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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:
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 (5th 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?
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