• Describe how you have improved your nursing practice through the use of safety and quality improvement strategies, including the use of outcome indicators.
• Discuss how you have improved the quality of patient care while controlling the cost of care.
• Utilizing the case study from #1, discuss the outcomes you developed to address the identified nursing diagnoses and evaluate their effectiveness.
Forty-year-old female with history of Crohn’s disease diagnosed at age seventeen. Other medical history includes hypertension, controlled with oral medication. Surgical history of ileo-colonic resection at age 25 secondary to ileal stenosis. When speaking with the patient about her disease she recalls having difficulty at the time of diagnosis, missing school during her senior year of high school and unable to attend college the year after high school until the disease was more under control. She reports a good support team throughout times of diagnosis and flares, including her parents and spouse. She states she has an employer who has been flexible with her time off for appointments and infusions. Patient is in my care for colonoscopy procedure to restage Crohn’s disease and assess for persistent ileal stenosis with or without inflammatory features. Patient denies any spiritual requests at time of procedure.
Pertinent Tests & Medications
Remission from disease for ten years until 2015 patient reported dark maroon stool, had negative esophagogastroduodenoscopy, found to have chronic anemia secondary to Crohn’s. Hemoglobin now stable, 12.7 gm/dL, with daily iron supplement. Since 2015 medications used for Crohn’s disease include immunomodulator, Imuran daily and biologic therapy, Remicade infusion. Remicade infusion is on an eight-week cycle, recently patient has had symptoms of increased abdominal pain and loose stools during the seventh week following infusion. CT scan shows ileal stenosis. Other medications include Vitamin B12, Vitamin D and Diclofenac gel. Crohn’s disease causes decreased absorption of Vitamin D and B12, B12 is absorbed mainly in the terminal ileum, the area of resection for the patient. Diclofenac gel was prescribed for shoulder and knee pain, joint pain related to Crohn’s disease. Colonoscopy completed with biopsies of colon, anastomosis site and small bowel. No signs of active Crohn’s disease, no evidence of stricture at anastomosis.
Anxiety related to and unknown outcome, possible change in health status evidenced by stating concern over possible procedure findings, and increase blood pressure.
Pain related to inflammatory process of disease as evidenced by verbal report of abdominal cramping and guarding, shoulder and knee pain and facial grimace when lifting arms.
Risk for fluid volume deficit related to excessive loss of fluid associated with diarrhea and restricted intake secondary to fear of diarrhea.
To support the patient related to her anxiety I would encourage verbalization of feelings and concerns related to procedure and outcomes and provide feedback. Feedback could relate to patients concerns over procedure and other necessary treatments for Crohn’s disease. I would provide a calm environment and validation of her concerns. I would initiate use of positive coping behaviors and help her identify coping mechanisms for short term procedure and outcome related relief and long term management of the disease. Interventions to help her with pain would include using warm blanket or warm packs for patient comfort, and review other non-pharmacologic pain interventions. Encourage patient to continue infusions and other medications as directed to assist with disease state. Review diet modifications that are helpful, including low fiber diet during times of flare up and medications such as loperamide to control cramping and diarrhea. To help patient decrease risk for fluid volume deficit I would discuss ways with patient to increase fluid intake, such as flavoring water, and keeping water bottle nearby. Advise her on dietary restrictions that may be helpful such as lactose free or low fiber, along with use of loperamide to decrease loss of fluid through diarrhea.