A 32-year-old patient with Crohn's disease is experiencing an exacerbation with significant anemia and inflammation, as indicated by her recent lab results. Given her current condition and diagnostic findings, which nursing intervention is the priority to address her most immediate health risk?

B) Monitor for signs of bowel obstruction due to the identified stricture.

A) Administer prescribed intravenous iron supplementation to address anemia.

B) Monitor for signs of bowel obstruction due to the identified stricture.

C) Educate the patient on dietary modifications to reduce intestinal inflammation.

D) Prepare the patient for possible surgical intervention for the enteroenteric fistula.

A 32-year-old patient with Crohn's disease has recently been diagnosed with a stricture and a small enteroenteric fistula. Her hemoglobin level is 9.2 g/dL, and her CRP is elevated. Which nursing intervention is most important to prioritize in her care plan to address her current condition?

B) Monitor for signs of bowel obstruction and report any new findings to the healthcare provider.

A) Encourage high-fiber dietary intake to promote bowel regularity.

B) Monitor for signs of bowel obstruction and report any new findings to the healthcare provider.

C) Administer oral iron supplements to manage anemia.

D) Educate the patient on the importance of staying hydrated to manage diarrhea.

A patient with Crohn's disease has developed a 3 cm abscess adjacent to the terminal ileum, confirmed by CT scan. Which nursing intervention is the highest priority in managing this patient's current condition?

B) Initiate broad-spectrum intravenous antibiotics as prescribed

A) Administer oral analgesics to manage severe abdominal pain

B) Initiate broad-spectrum intravenous antibiotics as prescribed

C) Encourage oral fluid intake to prevent dehydration

D) Prepare the patient for potential surgical drainage of the abscess

A patient with Crohn's disease has developed a 3 cm abscess adjacent to the terminal ileum. After confirming the diagnosis with an abdominal CT scan, which nursing intervention is most appropriate to prioritize at this time?

B) Prepare the patient for an immediate surgical consultation and potential drainage procedure.

A) Administer oral antibiotics and schedule a follow-up appointment in two weeks.

B) Prepare the patient for an immediate surgical consultation and potential drainage procedure.

C) Increase the patient's fluid intake to promote spontaneous drainage of the abscess.

D) Educate the patient about dietary changes to reduce inflammation and prevent future abscesses.

A patient with a history of Crohn's disease is being treated for an abdominal abscess with intravenous antibiotics and percutaneous drainage. Despite a decrease in fever and heart rate, the patient continues to experience abdominal pain and diarrhea. Which nursing intervention is the most appropriate to address the patient's ongoing symptoms and support her recovery?

D) Educate the patient on dietary adjustments to minimize gastrointestinal irritation.

A) Administer an analgesic and antidiarrheal medication as prescribed.

B) Encourage the patient to increase oral fluid intake to manage dehydration.

C) Monitor the patient's hemoglobin levels and prepare for a possible blood transfusion.

D) Educate the patient on dietary adjustments to minimize gastrointestinal irritation.

A nurse is evaluating the effectiveness of the treatments implemented for a patient with an abdominal abscess and Crohn's disease exacerbation. Which of the following findings would indicate a need to reassess the current treatment plan?

B) Persistent abdominal pain and diarrhea

A) Stabilization of temperature at 99.8°F

B) Persistent abdominal pain and diarrhea

C) Heart rate decreased to 98 bpm

D) Decreased white blood cell count to 13,500/µL

A patient with Crohn's disease has developed a small bowel perforation with localized peritonitis post-abscess drainage. As the nurse, which immediate intervention is most critical to address the patient's current hemodynamic instability?

B) Initiate aggressive fluid resuscitation to stabilize blood pressure.

A) Administer intravenous corticosteroids to reduce inflammation.

B) Initiate aggressive fluid resuscitation to stabilize blood pressure.

C) Prepare the patient for emergency exploratory surgery.

D) Administer a blood transfusion to correct the hemoglobin level.

A patient with Crohn's disease has developed a small bowel perforation and peritonitis. The nurse is preparing to implement the plan of care. Which intervention should the nurse prioritize to address the patient's hemodynamic instability?

B) Administer aggressive fluid resuscitation

A) Initiate broad-spectrum antibiotics

B) Administer aggressive fluid resuscitation

C) Prepare the patient for exploratory surgery

D) Monitor hemoglobin levels closely

A patient with a history of Crohn's disease is recovering post-operatively from an ileal resection and temporary ileostomy due to bowel perforation. As the nurse, which post-operative assessment finding would most likely indicate a complication requiring immediate intervention?

D) Sudden increase in abdominal girth and decreased urine output

A) Heart rate of 102 bpm and blood pressure of 110/70 mmHg

B) Abdominal pain rated as 6/10 on the pain scale

C) Drainage of 100 mL of serosanguineous fluid from the surgical site over 4 hours

D) Sudden increase in abdominal girth and decreased urine output

A nurse is caring for a patient who has undergone an ileal resection and temporary ileostomy due to bowel perforation in the context of Crohn's disease. Post-operatively, the patient's heart rate has decreased to 102 bpm and blood pressure improved to 110/70 mmHg. Which nursing intervention is most important to prioritize in the immediate post-operative period?

B) Monitoring stoma output and character to assess for potential complications

A) Encouraging early ambulation to prevent thromboembolic complications

B) Monitoring stoma output and character to assess for potential complications

C) Providing education on long-term nutritional management with an ileostomy

D) Administering analgesics to manage post-operative pain effectively

crohn's disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Crohn's disease primarily involves a dysregulated immune response to intestinal microbiota. This inappropriate immune activation leads to chronic inflammation, particularly in the gastrointestinal tract, causing tissue damage and the formation of granulomas.

• Secondary mechanism: Genetic predispositions, such as mutations in the NOD2 gene, contribute to an impaired mucosal barrier and defective autophagy. This increases susceptibility to intestinal infections and perpetuates the inflammatory cycle.

• Key complication: Chronic inflammation from Crohn's can lead to fibrosis and strictures, resulting in bowel obstruction. Additionally, transmural inflammation can cause fistulas, creating abnormal connections between bowel segments or other organs, significantly impacting patient quality of life.

Patient Profile

Demographics:

32-year-old female, high school teacher

History:

• Key past medical history: Diagnosed with Crohn's disease 5 years ago, history of anemia

• Current medications: Mesalamine, Prednisone (recently increased dose), Iron supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Abdominal pain and increased frequency of diarrhea

• Key symptoms: Persistent diarrhea (5-6 times a day), lower right quadrant abdominal pain, unintentional weight loss, fatigue

• Vital signs: Temperature 100.4°F (38°C), Heart Rate 102 bpm, Blood Pressure 110/70 mmHg, Respiratory Rate 20 breaths per minute

Section 1

New Diagnostic Results:

Following her admission, the 32-year-old patient underwent several diagnostic tests to further evaluate her current condition and assess for potential complications related to Crohn's disease. Laboratory results revealed significant findings: her hemoglobin level dropped to 9.2 g/dL, indicating worsening anemia despite ongoing iron supplementation. C-reactive protein (CRP) was markedly elevated at 28 mg/L, suggesting active inflammation. A fecal calprotectin test, an indicator of intestinal inflammation, was also elevated at 450 µg/g, confirming an exacerbation of her Crohn's disease. These results prompted further imaging studies to assess the structural complications.

An abdominal CT scan with contrast was performed, which identified a thickened segment of the terminal ileum with significant narrowing consistent with a stricture. Additionally, there was evidence of a small enteroenteric fistula between two loops of the small intestine. These findings corroborated her symptoms of abdominal pain and increased diarrhea, aligning with the complications that can arise from untreated or poorly controlled Crohn's disease. The presence of a fistula introduces a new layer of complexity to her management, potentially requiring surgical intervention if medical management fails to control the disease or improve her symptoms.

These diagnostic results necessitate a multidisciplinary approach, involving gastroenterology, nutrition, and potentially surgical teams, to address the identified complications. Clinical reasoning now involves optimizing her current medication regimen, considering the addition of biologic therapies like anti-TNF agents, and closely monitoring for signs of further complications such as bowel obstruction or abscess formation. The focus will be on reducing inflammation, managing her anemia, and improving her overall nutritional status to prevent further weight loss and fatigue. The next steps in her care involve reassessing her response to the adjusted treatment plan and determining if surgical consultation is warranted for the stricture and fistula management.

Section 2

Following the adjustment of her treatment plan to include a biologic therapy, the patient initially showed signs of improvement, with a slight reduction in abdominal pain and diarrhea frequency. However, two weeks into the new regimen, she returned to the clinic with new complications. She reported experiencing fevers, night sweats, and increased fatigue, alongside the resumption of severe abdominal pain and diarrhea, now with occasional blood.

Vital signs upon this assessment revealed a low-grade fever of 100.4°F, a heart rate of 110 bpm, and blood pressure of 100/60 mmHg, indicating potential hemodynamic instability. Physical examination noted a distended abdomen with diffuse tenderness and guarding, particularly in the lower right quadrant. Laboratory tests showed a further drop in hemoglobin to 8.5 g/dL, leukocytosis with a white blood cell count of 15,000/µL, and an elevated CRP of 35 mg/L. These findings suggested an exacerbation of inflammation and a possible infectious process.

Given the presence of a fistula, the development of fever and leukocytosis raised concerns for an abscess formation. An urgent repeat abdominal CT scan was ordered, which confirmed the presence of a 3 cm abscess adjacent to the terminal ileum. This new complication required immediate attention, prompting the initiation of broad-spectrum intravenous antibiotics and consultation with the surgical team for potential drainage. This development necessitates a reevaluation of the patient's overall management strategy, emphasizing the importance of addressing both the inflammatory and infectious components of her Crohn's disease to prevent further deterioration.

Section 3

Response to Interventions:

After the initiation of broad-spectrum intravenous antibiotics, the patient was closely monitored for any signs of improvement or further complications. Over the next 48 hours, there was a slight reduction in her fever, with temperatures stabilizing around 99.8°F. Her heart rate decreased to 98 bpm, showing a mild improvement in hemodynamic stability, although her blood pressure remained on the lower side at 104/62 mmHg. Despite these positive changes, her abdominal pain persisted, and her diarrhea continued, suggesting that while the infection might be partially controlled, the underlying inflammatory process was still active.

Repeat laboratory tests showed a slight decrease in the white blood cell count to 13,500/µL, indicating a response to the antibiotic therapy. However, her hemoglobin level further declined to 8.2 g/dL, raising concerns about ongoing blood loss, likely from the gastrointestinal tract, and necessitating a transfusion to address anemia. The CRP remained elevated at 33 mg/L, reflecting ongoing inflammation.

The surgical team evaluated the patient for abscess drainage, considering both percutaneous and surgical options. Given the abscess's location near the terminal ileum, a percutaneous approach was deemed feasible and was performed successfully under imaging guidance. Fluid cultures from the abscess were taken to tailor antibiotic therapy more precisely. Post-procedure, the patient reported a modest decrease in abdominal pain and felt slightly more energetic, although continued monitoring was essential to ensure complete resolution of the abscess and address her Crohn's disease exacerbation effectively. This step in her care highlighted the need for an integrated management approach, combining infection control and continuous evaluation of her inflammatory disease component.

Section 4

New Complications:

As the clinical team continued to monitor the patient post-abscess drainage, it became apparent that her condition was not improving as expected. Over the next 24 hours, her abdominal pain intensified, and she began to exhibit signs of peritoneal irritation, such as guarding and rebound tenderness on examination. These findings raised concerns about a possible perforation or further complications related to her Crohn's disease. Her vital signs showed a concerning trend, with her heart rate increasing again to 112 bpm and her blood pressure dropping further to 98/58 mmHg, suggesting possible sepsis or worsening inflammation.

In addition to the clinical assessment, repeat imaging studies were ordered, including an abdominal CT scan. The results revealed not only residual abscess formation but also signs of a small bowel perforation with localized peritonitis. This new complication necessitated an urgent surgical consultation to evaluate the need for exploratory surgery. Meanwhile, her laboratory results showed a further drop in hemoglobin to 7.8 g/dL, indicating continued blood loss, likely exacerbated by the perforation, and a rising WBC count to 16,000/µL, suggestive of a secondary infection or inflammatory response.

The development of these complications required immediate intervention, including aggressive fluid resuscitation to address her hemodynamic instability and the initiation of broad-spectrum antibiotics to cover for intra-abdominal sepsis. The multidisciplinary team, including gastroenterology, surgery, and infectious disease specialists, was engaged to formulate a comprehensive plan addressing her acute needs while considering long-term management strategies for her Crohn's disease. This situation underscored the complexity of Crohn's disease management, where complications can arise rapidly and require swift, coordinated responses to stabilize the patient and prevent further deterioration.

Section 5

Response to Interventions

Despite the aggressive fluid resuscitation and initiation of broad-spectrum antibiotics, the patient's condition continued to show signs of deterioration. Over the next few hours, her vital signs remained unstable, with a heart rate persistently elevated at 118 bpm and blood pressure fluctuating between 95/55 mmHg and 100/60 mmHg. This hemodynamic instability suggested that the fluid resuscitation efforts were not adequately addressing her circulatory needs, possibly due to ongoing fluid losses into the peritoneal cavity or worsening sepsis. Additionally, her temperature spiked to 39.2°C (102.6°F), further indicating a systemic inflammatory response.

The surgical team, after reviewing the imaging and clinical findings, decided that exploratory laparotomy was necessary to address the bowel perforation and any additional intra-abdominal pathology. Pre-operative preparation began immediately, with an emphasis on optimizing her hemodynamic status. The anesthesiology team assessed her risk and implemented measures to maintain her cardiovascular stability during surgery. Meanwhile, the infectious disease specialist recommended adjusting her antibiotic regimen to include coverage for anaerobic and resistant bacterial strains, given the high risk of polymicrobial infection in perforated bowel scenarios.

Intraoperatively, the surgical team discovered a perforation in the ileum with extensive localized inflammation and beginning signs of necrosis. An ileal resection was performed, and a temporary ileostomy was created to divert fecal matter and reduce the risk of further contamination. Post-operatively, the patient's condition began to stabilize, with her heart rate decreasing to 102 bpm and blood pressure improving to 110/70 mmHg. Laboratory results showed a slight improvement in her white blood cell count, now at 14,000/µL, suggesting a positive response to infection control measures. The patient was transferred to the intensive care unit for close monitoring and continued support, marking a crucial turning point in her recovery process and highlighting the importance of timely surgical intervention in managing complications of Crohn's disease.