Rapid Reasoning Clostridium difficile Colitis

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Introduction:

This patient case study involves a 48-year-old female with a recent history of dental infection treated with oral amoxicillin and underlying Crohn’s disease and GERD, presenting to the emergency department with loose stools and lower abdominal pain. The following questions will address relevant data, lab/diagnostic results, primary problem, pathophysiology, nursing priorities and interventions, potential complications, and patient experience.

1. What data from the chief complaint, VS, & nursing assessment is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT data:
– Loose, liquid stools for the past 2 days after completing oral amoxicillin for a dental infection
– Lower abdominal pain for the past 2 days
– Underlying Crohn’s disease and GERD
– Tachycardia and orthostatic hypotension on standing
– Positive stool culture for C. difficile
– Elevated WBC count, low potassium, increased creatinine and BUN levels

Rationale: The patient’s recent history of antibiotics, complaints of loose stools and abdominal pain, and positive stool culture indicate the potential for C. difficile colitis. The elevated WBC count and altered electrolyte and renal function levels may also indicate systemic infection and dehydration, which can rapidly deteriorate the patient’s condition.

2. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Diagnostic results:
– Positive stool culture for C. difficile
– Elevated WBC count, low potassium, increased creatinine and BUN levels

Rationale: The positive stool culture confirms the suspicion of C. difficile colitis. The altered levels of electrolytes and renal function may indicate dehydration and potential renal impairment, which requires prompt attention.

3. What is the primary problem that your patient is most likely presenting with?
The patient most likely presents with C. difficile colitis.

4. What is the underlying cause/pathophysiology of this concern?
C. difficile is a spore-forming bacterium that can cause severe diarrhea and colitis, often after antibiotic use. These spores are resistant to routine cleaning and hand sanitizers, contributing to the spread of infection. The bacterium produces toxins that damage the colonic mucosa, causing inflammation, pseudomembranous colitis, and severe diarrhea.

5. What nursing priority will guide your plan of care?
The primary nursing priority is to manage the patient’s hydration status, electrolyte balance, and prevent further infection and complication.

6. What interventions will you initiate based on this priority?
Nursing Interventions:
1. Administer IV fluids and electrolytes as prescribed by the physician to manage dehydration and electrolyte imbalance.
2. Initiate contact precautions and implement strict hand hygiene protocols to prevent the spread of infection.
3. Administer antibiotics and antidiarrheal medications as prescribed to manage the infection and symptoms.
4. Monitor and document fluid intake and output, vital signs, electrolyte levels, renal function, and response to interventions.

Rationale: Hydration and electrolyte balance are crucial for managing C. difficile colitis. Early diagnosis and prompt initiation of antibiotics and contact precautions can prevent the spread of infection. Monitoring and documenting patient assessments and interventions can help identify potential complications and evaluate treatment effectiveness.

Expected Outcome:
– The patient’s hydration status and electrolyte balance will improve.
– The patient’s diarrhea and symptoms of infection will resolve.
– The patient will have no further complications or side effects from treatment.

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: Orthostatic BP’s, PIV establishment, and enteric precautions are essential ED standing orders to manage patient safety and assess fluid status. The 0.9% NS IV bolus and hydromorphone are prescribed to manage patient hydration status and pain. The stool culture, BMP, CBC, and vancomycin are diagnostic and treatment orders that address the primary concern of C. difficile colitis. The admission order ensures ongoing patient monitoring and management.

Expected Outcome: The interventions and orders are implemented promptly and effectively, resulting in improved patient outcomes and timely resolution of the primary medical problem.

8. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern?
The gastrointestinal and renal systems will be thoroughly assessed based on the patient’s chief complaint and concern.

9. What is the worst possible complication to anticipate? (start with A-B-C priorities)
The worst possible complications to anticipate in C. difficile colitis are airway compromise, dehydration, electrolyte imbalance, sepsis, and toxic megacolon.

10. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops?
Nursing assessments to initiate quickly if complications develop include airway, breathing, and circulation assessments, and continuous cardiac and oxygen saturation monitoring. Frequent monitoring of vital signs, fluid status, electrolyte and renal function would also be necessary.

11. What is the patient likely experiencing/feeling right now in this situation?
The patient is likely experiencing diarrhea, abdominal pain, fatigue, and discomfort.

12. What can you do to engage yourself with this patient’s experience and show that they matter to you as a person?
To engage with the patient’s experience and show that they matter, the nurse can actively listen to their concerns, educate them about the condition and treatment plan, and support their emotional and physical needs. Empathic, patient-centered communication can help reassure the patient and foster trust and collaboration in care.