Case Scenario:
J.J., a 79-year-old woman with a history of COPD and renal insufficiency, was hospitalized for pneumonia for over a month. While hospitalized, she received intravenous clindamycin and steroids. She was dis-charged a week ago on oral antibiotics and steroids. This morning, she developed severe, watery diarrhea that has a strong odor and abdominal pain. This evening, her daughter took her to the emergency depart-ment because J.J. had become extremely weak and drowsy,with some confusion. Her vital signs are: BP 100/68,P 118, R 24,T 100.5° F (38.1° C). Her daughter stated, "All of a sudden she had terrible diarrhea, about 8 or 9 times, and she said her belly hurt. She hasn't eaten a thing all day, and I could not get her to drink anything." An IV of 0.9% normal saline at 125 mL/hr was started.
Physician's Orders
Normal saline IV at 125 mL/hr
Obtain stool specimen for culture, O&P, and C. Diff PCR assay
CBC, basic metabolic panel
Admit to medical-surgical department
Clear liquids as tolerated
BRP with assistance only
1. Describe the correct way to obtain a stool specimen for these tests.
2. What problem is J.J. most at risk for because of the diarrhea? Want Professional Help?
3. Which signs and symptoms occur with fluid volume deficit? Select all that apply.
a. Weakness
b. Confusion
c. Decreased pulse
d. Increased urine output
e. Dry mucous membranes
Case Study Continues:
The Clostridium difficile PCR results are positive.The hospitalist visits J.J.and tells her daughter that J.J.has an antibiotic-associated C. difficile infection (CDI).
4. Explain CDI and the significance of the positive C. diff PCR result.
5. What likely led J.J. to develop CDI?
6. How is CDI spread to others?
7. Describe the precautions needed for the suspected diagnosis of CDI to prevent the spread of disease.
8. As J.J's daughter leaves the room to go home, the nurse notices that she removed the gown and gloves without washing her hands afterward. Which actions by the nurse are appropriate?
a. Nothing, because the daughter is going home.
b. Ask the daughter to wash her hands when she gets home.
c. Remind the daughter to wash her hands immediately with soap and water.
d. Remind the daughter to wash her hands with the alcohol-based hand cleanser.
The hospitalist orders vancomycin, 250 mg PO 4 times a day. When the nurse comes in to give J.J.the first dose, her daughter asks, "If this was caused by an antibiotic, why is she getting another antibiotic now?"
9. What is the nurse's best response to the daughter's question?
a. "You're right! I'll check with the hospitalist about this."
b. "The antibiotic will cause the bowel's normal bacteria to grow."
c. "We need to make sure she does not develop pneumonia again."
d. "This antibiotic works directly in the bowel to kill the organism that is causir diarrhea."
10. Which adverse effects are possible with oral vancomycin? Select all that apply.
a. Nausea
b. Tachycardia
c. Nephrotoxicity
d. Mouth irritation
e. Red rash on the face, neck, upper torso
11. True or False? Oral vancomycin is poorly absorbed by the GI tract.
12. J.J's daughter asks, "Can you give her some medicine to stop the diarrhea?" What is your response?
13. Which nursing action should the charge nurse delegate to the LPN/LVN?
a. Performing regular assessments of J.J.s hydration status.
b. Reviewing J.J's medical history for any risk factors for CDI.
c. Giving the ordered vancomycin 250 mg PO 4 times a day.
d. Explaining the purpose of the IV fluids to the patient and her family.
Over the next few days,J.J. continues to have frequent diarrhea stools. She is able to take some clear liquids, and she is less confused. She is able to make it to the bathroom for most of her bowel movements, but does have occasional incontinence.
14. List at least 4 problems that are high priorities in J.J's continued care.
15. What interventions would you implement to meet the expected outcome of maintaining perineal skin integrity?
16. Fecal microbiota transplantation (FMT) is a possible treatment for CDI. Explain this process.
Outcome:
JJ's diarrhea finally stopped after 5 days of treatment, and she started physical therapy (PT) to regain her strength. She was discharged to a skilled care facility to continue PT for strengthening and endurance.