Assignment: Develop a care plan for a patient that has a Clostridium difficile Colitis

Assignment: Develop a care plan for a patient that has a Clostridium difficile Colitis Assignment: Develop a care plan for a patient that has a Clostridium difficile Colitis 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. (Suggestion on using skyscape) c_diff_rapid_reasoning.pdf ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 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 (o) P: 92 R: 20 BP: 122/78 O2 sats: 98% RA Ortho BP’s: Lying: 122/78 HR: 92 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 Sodium Potassium Creatinine BUN CO2 Current 132 3.5 1.45 47 18 High/Low © 2012 Keith Rischer/www.KeithRN.com CBC WBC HGB PLTS Neuts. % Lymphs % Current 12.6 14.5 188 86 10 High/Low 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 complaint: VS/assessment: 2. What lab/diagnostic results are RELEVANT that must be recognized as clinically 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? © 2012 Keith Rischer/www.KeithRN.com 5. What nursing priority will guide your plan of care? 6.What interventions will you initiate based on this priority? Nursing Interventions Rationale: 1. 1. Expected Outcome: 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. Interventions/MD orders: Rationale: Expected Outcome: 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 © 2012 Keith Rischer/www.KeithRN.com 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? © 2012 Keith Rischer/www.KeithRN.com … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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