look at the provided case study and develop a care plan for a patient that has a urinary tract infection. 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). Provided format is uploaded below.
? 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 (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.
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