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Scenrios Maternal Child Atnepartum

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Mindy Perkins is 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, fever, or chills. She is on Prednisone for Crohn’s disease as well as Pantoprazole (Protonix) for severe GERD. Past Medical History:

Crohn’s Disease
Your Initial Vital Signs:
Temperature (Oral): 100.2o F
Pulse: 92
Respirations: 20
Blood Pressure: 122/78
O2 Saturations on Room Air: 98%
Orthostatic Blood Pressure:
Lying: B/P- 122/78 HR- 92
Standing: B/P- 120/70 HR- 114
W.I.L.D.A. Pain Scale (5th Vital Sign)
Words: CrampyIntensity: 7/10
Location: Generalized throughout RLQ & LLQ
Duration: Persistent since onset 2 days ago
Aggravate: None /Alleviate: None
Your Initial Nursing Assessment:
General Appearance: Appears weak and uncomfortable. Easily fatigued Respiratory: Breath sounds clear with equal aeration bilaterally, non- labored Cardiac: Skin pink, warm, & dry, S1S2, No edema, Pulses 3+ in all extremities Neuro: Alert & oriented x4

GI/GU: Active BS in all 4 quadrants, abdomen 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:
Admit to medical unit
0.9% Normal Saline 1000 mL IV bolus
Hydromorphone (Dilaudid) 1 mg IV push (IVP)
Stool culture for Clostridium difficile
Basic Metabolic Panel (BMP)
Complete Blood Count (CBC)
Vancomycin 250 mg IV
1000 mg/ 20 mL… determine dosage to administer: ______5ml__________________ Lab/ Diagnostic Results:
Stool Culture for Clostridium difficile: Positive
BMP Current Result Level is High or Low
Sodium 132 Low
Potassium 3.5 Normal
Creatinine 1.45 High
BUN 47 High
CO2 18 Low
CBC Current Result Level is High or Low
WBC 12.6 High
HGB 14.5 Normal
Plts188 High
Neuts % 86 High
Lymphs % 10 Low
What data from the chief complaint, VS, & nursing assessment is RELEVANT that must be recognized as clinically significant to the nurse? Relevant Data for Chief Complaint: Rationale:
10- 15 loose, liquid stools daily for the past 2 days
with lower abdominal pain for the past 2 days
This patient had a positive stool culture for Clostridium difficile. These are signs and symptoms of C. Diff.
The chief complaint that pt has shows there is something wrong with the GI system Relevant Data for Vital Signs: Rationale:
Temperature (Oral): 100.2o F
W.I.L.D.A. Pain Scale (5th Vital Sign)
Words: CrampyIntensity: 7/10
Location: Generalized throughout RLQ & LLQ
Duration: Persistent since onset 2 days ago
Aggravate: None /Alleviate: None
Temp is high due to the body trying to fight an infection
The patient is in pain due to complications from C. Diff infection The pain is in the lower quadrants because that is where the intestines are. Relevant Data for Physical Assessment: Rationale:
•General Appearance: Appears weak and uncomfortable. Easily fatigued
•GI/GU: abdomen 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 Patient is weak due to severe dehydration. She is uncomfortable because her pain scale is 7/10. Patient has tender lower abdomen due to infected and inflamed intestines. Patient has dry lips and no saliva due to severe dehydration.

What Lab & Diagnostic Results are RELEVANT that must be recognized as clinically significant to the nurse? Relevant Lab & Diagnostic results: Rationale:
Stool Culture positive for C.DiffSodium Low
Creatinine High
BUN High
C02 Low
WBC High
Platelets High
The stool tested positive for the bacteria.
Sodium is low related to the kidneys not working properly due to the C. Diff infection the body is not retaining water and she appears to be dehydrated with dry lips and no shiny saliva present because she has had runny diahrrea for 2 days. This leads to dehydration and this can happen fast. Creatinine and BUN levels are high related to the kidneys not functioning properly due to the C. Diff. Infection. The kidneys are not filtering out waste products of the body. The C02 is low because of the low kidney function.

This can also be caused by lung function as well. The WBC and platelets are high because the Pt.’s body is trying to fight an infection. What is the primary problem that your patient is most likely presenting with? The primary problem is the patient is having severe dehydration due to excessively having loose liquidly stools for the past two days caused by C. Diff. What is the underlying cause/ pathophysiology of this concern? The patient is positive for C. Diff, this is causing her to have diarrhea. The diarrhea is causing the patient to be dehydrated because she isn’t retaining any water. This is causing her kidneys to not function properly. What nursing priority will guide your plan of care?

My main priority would be to dehydrate the patient with a normal saline IV, then administer drugs for her pain, the dilaudid that the physician ordered for her. Then I would administer 5 ml’s of Vancomycin to treat the C. Diff. What interventions will you initiate based on this priority? Nursing Interventions Rationale Expected Outcome

1. Administer an IV of normal saline
This patient is very dehydrated due to diarrhea. The patient becomes rehydrated. 2. Administer dilaudid the physician ordered.
The patient is in pain. Scale of 7/10 The patient is relieved from pain. On pain scale her pain will be lower than 4 3. Administer Vancomycin 5 mls the physician ordered.
To treat the severe infection C. Diff. Med is for the treatment of C. Diff. To treat the patient and get them healthy again. 4. Evaluate the patient. Reassess everything. Observe any changes that have occurred to see if the patient has improved and became healthier. Evaluate pain to see if the patients pain has decreased with the pain meds. rehydrate the patient, decrease pain level, treat C. Diff What is the relationship between the following nursing interventions/ physician orders and your patient’s primary medical problem? Nursing Interventions/

MD Orders Rationale Expected Outcome
Orthostatic BP’s To identify reversible causes and underlying associated medical conditions. She appeared weak and uncomfortable Systolic decreased by 20
Diastolic decreased by 10
Establish PIV To get a blood culture for BMP, CBC, and administer normal saline IV Obtain enough blood for lab values and hydrate the patient
Initiate Enteric Precautions The patient was positive for C. Diff. C. Diff. is not transmitted
0.9% NS
1000 mL Bolus To rehydrate the patient
The patient is rehydrated, kidney functions improve
Hydromorphone 1 mg
IVP The patients pain was 7 out of 10
The patients pain is decreased to less than 4
Stool Culture
for C. diff To test for the bacteria
The culture would test positive due to suspicion from the patients chief complaints and history. BMP To test for an acute condition
The test would show low renal function
CBC To test for important information regarding organs and for conditions The test would show low renal function
Vancomycin 250 mg
IV The culture tested positive for C. Diff so start treating the C. Diff infection To rid the body of the C. Diff infection
Admit to  Medical Unit The serious infection, severe dehydration, and low renal function Increase overall health of patient, rehydrate the pt, increase kidney function, treat serious infection, and relieve pain. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/ priority concern? The Gastrointestinal System along with the Endocrine system. What is the worst possible complication to anticipate? (Start with A-B-C priorities) Respiratory depression, bracchycardia, hypotension.Opioid overdose What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops? Assess the patient’s airway to ensure its open if respiratory depression get physician to order oxygen, asses lung sounds and respirations. Assess the patient’s heart rate if the patient is experiencing bracchycardia. Assess the patient’s blood pressure, get physician to order medications if very low.

Asses the patient for opioid over dose, get physician to order Narcan. What is the patient likely experiencing/ feeling right now in this situation? The patient is probably going through pain and a lot of emotions. The patient is experiencing huge discomfort due to the pain that she is in from Crohn’s and C. Diff. If she cannot stop pooping she is probably experiencing a low self-esteem. What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? I would reassure that patient that she has an infection that medications can get rid of. I would also ask her over and over if there is anything that I can do help her like ease her pain. I would educate the patient on this infection so she can overcome it. I would reassure her that she should never feel embarrassed for defecating and that it’s a normal part of life.

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