Module 03 Written Assignment – Case Study (Care Plan)

31 May Module 03 Written Assignment – Case Study (Care Plan)

Rapid Reasoning: Clostridium difficile Colitis

Chief Complaint/History of Present Illness:

Mindy Perkins is a 48 year old woman who presents to the ED with 10-15 loose, liquid stools daily for the past 2 days. She completed a course of oral Amoxacillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abd. pain that began 2 days ago as well. She has not noted any blood in the stool. She denies vomiting or fever/chills. She is on Prednisone for Crohn’s disease as well as Pantaprazole (Protonix) for severe GERD.

Past Medical History:

• Crohn’s disease

• GERD

Your Initial VS:

	WILDA Pain Scale (5th VS)
	Words:	Crampy
	Intensity:	7/10
	Location:	Generalized throughout RLQ-LLQ
	Duration:	Persistent since onset 2 days ago
	Aggreviate:	None
	Alleviate:	None
T:100.2 (o)
P:92
R:20
BP:122/78
O2 sats:98% RA
Ortho BP’s:Lying: 122/78 HR: 92
Standing: 120/70 HR: 114

Your Initial Nursing Assessment:

GENERAL APPEARANCE: appears weak and uncomfortable. Easily fatigued

RESP: breath sounds clear with equal aeration bilat., non-labored

CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities

NEURO: alert & oriented x4

GI/GU: active BS in all quads, abd. soft/tender to palpation in lower abd-no rebound tenderness or guarding

MISC: Lips dry, oral mucosa tacky with no shiny saliva present in mouth

Nursing Interventions:

• Orthostatic BP’s (ED standing order)

• Establish PIV (ED standing order)

• Initiate enteric precautions (ED standing order)

Physician Orders:

• 0.9% NS 1000 mL IV bolus

• Hydromorphone (Dilaudid) 1 mg IVP

• Stool culture for C. difficile

• BMP, CBC

• Vancomycin 250 mg po

o 1000 mg/20 mL…determine dosage to administer

• Admit to medical unit

Lab/diagnostic Results:

• Stool culture for C. difficile: Positive

BMP	Current	High/Low
Sodium	132		CBC	Current	High/Low
Potassium	3.5		WBC	12.6
Creatinine	1.45		HGB	14.5
BUN	47		PLTS	188
CO2	18		Neuts. %	86
			Lymphs %	10

1. What data from the chief complaint, VS & nursing assessment is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT data:	Rationale:
Chief complaint:

VS/assessment:

2. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

	RELEVANT Diagnostic results:	Rationale:

3. What is the primary problem that your patient is most likely presenting with?

4. What is the underlying cause /pathophysiology of this concern?

5. What nursing priority will guide your plan of care?

6.What interventions will you initiate based on this priority?

Nursing Interventions	Rationale:	Expected Outcome:
1.	1.	1.
2.	2.	2.
3.	3.	3.
4.	4.	4.

7. What is the relationship between the following nursing interventions/physician orders and your patient’s primary medical problem?

Nsg. Interventions/MD orders:	Rationale:	Expected Outcome:
Orthostatic BP’s
(ED standing order)
Establish PIV
(ED standing order)
Initiate enteric precautions
(ED standing order)
0.9% NS 1000 mL IV bolus
Hydromorphone (Dilaudid) 1 mg
IVP
Stool culture for C. difficile
BMP
CBC
Vancomycin 250 mg po
Admit to medical unit

8. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and

primary/priority concern?

9. What is the worst possible complication to anticipate? (start with A-B-C priorities)

10. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this

complication develops?

11. What is the patient likely experiencing/feeling right now in this situation?

12. What can you do to engage yourself with this patient’s experience, and show that they matter to

you as a person?