C Diff Nursing Diagnosis and Care Plan

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C Diff Nursing Care Plans Diagnosis and Interventions

C. Diff NCLEX Review and Nursing Care Plans

Clostridioides difficile, formerly referred to as Clostridium difficile, is a pathogen that causes large intestines or colon infections.

Symptoms of C Diff infection may vary in each individual. However, the manifestation of the disease could be severe and fatal for the colon.

One of the most common symptoms is diarrhea. On the other hand, some individuals contain C. difficile bacteria inside their intestines, but it does not mean that they require active treatment.

They can be carriers and spread infections unknowingly.

Causes and Risk Factors of C. difficile Infections

C. difficile infection can also be a side effect of taking antibiotics. The signs and symptoms generally appear as early as the first day of antibacterial treatment or manifest three months later.

Below are the antibiotics that most constantly cause C. difficile infections:

  • Cephalosporins
  • Clindamycin
  • Fluoroquinolone
  • Penicillins

Taking proton pump inhibitors also contribute to C. difficile infections.

Moreover, several health conditions or procedures may increase the risk of contracting a C. difficile infection. These conditions are enumerated below:

  • IBD (Irritable Bowel Disease)
  • Chronic kidney illness
  • Gastrointestinal surgery
  • Other abdominal procedures
  • Immunocompromised patients as a result of a medical ailment or treatment (such as chemotherapy)

Symptoms of C. difficile Infections

The following are the most typical signs and symptoms of mild to moderate C. difficile infections:

  • Aqueous stool three or more times per day for at least a day
  • Mild cramping and soreness in the abdomen

Patients suffering from severe C. difficile infection frequently get dehydrated and require hospitalization.

C. difficile can also cause inflammation of the colon and induce patches of raw tissue to develop, which can bleed or generate pus. The following are signs and symptoms of severe C. diff infection:

  • In the feces, there is blood or pus.
  • Watery stool up to 10 to 15 times each day
  • Nausea and vomiting
  • Rapid heartbeat
  • Dehydration
  • Appetite loss
  • Loss of weight
  • Having contractions and pain in the abdomen, which can be severe
  • High Fever
  • An increase in the number of white blood cells
  • Renal failure
  • Bloated feeling

Diagnosis of C. difficile Infection

  • Physical exam and patient interview
  • Stool culture
  • Colon exams – such as colonoscopy or flexible sigmoidoscopy
  • Imaging tests – such as abdominal X-ray or CT scan

Treatment for C. difficile Infection

  1. Antibacterial medication. Glycopeptide antibiotic therapy is crucial in treating C. difficile infectious condition. The doctor may recommend an alternative antibiotic that is less probable to provoke C. difficile related diarrhea.
  2. Surgery. Surgery is considered to remove the affected part of the colon. Some of the complications that may require surgery are the following:
    • Failure of an organ
    • Extreme pain
    • Inflammation of the abdominal wall lining
    • Megacolon toxin
  1. Fecal microbiota transplant (FMT). FMT is a novel therapeutic option for multiple recurrent C. difficile infections, which has been examined in clinical trials
  2. Probiotics. Probiotics are substances that include live microbes meant to sustain and enhance the body’s “good” bacteria.

C Diff Nursing Care Plans

C Diff Nursing Care Plan 1

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less than body requirements related to diarrhea secondary to C. difficile infection as evidenced by watery stool and gradual weight loss.

Desired outcome: The patient will be able to identify the cause of the nutritional imbalance and will learn to manage it.

C Diff Nursing InterventionsRationale
Obtain baseline weight from the patient. Record the exact weight of the patient daily. Estimation of the patient’s weight is not advisable.    These anthropomorphic evaluations are critical and must be precise. These will serve as the foundation for caloric and nutritional requirements.
Take note of nutritional and medical history with the help of family and significant others.  Family, relatives, or friends of the patients may provide further accurate information on the patient’s eating patterns, remarkably if the patient has changed perception.  
Determine the risk factors of low nutrient intake.    Numerous factors may influence the patient’s nutritional status. Thus, appropriate assessment is essential. Individuals with dental issues should be referred to a dental professional, but patients with memory loss may benefit from services such as “Meals on Wheels.” Other drugs may also influence the patient’s desire for food.
Assess laboratory findings that suggest wellness or deterioration.  Laboratory tests are essential in establishing a patient’s nutritional health. An aberrant value in a single diagnostic study could have a variety of explanations.  
Albumin in the bloodThis indicates the level of protein loss (2.5 g/dl indicates significant reduction; 3.8 to 4.5 g/dl is deemed acceptable).  
TransferrinThis is necessary for iron transport and usually diminishes when serum protein levels fall.  RBC and WBC count:These levels commonly fall in malnutrition, indicating anemia and decreased immune system function.  Serum electrolyte levels:In malnutrition, potassium levels are often increased, whereas sodium levels are relatively low.  
Observe physical symptoms of inadequate nutritional intake in the patient.  A patient suffering from dietary inadequacies may appear lethargic and weary. Other symptoms include difficulty concentrating, confusion, light and dry skin, loss of subcutaneous tissue, bland and fragile hair, and a red, swollen tongue and mucous membranes. Arrhythmia and high blood pressure are possible findings on vital signs. Paresthesia is also possible.  

C Diff Nursing Care Plan 2

Risk for Infection

Nursing Diagnosis: Risk for Infection related to insufficient principal defenses secondary to C. difficile infection as evidenced by tissue damage and compromised skin integrity.

Desired outcome: The client will learn to reinstate and sustain primary defenses to fight infection.

C Diff Nursing Interventions Rationale
If an infection develops, advise the patient to take anti-infective medications as directed. If antibiotics are prescribed, educate the patient to complete the entire course of treatment, even if symptoms are resolved or diminished.    When antibiotics are used as recommended, they function best. Failure to complete the prescribed antibiotic course may result in antibiotic resistance in the microorganism and recurrence of symptoms.
Maintain proper aseptic techniques when changing dressings, caring for wounds, administering intravenous fluids, and dealing with catheters.  The aseptic approach reduces the possibility of pathogens being transmitted or disseminated to or between patients. Trying to disrupt the chain of infection is an efficient method of preventing infection transmission.  
Emphasize to the patient the importance of consuming protein- and calorie-rich meals and a well-balanced diet.    Eating healthy and a well-balanced diet improves the response of the immune system and the general well-being of the body’s tissues. Proper nutrition allows the body to repair and regenerate tissues and keep the immune system performing well.
Advise the patient to sleep and take some rest periods throughout the day.      A good night’s sleep is a critical regulator of immunological responses. Thus, sleep deprivation can reduce immunity and make the patient more susceptible to infection.
Before using any objects or equipment in the patient, ensure that they have been adequately sanitized or disinfected.    Harmful pathogens are reduced or eliminated by this intervention.

C Diff Nursing Care Plan 3

Deficient Knowledge

Nursing Diagnosis: Deficient knowledge related to lack of comprehension about the symptoms of specific health conditions secondary to C. difficile infection as evidenced by posing inquiries frequently and having inadequate information.

Desired outcome: The patient will learn to communicate his or her awareness of the causes of C. D. difficile infection, mechanism of dissemination, and symptoms management

C Diff Nursing Interventions Rationale
Examine the patient’s understanding of C. difficile infection, transmission method, and therapy    Individuals who experience vomiting and diarrhea may not associate their symptoms with an acquired C. difficile intestinal infection. The patient may be unaware of the risk of spreading the infection toward others.
Educate the patient about the following symptoms, which must be reported right away to a healthcare professional:   Watery stoolsIf there is blood or pus in the feces.A fever of more than 38.3° C (101° F)Symptoms of increased vertigo, loss of balance, or dehydrationInability to consume fluids.Vomiting or diarrhea worsens or lasts longer than five days or three days for elderly and immunocompromised patients.    The patient must know that alterations in his or her stool, a high temperature, and continuous vomiting and diarrhea may suggest gastrointestinal bleeding, and the infection progresses. Fluid volume deficit symptoms and the incapacity to replenish fluids orally may need hospital admission for fluid replacement.
Educate the patient and the family on the symptoms and treatment of C. difficile infection.  Understanding the possible factors of C. difficile infection will assist the patient in initiating preventative measures to avoid repeat occurrences. The patient must understand that antibiotics in the treatment of diarrhea are essential.  The patient must also comprehend the significance of fluid replacement therapy.
Examine the patient’s understanding of safe food storage and preparation.    The patient may be unaware of C . difficile infection’s relationship to the ingestion of undercooked food, food contaminated with pathogens during preparation, and foods not kept at the proper temperature.
Assess the patient’s standard techniques of diarrhea or vomiting management.    A good treatment plan will incorporate symptom management strategies that the patient has found helpful in the past.

C Diff Nursing Care Plan 4

Acute Pain

Nursing Diagnosis: Acute Abdominal Pain related to diarrhea, loss of appetite, and vomiting secondary to C. difficile infection as evidenced by an upset stomach and weight loss.

Desired outcome: The interventions are designed to stop the sensation of abdominal pain, deal with the underlying issue, and prevent any subsequent consequences.

C Diff Nursing Interventions Rationale
Perform a thorough pain evaluation. The evaluation was designed to assess the origin, aspects, onset, persistence, recurrence, intensity, and severity of abdominal pain.    The interventions are intended to alleviate abdominal discomfort, address the fundamental condition, and avert any negative repercussions.
Provide pain-relief methods to the patient before they become serious.      It is best to administer an analgesic prior to abdominal discomfort or before the pain becomes intense, as a higher dose may be needed.
Understand and acknowledge the patient’s pain.  The healthcare professional must ask their patients about their discomfort and believe their patients’ pain claims. Opposing or disputing their pain reports leads to an unsatisfactory therapeutic alliance, impeding pain treatment and damaging rapport.
Identify pain-relieving factors.  Ask whether patients have done anything to minimize the acute abdominal pain. Meditation, deep breathing exercises, praying, and other similar practices may be included. Knowledge of these pain-relieving activities can be incorporated into the pain-management strategy.  
Examine the patient’s intention or desire to try various pain-management approaches.Some patients may be apprehensive about trying nonpharmacological treatments yet willing to try standard pharmacological procedures like taking analgesics. However, a combination of both therapies may be more beneficial, and it is the nurse’s responsibility to inform the patient about the various pain management options.  

C Diff Nursing Care Plan 5

Nausea and Vomiting

Nursing Diagnosis: Nausea and Vomiting related to upset stomach and gastric distention secondary to C. difficile infection as evidenced by gagging sensation and dizziness.

Desired outcome: The patient will be knowledgeable enough about the management of nausea and vomiting.

C Diff Nursing Interventions Rationale
Analyze the patient’s episodes of nausea and vomiting through assessment of: Medical historyDurationFrequencyIntensityFactors that cause precipitationMedicationsActions that were taken to address the issue  A thorough assessment and evaluation of nausea might assist in determining effective management methods to decrease or relieve the problem.  
Employ acupressure or acu-stimulation bands as recommended.  In some instances, stimulation of the Neiguan P6 acupuncture point on the ventral surface of the wrist has been shown to alleviate nausea. This approach has been proven beneficial for those suffering from motion sickness.  
If tolerable and suitable for the patient’s diet, consider including cold water, ice chips, ginger items, and room temperature broth or bouillon to his or her regimen.    These methods aid with hydration. Ginger relieves nausea whether consumed as ginger ale, ginger tea, or candied ginger. Fluids that are excessively cold or too hot may be uncomfortable to drink.
Educate the patient or nurse on nausea-relieving fluid and food options.    By understanding food factors to consider while nauseated, patients and nurses can encourage proper hydration and meet the nutritional requirements.
Provide the patient with tiny quantities of meals that he or she likes regularly. These may include:This method will aid in the maintenance of nutritional status. An empty stomach can aggravate nausea in specific individuals.  
Dry foods such as biscuits or toasted bread:Dry foods such as biscuits or toasted bread before rising are beneficial.  
Bland, essential foods such as broth, rice, bananas, or Jell-O:The patients should consider consuming more of these foods.    
Inform the patient to avoid foods and fragrances that cause nausea.  Solid and offensive odors can make someone feel sick.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Nursing Stat Facts
Nursing Stat Facts

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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