NU231 Rasmussen M3 Rapid Reasoning Clostridium Difficile Colitis Care Plan

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Professional Nursing NU231 NUR2349

Rasmussen University

Description

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.

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Explanation & Answer

Attached.

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)
T: 100.2 (o)
Words:

Crampy
P: 92

Intensity:

7/10
R: 20

Location:

Generalized throughout RLQ-LLQ
BP: 1 22/78

Duration:

Persistent since onset 2 days ago
O2 sats: 98% RA

Aggreviate: None
Ortho BP’s: Lying: 122/78 HR: 92
Alleviate:

None
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
CBC...


Anonymous
I was having a hard time with this subject, and this was a great help.

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