NUR2349 2019 January Module 03 Written Assignment - Case Study (Care Plan) Latest

NUR2349 Professional Nursing I

Module 03 Written Assignment - Case Study (Care Plan)

© 2012 Keith Rischer/www.KeithRN.com

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

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

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
Potassium	3.5
Creatinine	1.45
BUN	47
CO2	18

CBC	Current	High/Low
WBC	12.6
HGB	14.5
PLTS	188
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:

Chief complaint:

VS/assessment:

Rationale:

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?

© 2012 Keith Rischer/www.KeithRN.com

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

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

Nursing Interventions

1.

2.

3.

4.

Rationale:

1.

2.

3.

4.

Expected Outcome:

1.

2.

3.

4.

7. What is the relationship between the following nursing interventions/physician orders and your

patient’s primary medical problem?

Nsg. Interventions/MD orders:

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

Rationale: Expected Outcome:

© 2012 Keith Rischer/www.KeithRN.com

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?