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 two days. She completed a course of oral Amoxicillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abdominal pain that began two days prior. 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 Pantoprazole (Protonix) for severe GERD.
Past Medical History:
- Crohn’s disease
- GERD
| WILDA Pain Scale (5th VS) Words: Crampy Intensity: 7/10 Location: Generalized throughout RLQ-LLQ Duration: Persistent since onset 2 days ago Aggravate: Alleviate: None |
Your Initial VS:
Your Initial Nursing Assessment:
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
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, abdominal soft/tender to palpation in lower abdomen-no rebound tenderness or guarding
MISC: Lips dry, oral mucosa tacky with no shiny saliva present in the 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 the medical unit
Lab/diagnostic Results:
- Stool culture for C. difficile: Positive
- 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: |
- What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
| RELEVANT Diagnostic results: | Rationale: |
- What is the most likely primary problem for this patient?
- What is the underlying cause /pathophysiology of the primary problem?
- What nursing priority will guide your plan of care?
- 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. |
- 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 the medical unit | Rationale: | Expected Outcome: |
- What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern?
- What is the worst possible complication to anticipate? (start with A-B-C priorities)
- What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops?
- What is the patient likely experiencing/feeling right now in this situation?
- What can you do to engage yourself with this patient’s experience and show that they matter to you as a person?
