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 Amoxicillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abdominal 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 Pantoprazole (Protonix) for severe GERD.

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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:

Alleviate:

None

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 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

Current

High/Low

Sodium

132

Potassium

3.5

Creatinine

1.45

BUN

CO2

CBC

Current

High/Low

WBC

12.6

HGB

14.5

PLTS

188

Neuts. %

Lymphs %

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?

5. What nursing priority will guide your plan of care?

6. What interventions will you initiate based on this priority?

Nursing Interventions

Rationale:

Expected Outcome:

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:

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?