RapidReasoning: ClostridiumdifficileColitis

ChiefComplaint/HistoryofPresentIllness:

Mindy Perkins is a 48-year-old woman who presents to the ED with 10-15 loose, liquid stools daily for the pasttwo days. She completed a course of oral Amoxicillin seven days ago for a dental infection. In addition to loosestools, she complains of lower abdominal pain that began two days prior. She has not noted any blood in thestool. She denies vomiting or fever/chills. She is on Prednisone for Crohn’s disease as well as Pantoprazole(Protonix)forsevereGERD.

PastMedicalHistory:

• Crohn’sdisease
• GERD

WILDAPainScale(5thVS) Words: Crampy Intensity: 7/10 Location: GeneralizedthroughoutRLQ-LLQ Duration: Persistentsince onset 2daysago Aggravate: Alleviate: None

YourInitialVS:

YourInitialNursingAssessment:

T:100.2(o)

P:92

R:20

BP:122/78

O2sats: 98%RA

OrthoBP’s:  Lying:122/78 HR:92

Standing:120/70HR:114

GENERAL APPEARANCE: appears weak and uncomfortable. Easily fatiguedRESP:breathsoundsclear withequal aerationbilat.,non-labored

CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremitiesNEURO:alert&orientedx4

GI/GU: active BS in all quads, abdominal soft/tender to palpation in lower abdomen-no rebound tenderness orguarding

MISC:Lipsdry,oralmucosa tackywithnoshinysalivapresentinthe mouth

NursingInterventions:

• OrthostaticBP’s(EDstandingorder)
• EstablishPIV(EDstanding order)
• Initiateentericprecautions(EDstandingorder)

PhysicianOrders:

• 0.9%NS 1000mLIV bolus
• Hydromorphone(Dilaudid) 1mg IVP
• StoolcultureforC. difficile
• BMP, CBC
• Vancomycin 250 mg PO

o1000mg/20mL…determinedosagetoadminister                                     

• Admittothe medicalunit

Lab/diagnosticResults:

• StoolcultureforC. difficile:Positive

1. What data from the chief complaint, VS &nursing assessment is RELEVANT that must berecognizedas clinicallysignificanttothenurse?

RELEVANT data:Chiefcomplaint:         VS/assessment:

Rationale:

• What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to thenurse?

RELEVANTDiagnosticresults:

Rationale:

• Whatisthemost likely primaryproblemfor thispatient?

• Whatistheunderlyingcause/pathophysiologyof the primary problem?

• Whatnursingprioritywillguideyour planof care?

• Whatinterventionswill youinitiatebasedonthispriority?

NursingInterventions 1.     2.     3.     4.

Rationale: 1.     2.     3.     4.

ExpectedOutcome: 1.     2.     3.     4.

• What is the relationship between the following nursing interventions/physician orders and yourpatient’sprimarymedicalproblem?

Nsg. Interventions/MDorders: OrthostaticBP’s (EDstandingorder)     EstablishPIV (EDstanding order)     Initiateentericprecautions (EDstandingorder)     0.9%NS 1000mLIV bolus Hydromorphone (Dilaudid) 1 mgIVP   Stool culture for C. difficileBMP CBC Vancomycin 250 mg POAdmittothe medicalunit

Rationale:

ExpectedOutcome:

• What body system(s) will you most thoroughly assess based on the patient’s chief complaint andprimary/priorityconcern?

• Whatistheworstpossiblecomplicationtoanticipate?(startwithA-B-Cpriorities)

1. What nursing assessment(s) will you need to initiate to identify and respond to quickly if thiscomplicationdevelops?

1. Whatisthepatientlikelyexperiencing/feelingrightnowinthissituation?

1. Whatcanyoudotoengage yourselfwiththis patient’sexperience andshowthattheymattertoyou as a person?