Kaiden Crumsford case study Patient Background Patient

Kaiden Crumsford case study Patient Background Patient Demographics Last Name: Crumsford First Name: Kaiden Gender: Male Age: 44 Ht: 72 Wt: 78 Ethnicity: White Religion: none Language: English Support system: Partner DOB: 09/23 MRN: 21-93339236 Code Status: Full Primary Medical Diagnosis: Crohn’s exacerbation, rule out small bowel obstruction Allergies: sulfa drugs, gluten, pollen, dog dander, citrus, and soy. Home Medications: Buproprion 200 mg PO BID Venlafaxine-XR 225 mg PO QAM Lorazepam 2 mg PO Q6H prn anxiety Infliximab 5 mg/ kg Q8 weeks Past Medical History/Surgical History: Crohn’s disease, s/p colectomy, descending colostomy, anxiety and depression Social History: Lawyer Diagnostics Test: 3-way abdomen X-ray Impression: Irregular thickening and distortion of valvulae conniventes, loop adhesions, and well thickening with typical cobblestone appearance of longitudinal ulcerations, with loops of dilated bowel. No extraluminal air noted at this time, however follow-up imaging is recommended. Complete blood count Lab Result WBC 14.3 RBC 4.2 Reticulocyte count 0.3% MCV 74 MCH 24 MCHC 29.6 Hemoglobin 11.6 Hematocrit 37.6 Platelets 219 Serum iron 52 mcg/dL Ferritin 22 ng/mL TIBC 198 mcg/dL TSAT 26% Complete metabolic panel Lab Result Sodium 138 Potassium 3.6 Chloride 98 BUN 18 Creatinine 0.78 Glucose 107 CO2 24 Magnesium 1.8 Serum Calcium 9.5 Phosphorous 4.7 Albumin 2.1 ALT 16 AST 32 Alkaline phosphatase 58 Total protein 6.1 Total bilirubin 1.1 Lab Result CRP 24 mg/L ESR 26 Fecal blood test Positive Medical Orders Admit Medical surgical floor Diagnosis: Crohn’s exacerbation, rule out small bowel obstruction Admit medical floor VS Qshift Strict I & O Daily weights NPO with ice chips Up ad lib LR @ 125mL/hr CBC, CMP in AM Colostomy care Insert NGT to LIWS Promethazine 25mg IV Q6H prn nausea Meperidine 50mg IV Q4H prn pain Lorazepam 2mg IV Q2H prn anxiety Rocephin 1gram IVPB Q12H Solumedrol 125mg IV Q6H SBAR Situation: Hi there! I’m going to introduce you to Mr. Crumsford. Mr. Crumsford was admitted yesterday from his primary provider’s office after a two day history of progressively worse abdominal pain, nausea and vomiting, and diarrhea. He was dehydrated and received a liter of fluid when he arrived. His abdominal x-ray didn’t show a complete bowel obstruction, so he is on bowel rest, and we are monitoring him at this point. I don’t think surgery has been consulted yet. Background: Mr. Crumsford is a 44 year old lawyer with a past medical history of Crohn’s disease for the past 12 years, anxiety and depression. He receives infliximab infusions to control his Crohn’s, but it is a bad case. He had a complete bowel obstruction a few years ago and ended up with a left descending colostomy. Assessment: He is alert and oriented x four and has complained of pain frequently although the meperidine seems to control his pain for the most part. His last set of vital signs are temp 100.9 oral, heartrate of 105, respirations at 24, blood pressure of 167/114, and his saturation has been around 96% on room air. He is probably due for more pain medication. His lungs are clear although he doesn’t like to take deep breaths because of his abdominal pain. His bowel sounds are positive times four; I thought they were hyperactive. His colostomy bag was changed yesterday, and he didn’t put much out for me – maybe less than a quarter bag with yellowish, liquid material. He does have an NGT to his left nares to low intermittent suction, and it put out 540 mL of greenish drainage for me. I marked the canister, but it may need changed. He moves all his extremities and can get himself to the bathroom with minimal assistance. I did have to remind him to use the call bell when he gets out of bed. He has LR running at 125 mL/hr to an IV in his left forearm. Recommendation: As far as I know, we are monitoring him for a bowel obstruction and providing pain control. Dr. Bustgar should be rounding on him soon, and you can get the plan for the day. I think he may be getting a CT with contrast sometime today. Questions for consideration Is this a good report? What questions, if any, would you ask the off-going nurse? How would you apply the nursing process to this situation? Assessments Analysis Planning Interventions Evaluation Discuss how the following client-need categories apply to this client’s nursing care? Safety and infection control Management of care Health promotion and maintenance Basic care and comfort Reduction of risk potential Pharmacological and parenteral therapies Physiological adaptation What communication and teaching would the nurse want to include in the care of this client?

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