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 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: • Temp: 100.8F/38.2C • O2 Sat: 94% • BP: 92/64 • Pain: Ongoing cramping with rate of 3/10 • BP is considerably low for someone that has due to lost of hydration with diarrhea and lack of fluid intake. - Being slightly febrile indicates the possibility of an infection. • Although the O2 sat is above 90%, we should continue to monitor so there is no drop in oxygen level • • Pain is currently uncontrolled -should monitor as it is at higher end of the normal The trend shows that patient’s condition is worsening • Pain : stable BP: worsening Temp: worsening Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably. NEUROLOGICAL: Lethargic, does not stay awake once aroused, oriented to person only, (was oriented x4 last recorded assessment 4 hours ago), has no focal neurologic deficits HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips dry, tongue, and oral mucosa pink and tacky dry. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pale, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, slightly distended, and tender to gentle palpation, BS + in all 4 quadrants GU: 100 mL clear, dark amber urine four hours ago INTEGUMENTARY: Skin normal color for ethnicity. No clubbing of nails, cap refill 3 seconds, Hair soft- distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: NEUROLOGICAL: Lethargic, does not stay awake once aroused, oriented to person only, (last assessment she was oriented x4/ 4 hours ago), pt has no focal neurologic deficits. HEENT: Lips dry, tongue, and oral mucosa pink and dry. GU: 100 mL clear, dark amber urine four hours ago • There is an improvement in urine color but it’s important to note the darker urine Q4hrs, it can be an indicator of fluid and electrolyte imbalance -Altered mental status change in orientation, alertness, and being lethargic may indicate symptoms of fluid and electrolyte imbalance to possible sepsis occurring. • Lips being dry is an indicate of fluid and electrolyte deficit. •