Nursing care plan for colitis

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 ...