A patient with worsening Crohn's disease presents with significant abdominal pain, elevated CRP, and a hemoglobin level of 9.2 g/dL. She reports increased fatigue and frequent loose stools, with recent unintended weight loss. Which nursing intervention is the priority in managing this patient's condition?

C) Collaborate with the healthcare team to initiate biologic therapy to control inflammation

A) Encourage the patient to maintain a high-fiber diet to manage bowel movements

B) Administer prescribed iron supplements to address anemia and monitor hemoglobin levels

C) Collaborate with the healthcare team to initiate biologic therapy to control inflammation

D) Educate the patient on the importance of fluid intake to prevent dehydration from frequent stools

A patient with worsening Crohn's disease is experiencing significant fatigue, increased bowel movements, anemia, and unintended weight loss. Which nursing intervention should be prioritized to address her nutritional deficiencies and improve her overall health status?

B) Collaborate with a dietitian to develop a high-calorie, nutrient-dense diet plan.

A) Encourage the patient to increase fiber intake to manage bowel movements.

B) Collaborate with a dietitian to develop a high-calorie, nutrient-dense diet plan.

C) Advise the patient to take over-the-counter iron supplements to improve anemia.

D) Recommend the patient to rest and limit physical activity to reduce fatigue.

A patient with Crohn's disease has been started on a TNF-alpha inhibitor and broad-spectrum antibiotics due to a small bowel stricture with an adjacent abscess. Which nursing intervention is most critical in the initial phase of treatment to prevent complications and ensure patient safety?

A) Monitor the patient's temperature every 4 hours to detect signs of infection.

B) Educate the patient on the importance of adhering to dietary recommendations.

C) Assess the patient's bowel sounds every 8 hours to monitor gastrointestinal function.

D) Evaluate the patient's skin for signs of rash or allergic reaction daily.

A patient with Crohn's disease is being treated with a TNF-alpha inhibitor and broad-spectrum antibiotics following the identification of a bowel stricture and adjacent abscess. Which nursing intervention is most critical to prevent a potential complication associated with this treatment regimen?

B) Monitor for signs of infection such as fever and chills.

A) Encourage increased fluid intake to prevent dehydration.

B) Monitor for signs of infection such as fever and chills.

C) Educate the patient on the importance of adhering to the prescribed diet.

D) Assess the patient's skin integrity regularly.

A patient with Crohn's disease has developed a fistula between the ileum and sigmoid colon, as well as a possible enterovesical fistula. Which nursing intervention is most appropriate to address the patient's nutritional needs while managing symptoms?

B) Recommend a low-residue diet to minimize bowel irritation

A) Encourage a high-fiber diet to promote bowel regularity

B) Recommend a low-residue diet to minimize bowel irritation

C) Advise increasing fluid intake to flush out toxins

D) Suggest a high-protein diet to promote fistula healing

A patient with a history of Crohn's disease presents with a new diagnosis of an enterovesical fistula. Which nursing intervention is most appropriate to address the patient's current symptoms and promote healing?

D) Monitor for signs of urinary tract infection and report any abnormalities to the healthcare provider.

A) Encourage a high-fiber diet to promote bowel regularity.

B) Administer prescribed TNF-alpha inhibitors to reduce inflammation.

C) Educate the patient on performing Kegel exercises to strengthen pelvic floor muscles.

D) Monitor for signs of urinary tract infection and report any abnormalities to the healthcare provider.

A patient with Crohn's disease and a confirmed enterovesical fistula is being managed with broad-spectrum antibiotics and a TNF-alpha inhibitor. Which nursing intervention is most important to prevent complications related to the fistula and ongoing inflammation?

B) Monitor vital signs and watch for signs of sepsis.

A) Encourage a high-protein diet to promote healing.

B) Monitor vital signs and watch for signs of sepsis.

C) Advise the patient to increase physical activity to improve circulation.

D) Educate the patient on maintaining a high-fiber diet to aid digestion.

A patient with Crohn's disease and a confirmed enterovesical fistula presents with mild tenderness in the lower abdominal quadrants and a low-grade fever. Which nursing intervention should be prioritized to address the potential complications of the identified abscess?

B) Administer prescribed broad-spectrum antibiotics on time.

A) Encourage a high-fiber diet to promote bowel regularity.

B) Administer prescribed broad-spectrum antibiotics on time.

C) Increase the patient's fluid intake to manage dehydration.

D) Encourage ambulation to prevent deep vein thrombosis.

A patient with Crohn's disease is experiencing increased diarrhea and signs of dehydration after starting antibiotic therapy. The nurse notes mild tachycardia and a slight decrease in potassium levels. What is the most appropriate nursing intervention to address these symptoms?

C) Provide oral rehydration solutions rich in electrolytes

A) Increase the patient's oral fluid intake with water

B) Administer intravenous fluids with potassium supplementation

C) Provide oral rehydration solutions rich in electrolytes

D) Suggest a diet change to increase fiber intake

A patient with Crohn's disease is experiencing increased episodes of diarrhea and signs of dehydration despite oral rehydration efforts. Laboratory results show a slight decrease in potassium levels. Which nursing intervention is most appropriate to address the patient's current condition?

B) Administer an oral potassium supplement as prescribed and monitor electrolyte levels.

A) Encourage the patient to increase fluid intake focusing on clear liquids.

B) Administer an oral potassium supplement as prescribed and monitor electrolyte levels.

C) Suggest the patient avoid all solid foods until diarrhea subsides completely.

D) Educate the patient on the importance of maintaining a high-fiber diet to bulk stools.

chronic bowel disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic bowel diseases, such as Crohn's disease and ulcerative colitis, are primarily driven by an inappropriate immune response. This involves an overactive immune system attacking the gastrointestinal tract, leading to inflammation and tissue damage.

• Secondary mechanism: The persistent inflammation disrupts the integrity of the intestinal lining, impairing nutrient absorption and contributing to symptoms like diarrhea, abdominal pain, and weight loss. Over time, this can lead to fibrosis and strictures, further complicating bowel function.

• Key complication: Prolonged inflammation increases the risk of complications, including bowel obstruction and colorectal cancer. Additionally, the chronic nature of the disease can lead to systemic effects such as anemia and fatigue due to nutrient malabsorption and chronic blood loss.

Patient Profile

Demographics:

45 years old, female, office manager

History:

• Key past medical history: Diagnosed with Crohn's disease 10 years ago, history of iron deficiency anemia

• Current medications: Mesalamine, prednisone (as needed during flare-ups), iron supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing abdominal pain and diarrhea

• Key symptoms: Abdominal cramping, frequent loose stools, fatigue, unintended weight loss, occasional fever

• Vital signs: Blood pressure 142/88 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute, temperature 100.2°F, oxygen saturation 96% on room air

Section 1

After an initial assessment, the patient exhibits signs of worsening Crohn's disease with potential complications. Physical examination reveals significant tenderness in the lower right quadrant of the abdomen, suggesting possible inflammation or the development of a stricture. Her mucous membranes appear pale, correlating with her history of iron deficiency anemia and potentially indicating a decrease in hemoglobin levels. Laboratory tests confirm this suspicion, with a hemoglobin level of 9.2 g/dL, indicative of moderate anemia, likely exacerbated by malabsorption and chronic intestinal blood loss. Her C-reactive protein (CRP) level is markedly elevated at 42 mg/L, pointing towards increased inflammatory activity.

The patient expresses heightened fatigue and reports an increase in the frequency of her bowel movements, now up to ten loose stools per day. This escalation in symptoms, combined with her elevated CRP and low hemoglobin, suggests that her disease is not adequately controlled with her current medication regimen. Additionally, her unintended weight loss of 10 pounds over the past month raises concerns about her nutritional status and the potential for further systemic effects. Given the persistence of fever and abdominal pain, imaging studies such as an abdominal CT scan are recommended to rule out complications like abscess formation or significant bowel obstruction.

These findings prompt a reassessment of her treatment plan. The healthcare team considers the need for more aggressive therapy, possibly including biologics or immunosuppressants to better control her disease and prevent further deterioration. Nutritional support and iron supplementation strategies require re-evaluation to address her anemia and weight loss. As the team plans to adjust her therapeutic approach, they also discuss the importance of regular monitoring to quickly identify and manage any new complications that may arise.

Section 2

Following the decision to conduct an abdominal CT scan, the results reveal the presence of a small bowel stricture with evidence of pre-stenotic dilation, confirming the suspicion of a complication from her Crohn's disease. Additionally, there is a small adjacent abscess measuring 2 cm, which aligns with her persistent fever and abdominal tenderness. These findings necessitate a prompt re-evaluation of her treatment strategy to address both the underlying inflammation and the newly identified abscess.

The healthcare team decides to initiate a biologic therapy, specifically a TNF-alpha inhibitor, to target the inflammatory pathways more effectively than her previous regimen. Given the risk of infection due to the abscess, she is also started on a course of broad-spectrum antibiotics to mitigate any potential bacterial growth. Her nutritional status is addressed by consulting with a dietitian to ensure adequate caloric and micronutrient intake, focusing on iron-rich foods and supplements to combat her anemia.

In the days following the intervention, the patient's clinical status is closely monitored. Her vital signs show a slight improvement; her temperature stabilizes at 99°F, and her heart rate decreases to 88 beats per minute. Her bowel movements reduce to six per day, indicating a positive initial response to the new treatment. However, the team remains vigilant, aware that the potential for new complications remains, and schedules a follow-up endoscopy to assess the response of the bowel mucosa to the biologic therapy. This proactive approach aims to prevent further deterioration and guide the next steps in her ongoing management.

Section 3

Two weeks into the revised treatment regimen, the patient returns for her scheduled follow-up endoscopy. The procedure reveals that the mucosal inflammation has decreased significantly, suggesting a favorable response to the TNF-alpha inhibitor. However, the endoscopy also uncovers a new area of concern: a developing fistula between a segment of the ileum and the sigmoid colon. This finding correlates with her recent complaints of intermittent diarrhea and occasional passage of air during urination, indicating a possible enterovesical fistula.

Laboratory tests show a slight elevation in her white blood cell count at 11,500/mm³, up from her baseline, hinting at a potential ongoing inflammatory or infectious process. Her C-reactive protein (CRP) levels, while reduced from initial levels, remain elevated at 30 mg/L, reinforcing the need for continued vigilance and management adjustments. Given these results, the healthcare team deliberates on the need for surgical intervention to address the fistula and prevent further complications, balancing this with the risks associated with surgery in patients with active Crohn's disease.

This new development necessitates a multidisciplinary approach, involving gastroenterologists, surgeons, and nutritionists, to optimize her management plan. The team considers the potential benefits of continuing biologic therapy in tandem with a carefully timed surgical intervention. Meanwhile, the patient's nutritional plan is adjusted to support healing and manage her symptoms, emphasizing low-residue foods to minimize bowel irritation. As they refine her care strategy, the team remains focused on her quality of life, aiming to mitigate symptoms and prevent further disease progression while monitoring for signs of any additional complications.

Section 4

The healthcare team decides to focus first on the immediate management of the patient's developing fistula and its implications. During this time, the patient reports increased fatigue and a slight rise in her body temperature, hovering around 100.4°F, suggesting a low-grade fever potentially linked to the inflammatory process. Physical examination reveals mild tenderness in the lower abdominal quadrants, but no significant guarding or rebound tenderness. The patient's weight has remained stable, and her nutritional intake is adequate, although she mentions occasional discomfort after meals.

To further investigate the scope of the fistula and assess any additional complications, the team orders a CT enterography. The imaging confirms the presence of an enterovesical fistula and reveals a small abscess forming near the ileocecal region. This finding aligns with her elevated white blood cell count and persistent CRP levels, indicating an ongoing inflammatory response. The multidisciplinary team, recognizing the potential for further complications such as sepsis or worsening infection, debates the timing of surgical intervention versus continued medical management.

After thorough discussion, the team decides to initiate a short course of broad-spectrum antibiotics to address the risk of infection related to the abscess while continuing the TNF-alpha inhibitor to manage mucosal inflammation. The patient is scheduled for close monitoring through regular follow-up visits, with plans for surgical consultation to assess the optimal timing for fistula repair. Nutritionally, the patient is advised to maintain a low-fiber diet to reduce bowel distress, and hydration status is closely monitored to prevent dehydration from her intermittent diarrhea. This comprehensive, coordinated approach aims to stabilize her current condition while planning for necessary surgical intervention, ensuring a balance between managing her Crohn's disease and addressing the new complications effectively.

Section 5

Several days into the antibiotic therapy, the patient begins to show signs of improvement, with her temperature stabilizing at around 99.5°F and a noticeable reduction in fatigue. However, during a follow-up visit, the nurse notes that the patient appears slightly more lethargic than usual and reports experiencing increased episodes of diarrhea, now averaging six times a day. While her weight remains stable, the patient expresses concern about feeling more dehydrated despite her efforts to maintain adequate fluid intake. Vital signs reveal a heart rate of 98 beats per minute, blood pressure of 110/68 mmHg, and respiratory rate of 18 breaths per minute, indicating mild tachycardia potentially related to dehydration.

Laboratory results show a decrease in her white blood cell count, now at 10,000 cells/µL, suggesting a partial response to the antibiotics. However, her CRP level remains elevated, indicating ongoing inflammation. Electrolyte panels reveal a slight decrease in potassium levels, now at 3.4 mmol/L, likely due to her increased diarrhea. Given these findings, the healthcare team decides to adjust her treatment plan to address the dehydration and electrolyte imbalance. They recommend oral rehydration solutions rich in electrolytes and consider the introduction of a low-dose corticosteroid to better control the inflammation and further manage her Crohn's disease symptoms.

The multidisciplinary team continues to closely monitor the patient, scheduling another follow-up to evaluate her response to the updated treatment regimen. Meanwhile, the surgical team plans to reassess the timing for potential surgical intervention for the fistula, balancing the need to resolve the structural complication with ensuring the patient's overall stability. This approach underscores the importance of a comprehensive strategy that addresses both the acute and chronic aspects of her condition, aiming to improve her quality of life and prevent further complications.