{"id":3330,"date":"2022-04-18T23:01:36","date_gmt":"2022-04-18T23:01:36","guid":{"rendered":"https:\/\/highclasswriters.com\/blog\/?p=3330"},"modified":"2022-04-18T23:01:37","modified_gmt":"2022-04-18T23:01:37","slug":"case-study-care-plan","status":"publish","type":"post","link":"https:\/\/highclasswriters.com\/blog\/case-study-care-plan\/","title":{"rendered":"Case study (Care Plan)"},"content":{"rendered":"\n<p>RapidReasoning: ClostridiumdifficileColitis<\/p>\n\n\n\n<p>ChiefComplaint\/HistoryofPresentIllness:<\/p>\n\n\n\n<p><em>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\u2019s disease as well as Pantoprazole(Protonix)forsevereGERD.<\/em><\/p>\n\n\n\n<p>PastMedicalHistory:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Crohn\u2019sdisease<\/li><li>GERD<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>WILDAPainScale(5<sup>th<\/sup>VS) <strong>W<\/strong>ords: Crampy <strong>I<\/strong>ntensity: 7\/10 <strong>L<\/strong>ocation: GeneralizedthroughoutRLQ-LLQ <strong>D<\/strong>uration: Persistentsince onset 2daysago <strong>A<\/strong>ggravate: <strong>A<\/strong>lleviate: None &nbsp; &nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p>YourInitialVS:<\/p>\n\n\n\n<p>YourInitialNursingAssessment:<\/p>\n\n\n\n<p><strong>T:<\/strong>100.2(o)<\/p>\n\n\n\n<p><strong>P:<\/strong>92<\/p>\n\n\n\n<p><strong>R:<\/strong>20<\/p>\n\n\n\n<p><strong>BP:<\/strong>122\/78<\/p>\n\n\n\n<p><strong>O2sats: <\/strong>98%RA<\/p>\n\n\n\n<p><strong>OrthoBP\u2019s:&nbsp; <\/strong>Lying:122\/78 HR:92<\/p>\n\n\n\n<p>Standing:120\/70HR:114<\/p>\n\n\n\n<p>GENERAL APPEARANCE: appears weak and uncomfortable. Easily fatiguedRESP:breathsoundsclear withequal aerationbilat.,non-labored<\/p>\n\n\n\n<p>CARDIAC: pink, warm &amp; dry, S1S2, no edema, pulses 3+ in all extremitiesNEURO:alert&amp;orientedx4<\/p>\n\n\n\n<p>GI\/GU: active BS in all quads, abdominal soft\/tender to palpation in lower abdomen-no rebound tenderness orguarding<\/p>\n\n\n\n<p>MISC:Lipsdry,oralmucosa tackywithnoshinysalivapresentinthe mouth<\/p>\n\n\n\n<p>NursingInterventions:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>OrthostaticBP\u2019s<strong>(EDstandingorder)<\/strong><\/li><li>EstablishPIV<strong>(EDstanding order)<\/strong><\/li><li>Initiateentericprecautions<strong>(EDstandingorder)<\/strong><\/li><\/ul>\n\n\n\n<p>PhysicianOrders:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>0.9%NS 1000mLIV bolus<\/li><li>Hydromorphone(Dilaudid) 1mg IVP<\/li><li>StoolcultureforC. difficile<\/li><li>BMP, CBC<\/li><li>Vancomycin 250 mg PO<\/li><\/ul>\n\n\n\n<p>o1000mg\/20mL\u2026determinedosagetoadminister&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Admittothe medicalunit<\/li><\/ul>\n\n\n\n<p>Lab\/diagnosticResults:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>StoolcultureforC. difficile:Positive<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><\/td><td><\/td><td><\/td><td><\/td><\/tr><tr><td><\/td><td><img loading=\"lazy\" decoding=\"async\" width=\"240\" height=\"110\" src=\"\" alt=\"Text Box: BMP\tCurrent\tHigh\/Low\nSodium\t132\t\nPotassium\t3.5\t\nCreatinine\t1.45\t\nBUN\t47\t\nCO2\t18\t\n\n\"><\/td><td><\/td><td><img loading=\"lazy\" decoding=\"async\" width=\"265\" height=\"110\" src=\"\" alt=\"Text Box: CBC\tCurrent\tHigh\/Low\nWBC\t12.6\t\nHGB\t14.5\t\nPLTS\t188\t\nNeuts.%\t86\t\nLymphs %\t10\t\n\n\"><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<ol class=\"wp-block-list\" type=\"1\"><li><strong>What data from the chief complaint, VS &amp;nursing assessment is RELEVANT that must berecognizedas clinicallysignificanttothenurse?<\/strong><\/li><\/ol>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong><u>RELEVANT data:<\/u>Chiefcomplaint:<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> <strong>VS\/assessment:<\/strong><\/td><td><strong>Rationale:<\/strong><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>What lab\/diagnostic results are RELEVANT that must be recognized as clinically significant to thenurse?<\/strong><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong><u>RELEVANT<\/u>Diagnosticresults:<\/strong><\/td><td><strong>Rationale:<\/strong><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Whatisthemost likely primaryproblemfor thispatient?<\/strong><\/li><\/ul>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Whatistheunderlyingcause\/pathophysiologyof the primary problem?<\/strong><\/li><\/ul>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Whatnursingprioritywillguideyour planof care?<\/strong><\/li><\/ul>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Whatinterventionswill youinitiatebasedonthispriority?<\/strong><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>NursingInterventions<\/strong> 1. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 2. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 3. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 4.<\/td><td><strong>Rationale:<\/strong> 1. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 2. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 3. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 4.<\/td><td><strong>ExpectedOutcome:<\/strong> 1. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 2. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 3. <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 4.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>What is the relationship between the following nursing interventions\/physician orders and yourpatient\u2019sprimarymedicalproblem?<\/strong><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Nsg. Interventions\/MDorders:<\/strong> OrthostaticBP\u2019s <strong>(EDstandingorder)<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> EstablishPIV <strong>(EDstanding order)<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> Initiateentericprecautions <strong>(EDstandingorder)<\/strong> <strong>&nbsp;<\/strong> <strong>&nbsp;<\/strong> 0.9%NS 1000mLIV bolus Hydromorphone (Dilaudid) 1 mgIVP <strong>&nbsp;<\/strong> Stool culture for C. difficileBMP CBC Vancomycin 250 mg POAdmittothe medicalunit<\/td><td><strong>Rationale:<\/strong><\/td><td><strong>ExpectedOutcome:<\/strong><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>What body system(s) will you most thoroughly assess based on the patient\u2019s chief complaint andprimary\/priorityconcern?<\/strong><\/li><\/ul>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Whatistheworstpossiblecomplicationtoanticipate?<em>(startwithA-B-Cpriorities)<\/em><\/strong><\/li><\/ul>\n\n\n\n<ol class=\"wp-block-list\" type=\"1\"><li><strong>What nursing assessment(s) will you need to initiate to identify and respond to quickly if thiscomplicationdevelops?<\/strong><\/li><\/ol>\n\n\n\n<ol class=\"wp-block-list\" type=\"1\"><li><strong>Whatisthepatientlikelyexperiencing\/feelingrightnowinthissituation?<\/strong><\/li><\/ol>\n\n\n\n<ol class=\"wp-block-list\" type=\"1\"><li><strong>Whatcanyoudotoengage yourselfwiththis patient\u2019sexperience andshowthattheymattertoyou as a person?<\/strong><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"<p>RapidReasoning: ClostridiumdifficileColitis ChiefComplaint\/HistoryofPresentIllness: Mindy Perkins is a 48-year-old woman who presents to the ED with 10-15 loose, liquid stools daily [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3330","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.9 - 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