Professional Nursing I
This week you will need to look at the provided case study and develop a care plan for a patient that has 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.
© 2012 Keith Rischer/www.KeithRN.com
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:
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
WILDA Pain Scale (5
th
VS)
Words: Crampy
Intensity: 7/10
Location: Generalized throughout RLQ-LLQ
Duration: Persistent since onset 2 days ago
Aggreviate:
Alleviate:
None
None
CBC Current High/Low
WBC 12.6
HGB 14.5
PLTS 188
Neuts. % 86
Lymphs % 10
BMP Current High/Low
Sodium 132
Potassium 3.5
Creatinine 1.45
BUN 47
CO2 18
© 2012 Keith Rischer/www.KeithRN.com
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 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
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:
© 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?