Assignment: Case Study Care Plan

Description: Utilize Case Study found in the Description of this Assignment as a hyper link in Module 3 Assignments.

Identifying Data and Rationale

1 (6.66666%)

Student identifies CLINICALLY SIGNIFICANT data from the chief complaint, vital signs, and nursing assessment AND explains WHY each piece of data identified is clinically significant. Faculty may assign partial points for missing parts.

Lab/Diagnostic Identification

1 (6.66666%)

Student identifies lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse AND WHY. Faculty may assign partial points for missing parts.

Primary concern and Pathophysiology/Cause

2 (13.33333%)

Student identifies the PRIMARY problem that the client is presenting with AND the underlying Pathophysiology/Cause of this concern. Faculty may assign partial points for missing parts. Assignment: Case Study Care Plan

Nursing Priority

1 (6.66666%)

Student identifies what nursing priority will guide their care (example: Maslow’s).

Nursing Interventions

2 (13.33333%)

Student lists FOUR interventions with Rationale and Expected Outcome based on the identified nursing priority. Faculty may assign partial points for missing parts.

#7 Rational and Expected Outcome

2 (13.33333%)

Student lists the rationale AND expected outcome for EACH nursing intervention/order listed in #7. Faculty may assign partial points for missing parts.

Body systems, Complications, and Assessments

3 (20.00%)

Student fully answers ALL of the following 1. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? AND 2. What is the worst possible complication to anticipate? (start with A-B-C priorities) AND 3. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops. Faculty may assign partial points for missing parts.

Client Experience

2 (13.33333%)

Student answers ALL of the following: 1. What is the patient likely experiencing/feeling right now in this situation AND 2. What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? Faculty may assign partial points for missing parts.

Grammar & Spelling

1 (6.66666%)

Few grammar and spelling errors that do not detract the reader from the message.

ORDER CUSTOM, PLAGIARISM-FREE PAPER

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 Assignment: Case Study Care Plan

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 Assignment: Case Study Care Plan

 Admit to medical unit Lab/diagnostic Results:

 Stool culture for C. difficile: Positive

WILDA Pain Scale (5 th 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

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:Assignment: Case Study Care Plan

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 1. 2. 3. 4.

Rationale: 1. 2. 3. 4.

Expected Outcome: 1. 2. 3. 4.

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? Assignment: Case Study Care Plan