CASE STUDY FOR NURSING CARE PLAN

CHIEF COMPLAINT: fever and pain on infected puncture wound in left foot

HISTORY OF PRESENT ILLNESS:

Mr. Peter Tan is a 65yo who presents to the emergency room complaining of fever and
pain on infected wound site x 4 days. Upon questioning, he states that he is diabetic but
not compliant with his maintenance. No medications taken at home.

PHYSICAL EXAMINATION:

Examination reveals an alert, oriented male. Presence of infected punctured wound

at left foot, skin -warm to touch. Vital signs are as follows: BP: 140/80 mmHg, Heart Rate -
120, Respiratory Rate: 23 /minute, and temperature- 39.9c Pain scale : 7/10

Laboratory results: Complete blood count - WBC - 15,000/mm, hemoglobin- 14g/dL.

Fasting blood sugar : 345 mgdl

MEDICATIONS

1. Clindamycin 300MG IVTT every 6 hours.

2. Ceftriaxone 1 gram IVTT every 8 hours
3. Paracetamol 300mg IVTT for fever >38c as needed
4. Tramadol 50mg IVTT every 6 hours as needed for pain
5. Regular Insulin 40units subcutaneous injection once a day