NUR2349 Module 03 Written Assignment – Case Study Care Plan

NUR2349 Module 03 Written Assignment – Case Study Care Plan

NUR2349 Module 03 Written Assignment – Case Study Care Plan

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.

Permalink: https://nursingpaperessays.com/nur2349-module-0…-study-care-plan/ ‎

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 Current High/Low
Sodium 132 CBC Current High/Low
Potassium 3.5 WBC 12.6
Creatinine 1.45 HGB 14.5
BUN 47 PLTS 188
CO2 18 Neuts. % 86
Lymphs % 10

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?

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:
1. 1. 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

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?

NUR2349 Module 04 Written Assignment – Improving Patient Care Worksheet

Your written assignment for this module is a worksheet that describes the following:

An example of an evidence-based practice (EBP) project

How EBP projects can improve patient care

You should be using complete sentences to answer the questions. Ensure that you are using correct grammar. In addition, support your answers using your textbook, course materials, credible internet resources, and scholarly journals. All citations must be in APA format.

Please click here to download the Improving Patient Care Worksheet.

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Name:

Date:

Complete all of your lesson materials and assigned readings. Make sure that you are focusing on:

• An example of an evidence-based practice (EBP) project

• How EBP projects can improve patient care

You should be using complete sentences to answer the questions. Ensure that you are using correct grammar. In addition, support your answers using your textbook, course materials, credible internet resources, and scholarly journals. SkyScape is a great suggestion for assistance in completion of this assignment. All citations must be in APA format. 1 Point

1. Give an example of an evidence-based practice (EBP) project that you have either been a part of or have knowledge regarding. 2 Points

2. Describe how the EBP project can improve patient care. 2 Points

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