(^294) Medical-Surgical Nursing Demystified
NURSING INTERVENTION
- Monitor intake and output.
- Monitor vital signs.
- Weigh patient daily.
- Measure abdominal girth—making sure to measure at level of umbilicus for
consistency; marks are typically made at sides of abdomen to align tape meas-
ure on subsequent days. - Assess peripheral edema.
- Assess heart and lung sounds for excess fluid.
- Elevate head of bed 30 degrees or greater to ease breathing.
- Elevate feet to decrease peripheral edema.
- Monitor for signs of bleeding or bruising.
- Monitor level of consciousness, orientation, recent and remote memory, be-
havior, mood, and affect.
Crohn’s Disease
WHAT WENT WRONG?
A noncontinuous inflammatory disease that can affect any point from the mouth to
the anus. The majority of cases involve the small and large intestine, often in the right
lower quadrant at the point where the terminal ileum and the ascending colon meet.
Patients typically have an insidious onset of intermittent symptoms. The disease
causes transmural inflammation, going deeper than the superficial mucosal layer of
the tissue to affect all layers. Over time the inflammatory changes within the gas-
trointestinal tract can lead to strictures or the formation of fistulas. The affected
tissue develops granulomas and takes on a mottled appearance interspersed with
normal tissue. There is a genetic predisposition and a bimodal peak of onset at 16 to
21 years old.PROGNOSIS
Crohn’s disease is a chronic disorder with periods of exacerbation and remission.
Many patients will ultimately need surgery to deal with bowel obstruction, devel-
opment of strictures, or fistula formation.4