C. difficile/Sepsis SKINNY Reasoning

C. difficile/Sepsis SKINNY Reasoning Minnie Taylor, 62 years old Primary Concept Infection/Inflammation Interrelated Concepts (In order of emphasis) • Perfusion • Clinical Judgment • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment  Management of Care 17-23%   Safety and Infection Control 9-15% ? Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity  Basic Care and Comfort 6-12%   Pharmacological and Parenteral Therapies 12-18%   Reduction of Risk Potential 9-15%   Physiological Adaptation 11-17%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Minnie Taylor is a 62-year-old African-American female with a history of diabetes mellitus type II, hypertension, and peripheral arterial disease who had a left below the knee amputation (LBKA) three days ago. She had two small loose, watery stools last night and a third large watery brown stool this afternoon that had a distinct foul odor. Minnie is now complaining of generalized lower abdominal cramping that she rates 3/10. She does not have an appetite and does not feel like drinking fluids. Minnie was awake and alert after lunch, but later that afternoon just before supper you note that Minnie is sleepy and once aroused, falls right back to sleep. Personal/Social History: Minnie is a retired teacher who never married and has no close friends. She lives alone in her own apartment. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 62-year-old African American female/ history of diabetes mellitus type II, hypertension, and peripheral arterial disease who had a left below the knee amputation (LBKA) three days ago. Chief complaint of two small loose, watery stools last night and a third large watery brown stool this afternoon that had a distinct foul odor. Generalized lower abdominal cramping with pain rated 3/10 Pt may be on antibiotics as a precaution due to the LBKA • Distinct foul odor may indicate C. Diff infection • Change in her physiological state may be from fluid imbalance due to fecal output, consistency of fecal matter, lack of fluid intake, and no appetite. RELEVANT Data from Social History: Clinical Significance: Retired teacher who was never married and has no close friends. She lives alone in her own apartment provide care taker to help with ADL • Social worker needs to be contacted so assign coordinate help with ADLs . Which medication(s) are clinically significant and have a relationship to the current problem? RELEVANT Medication(s): Clinical Significance: Vancomycin 1000 mg IVPB daily Vancomycin is commonly used to treat C. Diff as an antibiotic therapy. Adverse effects of Vancomycin are low blood pressure, indigestion, dizziness, hives, itching, and possible “red man syndrome” if meds are infused to fast. Patient Care Begins: Current VS: 4 Hours Ago: Current PQRST: T: 100.8 F/38.2 C T: 98.7 F/37.1 C Provoking/Palliative: Movement provokes pain P: 98 (reg) P: 84 (reg) Quality: Cramping R: 20 (reg) R: 18 (reg) Region/Radiation: Generalized lower abdomen BP: 92/64 MAP: 73 BP: 118/74 MAP: 89 Severity: 3/10 O2 sat: 94% RA O2 sat: 95% RA Timing: Ongoing since onset two hours ago