Details
Lucy is a 19 year old university student. She has been admitted to hospital with a six (6) day history of lower right quadrant abdominal cramping pain increasing with intensity, diarrhoea with blood, anorexia, fatigue, nausea and episodes of vomiting. Lucy states that she was diagnosed with Crohn’s disease at age 15. She has had two previous hospital admissions for acute exacerbations of Crohn’s disease with clinical manifestations of diarrhoea, abdominal pain and vomiting. Her Crohn’s disease has been managed with a combination of diet, medication and medical monitoring.
Remission of her Crohn’s disease was maintained by oral mesalazine (Mesasal). Lucy currently rates her pain as 9/10. On examination, Lucy was pale, her extremities were cool, and her skin was dry with poor turgor. Her abdomen was distended and tender. A mass was palpable in the lower right abdominal quadrant.
Observations on admission:
Blood pressure: 95/60
Pulse rate: 110 beats/minute
Respiratory rate: 22 breaths/minute
Temperature: 37.7C
Sa02: 98% in room air
Weight: 62 kilograms
Height: 165 cm
Urinalysis:
- specific gravity: 1040
- dark coloured urine
- no other abnormalities noted
Initial pathology results:
- Haemoglobin: 105 g/L (117 – 157 g/L)
- Haematocrit: 49% (35 – 47%)
- WBC 15000/mm3(3500 – 11000 mm3)
- Erythrocyte sedimentation rate (ESR): 28mm/hour (0 – 20 mm/hour)
- C-reactive protein (CRP): 30mg/dl (20 mg/dl)
- Albumin: 28g/L (35 – 50 g/L)
The MO orders the following:
- fentanyl 75mcg IMI QID PRN
- metoclopramide (Maxolon) 10mg IMI TDS
- 1000mL 0.9% normal saline over 8 hours
- nil by mouth
Lucy was prepared and sent for an urgent colonoscopy, upper barium x-ray and abdominal CT scan. A bowel obstruction at the proximal end of the ascending colon at the ileocecal junction was diagnosed. A balloon dilation of the obstructed colon was attempted, but was unsuccessful. Lucy was scheduled for a surgical resection of the affected proximal ascending colon and end-to-end anastomosis of her colon.
Questions:
Question 1. (250 words)
Explain the pathogenesis of Crohn’s disease that has led to the development of Lucy’s obstruction of the proximal ascending colon.
Question 2. (250 words)
Explain the pathophysiological processes that lead to Lucy’s conscious perception of pain in her lower right abdominal quadrant.
Question 3. (165 words)
Describe the characteristics of the intravenous fluid that was ordered for Lucy, and the specific rationale, related to the details of the case study, for the administration of this intravenous fluid to Lucy.
Question 4. (165 words)
Describe the mechanism of action of fentanyl in relation to its administration to Lucy.
Question 5. (165 words)
Prioritise the nursing responsibilities and associated rationales related to the administration of fentanyl to Lucy.