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:
Crohn’s Disease
GERD
Your Initial Vital Signs:
Temperature (Oral): 100.2o F
Pulse: 92
Respirations: 20
Blood Pressure: 122/78
O2 Saturations on Room Air: 98%
Orthostatic Blood Pressure: …show more content…

The patient becomes rehydrated.
2. Administer dilaudid the physician ordered.
The patient is in pain. Scale of 7/10 The patient is relieved from pain. On pain scale her pain will be lower than 4
3. Administer Vancomycin 5 mls the physician ordered.
To treat the severe infection C. Diff. Med is for the treatment of C. Diff. To treat the patient and get them healthy again.
4. Evaluate the patient. Reassess everything. Observe any changes that have occurred to see if the patient has improved and became healthier. Evaluate pain to see if the patients pain has decreased with the pain meds. rehydrate the patient, decrease pain level, treat C. Diff
What is the relationship between the following nursing interventions/ physician orders and your patient’s primary medical problem?
Nursing Interventions/
MD Orders Rationale Expected Outcome
Orthostatic BP’s To identify reversible causes and underlying associated medical conditions. She appeared weak and uncomfortable
Systolic decreased by 20
Diastolic decreased by 10
Establish PIV To get a blood culture for BMP, CBC, and administer normal saline IV
Obtain enough blood for lab values and hydrate the patient
Initiate Enteric Precautions The patient was positive for C. Diff.
C. Diff. is not transmitted
0.9% NS
1000 mL Bolus To rehydrate the patient
The patient is rehydrated, kidney functions improve
Hydromorphone 1 mg
IVP The patients