INTRODUCTION
Thi This s case case stud study y sc scru ruti tini nise ses s and and deve develo lops ps unde unders rsta tand ndin ing g of a cert certai ain n inflammatory condition called Crohn’s Disease (CD). It covers an array of medi edical cal
and and
nur nursing sing
term erms
conce oncerrning ning
the the
asses ssessm smen ent, t,
plan plann ning, ing,
implementation and evaluation of the case. This written report utilises the creative ‘six hats’ thinking game as devised by Edward de Bono to critically analyse analyse aspects of care provided provided in the case study and highlight highlight any issues identifie identified. d.
The main main sources sources of infor informatio mation n include include recent recent journal journal artic articles les
from relevant and professionally acceptable nursing publications around the globe.
Mr. X is a 32-year 32-year old male who lives lives at home with with wife and children. He was rushed to the QEH Emergency Department in October because of central abdominal pain. He has a diagnosis of acute cholitis and perianal abscess and fistulas as detected by the MRI. Past history reveals that he has had Crohn’s disease diagnosed at the beginning of the year. The condition was init initia iall lly y stab stabil ilis ised ed on Merc Mercap apto topu puri rine ne and and Pred Predni niso solo lone ne and and with with the the worsen worsening ing of the sympto symptoms, ms, these these medic medicati ations ons were were then then ceased ceased.. Two months prior to confinement, he has been experiencing ongoing intermittent centra centrall abdomi abdominal nal pain pain which which was initia initially lly sharp sharp then then dull dull after after openin opening g bowe bowels ls.. He was was open openin ing g bowe bowels ls 15 15-2 -20 0 x a day with bloo blood d and mucu mucus, s, accompanied by on and off fever. He had a rapid 15 kilogram weight loss for the past few months. He has had previous history of ER admissions with 1
differ different ent dis dischar charge ge diagno diagnoses ses.. He was an ex-smo ex-smoker ker and an occasi occasiona onall alcoholic drinker. Mr. W.A’s presenting symptoms have been improving for the past days. He says that he is greatly affected by the disease, as he is an engineer in a huge firm and has been on sick leave for quite a long time. BODY ASSESSMENT
SUBJECTIVE DATA
Patient often verbalises, “This disease has impacted my life tremendously. My self-esteem became low. I would not able to go to work anymore unlike before where I could be very productive for my family. It is just hopeless.” In addition, he would say, “I feel pain most of the time. It is usually centralised in my umbilical area, but at times I can feel the tenderness with cramping in the lower right portion of my abdomen and also on my perianal area.” OBJECTIVE DATA: Initial Assessment Weight: 60 kg Height: 170 cm Blood Pressure: 150/80 Pulse: 122, bounding and rapid, regular Respirations: 24, regular and nonexertional Oxygen Saturation: 96% Temperature: 37.8 C Pain: 7/10 abdominal and perianal area Head-to-Toe Assessment Hair: fine, straight, shiny Scalp: in good condition, (-) flakes Eyes: pale conjunctivae, anicteric sclerae, eyeballs parallel and symmetrical, symmetrical, eyelashes black and non-prominent Ears: at level with each other, (-) cerumen and discharge Nose: pointed and symmetric s ymmetric,, (-) discharge Lips: dry and cracked, pinkish to whitish 2
Mouth: pink and dry buccal mucosa, (-) stomatitis Tongue: moist, bright red; lies midline Neck: long, (-) palpable lymph nodes, muscles in bilateral symmetry Scapulae: wide, at level with each other Chest: broad and with symmetrical contour, hairy Abdomen: flabby, soft, (-) mass, (+) tenderness, (+) bowel sounds Upper and lower extremities: symmetrical, (-) lesions, pulses equal Pathophysiology The exact cause of Crohn's disease (CD) has not been identified. However, researchers have hypothesized various mechanisms of disease development. One theory is that the seal formed by tight junctions of epithelial cells is impaired and the helper T (TH) cell response that maintains tolerance to enteric bacteria is not working properly. Development of CD is likely a result of a combination of factors, including host susceptibility (possibly determined by genetics) genetics),, gastrointe gastrointestina stinall (GI) immune immune responses, responses, environm environmental ental,, and behavioral factors. Medical Procedures •
Colonoscopy (Sigmoidoscopy) is considered the best test for making the diagnosis of Crohn’s disease, as it allows direct visualisation of the colon and the terminal ileum, identifying the pattern of disease involvement. The sigmoi sig moidosc doscopy opy done done to the patien patientt reveal revealed ed the diagno diagnosis sis of Crohn’ Crohn’s s disease, which is severe to the splenic flexure.
•
Biopsy can be an accompaniment to colonoscopy, wherein small sample of tissues are obtained for laboratory analysis, which may help confirm the diagno diagnosis sis.. The pathol pathologi ogical cal diagno diagnosis sis for the patien patientt is sever severe e flare flare of Crohn’s and acute chronic cholitis with ulceration in keeping with chronic inflammatory bowel disease. 3
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Magnetic Resonance Imaging (MRI) is considered to be effective when it comes comes to lookin looking g for intraintra-abd abdomi ominal nal compli complicat cation ions s of Crohn’ Crohn’s s dis diseas ease e such such as absces abscesses, ses, small small bowel bowel obstru obstructi ction on or fis fistul tulae. ae. This This proced procedure ure revealed that the client has developed fistulas within the perianal area.
Laboratory Studies •
Complete blood count is helpful in the diagnosis of anemia, which may be caused by either blood loss or by vitamin B12 deficiency. It was evident that the patient has anemia because of the low hemoglobin levels (93 g/L) and red blood cell count (3.03 x 10 12/L).
•
Iron studies reveal that the patient has low transferrin levels (1.81 g/L), which reinforces the diagnosis of anemia.
•
Stool exams reveal positive of occult blood due to mucosal erosion.
PLANNING
Major Medical/ Nursing Diagnoses •
Crohn’s Disease, on severe flare to the splenic flexure, with severe active chronic cholitis with ulceration (Medical)
•
Acute cholitis and perianal abscess (Medical)
•
Diar Diarrh rhoe oea a rela relate ted d to the the infl inflam amma mati tion on of the the bowe bowell as evid eviden ence ced d by increased bowel sounds, frequent watery stools and abdominal cramps (Nursing)
•
Risk Risk for Defici Deficient ent Fluid Fluid Volume Volume as evide evidence nced d by excess excessive ive fluid fluid losses losses through the stools (Nursing) 4
•
Imbalan Imbalanced ced Nutri Nutritio tion n less less than than Body Body Requir Requireme ements nts relat related ed to alter altered ed abso absorp rpti tion on of nutr nutrie ient nts s as evid eviden ence ced d by rapi rapid d weig weight ht loss loss of 15 kilo kilos s (Nursing)
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Acute Pain related to hyperperistalsis and presence of perianal excoriation and fistulas (Nursing)
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Ineffective Coping related to presence of disease as evidenced by frequent verbalization of the process’ tremendous impact on his life (Nursing)
Associated legal and ethical issues Confidentiality has a big role in the patient’s case. All information pertinent to his care must not be divulged to anyone other than the health care team provi providin ding g him the holistic holistic care. care. The patien patientt is given given autono autonomy my over over the management of his disease. He has the right to refuse any procedure and treatment should he wish to. Relevant organisation policies and procedures Protocols, such as referrals to other services (i.e. from gastro to neurology and psychiatry) are implemented whenever there is an occurrence of new medi medica call prob proble lems ms.. This This coll collabo abora rati tive ve aspec aspectt is impo import rtan antt for for the the more more effective management of the patient’s case. Brief discussion on relevant discharge plan In case case of dis dischar charge, ge, patien patientt will will be contin continued ued on Humira Humira (adali (adalimum mumab) ab).. Adalimumab has been shown to be “effective for the treatment of acute flares of Crohn’s disease” (Young, 2008). Lifestyle modifications need to be done, done, like like having having freque frequent nt rest, rest, avoidi avoiding ng overe overeati ating ng and exhaus exhaustio tion n and 5
main mainta tain inin ing g cord cordia iall rela relati tion onshi ships ps with with othe otherr peop people le.. Ther There e is a plan plan of including patient in a foundation for those afflicted with Crohn’s and colitis, but this has not been finalised.
IMPLEMENTATION •
Diarrhoea 1. The The pati patien entt was was told told to have have a reco record rd of the the char charac acte teri rist stic ics s and and amount of his stools, so that these will be noted in the bowel chart. 2. The The pati patien entt was was plac placed ed in no acti activi vity ty rest restri rict ctio ion; n; he can can ambu ambula late te anytime he wanted to. 3. The client client was placed placed on on a ward ward diet. diet.
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Risk for Deficient Fluid Volume 1. The The patien patient’s t’s medic medicati ation on chart chart consis consisted ted of fluid fluid balanc balance e record record to
trace his intake and output of fluids. 2. The patient patient was weighed weighed once once a week. •
Imbalanced Nutrition less than Body Requirements 1.
The patient was on ward diet, frequently receiving wheat bread,
milk and yogurt for his breakfast and afternoon tea. •
Acute Pain 1.
The patient was encouraged to assume position of comfort, like
the knees flexed, whenever pain occurs. 2. •
The patient had been told to rate pain numerically.
Ineffective Coping 6
1. At times, times, the patient patient was encouraged encouraged to verbalise verbalise how his his illness illness has affected his life and his relationship with the family. 2. The The patie patient nt was was told told to iden identi tify fy his his copi coping ng skil skills ls and wheth whether er thes these e were successful or not. Major Medications •
Humira 160 mg, subcutaneous (Adalimumab) -
Indi Indica cate ted d for for the the trea treatm tmen entt of mode modera rate te-t -too-se seve vere re Crohn Crohn’s ’s dise disease ase in adults to reduce the signs and symptoms and to induce and maintain clinical remission in patients who have had an inadequate response to conventional therapies.
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Major Major sid side e effect effects: s: pulmon pulmonary ary haemor haemorrha rhage, ge, dyspno dyspnoea, ea, diarrh diarrhoea oea,, haemoptysi haemoptysis; s;
Contraindi Contraindicatio cations: ns: Severe Severe infection infection including including sepsis, sepsis,
active tuberculosis and moderate to severe heart failure -
Nursing responsibilities: 1) Find out any presence of allergies to food, medicines, or dyes 2) Tell client that taking the drug with anakinra may increase the risk of infection 3) Inform client that the medication will not cure the condition, but will reduce only the signs and symptoms of Crohn’s disease
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Mercaptopurine 75 mg PO -
Indica Indicated ted for draini draining ng fist fistula ulas s in Crohn’ Crohn’s s disea disease se
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Major side effects: severe joint pain, severe abdominal pain, unusual fatigue Contraindications: pregnant women, if with active bleeding 7
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Nurs Nursin ing g respo respons nsib ibil ilit itie ies: s: 1) Ad Advi vise se clien clientt that that drug may be taken taken with with food and milk 2) Inform client that the drug may take several months to take full effect
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Gentamicin 400 mg/IV -
Antimicrobial
used sed
to
treat Crohn’s
with
colonic
and and
perianal
involvement -
Major Major side side effe effect cts: s: nause nausea, a, vomit vomiting ing,, muscle muscle weakne weakness ss Contraindications: kidney failure or other forms of renal impairment
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Nurs Nursin ing g resp respon onsi sibi bili liti ties es:: 1) Moni Monito torr clie client nt for for rena renall impa impair irme ment nt 2) Periodically have culture and sensitivity tests
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Hydrocortisone 100 mg/IV -
Decr Decrea ease ses s acut acute e infl inflam amma mato tory ry pro proce cess ss
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Major Major side side effec effects: ts: weig weight ht gain, gain, elec electro troly lyte te imbal imbalanc ances es Contraindications: those with hypersensitivity to steroidal agents
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Nursing Nursing responsi responsibili bilities: ties: 1) Taper Taper use, do not not stop stop taking taking abruptl abruptly y 2) Do not use for a long time, as tolerance to drug may develop
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Loperamide 4mg PO -
Decr Decrea ease ses s gast gastro roin inte test stin inal al mot motil ilit ity y
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Majo Majorr side side eff effec ects ts:: naus nausea ea,, vomi vomiti ting ng Contraindications: peptic ulcer conditions, upper GI bleeding
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Nursing responsibilities: 1) Listen for bowel sounds; do not administer if active and gurgling 2) Do not use for a long time in managing diarrhea
Collaborative Care 8
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Administration of parenteral fluids
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Laboratory studies such as blood chemistry, iron studies and complete blood count
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Referral to support group of people with debilitating condition
EVALUATION/ REVIEW
A
char charac acte teri rist stic ic
mani manife fest stat atio ion n
of
Croh Crohn’ n’s s
dise diseas ase e
is
seve severa rall
bowe bowell
movements, which may reach up to 20 times in a day. “Diarrhea in Crohn’s disease is present in almost all cases, but the severity is dependent upon the anatomic location of the disease process” (Ruthruff, 2007). Thus the nurse must implement strict monitoring of stool frequency in the bowel chart. In regards the patient’s case, this was carefully planned and developed. This will help differentiate and assess severity of episodes of diarrhoea. However, two interventions were not implemented properly by the nurses. First, the patient was allowed to have frequent body movements, even in ambulating. According to Chan (2008), it is essential to promote bed rest and provide bedside commode to patients with Crohn’s disease. Rest decreases intestinal motility, thereby decreasing the worsening of diarrhoea. Secondly, the client was was plac placed ed on ward ward diet diet.. This This clea clearl rly y mean means s that that he has has a litt little le or no restriction at all when it comes to diet. “Trigger foods must be avoided like those high in fiber and products that contain caffeine, alcohol and those dairy products” (Figueras, 2010). Usually, these types of food are served to
9
patients if they are not on a specified diet. Consuming these will only worsen the condition of the patient.
“Weight loss can occur in almost all patients with CD. This is usually a result of malabsorption, but also can be related to diminished intake” (Ruthruff, 2007 20 07;; Sten Stenso son, n, 19 1999 99). ). Ther Theref efor ore, e, it is a nece necessi ssity ty that that the the pati patien entt be weighed daily for this will be an indicator of overall fluid and nutritional status. In his case, he was weighed only once a week which is a clear tran transg sgre ress ssio ion n from from the the idea ideal. l. Also Also,, a prim prime e targ target et of trea treati ting ng CD is main mainta tain inin ing g
adeq adequa uate te flui fluid d
volu volume me as
evid eviden ence ced d
by mois moistt
muco mucous us
memb membra rane nes, s, good good skin skin turg turgor or,, stab stable le vita vitall sign signs s and and urin urine e of norm normal al concentration and amount. The intervention made by the nurses of having a strict strict fluid and balance chart is the best way of providing providing informatio information n about over overal alll flui fluid d bala balanc nce, e, rena renall func functi tion on,, as well well as guid guidel elin ines es for for flui fluid d replacement.
Because of the occurrence of diarrhoea, most nutrients are not absorbed by the gastrointestinal tract, resulting in an imbalance in the nutritional status of the individual at less than the body requirements. “Food plays a crucial role in the remission and exacerbation of Crohn’s disease” (Dettinger et al, 2008). Figueras (2010) states that certain trigger foods must be avoided like those high in fiber, caffeine and dairy products. However, the nurses and doctors did not pay attention to the patient’s diet. The dietary department 10
would frequently bring him wheat bread, milk and yogurt for breakfast and afternoon tea. The patient was not aware that these were trigger foods.
One serious problem encountered by patients with Crohn’s disease is pain. “Abdominal pain is the hallmark of CD and is dependent upon anatomic location. Patients with CD may also experience visceral pain, which is related to infl inflam amma mati tion on of the the sero serosa sa and is ofte often n seen seen in tran transm smur ural al dise diseas ase” e” (Ruthruff, 2007). Many drugs are readily available in treating and relieving pain, however the natural ones are still advised to be used. The patient was frequently encouraged by the health team to assume position of comfort like the knees knees flexed flexed,, when when pain pain occurs occurs.. It is effect effective ive because because through through this this simp simple le acti action on,, abdo abdomi minal nal dist disten enti tion on is redu reduce ced d and and sens sense e of cont contro roll is deve develo lope ped. d. The The pati patien entt is also also advi advise sed d to rate rate his his pain pain ever everyt ytim ime e he experienced it to be given proper action.
“While the physical symptoms are intense enough to cause even the most reserved unyielding discomfort, perhaps one of the most damaging results of Crohn's are the emotional side-effects of the disease” (Straver & Grause, 2010). Oftentimes, the nurses would encourage him to verbalise how his illne illness ss has affect affected ed him and his famil family. y. “Verba “Verbalis lisati ation on of feelin feelings gs from from a person person with with Crohn’ Crohn’s s would would help help allevi alleviate ate his feelin feelings gs of depres depressio sion n and hopelessness” (Straver & Caple, 2010). In addition the patient would be told to identify his coping skills and whether these were successful or not. The 11
patient would state a feeling of relief after expressing his thoughts to other people.
Discharge Plan In case case of dis dischar charge, ge, patien patientt will will be contin continued ued on Humira Humira (adali (adalimum mumab) ab).. Adalimumab has been shown to be “effective for the treatment of acute flares of Crohn’s disease” (Young, 2008). Lifestyle modifications need to be done, done, like like having having freque frequent nt rest, rest, avoidi avoiding ng overe overeati ating ng and exhaus exhaustio tion n and main mainta tain inin ing g cord cordia iall rela relati tion onshi ships ps with with othe otherr peop people le.. Ther There e is a plan plan of including patient in a foundation for those afflicted with Crohn’s and colitis, but this has not been finalised.
DE BONO’S SIX THINKING HATS
The White Hat Croh Crohn’ n’s s dise diseas ase e (CD) (CD) is “a chro chroni nic c infl inflam amma mato tory ry cond condit itio ion n of unkno unknown wn etiology, which may involve the whole digestive tract from the oral cavity to the anus. It most commonly involves either the lower part of the ileum, ileocecal region, or the colon” (Morrison, 2008; Metcalf, 2002). Because it has an immune-mediated pathology, treatment is geared toward attenuating the immune response. The patient knows that the condition especially the symptoms can be managed, but not totally cured. He has been told by the doctors about this. He would be concerned about his family and work, as he has been conditioned about the possibility of frequent hospital admissions. 12
The wife is also aware of the disease. She fears that her husband’s condition would aggravate, and may lead to more serious impairments. The Red Hat If I had had Croh Crohn’ n’s s dise diseas ase, e, I woul would d prob probab ably ly feel feel very very desp despon onde dent nt and and depressed knowing that I have a chronic and non-curable condition. That is why, the wife’s denial about it is understandable. Sometimes, she would just be seen sobbing out of the patient’s room. She would reason out that she pities not just her husband, but the kids as well. Her eldest is only seven, and this child is still not able to feel the weight of the situation, according to her. She says that the first time her husband came to know about the diagnosis, he would cry like a child and would just be seen staring at something. He would keep on uttering that he was hopeless and he was living in a curse. The Black Hat Crohn’s disease is a serious health condition which poses many physical and emot emotio iona nall
conc concer erns ns..
“Ext “Extre reme me
abdo abdomi mina nall
disc discom omfo fort rt
and and
cont contin inua uall
evacuation of watery stools in Crohn’s may warrant frequent hospitalisations as these give rise to other medical problems” (Figueras, 2010). This can cause cause financ financial ial burden burden and eventu eventuall ally y emotio emotional nal dis distr tress ess to the patient patient.. Some scenarios might even get worse. “While treatment of Crohn's disease has impro improved ved in recen recentt decade decades, s, death death from from CD is sti still ll possibl possible” e” (Chan, (Chan, 2008). That is why the patient would opt to continue the treatment even if the condition has no cure. Up to now, he is still in denial of his diagnosis but he is learning to accept it every day of his life. 13
The Yellow Hat Gene Genera rall lly, y, peop people le who who do not not have have Croh Crohn’ n’s s dise disease ase are are less less like likely ly to experience intense abdominal pain, severe diarrhea, perianal discomfort and psychological effects like altered self-image, social withdrawal, anger and hopelessness than those afflicted with the disease itself. If I were a person who had Crohn’s disease and had recovered, I would probably feel grateful and blessed that I was able to escape the chronicity and incurability of the condition. Because Crohn’s is debilitating, it is important to plan for a holistic care not just to the patient, but also to the wife and their kids. The wife may be involved in a talk with some of the health care members, and allow her to plan some of the actual and alternative care for the patient. She can be made cognisant that acute treatment uses medications to treat any infection and and
to redu reduce ce infl inflam amma mati tion on whic which h
are are anti anti-i -inf nfla lamm mmat ator ory y
drug drugs s
and and
corticosteroids. corticosteroids. On a different different note, surgical options options may also be employed. employed. “Three quarters (75%) of Crohn's disease patients require surgery at some stage of their lives. Surgery does not cure the disease, and the majority of patients relapse after surgery. Thus surgery for Crohn's disease is only a crisis management technique” (Veerappan & Breslin, 2009). The Green Hat The fact that no cure exists can be disheartening, but help is available. “The important thing for people suffering from Crohn’s to remember is that they are not alone, alone, their symptoms are treatable, treatable, and they do not have to suffer suffer the effects of Crohn’s Disease indefinitely” (Panes et al, 2007). The family 14
and relatives of the patient are the most proximate forms of support that he coul could d have have.. Supp Suppor ortt grou groups ps for for thos those e affl afflic icte ted d with with CD are are no long longer er uncommon. In addition, consulting a mental health practitioner such as a psychiatrist or psychologist can sometimes help those with the disease to better adjust to living with it. When symptoms flare up, sufferers should seek the care and advice advice of a physician. physician. Getting Getting help from a trained trained professional professional familiar with the effects of chronic illness may be very helpful in helping sufferers of the disease cope with their circumstances. Most of all, nurses with their caring and nonjudgmental attitude can convey feeling of support and understanding to the patient. The Blue Hat Overall, the health team handling the patient has done successfully when it comes to managing his Crohn’s disease. Although there were some flaws in the nursing interventions, still the condition was controlled and the signs and symptoms were minimised. These are the main goals of managing Crohn’s disease. disease. In the end, the success success of the treatment treatment lies in the patient himself, himself, whether he would be participative to the regimen or not.
CONCLUSION
Crohn’s disease is a debilitating condition which may significantly impact an indi indivi vidu dual al
both both
phys physic ical ally ly
and and
emot emotio iona nall lly. y.
The The
pati patien entt
expe experi rien ence ced d
uncontrollable diarrhoea, severe pain, and imbalanced nutrition with risk for dehydration. It was evident that he had altered self-image, social withdrawal 15
and hopelessness. The management provided to him by the entire health care team is satisfactory overall; however some nursing interventions were not appropriat appropriately ely executed executed as they should should ideally ideally be.
Through Through the aid of
Edward de Bono’s six hats game to aid critical thinking, the perceived needs and proble problems ms of the patient patient were were broade broadened ned and were were though thoughtt of more more creatively, which could pave the way for a more holistic care and approach. It encourages health care professionals to answer the basic questions at the same time, consider situations from a myriad of perspectives. It gives them the opportunity to reflect on their own feelings about the clinical situation they are into, thereby lessening stress. Nurses play a critical role in the manage managemen mentt of patien patients ts with with Crohn’ Crohn’s s dis diseas ease. e. Their Their first first respon response se is to ensure that these patients receive the tools and information that they need to live as healthy a life as possible. Nurses play a key role in ensuring that patients receive proper education, care and support.
RECOMMENDATIONS •
Nurses Nurses should should suppor supportt their their profes professio sional nal develo developme pment nt by contin continual ually ly wide wideni ning ng thei theirr know knowle ledg dge e base base of Croh Crohn’ n’s s dise diseas ase. e. By this this,, they they can can execute the proper knowledge, skills and attitudes in terms of caring for patients afflicted with this chronic condition.
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Nurse Nurses, s, in conj conjun unct ctio ion n with with othe otherr heal health th prof profes essi sion onal als, s, sh shou ould ld work work coll collabo abora rati tive vely ly to care care for for the the patie patient nts s with with CD in a holi holist stic ic mann manner er.. Management of the patient’s other relevant medical concerns is a must. 16
Effective Effective independen independentt and dependent dependent nursing nursing intervent interventions ions are thereby thereby suggested to be reinforced. •
Nurses should continue to be advocates for the patients and their rights. Confidenti Confidentiality ality and privacy privacy should always be observed observed and informatio information n abou aboutt the the pati patien entt sh shou ould ld not not be disc disclo lose sed d to anyo anyone ne.. They They sh shou ould ld endeavour to provide emotional support to inflate sense of self-esteem and minimise depression and hopelessness on the part of the client.
17