Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

COMPREHENSIVE CLINICAL CASE ANALYSIS

CHAPTER 1: ASSESSMENT
A. Introduction:
Learning objective:

In this case the learners will have an opportunity to:

1. Review the etiological factors (i.e., risk factors, prevalence, comorbidities) associated
with tissue abscess
2. Build knowledge related to the patient’s experience of swelling on the lower extremities
3. Continue to develop comprehensive assessment, monitoring skills, and abilities
(physical assessment, diagnostic studies, laboratory data)
4. Develop and justify optimal therapy based on the current understanding of the
pathophysiology of tissue abscess and available of clinical evidence
5. Recommend interventions based on the risk factors, status, and progression
6. Define the roles of healthcare professionals and the healthcare team

B. Nursing Health History

a) Personal Data
Patient’s Name: Sañosa, Remedios Rosal
Age: 83
Birth Date: 02-05-1940
Sex: Female

Admission:
Date: 02-24-2023 (11:30 pm)
Admitting Physician: Dr. W. Consuegra

b) Chief Complaint: Swelling on lower extremities

Diagnosis: Soft tissue abscess, right foot

c) History of the present illness

Patient was admitted on February 24, 2023 at 11:30 pm with complain of + swelling at
right leg and foot

d) Family Health History (predisposing Factors)

N/A

e) Social History (precipitating Factors)

N/ A
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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

C. Physical Examination (Head to Toe)

- Extremities: Edema on both leg, blisters and abrasion

Review of Systems
General: Swelling
Neurological: N/A
Respiratory: Difficulty of Breathing
Cardiovascular: N/A
Gastrointestinal: N/A
Urinary: N/A
Hematologist: N/A
Genital: N/A
Musculoskeletal: N/A
Psychiatric: N/A
Clinical Impression: Electrolyte Imbalance, CKD, super impose bacterial wound
infection, leg and foot

D. Definition and description of the disease

Skin or Soft Tissue Abscess - An abscess is a pocket of infected fluid with a thick wall around
it. Skin or soft tissue abscesses occur when bacteria get into tissue below the outer layer of
skin.
Most of the time an abscess forms when bacteria enter a break in the skin. For example,
an abscess might develop when a hair becomes ingrown or when the skin is scratched or poked
with something sharp. As more bacteria grow (multiply) in the skin or soft tissues, the body
responds by forming a wall around the area to help keep the bacteria from spreading to other
parts of the body. The bacteria in this pocket continue to multiply and as they do, the pocket
becomes more swollen. Some of the bacteria may get through the wall and cause an infection
of the tissues around the abscess or even get into the blood and infect other parts of the body.
Often abscesses occur when hair follicles or sweat glands get infected or after minor
scrapes or puncture wounds.
Abscesses are more common in people who have diabetes or poor circulation, and in people
whose immune systems are weakened.

E. Assessment ( Gordon’s 11 Functional Health Pattern)

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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Functional Health Assessment Data Nursing Diagnosis

Pattern
Health Compliance with medication regimen, Risk for aspiration
Perception/Health use of health promotion activities such
Management as regular passive assistive range of
motion.
Nutritional-Metabolic Presence of wound; blisters cellulitis; Risk for infection
thin gray hair; underweight
Elimination Voiding patent N/A
Activity- Exercise Passive ROM exercises Activity intolerance related
to increased metabolic
demand as evidenced by
reports of weakness.
Cognitive-Perceptual Inability to remember, think, or make Risk for fall
decisions.
Sleep-Rest Disturbed sleep pattern Disturbed sleep pattern
Self-Perception/Self- Impaired sensory and motor skills. Disturbed body image
Concept
Role-Relationship Mother/Grandmother Ineffective role
performance
Sexuality- Sexually incapable N/A
Reproductive
Coping/Stress Emotional support provided by SO. Family Coping
Tolerance
Value-Belief Religious affiliation, what client Readiness for Enhanced
perceives as important in life, value Spiritual Well-Being.
belief conflicts related to health, special
religious practices.

F. Anatomy and Physiology (only the organ system involve with drawing)
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

PARTS AND ITS FUNCTIONS:

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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Facts about the skin

The skin is the body's largest organ. It covers the entire body. It serves as a protective
shield against heat, light, injury, and infection.

Epidermis The epidermis is the thin outer layer of

the skin. It consists of 3 types of cells:
Squamous cells. The outermost layer is
continuously shed is called the stratum
corneum.
Basal cells. Basal cells are found just
under the squamous cells, at the base of
the epidermis.
Melanocytes. Melanocytes are also found
at the base of the epidermis and make
melanin. This gives the skin its color.

Dermis The dermis is the middle layer of the skin.

The dermis contains the following:
● Blood vessels
● Lymph vessels
● Hair follicles
● Sweat glands
● Collagen bundles
● Fibroblasts
● Nerves
● Sebaceous glands

The dermis is held together by a protein

called collagen. This layer gives skin
flexibility and strength. The dermis also
contains pain and touch receptors.

Subcutaneous fat The subcutaneous fat layer is the deepest

layer layer of skin. It consists of a network of
collagen and fat cells. It helps conserve
the body's heat and protects the body
from injury by acting as a shock absorber.

G. Pathophysiology of the disease process in schematic diagram (includes signs &

symptoms)
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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

H. Clinical Manifestations:

Signs and symptoms

❖Heart palpitations.
❖Extreme tiredness (fatigue).
❖Muscle weakness and spasms.
❖Tingling and numbness

Chapter II: Planning

A. List of prioritized Nursing Diagnosis

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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Impaired skin integrity related to bacterial infection as manifested by redness, itching,

swelling of the right leg & foot
 Risk for unstable Blood Glucose related to activity level
B. Nursing care plan

Cues Nursing Planning Nursing Rationale Expec

Dx Interventions Outco
Subjective: Impaired Short – Term Independent: Short Ter
“Makati itong part skin Goal: >Identify underlying >To asses
na ito tapos integrity cause/conditions involved. causative/
namamanhid din” related to After 8 hours Contributing After 8 ho
as verbalized by the bacterial of rendering factors. nursing
patient infection nursing intervent
as interventions, >Inspect skin on a daily >To assist with the patien
manifested the patient/SO basis, describing lesions correcting/ was able
Objective: by will be able to: and changes observed. minimizing
>Changes to skin redness, condition and
color itching, >understand promote optimal >underst
> Warmth on the swelling of the factors healing. the factor
skin the right affecting the affecting
> Observed open leg & foot condition >Note changes in skin color >To assess extent condition
areas or and texture. of involvement /
breakdown, > SO will be injury.
excoriation able to >Maintain clean, >SO was a
perform and >Demonstrate good skin dry skin provides perform a
assist the hygiene e.g. wash a barrier to assist the
patient with thoroughly and pat dry infection. patient w
basic carefully. basic
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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

management >To assist body’s managem

and safety >Keep the area clean/dry natural process of and safet
measures. and stimulate circulation to repair. measures
surrounding areas.
>To promote
>Review importance of skin wellness.
and measures to maintain
proper skin functioning.

Dependent/
Collaborative:
>To relieve
>Assist nurse on duty in inflammation
give prescribed IV
meds as indicated.
>To prevent
>Ensure adequate dietary malnutrition &
intake, review dieticians delayed healing
recommendation.
>To
> Administer (antibiotic) as decrease/reduce
ordered. invading bacteria

Long – Term
Goal:

After Long-Ter
weeks/months goal:
of nursing
interventions,
the client’s After
skin will have weeks/m
reduced of nursing
further the intervent
impairment of the client
the skin for had slight
the promotion reduced o
or recovery recovered
about the
condition.

Risk for Physical *Short term *Dependent

Subjective unstable Activity helps >After 8 hrs. of duty,the SO >Monitor Blood •To ensur
--- Blood controls blood will acknowledge factors that Glucose Level blood gluc
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Objective: Glucose sugar levels. may lead to unstable blood atleast once a day level is wi
CBG @ 03/1/23:5.97 related to Without glucose level of the client. or depends upon target ran
mmol/l; activity Physical >SO and cient will initiate to the scheduled
CBG @03/03/23: level Activity,theres formulate a plan to prevent time. •To keep
6.57 mmol/l No change in or minimize shifts in glucose >Administer Glucose le
>Lethargic;consciou glycogen. level antiabetic meds within nor
s but incoherent Muscles cannot (linaglipitin)as range,effe
respond to *Long term prescribed. controllin
insulin as the >After 16 hrs of duty the pt. Blood Glu
glycogen are will maintain a blood glucose Level and
still level within the normal range reducing r
full,therefore blood ves
Blood Glucose damage,n
will damage,k
remain ,insulin injury and
continue to complicati
release and
sustained
insulin release *Independent
can lead to -To determ
>Asses for signs of
elevated Blood appropria
hyperglycemia or
Glucose. treatment
hypoglycemia such
maintainin
as
target Blo
weakness,numbnes
glucose le
>Encourage patient
to increase -Physical a
minimal movement helps con
or do relaxation blood sug
technique such as level by m
breathing exercise the body
sensitive t
insulin.
>Encourage patient
to adhere to his
-Low fat lo
dietary plan which
calories d
is LSLF, and low
high fiber
sugar diet
are ideal f
unstable b
*Collaborative
glucose le
•Advise SO in
planning of
•This help
managing Blood
manage th
glucose level of the
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

client such as help cond

insulin therapy.

Chapter III: Implementation

A. Medical Management:

a.) Name of Diagnostic Procedure

● Urinalysis
● CBC
● SARS-CoV-2
● Electrolytes Monitoring
● Cardiac Marker
● Glucose Monitoring

b.) Definition/Description
 Urinalysis - A urinalysis is a test of your urine. It's used to detect and manage a wide
range of disorders, such as urinary tract infections, kidney disease and diabetes.
 CBC - A complete blood count (CBC) is a blood test used to evaluate your overall health
and detect a wide range of disorders, including anemia, infection and leukemia.

 Electrolyte Monitoring- an electrolyte test is a blood test that measures if there’s an

electrolyte imbalance in the body. Electrolytes are salts and minerals such as sodium,
potassium, chloride and bicarbonate, which are found in the blood they can conduct an
electrical impulses in the body
 Cardiac marker- Cardiac markers are biomarkers measured to evaluate heart function.
They can be useful in the early prediction or diagnosis of disease. Although they are
often discussed in the context of myocardial infarction, other conditions can lead to an
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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

elevation in cardiac marker level. Most of the early markers identified were enzymes,
and as a result, the term "cardiac enzymes" is sometimes used. However, not all of the
markers currently used are enzymes.
 Glucose monitoring- Regular blood sugar monitoring is the most important thing you
can do to manage type one or type two diabetes. You’ll be able to see what makes your
number go up or down such as eating different foods taking a medicine or being specific
physically active

Laboratory Results:

ELECTROLYTES
TEST RESULT NORMAL VALUES

Sodium (Na+) 142.3 135.00 - 155.00 mmol/l

Potassium (K+) 3.42 3.50.-5.50 mmol/l

Chloride Cl- 100.2 98.00 - 108.00 mmol/l

Ionized Calcium 1.23 1.15 - 1.35 mmol/l

CARDIAC MARKER
TEST RESULTS NORMAL VALUE

Troponin T 20.49 0 -14.0 pg/ml

NT-pro BNP 56.1 < 75 years old:

0 - 300 pg/ml
>75 years old:
0 - 450 pg/ml

CHEMISTRY
RESULT UNIT REFERENCE RANGE

GLUCOSE 5.97 mmol/L [4.11 - 5.89]

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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

DATE & TIME PROGRESS NOTE PROGRESS NOTE

02-24-2023 ● IVF: PNSS 1L x @ 20

gtts/min.
● Low fat, Low salt diet
● Apply mupirocin ointment
to blisters
● Stat nebulizer
● refer to Neurologist for co-
management
●

● Urinalysis
● CBC
● SARS-CoV-2
● Electrolytes Monitoring
● Cardiac Marker
● Glucose Monitoring

Writing an order in a hospital chart or otherwise formally recording orders for PEs is
the most usual method of assigning authority. The order may be written by the physician in
person, or it may be entered into the chart by a nurse under the physician's supervision. Formal
orders are useful for explaining authority delegation in that situation, although they are less
typically employed in private offices.
The following drugs and health education are prescribed to a patient who has soft
tissue abcess:

Medications:
Parenteral (IV / IM / SQ / ID)
● Furosemide 20mg IV OD
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CAMARINES SUR POLYTECHNIC COLLEGES
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COLLEGE OF HEALTH SCIENCES

● cefuroxime 750 mg IV
● Clindamycin 500 mg
● Diphenhydramine cap at bedtime
● soludexided 250 mg 1 tab BID
● Klyte 600 mg tab 3x daily

Oral / Sublingual
● Solfigreen BID
● Tidomet 250/120 mg tab
● Kaiden 2 mg
● Exulted 520 mg 1 tab
● klyte 600 mg OD tab
● Trajenta 50 mg 1 tab OD
● Pletial 50 mg 1 tab OD
● Vit. B complex 1 tab OD
● Simvastatin 10 mg tab every other day
● Losartan 50 mg 1 tab OD
● Rivatal 1/4 tab at bedside
● Neurotcin plus cap OD
● Mupirocin ointment BID
● Pantoprazole 40 mg tab OD
● Canesten Cream (apply at chest / back)
● Clindamycin 300 mg capsule TID

B. Surgical Management (if any)

NONE

C. Nursing Management (general intervention related to disease process)

NURSING MANAGEMENT FOR INFECTION:

a) Drug study
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COLLEGE OF HEALTH SCIENCES

b) Treatment

Name Frequency/ Regulation Expected Nursing

Mode/ Route of outcome responsibilitie
Administration s

PNSS Dosage: 1 L 20 gtts/min Daily Caution must

Route: maintenance be exercised in
Intravenous of body fluids the
Frequency: and nutrition, administration
STAT/ to therefore of parenteral
consume rehydration fluids,
will especially
achieve by the those
mother. containing
sodium
ions to
patients
receiving
corticosteroids
or
corticotrophin.

c) Diet

Kind of diet Route of Frequency Nursing responsibilities

administration

Low salt,
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COLLEGE OF HEALTH SCIENCES

Low fat Diet

d) Activity/Exercises
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CAMARINES SUR POLYTECHNIC COLLEGES
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CHAPTER IV: EVALUATION

A. Evaluation


B. Discharge planning instruction

Medication:
 Describe the importance of regularly taking of prescribed medications including the
potential
● unpleasant effects of non-compliance.
● Instruct the client to continue with follow up medical care.
● Advise the client not to miss the intake of medications given by her physician upon
discharge.
● Maintain a quiet, pleasant, environment to promote relaxation.
● Provide clean and comfortable environment. Follow the diet ordered.

Exercises:
● Encourage client to continue deep breathing exercises,
● passive-assistive range of motion exercises

Treatment:
● Continue home medications.
● For the follow-up check-up repeat.
● Encourage patient to take multivitamins for immunity.
● Increase Water Intake
● Soft Diet
● Low salt, Low fat diet

Health teachings:
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● Explain the underlying disorder and treatment plan.

● Encourage a lifestyle change, general health measures (adequate sleep, proper diet,
and maintaining a clean surrounding).
● Provide written and oral instructions about activity, diet recommendations,
medications, and follow- up visits.
● Take an adequate rest
● Eat nutritious food such as fruits and vegetables
● Maintain proper food diet

Out Patient department (schedule to come back)

● The patient is under monitoring and no schedule yet for consultation after getting
discharged.
● Patient will be advised to go back in the hospital in a specific date to have a follow-up
check-up after discharge.
● Consult doctor for are any problems or complications encountered.

Diet
● Low salt, Low fat Diet
● Soft Diet

Spiritual counseling

Nursing actions to help clients meet their spiritual needs include:

● Providing presence, supporting religious practices, assisting clients with prayer, and
referring client for spiritual counseling
● Follow religious customs like prayer or going to religious services.
● Spend time with the family, nature and hobbies.
● Provide spiritual care experience lower stress and less burn out.
● Focus meditation or psychotherapy.