DLMC Case Study Presentation

LIPA CITY COLLEGES OF NURSING
Case Study Presentation

Abscess, Left Ankle, DM Type 2
Group Members:
Maria Ella Allianah B. Alip
Ariane B. Barretto
Jenalyn R. De Castro
Clarisee C. Guevarra
Angel Fatima H. Magleo
Andrea Mae R. Mercado
Trixia Mae M. Rempiloo
Krizha Mae M. Valencia
Ar-Jay D. Cardenas
Karl Justine B. Dimaano
Gerald R. Polopot
Presentation
12/10/2022
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Table of Contents
I. Introduction 3
 General Objectives
 Specific Objectives
II. Case Description 4
III. Patient’s Profile 5
IV. Health History of The Patient 6
V. Review of Systems 7
VI. Physical Assessment 8
VII. Anatomy and Physiology 11
VIII. Pathophysiology 15
IX. Laboratory and Diagnostic Tests 17
X. Nursing Care Plan 1 23
XI. Nursing Care Plan 2 25
XII. Nursing care Plan 3 27
XIII. Nursing Care Plan 4 30
XIV. Drug study 32
XV. Course in the ward 46
XVI. Discharge Plan 48
XVII. Prognosis 49
XVIII. References 50
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Patient’s Profile
Name: Patient A (Isidro Concepcion)

Age: 61 yo
Sex: Male
Birthday: March 12, 1960
Civil Status: Married
Occupation: Truck Driver
Height: 172 cm
Weight: 78 kg
BMI: 26.4 (Overweight)
Date of Admission: Sept 12, 2021

VITALS:
BP = 140/80 mm Hg
T = 38.2 ℃
P = 95 bpm
R = 20 bpm
O2 sat = 96%
CHIEF COMPLAINT: fever and swelling on the wound
ADMITTING/INITIAL DIAGNOSIS
Abscess, Left Ankle
FINAL DIAGNOSIS
Abscess, Left Ankle, DM Type 2
S/P Incision and Drainage under IV Sedation
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History of the Patient
 HISTORY OF PRESENT ILLNESS

10 days PTA, pt. had a traumatic fall. Open wounds on the left ankle and bruises all
over the body. No medical consultation was made but seek advice from albularyo and
unknown herbal medication was applied on the wound.
NOI: Fall
POI: Amore St., Kalamansian, Bats. City
DOI: 9-2-21
TOI: 10:00 am
5 Days PTA, patient develop fever and redness was observed.
3 Days PTA, patient noted swelling and pain on the wound
1 day PTA, patient is unable to walk.
 PAST MEDICAL HISTORY

No known comorbidities,
No history of previous hospitalizations and surgery.
 ALLERGIES
No known Allergy to Food and Drugs
 FAMILY HISTORY
His mother has Diabetes Mellitus Type 2
His father is known Hypertensive and Diabetic. Died at age of 82 of Myocardial
Infarction.
 LIFESTYLE & SOCIAL HISTORY

He was living with his wife and 5 children. His salary is enough for the daily expenses.
He has a good relationship with his friends and neighbours. He seeks advice primarily
from Albularyo. He takes herbal medicines and some OTC drugs. He has not had any
medical consultation. He was a smoker for 20 years at least 6-7 sticks per day and
known alcohol drinker for 20 years at least 1 bottle of gin (bilog) a day. He denies use of
illegal drugs.
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Review of Systems
GENERAL CONDITION
Patient arrived via stretcher. Conscious and coherent. In pain with pain scale of 7/10.
HEAD & NECK
No problem with conjunctiva and sclera, no sign of jaundice. Dry lips, no oral
candidiasis. Supple neck. Showed facial grimace.
CARDIOVASCULAR SYSTEM
Normal HR without murmurs.
RESPIRATORY SYSTEM
Clear breath sounds. No crackles, wheezing heard. No use of accessory muscle.
ABDOMEN
Umbilicus was centrally located, inverted, no scars. Normoactive abdomen, No mass
and tenderness.
GU SYSTEM
No problem with Genito-Urinary system.
MUSCULOSKELETAL SYSTEM
Infected wound at L/ankle. Redness and warm sensation in area. In pain with pain scale
7/10. Wound was swollen w/pus draining from wound. Unable to walk and bare weight
of the body due to pain.
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Physical Assessment
A method of head-to-toe physical examination is conducted. The penlight, thermometer,

sphygmomanometer, tape measure, as well as the senses and stethoscope. Inspection,
palpation, percussion, and auscultation techniques are used to conduct this process in a
systematic manner. In addition to comforting the client, acknowledge and respect their
feelings and take the necessary safety measures.
Date Performed: September 12, 2021

General Physical Examination
General condition: Patient is a 61 years old male, stands 172 cm. Patient arrived via
stretcher. He is conscious and coherent. Patient is in pain with pain scale of 7/10. Vital
signs taken upon admission as follows:
Vital Signs:
Temperature Pulse Respiration Blood O2 sat Height Weight BMI
Rate Rate Pressur
e
38.2 0C 95 bpm 20 bpm 140/80 96% 172 cm 78 kg 26.4
mm Hg
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AREA/SYSTEM NORMAL FINDINGS INTERPRETATION

FINDINGS
Neurological Conscious Conscious Findings in the
neurological are
Clear Speech Coherent normal
Coherent
Oriented to date,
time, place, and
person
Head and Neck (-) masses, Conjunctiva was Findings in the
tenderness, or not pale head and neck are
enlargement normal except the
Sclera is white lips were dry.
Conjunctiva is
transparent; no (-) jaundice
swelling
Lips were dry
Sclera appeared
white (-) Oral candiasis
No changes in Supple neck

vision
(+) Facial Grimace
Be able to hear
clearly
Nose is
symmetrical and no
presence of
discharge
Moved head with

no discomfort
Respiratory (-) DOB (-) DOB No signs of DOB
(-) SOB (-) SOB and SOB.
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RR: 15-20 bpm RR: 20 bpm Respiratory rate is
within normal range
Cardiovascular HR: 60-100 bpm HR: 95 bpm Within normal rang
Genitourinary (-) signs of infection (-) signs of infection No signs of

mass noted on the mass noted on the infection
genetalia. genetalia.
(-) pain during (-) pain during

urination urination
Circulatory BP: 130/90 mm Hg BP: 130/90 mm Hg The blood pressure
indicates Stage 2
BP: 140/80 mm Hg hypertension
Musculoskeletal Normal Muscle Infected wound at Findings results

Tone the left ankle. that there is
infected wound as
Normal Muscle Redness and warm evidenced redness
strength sensation on the and warm
area. sensation on the
area and with pus
Pain felt with Pain draining on the
(-) pain during Scale 7/10. wound.
movement
Wound was swollen
(-) Deformities, with pus draining
redness, from the wound.
tenderness or
swelling, and Pain is unable to
masses walk and bare the
weight of the body.
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Anatomy & Physiology
RESPIRATORY SYSTEM
Breathing is the process that brings oxygen in the air into your lungs and moves oxygen
and through your body. Our lungs remove the oxygen and pass it through our
bloodstream, where it's carried off to the tissues and organs that allow us to walk, talk,
and move. Our lungs also take carbon dioxide from our blood and release it into the air
when we breathe out.
o SINUSES
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- The sinuses are hollow spaces in the bones of your head. Small openings
connect them to the nasal cavity. The sinuses help to regulate the temperature
and humidity of air your breathe in, as well as to lighten the bone structure of the
head and to give tone to your voice.
o NASAL CAVITY
- The nasal cavity (nose) is the best entrance for outside air into your respiratory
system. The hairs that line the inside wall are part of the air-cleansing system.
- Air can also enter through your ORAL CAVITY (mouth), especially if you have a
mouth-breathing habit or your nasal passages may be temporarily blocked.
o ADENOIDS
- The adenoids are overgrown lymph tissue at the top of the throat. When your
adenoids interfere with your breathing, they are sometimes removed. The lymph
system, consisting of nodes (knots of cells) and connecting vessels, carries fluid
throughout the body. This system helps your body resist infection by filtering out
foreign matter, including germs, and producing cells (lymphocytes) to fight them.
o TONSILS
- The tonsils are lymph nodes in the wall of your pharynx. Tonsils are not an
important part of the germ-fighting system of the body. If they become when
infected, they are sometimes removed.
o PHARYNX
- The pharynx (throat) collects incoming air from your nose and passes it

downward to your trachea (windpipe).
o EPIGLOTTIS
- The epiglottis is a flap of tissue that guards the entrance to your trachea. It

closes when anything is swallowed that should go into the esophagus and
stomach.
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o LARYNX
- The larynx (voice box) contains your vocal cords. When moving air is

breathed in and out, it creates voice sounds.
o ESOPHAGUS
- The esophagus is the passage leading from your mouth and throat to your
stomach.
o TRACHEA
- The trachea (windpipe) is the passage leading from your pharynx to the

lungs.
o RIBS
- The ribs are bones supporting and protecting your chest cavity. They

move a small amount and help the lungs to expand and contract.
o The trachea divides into the two main BRONCHI (tubes), one for each lung. The
bronchi, in turn, subdivide further into bronchioles.
o The RIGHT LUNG is divided into three LOBES, or sections.
o The left lung is divided into two LOBES.
o PLEURA
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- The pleura are the two membranes that surround each lobe of your lungs
and separate the lungs from your chest wall.
o The bronchial tubes are lined with CILIA (like very small hairs) that have a wave-
like motion. This motion carries MUCUS (sticky phlegm or liquid) upward and out
into the throat, where it is either coughed up or swallowed. The mucus catches
and holds much of the dust, germs, and other unwanted matter that has invaded
your lungs. Your lungs get rid of the mucus through coughing.
o DIAPHRAGM
- The diaphragm is the strong wall of muscle that separates your chest

cavity from your abdominal cavity. By moving downward, it creates suction
to draw in air and expand the lungs.
o BRONCHIOLES
- The smallest section of the bronchi, at the end of which are the alveoli
(plural of alveolus).
o ALVEOLI
- The alveoli are the very small air sacs that are the destination of air that
you breathe in.
o CAPILLARIES
- The capillaries are blood vessels that are imbedded in the walls of the

alveoli. Blood passes through the capillaries, brought to them by
the PULMONARY ARTERY and taken away by the PULMONARY VEIN.
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While in the capillaries, the blood moves carbon dioxide into the alveoli
and takes up oxygen from the air in the alveoli.
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Laboratory Findings & Diagnostic Test

Blood Test Reference Values
Sodium: 141mEq/L 135-147mEq/L

Potassium: 3.52 mEq/L 3.5-5.2 mEq/L
Chlorides: 99 mEq/L 95-107 mEq/L
Creatinine: 100 umol/L 46-92 umol/L
BUN: 5.13 mmol/L 2.86-8.20 mmol/L
SGPT (ALT): 21 U/L 0.00-50 U/L
RBS: 252 mg/dl 79 – 140 mg/dl
RBS 1hr PTOR: 157 79 – 140 mg/dl
FBS: 103 mg/dl 80-100 mg/dl
HBSAG: Non-Reactive
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URINALYSIS
Color: light yellow
Transparency: clear
Specific gravity: 1.012
pH: 7.45
WBC: 1-2/hpf
Protein: negative
Glucose: +
RBC: 0-1/hpf
Squamous: 0-1/hpf
Bacteria: few
Amorphous Urates: few
Chest PA
Results:
Both Lungs are clear and expanded with no
infiltrates.
Heart Size Normal.
Calcified Right Hilar are present.
Impression:
Normal Chest Findings
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Ankle Xray
Presence of abscess on the left ankle

No Fracture
Impression:
Abscess, Left ankle
COVID-19 RAPID ANTIGEN TEST
RESULTS: Negative
Wound GSCS
Date of Admission: 9-12-21 Specimen Type: Wound
Date of Collection: 9-12-21 Location: Left ankle
Results:
Organism: Staphylococcus aureus
Gram Stain: +
Amoxicillin/Clavulanic acid S < 4mcg/ml Meropenem S < 1mcg/ml
Ampicillin- Sulbactam S 17mm
Cefuroxime S < 4mcg/ml
Cefoxitin S < 4mcg/ml
Gentamycin S < 2mcg/ml
Piperacillin-Tazobactam S < 4mcg/ml
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COMPONENT NORMAL VALUES RESULT INTERPRET ROLE/FUNCTION
ATION
Hematocrit Male: 42- 54 vol% 44 NORMAL The hematocrit test, commonly known
as the packed-cell volume (PCV) test, is
a basic blood test. It determines the
Female: 35-46 vol% percentage of red blood cells in your
blood. Red blood cells transport oxygen
throughout your body. Having too few
or too many red blood cells might
indicate the presence of certain
disorders.
Hemoglobin Male: 14-18 g% 14.0 NORMAL It determines the level of hemoglobin in

your blood. Hemoglobin is a protein
Female: 12-16 g% found in red blood cells that delivers
oxygen to organs and tissues and
carbon dioxide from organs and tissues
back to the lungs.
WBC count 5,000-10,000/cumm 13,500/ HIGH WBC is a kind of blood cell that aids in
cumm disease resistance. WBC are created in
the bone marrow by stem cells and are
located in the blood and lymph tissue.
WBC are also known as leukocytes.
DIFFERENTIAL COUNT NORMAL VALUE RESULT INTERPRETATI ROLE/FUNCTION

ON
Segmenter 0.42 – 0.65 0.80 HIGH The term segmenters refers to

neutrophils, which are a kind of
white blood cell. The majority of
cells that react to bacterial
infections are segmenters.
Lymphocyte 0.24 – 0.05 0.50 NORMAL Lymphocytes are white blood
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cells that serve as one of the
body's primary immune cells.
They are produced in the bone
marrow and can be detected in
the blood and lymph tissue.
Monocyte 0.04 – 0.11 0.19 HIGH Monocytes are the most

numerous forms of white blood
cell. These immune cells
circulate in the circulation for
many days before becoming
macrophages or dendritic cells in
the tissues. Monocytes are
antiviral, antibacterial,
antifungal, and antiprotozoal.
Eosinophil 0.01 – 0.10 0.01 NORMAL Eosinophils are white blood cells
that are released in response to
allergy responses, skin problems,
parasite and fungal infections,
autoimmune illnesses, some
malignancies, and bone marrow
abnormalities.
Platelet count 150,000-400,000/ 334, 000/ NORMAL A platelet count is a blood test
cumm cumm that determines the number of
platelets in your blood. Platelets
are cells that aid in blood
clotting.
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RBC COUNT 4.20-6.30 m/ ul 4.33 NORMAL The purpose of red blood cells is
to transport oxygen from the
lungs to the tissues throughout
the body. They also serve an
important role in transporting
waste carbon dioxide from your
tissues to your lungs, where it
may be expelled.
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Nursing Care Plan 1
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Nursing Care Plan 2
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Nursing Care Plan 3
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Nursing Care Plan 4
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Course In The Ward
Date of Admission: (Sept. 12, 2021) – 9am

 BP: 140/80 mmHg and Temp: 38.2oC
 Patient has fever and swelling on the wound
 Patient was admitted DAT, then was placed NPO post-midnight.
 Patient was given IVF: PLR 1L to run at 60 cc/hr.
 Laboratory including: CBC with platelet count, Blood typing, HBSAG, Wound
GSCS, Chest x-ray PA, Xray of the Left Ankle, 12 LECG, Na, K, RBS, BUN,
Crea, SGPT, UA, Covid Antigen were requested.
 CBC results with high WBC:13,500 cells/cu.mm, Non-Reactive HBSAG, Wounds
G5CS has no result but with staphylococcus Aureus and a positive gram stain.
 Patient chest x-ray PA and 12 LECG showed normal results, then X-ray LA
showed an impression of abscess, left ankle.
 RBS showed hyperglycemia (RBS: 252mg/dL) and high level of creatinine
100umol/L. UA is light yellow and clear, then Negative Covid Antigen.
 Patient was given Tetanus Toxoid 0.5ml IM now, Tetagam 250IUIM now,
Monowel 1gm IV Q8 ANST, Ketomed 30mg IV Q8 and Mupirucin Ointment on
affected area 3x a day.
 Performed wound care.
 Vital signs were monitored q4 and fluid input and output q shift.
Date of Admission: (Sept. 12, 2021) – 12nn

 Patient’s blood pressure and temperature became normal.
 Patient wound has redness, swelling and pus draining with a pain scale on rest of
7/10 and was unable to walk.
 Patient will undergo for incision and drainage under IV Sedation tomorrow at
8am.
Date of Admission: (Sept. 12, 2021) – 1pm

 Patient’s vital signs, CXR and ECG are all normal and with an RBS of 252 mg/dl.
 Patient have no objection for contemplated procedure with no cardio-pulmonary
risk.
 Performed FBS in the morning.
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 Monitor RBS 1 hr. prior to OR and administer Hum R 4 units for RBS to be
greater than 180 mg/dl.
Date of Admission: (Sept. 12, 2021) – 9pm

 Patients vital signs are all normal.
 Patient experienced good wound healing with a pain scale of 1/10.
 Patient was advice to go home.

 The following home medicine given:
1. Co-Amoxiclav 625mg tab 2x a day for 7days.
2. Celecoxib 200 mg tab 2x a day as needed for pain.
 Given a wound care.
 Scheduled for a follow-up on Sept. 22, 2021, 9am at MAB RM 517.
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Discharge Plan
•Home Mediations instructed as follows:

- Co-Amoxiclav 625mg tab 2x a day for 7days
-Celecoxib 200mg tab 2x a day as needed for pain
- Wound Care
• Instructed on follow up check ups:

-Dr.cAssissimo:
-Dr. Gualberto:
•Home Instructions:
Diet: low carbohydrates, low sugar diet
Activities:
- daily wound dressing
- instructed not to scratch and rub his skin
- advised not to engaged on strenuous activities
- instructed to adhere on his drug therapy treatment especially his oral hypoglycemic
medications
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Prognosis
 Negative Prognosis:
If the patient was not treated properly due to his non compliance to the management,
especially if his blood sugar level was not controlled and normalized, there is a
possibility of Below Knee Amputation.
A below-knee amputation (BKA) is an amputation often performed for foot and ankle
problems. The BKA often leads to the use of an artificial leg that can allow a patient to
walk. A BKA is performed roughly in the area between the ankle and knee. This
amputation provides good results for a wide range of patients with many different
diseases and injuries.

 Positive Prognosis:
if the patient was treated properly and compiled on his medications and management,
blood sugar was normalized, there is a good chance of wound healing. Encouraged the
patient to live a healthy lifestyle and have a proper diet so that further complications of
his diabetic condition may be prevented.
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LIPA CITY COLLEGES OF NURSING

Case Study Presentation

Name: Patient A (Isidro Concepcion)

Date of Admission: Sept 12, 2021

CHIEF COMPLAINT: fever and swelling on the wound

History of the Patient

 HISTORY OF PRESENT ILLNESS

 PAST MEDICAL HISTORY

 LIFESTYLE & SOCIAL HISTORY

A method of head-to-toe physical examination is conducted. The penlight, thermometer,

Date Performed: September 12, 2021

AREA/SYSTEM NORMAL FINDINGS INTERPRETATION

No changes in Supple neck

Moved head with

Genitourinary (-) signs of infection (-) signs of infection No signs of

(-) pain during (-) pain during

Musculoskeletal Normal Muscle Infected wound at Findings results

Anatomy & Physiology

- The pharynx (throat) collects incoming air from your nose and passes it

- The epiglottis is a flap of tissue that guards the entrance to your trachea. It

- The larynx (voice box) contains your vocal cords. When moving air is

- The trachea (windpipe) is the passage leading from your pharynx to the

- The ribs are bones supporting and protecting your chest cavity. They

o The RIGHT LUNG is divided into three LOBES, or sections.

o The left lung is divided into two LOBES.

- The diaphragm is the strong wall of muscle that separates your chest

- The capillaries are blood vessels that are imbedded in the walls of the

Laboratory Findings & Diagnostic Test

Sodium: 141mEq/L 135-147mEq/L

Presence of abscess on the left ankle

COVID-19 RAPID ANTIGEN TEST

Hemoglobin Male: 14-18 g% 14.0 NORMAL It determines the level of hemoglobin in

DIFFERENTIAL COUNT NORMAL VALUE RESULT INTERPRETATI ROLE/FUNCTION

Segmenter 0.42 – 0.65 0.80 HIGH The term segmenters refers to

Lymphocyte 0.24 – 0.05 0.50 NORMAL Lymphocytes are white blood

Monocyte 0.04 – 0.11 0.19 HIGH Monocytes are the most

Nursing Care Plan 1

Nursing Care Plan 2

Nursing Care Plan 3

Nursing Care Plan 4

Course In The Ward

Date of Admission: (Sept. 12, 2021) – 9am

Date of Admission: (Sept. 12, 2021) – 12nn

Date of Admission: (Sept. 12, 2021) – 1pm

Date of Admission: (Sept. 12, 2021) – 9pm

 Patient was advice to go home.

•Home Mediations instructed as follows:

• Instructed on follow up check ups:

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