A patient with Crohn's disease presents with a small bowel obstruction and fistula formation between the ileum and sigmoid colon. In managing this patient, which nursing intervention is most critical to prioritize?

B) Initiating bowel rest and intravenous fluid therapy

A) Administering oral iron supplements to address anemia

B) Initiating bowel rest and intravenous fluid therapy

C) Encouraging a high-fiber diet to promote bowel motility

D) Preparing the patient for immediate surgical intervention

A patient with Crohn's disease is experiencing an exacerbation with a small bowel obstruction and fistula formation. The patient presents with abdominal pain, diarrhea, anemia, and electrolyte imbalances. Which of the following nursing interventions is most appropriate to prioritize initially?

C) Initiate bowel rest and administer intravenous fluids.

A) Encourage oral intake to prevent dehydration.

B) Administer oral iron supplements to address anemia.

C) Initiate bowel rest and administer intravenous fluids.

D) Increase physical activity to prevent deconditioning.

A patient with Crohn's disease is experiencing ongoing diarrhea, fatigue, and a decline in hemoglobin levels despite bowel rest and intravenous fluid therapy. Laboratory results show hypokalemia with potassium levels at 2.9 mmol/L. What is the most appropriate nursing intervention to address the patient's current condition?

B) Administer prescribed potassium supplements and monitor for cardiac dysrhythmias.

A) Encourage increased oral fluid intake to correct electrolyte imbalances.

B) Administer prescribed potassium supplements and monitor for cardiac dysrhythmias.

C) Advise the patient to increase dietary fiber intake to manage diarrhea.

D) Initiate a low-residue diet to decrease bowel activity and reduce symptoms.

A patient with Crohn's disease is experiencing ongoing diarrhea, fatigue, and electrolyte imbalances despite current interventions. The healthcare team is considering the initiation of total parenteral nutrition (TPN) and adjusting potassium supplementation. Which nursing intervention is most critical to prioritize at this time?

A) Monitor the patient's blood glucose levels regularly.

B) Educate the patient on the importance of oral hydration.

C) Encourage the patient to increase oral fiber intake.

D) Assess the patient's ability to manage self-care at home.

A patient with inflammatory bowel disease initiated on total parenteral nutrition (TPN) and potassium supplementation shows signs of increased abdominal distension, cramping pain, and diminished bowel sounds. Imaging reveals a partial bowel obstruction. Which nursing intervention is most appropriate to address the patient's current condition?

D) Monitor and document abdominal girth every 4 hours.

A) Administer intravenous fluids to maintain hydration.

B) Encourage oral intake to stimulate bowel function.

C) Position the patient in a semi-Fowler's position to reduce abdominal pressure.

D) Monitor and document abdominal girth every 4 hours.

A patient with a history of inflammatory bowel disease is experiencing increased abdominal distension and pain, leading to a suspicion of bowel obstruction. After initiating total parenteral nutrition (TPN) and potassium supplementation, her potassium level remains low, and surgery is planned. Which nursing intervention is most important to perform preoperatively to prevent further complications?

D) Verify that the patient's electrolytes, particularly potassium levels, are adequately corrected.

A) Administer an antiemetic as prescribed to prevent nausea and vomiting.

B) Monitor fluid intake and output closely to assess for signs of dehydration.

C) Educate the patient about postoperative pain management techniques.

D) Verify that the patient's electrolytes, particularly potassium levels, are adequately corrected.

A patient is recovering from a laparoscopic procedure to relieve a bowel obstruction and has a critically low potassium level of 2.6 mmol/L. Which nursing intervention is most important to implement to prevent complications associated with hypokalemia?

A) Monitor the patient's cardiac rhythm continuously.

B) Encourage the patient to increase their oral fluid intake.

C) Administer oral potassium supplements as prescribed.

D) Educate the patient about the importance of dietary potassium.

A post-operative patient with a history of Crohn's disease is receiving total parenteral nutrition (TPN) and potassium supplementation following ileocolic resection. The nurse notes the patient is at risk for complications related to her current treatment. Which assessment finding should prompt the nurse to contact the healthcare provider immediately?

C) The patient develops a new onset of irregular heartbeat.

A) The patient reports mild abdominal pain and passes gas.

B) The patient's serum potassium level increases to 3.4 mmol/L.

C) The patient develops a new onset of irregular heartbeat.

D) The patient's temperature is 37.5°C with no other symptoms.

A post-operative patient with Crohn's disease is experiencing increased abdominal distension and discomfort on the third day after surgery, along with a gradual increase in heart rate to 95 bpm and a slight elevation in temperature to 37.8°C. Imaging shows a small collection of free air and fluid near the ileocolic anastomosis site. Which nursing intervention is most critical at this time to prevent further complications?

A) Administer prescribed antibiotics and continue to monitor vital signs closely

B) Encourage the patient to ambulate frequently to promote gastrointestinal motility

C) Increase the patient's oral fluid intake to enhance hydration and electrolyte balance

D) Educate the patient about the importance of early mobilization in preventing post-operative ileus

A post-operative patient with Crohn's disease is showing signs of potential complications. Which nursing intervention is most appropriate to prioritize in response to the imaging findings of free air and fluid near the ileocolic anastomosis?

B) Administer prescribed antibiotics and monitor for signs of infection.

A) Encourage early ambulation to promote bowel function.

B) Administer prescribed antibiotics and monitor for signs of infection.

C) Increase oral fluid intake to maintain hydration.

D) Apply a heating pad to the abdomen to alleviate discomfort.

crohn's disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Immune dysregulation leads to an inappropriate immune response against intestinal flora, causing chronic inflammation primarily in the gastrointestinal tract's ileum and colon. This results in the formation of granulomas and transmural inflammation, which can disrupt normal tissue architecture.

• Secondary mechanism: Genetic predisposition, such as mutations in the NOD2 gene, contributes to altered immune system function and barrier defects in the intestinal epithelium. This genetic factor increases susceptibility to environmental triggers that activate the inflammatory process.

• Key complication: Chronic inflammation and transmural lesions can lead to fibrosis, strictures, fistulas, and abscesses, causing bowel obstruction, malabsorption, and increased risk of colorectal cancer, significantly impacting patients' quality of life.

Patient Profile

Demographics:

29-year-old female, graphic designer

History:

• Key past medical history: Diagnosed with Crohn's disease 5 years ago, history of anemia, and previous small bowel resection

• Current medications: Mesalamine, azathioprine, iron supplements, vitamin B12 injections, oral contraceptive

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing abdominal pain and diarrhea

• Key symptoms: Frequent loose stools, fatigue, weight loss, abdominal cramping, low-grade fever, and joint pain

• Vital signs: Blood pressure 110/70 mmHg, heart rate 102 bpm, respiratory rate 20 breaths per minute, temperature 100.1°F, oxygen saturation 97% on room air

Section 1

As the patient's clinical evaluation continues, new diagnostic results reveal concerning developments. A recent colonoscopy shows strictures in the terminal ileum with evidence of patchy inflammation and ulceration, consistent with Crohn's disease exacerbation. Additionally, imaging studies, including an abdominal CT scan, identify the presence of a small bowel obstruction and suggest the formation of a fistula between the ileum and the sigmoid colon. These findings highlight the progression of the disease and the complication of fistula formation, which could account for the patient's worsening symptoms, including abdominal pain and diarrhea.

Laboratory tests further complicate the picture, revealing elevated inflammatory markers, with C-reactive protein (CRP) at 18 mg/L and erythrocyte sedimentation rate (ESR) at 45 mm/hr, indicating systemic inflammation. The complete blood count demonstrates anemia with hemoglobin at 9.8 g/dL and a decreased mean corpuscular volume (MCV), pointing towards iron deficiency as a result of chronic blood loss and malabsorption. Electrolyte imbalances are also noted, with low potassium levels at 3.2 mmol/L, contributing to her fatigue and muscle weakness.

These new complications necessitate immediate clinical interventions. The healthcare team initiates bowel rest and intravenous fluid therapy to manage the obstruction and correct electrolyte imbalances. A surgical consultation is requested to evaluate the need for potential intervention to address the fistula and obstruction. Meanwhile, the patient's medication regimen is reviewed, with consideration for adjusting immunosuppressive therapy to better control the inflammatory response. These actions aim to stabilize the patient and improve her quality of life while addressing the underlying disease progression and complications.

Section 2

As the healthcare team closely monitors the patient's response to the interventions, a change in her clinical status is observed. The patient initially reports a slight improvement in abdominal pain, suggesting some relief from the bowel rest and intravenous fluid therapy. However, despite these measures, she continues to experience frequent episodes of diarrhea and increasing fatigue, raising concerns about ongoing malabsorption and nutritional deficiencies. Her vital signs show a low-grade fever of 37.8°C (100°F), a heart rate of 102 beats per minute, and a blood pressure of 100/65 mmHg, indicating continued systemic inflammation and potential hemodynamic changes as a result of fluid loss and anemia.

Further laboratory tests reveal a persistent decline in hemoglobin, now at 9.2 g/dL, and a worsening of electrolyte imbalances, with potassium levels dropping to 2.9 mmol/L. These findings suggest that the current interventions are insufficient in addressing the underlying complications. The patient's nutritional intake is assessed, revealing inadequate oral intake due to pain and nausea, further contributing to her electrolyte disturbances and anemia. The team considers the initiation of total parenteral nutrition (TPN) to provide adequate caloric and nutritional support, while also adjusting her potassium supplementation to correct the hypokalemia more effectively.

Given the complexity of the case, a multidisciplinary meeting is convened to discuss the next steps. The surgical team evaluates the possibility of an elective resection to address the strictures and fistula, weighing the risks of surgery against the potential benefits of relieving the obstruction and preventing further complications. Simultaneously, the gastroenterology team contemplates intensifying her immunosuppressive therapy, exploring options such as biologic agents to achieve better disease control. These discussions underscore the importance of a coordinated approach to manage her Crohn's disease exacerbation and its associated complications, with the ultimate goal of stabilizing her condition and improving her quality of life.

Section 3

As the multidisciplinary team implements the adjusted treatment plan, including the initiation of total parenteral nutrition (TPN) and enhanced potassium supplementation, the patient's condition initially appears to stabilize. However, within 48 hours, she develops a new complication: increased abdominal distension accompanied by severe, cramping pain that does not resolve with medication. Upon physical examination, her abdomen feels tense and tender, with diminished bowel sounds, raising concerns for a possible bowel obstruction or worsening of her existing strictures.

Further imaging studies, including an abdominal CT scan, reveal significant luminal narrowing in the terminal ileum with proximal bowel dilation, consistent with a partial bowel obstruction. The imaging also suggests the presence of new inflammatory changes around the affected bowel segments, indicating ongoing disease activity despite current medical therapy. Additionally, her laboratory results show a further drop in hemoglobin to 8.5 g/dL and a continued decrease in potassium to 2.7 mmol/L, suggesting ongoing nutritional deficits and a need for more aggressive corrective measures.

In light of these findings, the team deliberates the urgency of surgical intervention versus continued medical management. The surgical team, after assessing the risks of emergent surgery, decides to proceed with a laparoscopic evaluation and possible resection to relieve the obstruction and address the strictures. Concurrently, the gastroenterology team plans to escalate her immunosuppressive therapy post-operatively, considering biologic agents to better control her inflammatory disease. This coordinated approach aims to address both the immediate complication of bowel obstruction and the underlying inflammatory process, with the goal of preventing further exacerbations and improving her overall clinical status.

Section 4

Following the decision for surgical intervention, the patient undergoes a laparoscopic procedure to relieve the bowel obstruction and assess the extent of the strictures. During surgery, the team identifies a significant stricture in the terminal ileum, which is resected, and an ileocolic anastomosis is performed. Post-operatively, the patient is transferred to the recovery unit for close monitoring. In the immediate post-operative period, she is hemodynamically stable with vital signs as follows: blood pressure 115/75 mmHg, heart rate 82 bpm, respiratory rate 18 breaths per minute, and temperature 37.1°C. However, her potassium level remains critically low at 2.6 mmol/L, necessitating careful electrolyte management to prevent complications such as arrhythmias.

Over the next 24 hours, the patient's abdominal pain improves significantly, and she starts to pass gas, indicating a return of bowel function. However, the team notes that her hemoglobin has further decreased to 7.9 g/dL, raising concerns about potential blood loss during surgery or ongoing anemia of chronic disease. The decision is made to administer a blood transfusion and continue iron supplementation. Additionally, her nutritional status is addressed with adjustments to her TPN regimen to ensure adequate caloric and nutrient intake, while her potassium supplementation is intensified to correct the persistent hypokalemia.

As the patient begins to stabilize post-operatively, the multidisciplinary team shifts focus to her long-term management. The gastroenterology team plans to initiate a biologic agent to better control her Crohn's disease and prevent future exacerbations. The nursing team plays a critical role in educating the patient about her new medication regimen, stressing the importance of adherence to prevent complications. They also educate her on monitoring for signs of infection, a potential side effect of immunosuppressive therapy. The coordinated efforts of the team and the patient's gradual improvement suggest a positive trajectory, yet the need for vigilant monitoring and ongoing care remains imperative to her recovery and long-term health.

Section 5

As the patient continues to recover post-operatively, the nursing team diligently monitors her for any new complications. On the third day after surgery, the patient begins to experience increased abdominal distension and discomfort. Her vital signs remain stable, but the nursing staff notes a gradual increase in her heart rate to 95 bpm and a slight elevation in her temperature to 37.8°C. Concerned about the possibility of ileus or anastomotic leakage, the surgical team orders an abdominal X-ray and a CT scan to further evaluate her condition.

The imaging studies reveal a small collection of free air and fluid near the site of the ileocolic anastomosis, suggesting a potential leak. In response to this finding, the patient's oral intake is halted, and she is placed on bowel rest while receiving intravenous fluids to maintain hydration and electrolyte balance. Antibiotic therapy is initiated to prevent infection, and her vital signs are closely monitored to detect any signs of sepsis or further complications. The patient's laboratory results are reviewed, showing a slight increase in white blood cell count to 12,000/mm³, adding to the suspicion of an inflammatory or infectious process.

Despite these challenges, the interdisciplinary team remains hopeful that conservative management will suffice, and they continue to monitor the patient's response to the interventions. The nursing staff plays a crucial role in educating the patient about the signs and symptoms of potential complications, such as fever, increased pain, or changes in bowel habits, that would necessitate immediate medical attention. This collaborative approach ensures that the patient receives comprehensive care as she navigates this critical phase of her recovery, highlighting the importance of vigilance and timely intervention in managing post-operative complications in patients with Crohn's disease.