Scenrios Maternal Child Atnepartum
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:
Lying: B/P- 122/78 HR- 92
Standing: B/P- 120/70 HR- 114
W.I.L.D.A. Pain Scale (5th Vital Sign)
Words: CrampyIntensity: 7/10
Location: Generalized throughout RLQ & LLQ
Duration: Persistent since onset 2 days ago
Aggravate: None /Alleviate: None
Your Initial Nursing Assessment:
General Appearance: Appears weak and uncomfortable. Easily fatigued
Respiratory: Breath sounds clear with equal aeration bilaterally, non- labored
Cardiac: Skin pink, warm, & dry, S1S2, No edema, Pulses 3+ in all extremities
Neuro: Alert & oriented x4
GI/GU: Active BS in all 4 quadrants, abdomen soft & tender to palpation in lower abdomen- No rebound tenderness or guarding
MISC: Lips dry, oral mucosa tacky with no shiny saliva present in mouth
Nursing Interventions:
Orthostatic BP’s (ED standing order)
Establish PIV (ED standing order)
Initiate Enteric Precautions (ED standing order)
Physician Orders:
Admit to medical unit
0.9% Normal Saline 1000 mL IV bolus
Hydromorphone (Dilaudid) 1 mg IV push (IVP)
Stool culture for Clostridium difficile
Basic Metabolic Panel (BMP)
Complete Blood Count (CBC)
Vancomycin 250 mg IV
1000 mg/ 20 mL… determine dosage to administer: ______5ml__________________
Lab/ Diagnostic Results:
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:
Lying: B/P- 122/78 HR- 92
Standing: B/P- 120/70 HR- 114
W.I.L.D.A. Pain Scale (5th Vital Sign)
Words: CrampyIntensity: 7/10
Location: Generalized throughout RLQ & LLQ
Duration: Persistent since onset 2 days ago
Aggravate: None /Alleviate: None
Your Initial Nursing Assessment:
General Appearance: Appears weak and uncomfortable. Easily fatigued
Respiratory: Breath sounds clear with equal aeration bilaterally, non- labored
Cardiac: Skin pink, warm, & dry, S1S2, No edema, Pulses 3+ in all extremities
Neuro: Alert & oriented x4
GI/GU: Active BS in all 4 quadrants, abdomen soft & tender to palpation in lower abdomen- No rebound tenderness or guarding
MISC: Lips dry, oral mucosa tacky with no shiny saliva present in mouth
Nursing Interventions:
Orthostatic BP’s (ED standing order)
Establish PIV (ED standing order)
Initiate Enteric Precautions (ED standing order)
Physician Orders:
Admit to medical unit
0.9% Normal Saline 1000 mL IV bolus
Hydromorphone (Dilaudid) 1 mg IV push (IVP)
Stool culture for Clostridium difficile
Basic Metabolic Panel (BMP)
Complete Blood Count (CBC)
Vancomycin 250 mg IV
1000 mg/ 20 mL… determine dosage to administer: ______5ml__________________
Lab/ Diagnostic Results: