Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
(Care Plans)
Comparison of Inflammatory Bowel Diseases
(Image)
Outline
Ms. Hale is a 19 year old female who presents to the Emergency Department (ED) reporting bloody diarrhea. She reports that she has been told she has Irritable Bowel Syndrome (IBS) in the past, and sometimes has bloody stools, but this is the first time she’s seen this much blood
Critical Thinking Check
Bloom's Taxonomy: Application
What further history questions would you ask Ms. Hale?
Normal” bowel habits – how many times a day, color, consistency
Previous experiences with bleeding?
Diet and lifestyle habits
Other medical conditions and medication history
Ms. Hale reports she has 5-10 bowel movements daily, she has had 3 already this morning. She reports she’s used to that, especially if she eats greasy foods. She says “I had just accepted that I would never poop normally, but I’ve never seen that amount of blood before. It was crazy!”. She reports a weight loss of 10 lbs in the last 4 months.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What additional nursing assessments need to be performed?
CBC – to assess for severity of bleeding (keep in mind that the H/H may take some time to ‘catch up’ to the blood loss)
Colonoscopy – to evaluate for a source of bleeding
Digital Rectal Exam and fecal occult blood test
Ms. Hale’s vital signs are stable. The provider found frank blood on a digital rectal exam. Ms. Hale received a colonoscopy, which showed a bleeding ulcer in her transverse colon, which was cauterized, but no other signs of bleeding. The provider believes this may have been an isolated incident due to irritation caused by the patients greasy food diet and IBS. He orders for her to be discharged home.
Critical Thinking Check
Bloom's Taxonomy: Application
What discharge instructions should be included for Ms. Hale?
Report increased bleeding/bloody stools or severe abdominal pain
Drink plenty of water
Eat bland foods for 2-3 days to avoid irritation to the ulcer that was cauterized
Ms. Hale returns to the ED 2 days later complaining of bright red blood in her stools – two yesterday and five already today. She reports severe lower abdominal pain, nausea and vomiting.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What further diagnostic testing should be done at this time?
The nurse notes open sores in Ms. Hale’s mouth and Ms. Hale also begins reporting epigastric pain.
An endoscopy, repeat colonoscopy, and CT scan show severe thickening of the mucosa in the small and large intestine, with some ulcerations in the duodenum and ileocecal junction, in addition to the previous one seen in the transverse colon.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What do you believe might be the issue for Ms. Hale?
Ms. Hale is presenting with signs of Crohn’s Disease – the telltale sign is that there are ulcerations and thickening of the mucosa in places OTHER than the large intestine. Ulcerative Colitis ONLY affects the colon.
Ms. Hale has ulcerations in her mouth and small intestine.
Although Ulcerative colitis tends to have bloody stools more often than Crohn’s, bloody stools are also possible during Crohn’s exacerbations
A Gastroenterology specialist officially diagnoses Ms. Hale with Inflammatory Bowel Disease, and explains that these symptoms can sometimes be misdiagnosed until they become severe. Specifically, he diagnoses her with Crohn’s Disease and explains how it affects the entire GI tract. He will write for new medications and discharge her home tomorrow, as long as she is stable.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What medications would you expect Ms. Hale to be discharged with? Why?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 