Running head: CLINICAL CASE STUDY 1

Clinical Case Study

Lisa M. Torchick
Ohio University

CLINICAL CASE STUDY 2
Introduction
W.M. is a 47 year old, right hand dominant man. He is full code with no known drug
allergies. He presented to the Adena Regional Medical Center Emergency Room, on July 3,
2014, with a one week history of left forearm swelling, pain and redness. W.M. admitted to an 8
year history of IV drug abuse. The physicians report stated that the patient shot some IV heroin
into his left forearm and noted track marks. The patient states that a blood pressure cuff, used
during his GI procedure 2 weeks ago, caused the left forearm swelling.
The ER physician performed a small Incision (I and D) which was able to decompress his
left forearm, but the patient was still experiencing pain and the left forearm still appeared grossly
infected with an abscess/cellulitis remaining. The patient was admitted to the hospital for
optimization of his medical care. Dr. Ghany performed a formal I and D, on July 4, 2014, on the
patients upper left extremity abscess/cellulitis. On July 5, 2014, W.M. signed himself out of
Adena Regional Medical Center, against medical advice (AMA). He was readmitted, to 3NE,
on July 6, 2014, due to medication noncompliance, as evidenced by patient leaving the hospital
AMA, and a hemoglobin A1c of 17.5.
On July 7, 2014, the patient was assigned to myself and nurse Tonette Seitz. We were
informed that the patient would likely be discharged, later that day. Since the patient was
scheduled to be discharged, the care plan focus was on providing patient information and
education, to promote the clients health.
Pathophysiology
Cellulitis is a condition where the subcutaneous or connective tissue becomes infected
and inflamed, causing tenderness, swelling, and redness that can spread to other areas of the
body (Huether & McCance, 2012). This patient apparently, injected heroin into the
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subcutaneous tissue of his left forearm. This caused local irritation and the inflammation, which
progressed into a bacterial infection and led to an abscess/cellulitis. The inflammation caused
localized swelling, which put pressure on area nerves and resulted in pain. Cellulits responds
well to systemic antibiotics and the patient received IV Vancomycin, while admitted (Huether &
McCance, 2012).
Sometimes an abscess needs draining, through a small operation carried out under
anesthetic. During the procedure, the surgeon will make a cut in the abscess to allow all of the
pus to drain out, this is known as an Incision and Drainage (I and D). They may also take a
sample of pus for testing to confirm which bacteria caused the infection. Once all of the pus has
been removed, the surgeon will clean the hole that is left by the abscess using a saline solution;
the procedure may leave a small scar (Ignatavicius & Workman, 2013).
History
W.M. has a diagnosis of Type 2 Diabetes Mellitus, which is noted as being poorly
controlled. He also has a history of: diabetic retinopathy, hypertension, hyperlipidemia, gastro
esophageal reflux disease, anemia (secondary to gastrointestinal bleed), hepatitis C, coronary
artery disease, and a poorly controlled seizure disorder.
His past surgical history includes: colonoscopy, recent polyp removal, treatment of
gastric ulcer (2 weeks ago), liver biopsy, exploratory laparotomy, and heart catheterization (June
2012). The patient has a social history that includes: 1 & pack per day, smoker, 8 year IV
drug abuse with heroin, and daily marijuana use. He denies any ethanol abuse
Nursing Physical Assessment
W.M. is a 55, 150 lbs., man. He has an oral temperature of 98.1 degrees Fahrenheit
and his pulse is 89 beats/minute. The patients blood pressure reading is 134/92, with
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respirations at 18 per minute, without any effort. His oxygen saturation is 99%, capillary refill is
less than 2 seconds, and radial and pedis pulses are 2+ and equal. W.M.s lungs are clear in all
fields and he is sinus rhythm. His abdomen is soft, non-tender and non-distended and bowel
sounds are active in all four quadrants. He denies any nausea, vomiting or diarrhea. W.M.s
musculoskeletal assessment indicates left arm limited motion, due to surgical incisional pain,
rated at 8/10. The patients integumentary findings indicate a left forearm dry/intact dressing
with localized swelling. His skin is pink, warm and dry and no tenting is observed.
Neurological assessment data includes subjective, left hand numbness. W.M.s pupils are 2mm,
equal, and reactive. He is alert and oriented times three and opens his eyes spontaneously. His
speech is clear, articulate and appropriate. The patient is continent and he is able to ambulate as
tolerated.
W.M. had a 22 gauge IV, in his right forearm that was p-locked. He was weaned off his 1
liter, nasal cannula at 0900.
Related Treatments
The patient was on contact precautions for a blood culture that tested positive for MRSA.
I removed the patients wound dressing, as the physician ordered, to allow him to shower. After
his shower, I applied a clean, dry, gauze dressing, dating and signing the dressing tape.
W.M. medications include: Aspirin 81 mg PO, daily, Nabumetone 750 mg PO, BID,
Percocet 1 tab q6h PO, PRN, Clonazepam 1 mg PO, BID, Neurontin 300 mg PO, TID, Vimpat
20 mg PO, BID, Citalopram 20 mg PO, daily, Remeron 15 mg PO at bedtime, Nexium 40 mg
PO, daily, Naprosyn 500 mg PO, TID, Lisinopril 10 mg PO, daily, Novolog insulin, sliding scale,
Metformin 500mg PO, BID, Vancomycin 1g IV q12hr. The patients medications were
administered appropriately, while in my care.
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The patients current, elevated lab values are as follows: Glucose, 112 (70-110 normal
value); A1c, 17.5% (<7% normal value); and WBC, 17 (5-10 normal value). His WBC count
was elevated, due to the infection he had; however, it had dropped from 22.3, with 90%
neutrophils (50-81% normal value), at his first admission. His current, low lab values include:
Hemoglobin, 10.5 (14-18 normal value); Hematocrit, 32.1 (42-52 normal value); Sodium, 134
(135-145 normal value); and BUN, 7 (10-20 normal value). W.M.s normal range lab values are:
Platelets, 367; Creatinine, 0.84; and Potassium, 3.9. The patients glucose levels were low and
indicated that no coverage was needed. M.W. tested positive for Cannabis (THC) and Opiates.
Nursing Diagnosis and Patient Goal
A nursing diagnosis for M.W. would be, Impaired Tissue Integrity, related to
inflammatory process damaging skin and underlying tissue, as evidenced by his abscess and
cellulitis. A second nursing diagnosis, for this patient, would be Ineffective Self-Health
Management, related to failure to take insulin and follow diabetic diet, as evidenced by his A1c
of 17.5. A third nursing diagnosis would be, Readiness for enhanced Knowledge, related to his
non-compliance, as evidenced by leaving the hospital AMA.
My goal is to assist D.T. in managing his Diabetes Mellitus and non-compliance and
support skin integrity, to promote healing. In order to accomplish this, I will work with the
patient to understand the importance of managing his Diabetes Mellitus and how this will impact
his wound healing.
Nursing Intervention
I began my patient education session, by going over insulin administration and diet
regulations, with the patient. I discussed how disease management would help the patients
surgical wound to heal and reduce complications. I asked M.W. questions, to ensure
CLINICAL CASE STUDY 6
understanding. I then asked him what concerns he had about his medications or diet and
answered any questions. Knowledge is a factor that contributes significantly to the clients
taking action for health promotion and protection (Ackley & Ladwig, 2014).
In order to make sure M.W. would know how to care for his wound at home, I observed
him dress his wound. He was educated on signs and symptoms of infection that he should
monitor for. Early assessment and intervention helps prevent serious problems from developing
(Ackley & Ladwig, 2014). We discussed the importance of taking all of his antibiotic
medication and why.
Lastly, I provided written information regarding Diabetes Mellitus and wound care,
for the patient to refer to.
Evaluation
During patient education, W.M. was able to express why and how he was going to
manage his Type 1 Diabetes Mellitus. When asked if it is appropriate to discontinue taking his
insulin, as ordered, he abruptly, stated, no. W.M. was given a medication list that stated his
medication administration schedule, and Diabetes Mellitus information, to refer to.
Wound Care was discussed and the patient demonstrated his ability to re-dress his wound.
The patient was not interested in smoking cessation information or drug abuse treatment or
support. He stated that he could, quit on my own. Written Hepatitis C information was
provided. The patient was not discharged before Tonette and I completed our shift.
Recommendations
It is my recommendation that M.W. adhere to his diabetic diet, and insulin administration
regimen. I also recommend that he take all of his oral antibiotic medications, keep his wound
dressing dry and intact, and report any signs of infection, to his physician. This patient would
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benefit from smoking cessation and drug abuse treatment/support, although he was not receptive
to it. He should attend any follow-up appointments with his physician(s) or therapists.



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Clinical Case Study

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References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights: Elsevier Inc.
Huether, S. E., & McCance, K. (2012). Understanding pathophysiology. St. Louis: Mosby, Inc.
Ignatavicius, D., & Workman, L. (2013). Medical-surgical nursing: Patient-centered
collaborative care. St. Louis: Saunders.

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