patient had of severe pain (pain score 5/10) , redness , swelling ++ at anterior
abdominal wall.
On 10/11/2022 patient come to emergency department HCTM , doctor has
examined around abdomen area (carbuncle) ,size 8cm x8cm and punch hard over
border. Pus +++ seen and packed with gauze before proceed to operation. Iv Unasyn
3gm stat dose given .Patient also having Type 1 Diabetic Mellitus , dextrostix reading
12.5 mmol/l and claimed using pump insulin almost 5years .
Patient admitted to surgical ward (5B) for further management under surgery team
plan for Incision and Drainage (I &D). Start actrapid infusion according to sliding scale.
Patient keep NBM ( nil by mouth) last meal 8pm .

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

Past medical history

 Type 1 Diabetes mellitus since 4 years old
using insulin pump since 21yrs old
 Follow up Endocrine clinic HCTM
 RVD (+ve) since April 2019 , started on HAART( Highly Active Antiretroviral
Therapy)
Follow up KK Ampang

Past surgical history

 No any surgical history

 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

LIM JIA HUI

SISTER YOUNGER BROTHER
(DM TYPE 1)

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)

DIABETES EDUCATOR REVIEW

 Reinforced patient regarding diabetes care, sugar control ,insulin pump care ,
meal time 3 times perday most importance, stop smoking and alcohol , rotation
site injection
 Continue self – monitoring of blood glucose (SMBG) at home every meal
 Continue endocrine appointment 4/12 @ 09/3/2023 with (repeat blood ix FBC
,RP, ,LFT and HbA1c )

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

INVESTIGATIO 11/4/2022 14/7/2022 10/11/2022

N
HB 14.5
WCC 17.7
Platelet 428
CRP 3.83
HbA1c 11.9 % 14.6 %
FBG 13.46 mmol/L
TG 2.67
LDL 1.73
HDL 1.54
UREA 4.1
CREAT 69.7
PH 7.39
HCO3 23
GLUCOSE 17 ++
KETONE -(ve)

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 BLOOD GLUCOSE MONITORING

Date Time DXT (mmol/L) Actrapid infusion

10/11/2022 6 pm (ED) 12.0 3 mls /h
10pm 12.5 3 msl /h
11/11/2022 1am 12.6 3 mls /h
4am 16.0 4 mlsl/h
5am 16.0 4 mls /h
6am 12.5 3 mls/h
8am 8.6 2 mls/h
10am 9.4 2 mls/h
12pm 10.2 2 mls/h

Table 1 : Sliding scale pre & post op ( day 1)

Sliding scale pre & post op day 1

18
16 16
16

14
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)

Graf 2 : Sliding scale

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BLOOD GLUCOSE MONITORING

Date Time DXT (mmol/L) Medication

13/11/2022 6am 15.4 s/c novarapid 16 ii given
12pm 3.8 Omit – Dr Naufal noted
3pm 16.6 (repeat) s/c novarapid 16 ii given v/o by
Dr Naufal
6pm 13.9 s/c novarapid 16 ii given
10pm 10.2
14/11/2022 6am 9.4 s/c novarapid 16 ii given
12pm 8.8 s/c novarapid 16 ii given
6pm 9.0 s/c novarapid 16 ii given

Table 2 : Basal Bolus

18

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

1) SMBG – Self monitoring of blood glucose

 Advise patient to do SMBG every meal and record all the result in glucose diary
with additional food intake , physical activity
 Advice patient to do SMBG once sick ,stress level , hypoglycemia /
hyperglycemia symptoms occurs and record in diary
 Remind patient to bring the diary upon appointment with doctor
 Write down any possible reason for any changes in your blood sugar such as
type of food you eat , timing of insulin

2) Care of injection site and infusion therapy

 Explain to patient make sure with clean hands , wash and dry the skin site
thoroughly ,prepare as recommended, and dispose of needle properly
 Advice patient if change infusion site make sure it at least 3 hours before going
to sleep , This will allow to check whether or not the set is working properly
 Explain patient to check infusion rate , site and tubing , make sure that there are
no signs of infection at the site , that the infusion set is securely attached and that
there is no air in the tubing.
 Explain patient to change infusion set and site every 2-3 days as directed by your
doctor or pump educator
 If pregnant women may need to change their set and site every day
 Explained to the patient side effect of insulin hypoglycemia and hyperglycemia,
educate regarding management
 Re-educate about injection sites around the body example abdomen for adult ,
buttocks for young children. , thighs , hip and upper arm also are used.
 Keep track of your injections sites and inject about 2 inch away from a previous
site
 Stored new insulin cartridge in the refrigerator with date ( temperature 2-8 ‫ﹾ‬c )
 Explain to patient a higher risk for developing ketones on pump therapy. This is
because long-acting insulin are not used , and raping -acting insulin is delivered
in extremely small amounts.If basal insulin delivery is interrupted heck blood
sugar and ketone.If still continue to not get insulin, blood glucose and ketone
levels may increase into a dangerous range.

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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

4 )Traveling with Pump Therapy

 Advise patient take extra supplies remember to bring a backup pump , syringe
and bottle of long acting insulin
 Advise patient to inform security screeners that you wear an insulin pump and
are caring diabetes supplies
 Explain patient to understand that your insulin pump may trigger metal
detectors .Do not disconnect your insulin pump for inspection

4) Exercise with Pump Therapy

 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

7) Stop smoking and alcohol

 Advise patient to quit smoking –nicotine increases blood sugar level and
smoking slows the process of wound healing
 Stop alcohol to prevent worsen blood sugar control , example long -term alcohol
use in well – nourished diabetics can result in excessive blood sugar level.

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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

Upon discharge patient able to understand diabetes mellitus is a

chronic disease that requires continues medical treatment to delay complications.
Patient also understand all education advises given and promised to improved
himself to be better person , compliance to medication , stop smoking and
alcohol and will doing lifestyle modification. Patient also noted importance of
hygiene to prevent infections due to recurrent carbuncle .

Follow up via phone done .Patient claimed try to manage himself

especially diet pattern and blood glucose control .Patient started took meal 3
times per/day and avoid snacking .Self-monitoring of blood glucose ( SMBG )
done every meal and count carbohydrate .The lowest fasting level was 7.0
mmol/L and the highest was 8.5 mmol/L , no hypoglycemia symptoms occur.
Also recorded to the diary.

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 .

Involvement of family members and caregivers when appropriate

should be encouraged . Diabetic educator must work together with patients and
their families to teach diabetes self management and advised patient healthy
lifestyle . Advances in technology have provided more efficient means of
monitoring diabetes and maintaining glycemic control in an outpatient setting .

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 SUGGESTION

 To advise patient making healthier food choices is important to manage your

diabetes and to reduce your risk of diabetes complications. We know that not
everyone agrees on what is the best diet .
 As a patient type 1 diabetes , make sure carb counting is really importance to
keep blood glucose level steady . This is where as a patient estimate how many
carb are in your meal and match it with how much insulin need to take .
 Reinforce patient regarding stop taking alcohol – alcohol is high in calories .If
take insulin or other diabetes medications , it’s also not good idea to drink on an
empty stomach .This is because alcohol can make hypo more likely to happen.
 To promote diabetes prevention through social media campaigns or radio
announcements
 Suggest to write about healthy lifestyle choices in your community ,school and
newspaper
 Donate a diabetes magazine subscription or diabetes related books to library
 Invite a role model with diabetes to local school / department to talk about
healthy lifestyle
 Donate needed exercise equipment to a community center or school

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 REFERRANCE

1 ) Gulanick, M., & Myers, J. L. (2022).

Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO:
Elsevier.
2 ) Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M.
(2020).
Nursing diagnoses handbook: An evidence-based guide to planning care. St.
Louis, MO: Elsevier. Buy on Amazon
3 )Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M.
(2020). 
Nursing diagnoses handbook: An evidence-based guide to planning care. St.
Louis, MO: Elsevier. 

4 ) Gulanick, M.,& Myers, J.L.(2017).

Nursing care plans: Diagnoses , interventions, outcomes .St. Louis ,Mo:
Elsevier.
5) http://www.medtronicdiabetes.com/treatments/insulin-pump-therapy

6) https://www.mayoclinic.org/diseases-conditions/boils-and-carbuncles/symptoms-
cause/syc-20353770

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