Chief Complaint/ History of Present Illness:
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:
Your Initial Vital Signs:
Temperature (Oral): 100.2o F
Blood Pressure: 122/78
O2 Saturations on Room Air: 98%
Orthostatic Blood Pressure:…show more content…
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.