nur2349 week 03 Written Assignment Case Study (Care Plan) latest 2018 april
Module 03
Written Assignment – Case Study (Care Plan)
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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
Your Initial VS:
WILDA Pain Scale (5th VS) |
||||
Words: |
Crampy |
|||
Intensity: |
7/10 |
|||
Location: |
Generalized throughout RLQ-LLQ |
|||
Duration: |
Persistent since onset 2 days ago |
|||
Aggreviate: |
None |
|||
Alleviate: |
None |
|||
T:100.2 |
||||
P:92 |
||||
R:20 |
||||
BP:122/78 |
||||
O2 sats:98% RA |
||||
Ortho BP’s:Lying: |
||||
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 or guarding
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 |
CBC |
Current |
High/Low |
|
Potassium |
3.5 |
WBC |
12.6 |
||
Creatinine |
1.45 |
HGB |
14.5 |
||
BUN |
47 |
PLTS |
188 |
||
CO2 |
18 |
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: |
Rationale: |
Chief |
VS/assessment:
2.
What lab/diagnostic
results are RELEVANT that must be recognized as clinically significant to the
nurse?
RELEVANT |
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 |
Rationale: |
Expected Outcome: |
1. |
1. |
1. |
2. |
2. |
2. |
3. |
3. |
3. |
4. |
4. |
4. |
7. What is
the relationship between the following nursing interventions/physician orders
and your patient’s primary medical problem?
Nsg. |
Rationale: |
Expected |
Orthostatic BP’s |
||
(ED standing order) |
||
Establish PIV |
||
(ED |
||
Initiate enteric precautions |
||
(ED |
||
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 |
||
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?
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