Module 3 Assignment<\/p>\n
This week you will need to look at the provided case study and develop a care plan for a patient that has a Clostridium difficile Colitis. Please use the provided format for building your care plan. You will need to use your nursing reference materials as you build this care plan.<\/p>\n
Rapid Reasoning: Clostridium difficile Colitis<\/p>\n
Chief Complaint\/History of Present Illness:<\/p>\n
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\u2019s disease as well as Pantaprazole (Protonix) for severe GERD.<\/p>\n
Past Medical History:<\/p>\n
\u2022 Crohn\u2019s disease<\/p>\n
\u2022 GERD<\/p>\n
Your Initial VS:<\/p>\n
WILDA Pain Scale (5th VS) T: 100.2 (o)<\/p>\n
Words: Crampy<\/p>\n
P: 92<\/p>\n
Intensity: 7\/10<\/p>\n
R: 20<\/p>\n
Location: Generalized throughout RLQ-LLQ<\/p>\n
BP: 122\/78<\/p>\n
Duration: Persistent since onset 2 days ago<\/p>\n
O2 sats: 98% RA<\/p>\n
Aggreviate: None<\/p>\n
Ortho BP\u2019s: Lying: 122\/78 HR: 92<\/p>\n
Alleviate: None<\/p>\n
Standing: 120\/70 HR: 114<\/p>\n
Your Initial Nursing Assessment:<\/p>\n
RESP: breath sounds clear with equal aeration bilat., non-labored<\/p>\n
CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities<\/p>\n
NEURO: alert & oriented x4<\/p>\n
GI\/GU: active BS in all quads, abd. soft\/tender to palpation in lower abd-no rebound tenderness or guarding<\/p>\n
MISC: Lips dry, oral mucosa tacky with no shiny saliva present in mouth<\/p>\n
Nursing Interventions:<\/p>\n
\u2022 Orthostatic BP\u2019s (ED standing order)<\/p>\n
\u2022 Establish PIV (ED standing order)<\/p>\n
\u2022 Initiate enteric precautions (ED standing order)<\/p>\n
Physician Orders:<\/p>\n
\u2022 0.9% NS 1000 mL IV bolus<\/p>\n
\u2022 Hydromorphone (Dilaudid) 1 mg IVP<\/p>\n
\u2022 Stool culture for C. difficile<\/p>\n
\u2022 BMP, CBC<\/p>\n
\u2022 Vancomycin 250 mg po<\/p>\n
o 1000 mg\/20 mL\u2026determine dosage to administer<\/p>\n
\u2022 Admit to medical unit<\/p>\n
Lab\/diagnostic Results:<\/p>\n
\u2022 Stool culture for C. difficile: Positive<\/p>\n
BMP Current High\/Low<\/p>\n
Sodium 132<\/p>\n
Potassium 3.5<\/p>\n
Creatinine 1.45<\/p>\n
BUN 47<\/p>\n
CO2 18<\/p>\n
CBC Current High\/Low<\/p>\n
WBC 12.6<\/p>\n
HGB 14.5<\/p>\n
PLTS 188<\/p>\n
Neuts. % 86<\/p>\n
Lymphs % 10<\/p>\n
1. What data from the chief complaint, VS & nursing assessment is RELEVANT that must be recognized as clinically significant to the nurse?<\/p>\n
RELEVANT data: Rationale:<\/p>\n
Chief complaint:<\/p>\n
VS\/assessment:<\/p>\n
2. What lab\/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?<\/p>\n
RELEVANT Diagnostic results: Rationale:<\/p>\n
3.What is the primary problem that your patient is most likely presenting with?<\/p>\n
4.What is the underlying cause \/pathophysiology of this concern?<\/p>\n
5. What nursing priority will guide your plan of care?<\/p>\n
6.What interventions will you initiate based on this priority?<\/p>\n
Nursing Interventions Rationale: Expected Outcome:<\/p>\n
1. 1. 1.<\/p>\n
2. 2. 2.<\/p>\n
3. 3. 3.<\/p>\n
4. 4. 4.<\/p>\n
7. What is the relationship between the following nursing interventions\/physician orders and your patient\u2019s primary medical problem?<\/p>\n
Nsg. Interventions\/MD orders: Rationale: Expected Outcome:<\/p>\n
Orthostatic BP\u2019s<\/p>\n
(ED standing order)<\/p>\n
Establish PIV<\/p>\n
(ED standing order)<\/p>\n
Initiate enteric precautions<\/p>\n
(ED standing order)<\/p>\n
0.9% NS 1000 mL IV bolus<\/p>\n
Hydromorphone (Dilaudid) 1 mg<\/p>\n
IVP<\/p>\n
Stool culture for C. difficile<\/p>\n
BMP<\/p>\n
CBC<\/p>\n
Vancomycin 250 mg po<\/p>\n
Admit to medical unit<\/p>\n
8. What body system(s) will you most thoroughly assess based on the patient\u2019s chief complaint and primary\/priority concern?<\/p>\n
9. What is the worst possible complication to anticipate? (start with A-B-C priorities)<\/p>\n
10. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops?<\/p>\n
11. What is the patient likely experiencing\/feeling right now in this situation?<\/p>\n
12. What can you do to engage yourself with this patient\u2019s experience, and show that they matter to you as a person?<\/p>\n
—-
\nAssignment for Module 3<\/p>\n
This week, you must examine the accompanying case study and create a care plan for a patient with Clostridium difficile colitis. Please create your care plan using the template supplied. As you create this care plan, you will need to use your nursing reference sources.<\/p>\n
Clostridium difficile Colitis: Rapid Reasoning<\/p>\n
Chief Complaint\/Previous Illness History:<\/p>\n
Mindy Perkins, 48, presents to the emergency department with 10-15 loose, watery stools every day for the past two days. She finished a seven-day course of Amoxacillin for a tooth infection. She also has lower abdominal pain that started two days ago, in addition to the loose stools. She has not made any observations.<\/p>\n","protected":false},"excerpt":{"rendered":"
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