PBL ON INFLAMMTORY DISEEASES

Tom Jones., a 26-year-old Caucasian male, presents to the emergency department with
a chief complaint of abdominal pain. His symptoms began two days earlier, with abdominal pain
that is mostly diffuse but seems to be more intense in the right lower quadrant. He rates the pain
as an 8 on a scale of 1 to 10. He also has had associated anorexia, nausea, vomiting, diarrhea,
fatigue, weakness, and shortness of breath. The diarrhea is described as watery, non- bloody,
and occurring approximately 10 times per day, without bowel incontinence and hematochezia.
He describes the nausea as occasional, with two episodes of vomiting that day. The patient has
never had this type of pain or combination of symptoms before. The patient’s past medical
history is significant for cervical spine fracture and phrenic nerve damage seven years ago. He
denies taking any medications in the past month, but does admit to a Sulfa drug allergy.
Past surgical history is unremarkable. The family history is significant for hypertension.
T.J. is a Christian minister who lives with his pregnant wife and their two-year old female child.
He has a five pack-year smoking history, with smoking abstinence for the past five years. He
denies alcohol or illicit drug use or any recent travel history or contact with individuals with
similar gastrointestinal symptoms. He also denies unsanitary living and working conditions.
Physical examination reveals a height of 5 feet, 10 inches, weight of 200 lbs, body mass
index of 29, blood pressure of 108/70, heart rate of 90 bpm, respiratory rate of 20 breaths per
minute, and a temperature of 98.6 °F. The patient appears appropriate for his stated age, and is
alert and oriented to person, place, and time. Skin is found to be pale, warm, and dry, without
edema present. There is poor capillary return at greater than 2 seconds refill time in the
fingernail beds. Head, eyes, ears, nose, and throat reveal no abnormalities. Pulmonary and
cardiovascular systems are within normal limits. The abdomen is observed to be flat and tense
with no masses or organomegaly; bowel sounds are present. Diffuse tenderness to palpation is
present, with the greatest tenderness in the right lower quadrant. No hernias are palpated.
Rectal examination reveals no fistulas or fissures. There is good anal sphincter tone, no
palpable masses, and no occult blood. The genitourinary system is within normal limits. There
are no gross neurological or musculoskeletal deficits.
The CMP was found to be unremarkable, with results within normal limits. The CBC
revealed leukocytosis at 18,000/_L and all other components within normal limits. The chest
radiographs revealed no acute cardiopulmonary process, unchanged from the previous study.
Computed tomography of the abdomen and pelvis revealed: (1) thickening of bowel at the
illeocecal and sigmoid areas and (2) normal appendix observed without acute inflammatory
changes. Stool studies were negative for ova, parasites, C. difficile, and other bacterial
pathogens. A colonoscopy with lesion biopsy was recommended for further diagnostic
clarification. However, a colonoscopy was determined to be contraindicated during the acute
inflammation period and deferred to a later time. The initial management plan included
intravenous fluid rehydration with normal saline to run at 250 mL/hour, along with recording
accurate daily inputs and outputs.
The plan also included intravenous metronidazole 500 mg every 6 hours and
intravenous methylprednisolone 125 mg every 12 hours. With the reduction in acute
inflammation, a colonoscopy was performed. Colonoscopic findings indicated aphtoid
ulcerations, cobblestoning, and skip lesions in the sigmoid and illeocecal areas, as well as
histologic findings of transmural inflammation and granulomas.

JUMP 1
 Sulfa drug allergy- A sulfa allergy is when you have an allergic reaction to drugs that
contain sulfa.
 Organomegaly- abnormal enlargement of organs
 Genitourinary system- are the organs of the reproductive system and the
urinary system
 C. difficile- Clostridium difficile (C. diff) is bacteria that can infect the bowel and cause
diarrhea.
 Aphtoid ulceration- a kind ulceration that is caused by inflammation that may affects the colon/
gastrointestinal tract
 Granulomas – abnormal appearance or formation of granular structure that may cause
inflammation that can be located anywhere in the body

JUMP 2
1. What is the diagnosis of the given scenario?
The diagnosis in the given scenario is CHRON’S DISEASE.
2. What are the causes of the disease?
 Genes: Inflammatory bowel disease (IBD) often runs in families. If you have a
parent, sibling or other family member with Crohn’s, you may be at an increased
risk of also having it. There are several specific mutations (changes) to your
genes that can predispose people to developing Crohn’s disease.
 Race
 Age & Gender
 Smoking: Cigarette smoking could as much as double your risk of Crohn’s
disease.
 Environmental Stress
 Lifestyle & Diet

3. What are the risk factors of the disease?

 Age. Crohn's disease can occur at any age, but you're likely to develop the
condition when you're young. Most people who develop Crohn's disease are
diagnosed before they're around 30 years old.
 Ethnicity. Although Crohn's disease can affect any ethnic group, whites have the
highest risk, especially people of Eastern European (Ashkenazi) Jewish descent.
However, the incidence of Crohn's disease is increasing among Black people
who live in North America and the United Kingdom.
 Family history. You're at higher risk if you have a first-degree relative, such as a
parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn's
disease has a family member with the disease.
 Cigarette smoking. Cigarette smoking is the most important controllable risk
factor for developing Crohn's disease. Smoking also leads to more-severe
disease and a greater risk of having surgery. If you smoke, it's important to stop.
 Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil,
Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium and others. While
they do not cause Crohn's disease, they can lead to inflammation of the bowel
that makes Crohn's disease worse.

4. What are the signs and symptoms of the disease?

FOUND IN THE SCENARIO
 Abdominal Pain (more intense in the right lower quadrant)
 Anorexia
 Nausea
 Vomiting
 Diarrhea (watery, non- bloody)
  Fatigue
 Weakness
 Shortness of breath
 Skin is found to be pale, warm, and dry
 There is poor capillary return at greater than 2 seconds refill time in the fingernail
beds
 Diffuse tenderness to palpation is present, with the greatest tenderness in the
right lower quadrant.
 Findings of transmural inflammation and granulomas
 Thickening of bowel at the illeocecal and sigmoid areas
 Colonoscopic findings indicated aphtoid ulcerations, cobblestoning and skip
lesions in the sigmoid and illeocecal areas

NOT FOUND IN THE SCENARIO

 -Weight loss
 -Bloody stool
 -Mouth sores
 -Decreased appetite
 -Pain around the anus
 -Fever

5. What are the diagnostic procedures of the disease?

-Complete Blood Count
-CT scan
-Colonoscopy
-Stool Test
-CMP
-Rectal Examination
-MRI
-Endoscopy

6. What are the medical management?

Pharmacologic Managements:
1. IV Metronidazole
2. IV Methylprednisolone
3. Corticosteroid
4. Anti-diarrheal agent
5. Normal Saline for FE replacement
6. Nutrional Supplement

Surgical Management

1. Colectomy – removal of damaged colon

2. Proctocolectomy
3. Colostomy
4. Bowel Resection
5. Fistula removal
 7. What are the nursing managements?
Independent:
1. Proper positioning for shortness of breathing
2. Encourage Hydration to client
3. Provide comfortable environment
4. Encourage high-fiber diet
5. Promote bed rest

Dependent:
1. Administer anti-inflammatory drugs
2. Administer analgesic drug
3. Administer oxygen therapy
4. Administer Parental fluid
5. Administer Multivitamins

Interdependent:
1. Refer to dietician
2. Refer to nutritionist
3. Refer to respiratory therapist

Learning Goals
 Hematochezia
 Phrenic nerve
 CMP (Complete Metabolic Panel)
 Cobblestoning
 Significance of past medical history of cervical spine fracture and phrenic nerve damage
 Incidence
 Complete Blood Count
 CT scan
 Colonoscopy
 Stool Test
 CMP
 Rectal Examination
 MRI
 Endoscopy
 Independent and Dependent N. Management