Nursing Care Plan

CROHN’S DISEASE

In Partial Fulfilment of the

Requirements in NCM-212 RLE
IMMUNOLOGY/CANCER ROTATION

Submitted to:
Lovely E. Erediano, RN
Clinical Instructor

Submitted by:
Janiel Kayyi D. Torralba, St.N.
BSN 3E GROUP 2

September 27, 2021

SCENARIO:
o Belinda Garcia a 25 year old female patient was admitted to the hospital with a chief complaint of fatigue and diarrhea; after tests and an examination, she
was diagnosed with Crohn’s Disease of the ileum on September 23, 2021. Upon assessment on September 25, 2021, she verbalized that “ Lain akoang
paminaw kanang kapoy kaayo…bisan wala koy gibuhat kay hawoy na di ko makalihok”, “Nag sige gihapon ko ug kalibanga.”, and “Mahadlok ko mukaon kay
basi di muundang ako kalibanga kung mag sige sad kog kaon”. The nurse found out she has severe diarrhea 4-5 times a day that started out as 1-2 times
until it progressed. According to her spouse, Belinda has not eaten that frequently due to fear of persistent diarrhea; hence, drastic weight loss of 19
kilograms from the last 2 months, from 75 kilograms to 56 kilograms. Further assessment reveals a lack of appetite, pale conjunctiva and mucous
membranes, excessive hair loss, general fatigue, anemia due to blood tests of hematocrit of 33% and hemoglobin of 12 mg/dL; and an electrolyte panel of
potassium (3.3 mmol/L) and sodium (130 mEq/L). Last vital signs taken were BP of 125/80 mmHg, PR of 96 bpm, CR of 99 bpm, and RR of 18 cpm.

CLUSTERING OF CUES:

SELF-PERCEPTION/SELF- NUTRITIONAL-METABOLIC ELIMINATION PATTERN ROLES/RELATIONSHIP HEALTH PERCEPTION –

CONCEPT PATTERN PATTERN PATTERN HEALTH MANAGEMENT
 “Lain akoang paminaw PATTERN
kanang kapoy kaayo…  Crohn’s Disease of
bisan wala koy gibuhat the Ileum
kay hawoy na di ko
makalihok.”
 ”Nag sige gihapon ko ug
kalibanga.”
 “Mahadlok ko mukaon
kay basi di muundang ako
kalibanga kung mag sige
sad kog kaon.”

Name of Patient: Belinda Garcia Age: 25 years old Sex: Female Attending Physician: Dr. Santos Ward: St. Catherine

Chief Complaint: Fatigue, Diarrhea Diagnosis: Crohn’s Disease

DATE NURSING
& CUES NEED DIAGNOSIS PATIENTS OUTCOME INTERVENTIONS IMPLEMENTATIONS EVALUATION
TIME S
S  “Lain akoang N Imbalanced nutrition: Within the 8-hour span of INDEPENDENT: September
E paminaw U Less than body care the patient will be  Assess nutritional 1 25, 2021
P kanang kapoy T requirements related able to: status @ 3PM
T kaayo…bisan R to malabsorption and R: Adequate energy
E wala koy I malnutrition as a. Demonstrate a reserves are needed
M gibuhat kay O evidenced by pale better eating habit when fulfilling activities of
B hawoy na di ko N conjunctiva and by consuming small daily living (Vera, 2017). Janiel Kayyi
E makalihok.” A mucous membranes, meals or snack D. Torralba,
2 St,N.
R  ”Nag sige L weight loss, and every 3 to 4 hours  Assess sleep pattern
gihapon ko ug fatigue associated and staying and amount of sleep
25, kalibanga.” - with Crohn’s hydrated that will and rest achieved.
 “Mahadlok ko Disease. lead to progressive R: Sleep deprivation and
2 mukaon kay M weight gain. difficulty in sleeping
0 basi di E Rationale: The b. Attain a slightly affects the activity level
2 muundang ako T chronic inflammation pinkish mucosal of patient (Vera, 2017).
1 kalibanga kung A of the small intestine membrane and 3
mag sige sad B from Crohn’s conjunctiva.  Assess the extent of
7AM O Disease damages c. Experience slight overall weakness and
kog kaon.”
(As verbalized by the L the intestinal lining relief from fatigue fatigue.
patient) I resulting in the by a relief scale of R: Provides adequate
C dysfunctional at least 6/10. information to help the
Objective: mucosal absorptive d. Verbalize health care team in
 Has Crohn’s P surface (Kerr, 2018); understanding on making the right
Disease of the A thus, ineffective the importance of treatment decision
Ileum T nutrient absorption of nutritional and (Cancer Research UK,
T the organ. The hydration intake 2020). 4
 Severe Diarrhea: 4-
E malabsorption can allowed in Crohn’s
5 times a day
R lead to imbalanced Disease diet.  Weigh patient daily.
 Weight Loss: of 19
N nutrition from protein- R: Provide information
kilograms in 2
months according calorie malnutrition, about the dietary needs
 to medical history dehydration, and and the effectiveness of
(56 kg from 75 kg) multiple nutrients, interventions done (Vera, 7
 Lack of appetite vitamin, and mineral 2020).
 Pale conjunctiva deficiencies, which
and mucous cause weight loss,  Encourage the
membranes and diarrhea (Ghazi, patient to rest and
 Excessive hair loss 2019). Additionally, limit activity during
 General fatigue fatigue comes from recurrence or acute
 Anemia the malabsorption of phase of illness.
 Electrolyte Panel: B12 and Folic Acid, R: Decreasing metabolic
o Potassium: 3.3 but in most cases is demands aid in
an effect of blood preventing caloric 6
mmol/L
loss that decreases depletion and conserving
o Sodium: 130
iron and red blood energy (Vera, 2020).
mEq/L
cell levels,
 Blood Test: generating pale  Recommend to rest
o Hematocrit: 33% conjunctiva and before taking meals.
o Hemoglobin: 12 mucosal membrane R: Reduces intestinal
mg/dL (Crohn’s & Colitis peristalsis and increases
 Vitals Signs: 5
Foundation, 2020). available energy
o BP= 125/80 reserves for eating
mmHg (Vera, 2020).
o PR= 96 bpm
o CR= 99 bpm  Provide proper oral
o RR= 18 cpm hygiene. 12
R: A clean mouth
enhances the taste of
food (Vera, 2020).

 Serve meals in well-

ventilated and
pleasant
surroundings with
 unhurried
atmosphere and
congenial company. 21
R: A pleasant dining
environment aids in the
reduction of stress (Vera,
2020).

 Avoid foods that

might cause or
worsen abdominal
cramping, flatulence
such as milk
products, foods high
in fiber or fat, alcohol,
caffeinated
beverages,
chocolate,
peppermint,
tomatoes, orange
juice, and spicy 17
foods.
R: Food tolerances vary
per person, depending
on the stage of disease
and area of GI track
affected (Vera, 2020)

 Record food intake

and if there a
11
changes in the
symptomatology.
R: Evident in identifying
specific nutrient
deficiencies and
determining GI response
to food (Vera, 2020).

 Encourage the
14
patient to verbalize
concern toward diet
resumption.
R: The fear that food
intake will cause
exacerbation of
symptoms may lead to
hesitation (Vera, 2020).

 Encourage patient to
drink plenty of fluids;
drink small amounts 13
of water throughout
the day around 8-12
glasses.
R: Chronic diarrhea can
cause dehydration,
which can lead to feeling
of weakness and fatigue
(Conaway, 2020). 20

 Encourage patient to
eat 4-6 small meals
daily or snack every 3
to 4 hours.
R: Reduces meal size to
help ease the symptoms
of Crohn’s Disease
(Konkel, 2021).

 Provide information
and importance on
food allowed for
8
Crohn’s Disease.
R: Proper nutrition is
beneficial for promoting
overall health and well-
being as CD can cause
serious complications,
including nutrient
deficiencies, weight loss,
and malnutrition (Crohn’s
& Colitis Foundation,
2021).
9
 Provide a cool, quiet,
and dark environment
conducive for rest.
R: Having adequate
sleep and taking naps
during the day ( Fairview
Health Services, 2019)
helps cellular restoration
by repair and regrowth
(Lamoreux & Nunez,
2020). 10

DEPENDENT:
 If health care provider
indicates, keep
 patient NPO.
R: Resting the bowel
decreases intestinal
peristalsis and diarrhea
as well as limiting
malabsorption and
nutrient loss (Vera,
2020).

 Resume or advance
diet as indicated by
health care provider
(clear liquids
progressing to bland, 15
low residue; then
high-protein, high-
calorie, caffeine-free,
non-spicy, and low-
fiber as indicated).
R: Allow the intestinal
tract to readjust to the
digestive process. The
consumption of protein
aids in tissue repair, and
food taken in small
amounts decreases
peristaltic response
(Vera, 2020).
16
 Provide medications
such as iron,
multivitamin, and
mineral supplements
 as ordered by health
care provider.
R: Help alleviate
malnutrition and treat
anemia to reduce fatigue
from decreased red
18
blood cell count that
limits oxygen amount
carried through the
body’s tissues
(DiGiacinto & Murphy,
2021).

 Provide anti-diarrheal
drugs for Crohn’s
Disease as ordered
by health care 19
provider.
R: Diarrhea is one of the
unsettling and
bothersome symptoms of
CD that disrupt ADL
(Faris, 2019).

COLLABORATIVE:
 Promote patient
participation in
special dietary
planning. 22
R: Provides the patient
sense of control and
opportunity to select
desired foods that may
aid in increased food
intake (Vera, 2020).

 Discuss with patient

the short and long
term nutrition and
weight goals from a
created daily weight,
and food and fluid
chart.
R: Effectively monitors
patient’s daily nutritional
intake and progress in
weight goals
(Nursestudy.net, 2021).

 Encourage patient to
seek aid from a
Dietician who
specializes in Crohn’s
Disease.
R: Provides a more
individualized care when
it comes to diet and
nutrition (Nursestudy.net,
2021).
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