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 of oral Amoxicillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abdominal 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 Pantoprazole (Protonix) for severe GERD.
© 2012 Keith Rischer/www.KeithRN.com
Past Medical History:
· Crohn’s disease
Your Initial VS:
WILDA Pain Scale (5th VS)
Generalized throughout RLQ-LLQ
Persistent since onset 2 days ago
Your Initial Nursing Assessment:
T: 100.2 (o)
O2 sats: 98% RA
Ortho BP’s: Lying: 122/78 HR: 92
Standing: 120/70 HR: 114
GENERAL APPEARANCE: appears weak and uncomfortable. 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, abdominal soft/tender to palpation in lower abdomen-no rebound tenderness or guarding
MISC: Lips dry, oral mucosa tacky with no shiny saliva present in mouth
· 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
o 1000 mg/20 mL…determine dosage to administer
· Admit to medical unit
· Stool culture for C. difficile: Positive
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 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 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:|
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?