NURS 1593: Developing Adult Nursing Practice Case Study

Introduction

The purpose of this assessment is to design a case report on a patient, by including elements of the care plan and risk assessment tools being used to ensure the well-being of the patient. For this proposed report, the case scenario of Sky, a 17-year-old girl, has been taken into consideration; she has been admitted to the hospital with a worsening case of Crohn’s disease. This case report explores the acute care management of Sky, a young adult from the travelling community who presented at the emergency department with a severe flare-up of Crohn’s disease. As a nursing student, I have selected this case to understand the complexities involved in caring for patients with chronic illness, specifically when social and cultural factors pose additional challenges. The case scenario of Sky illustrates the intersection of complex inflammatory bowel disease with significant psychosocial vulnerabilities, demonstrating how social determinants impact adolescent Crohn’s outcomes and highlighting the need for culturally sensitive, trauma-informed care approaches in vulnerable populations.

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Presenting condition

Sky’s current presentation is acutely concerning and suggests serious complications related to her Crohn’s disease, likely a severe flare-up or possible sepsis. As per the case scenario, in the case of Sky, her severe right-sided abdominal pain, bloody diarrhoea, active vomiting, and hot, clammy skin are the primary indications of an acute gastrointestinal inflammatory reaction, which is possibly complicated by an infection or bowel perforations. Despite receiving 10 mg of morphine, her pain remains uncontrolled, indicating high pain severity. Sky is also showing signs of systemic deterioration, as she is showing disorientation, confusion and hallucination, and also reported her onset of agitated behaviour. These neurological signs could be due to the onset of sepsis-associated delirium, dehydration, electrolyte imbalance or ongoing cannabis-induced psychosis (Ali & Cascella, 2024). The lack of urine output is a critical red flag, which suggests persistent dehydration and risk of acute kidney injury. Sky’s swollen and painful lower leg raises concern for deep vein thrombosis, specifically when she has inflammatory bowel disease.

Sky is presently receiving treatment under the acute exacerbation/inflammatory bowel disease (IBD) flare-up care route, which entails prompt evaluation, stabilisation, and management of Crohn's disease symptoms. There was blood in her stool, terrible stomach pain, and systemic signs of likely sepsis when she came to the emergency room. As such, immediate measures such as IV fluids,  analgesics and antibiotics were initiated. Due to her deteriorating consciousness disorder and the risk of complications (eg, infection or thrombosis), she was transferred to a medical facility for further observation. The care pathway dictates that a strong emphasis will be placed on multidisciplinary team involvement, prompt diagnostic testing, resuscitation and nutritional support.

Nursing Assessment

Considering the case scenario of Sky, it can be stated that nursing assessment is important to provide safe, patient-centred, and informed care by integrating the patient’s needs and preferences into the treatment plan. This aligns with the Nursing and Midwifery Council Code (2018), where the stress has been placed on prioritising the needs of the patient first while administering treatment and maintaining safety during the process. In the case of Sky, the assessment reveals that decreased eating, tiredness, and distorted mental status trigger the physical and emotional deterioration of the patient. These signs call for quick and caring actions, as nurses have a professional duty to evaluate needs and provide care based on evidence (NMC, 2018). The patient's eating issues are made worse by possible worry or sadness, which fits with the NMC's rule to look at health as a whole (NMC section 6.2). A person's mental state can have a big impact on their physical health when it comes to appetite, drinking enough water, and taking part in their care. Regarding the care aspect of eating and drinking, the nurse has followed section 9.4 of the NMC Code (National Institute for Health and Care Excellence, 2019). This part requires nurses to use the best evidence available to plan and evaluate care. The nurse's actions show a commitment to working with different specialists and basing decisions on solid research. These actions include sending the patient to see a dietitian and a SALT team, as well as keeping close track of what the patient eats and drinks. To preserve dignity and respect (NMC section 1), patient preferences and cultural and dietary needs of the patient should be followed by the caregivers at the time of designing treatment plans for Sky (Nursing and Midwifery Council, 2018). Encouragement at mealtime, providing assistance where needed, and enabling choices can support nutritional recovery and emotional well-being. As a whole, the nursing assessment and care plan demonstrates a patient-centric and ethical approach, aligned with the NMC code’s value of compassionate, safe, and responsive nursing care.

Element of the Care plan

Nutrition and Fluid Management: Person-Centred Care Analysis:

MUST Evaluation and Risk of Malnutrition

Sky has a very high nutritional risk, and MUST (Malnutrition Universal Screening Tool) should be conducted immediately. Her BMI = 25.3 would seemingly not be high, but with recent severe exacerbation of Crohn's with ongoing persistent vomiting, and bloody diarrhoea,  with hardly any oral intake, that significantly raises the risk. The MUST score would likely be high because of acute illness upon nutritional intake and underlying chronic inflammatory bowel disease.

Fluid Balance Crisis

Sky would've been watered down to the point of ruin. She has not passed urine since admission, removed her IV cannula, and shows signs of severe hydration, including confusion and disorientation. Immediate fluid balance assessment and OV access re-establishment are essential, following the NICE guidelines for fluid resuscitation (NICE Guideline, 2020).

Person-centred challenges

Sky’s care needs significant adaptation due to multiple factors. As she is 17 years 17-year-old girl coming from a Travelling Community with a mild learning disability, her nutritional management prioritises cultural dietary practices while addressing her medical needs. Her current behavioural challenges, including verbal aggression and hallucination, create barriers to voluntary nutritional compliance.

Evidence-based interventions

Research demonstrates that active Crohn’s disease needs increased caloric intake (25-35 kcal/kg/day) and protein supplementation (Jabłońska & Mrowiec, 2023). Eternal nutrition may be more appropriate than corticosteroids alone for paediatric Crohn’s disease. Micronutrient monitoring for B12, Folate, iron, and fat-soluble vitamins is essential to suppress the risk related to malabsorption of nutrients.

The comprehensive ABCDE assessment framework employed for Sky demonstrates a systematic evaluation of her complex presentation (Schoeber et al., 2022). This structured approach effectively identifies multiple interconnected health concerns requiring immediate intervention.

Physical Assessment Analysis

Concerning findings from the respiratory evaluation include bilateral basal wheezing, a high respiratory rate (28 breaths per minute), and an oxygen saturation of 96%. According to these metrics, there may be respiratory compromise as a result of systemic inflammation brought on by a Crohn's disease flare-up (Jochmann et al., 2021). The circulatory evaluation shows tachycardia (HR 105) and a high temperature (38.2°C), which are indicative of an inflammatory reaction and the potential onset of sepsis. Important neurological issues are brought to light by the disability evaluation (Tamez-Pérez, 2015). On the other hand, Sky’s confusion, dizziness, and hallucinations signify the continuous deterioration of her health and well-being, which requires immediate medical attention. These symptoms could be considered as a sign of metabolic disorder, the onset of septic encephalopathy, and drug-related side effects from cannabis use.

Mental health assessment

Sky’s aggressive behaviour and agitation indicate the development of physiological distress and psychological trauma. Her case scenario, including mild learning disabilities and premature school departure, worsened her health condition and made Sky more vulnerable towards physical and psychological distressful situations. The recent loss of family support through hospital abandonment may exacerbate existing mental health fragility. Selected Care Priority: Fluid Balance Management (Castera & Borhade, 2021). From the assessment, fluid balance emerges as a critical care element. Sky presents with active vomiting, bloody diarrhoea, and an absence of urination since admission. Her disconnected intravenous cannula compounds dehydration risks. Additionally, as per the case scenario, Sky’s existing mental health fragility may worsen as a result of the recent hospital abandonment and loss of family support.

Priority for Selected Care: Fluid Balance Management

Fluid balance is identified as a critical care component based on the assessment. Sky has bloody diarrhoea, active vomiting, and hasn't urinated since being here. Dehydration dangers are increased by her unplugged intravenous cannula. Addressing Sky’s fluid balance is certainly a top clinical concern because severe dehydration is evident. She vomits constantly, has had multiple episodes of bloody diarrhoea and has not passed urine since admission, all concerning signs of fluid loss and poor renal perfusion. To make matters even worse, she is taken off the IV cannula, breaking the prescription for sodium chloride to run (PMC, 2024). Sky's disorientation, hallucinations, and diaphoretic appearance can be related to electrolyte imbalances (Castera & Borhade, 2021). With her Crohn’s disease, flare-ups like this can result in significant fluid and electrolyte losses, necessitating quick replacement. In addition, her tender, swollen right leg is suggestive of potential deep vein thrombosis, which further complicates her situation.

Risk Assessment Tools

In the case of Sky, MUST or Malnutrition Universal Screening Tool has been used as a risk assessment tool, which is specifically designed to identify adults who are malnourished and at risk of obesity and malnutrition.

MUST score calculation:

Height: 1.60 meters

Weight: 143 lbs

Unplanned weight Loss: not mentioned

Acute illness with no nutritional intake>5 days: at risk- Yes (due to vomiting, diarrhoea, and hallucination)

Table 1: MUST Score:

MUST Criteria	Value Assessment	Score
BMI	25.35	0
Weight loss	Unknown	0
Acute disease	Yes	2
Total	2

This score interprets the high risk of malnutrition for Sky.

Clinical justification:

• Despite having a normal 25.3 BMI, Sky is at high risk because of the immediate impact of her Crohn’s disease (PMC, 2024).
• She has severe symptoms: recurrent vomiting, diarrhoea with blood, failure to produce urine, confusion and delirium — suggestive of severe dehydration and electrolyte disturbance.
• Her present condition implies insufficient nutrient consumption and, if continued, is likely to cause progressive physiological decompensation.
• She also has problems with medical adherence and comes from a vulnerable social background (Traveller, low literacy, no stable access to care), which further adds to her nutrition risk.

Based on the MUST score and clinical justification, one person-centred care that Sky has in need on an immediate basis includes Fluid Balance Management. Delivering person-centred fluid balance care for Sky requires understanding her cultural background and individual needs. The Travelling Community's heritage influences healthcare perceptions, particularly following maternal loss and repeated hospital experiences. Effective care acknowledges these factors whilst addressing immediate physiological requirements (Seixas et al., 2021).

In the case of Sky, the care team must implement a food and fluid intake chart, rehydration through IV fluids administration, and initiate continuous monitoring of fluid balance and bowel patterns. Such a person-centred care approach can help care providers meet Sky’s specific needs, and understanding is accounted for. Additionally, as mild learning disability and poor health literacy are other important risk factors for Sky, with personal personal-centred care approach, the care providers can use communication in such a way that it suppresses the risk of communication barriers between care users and care providers, and provide reassurance to Sky regarding effectiveness of her treatment process (Huang, 2019). Sky’s travelling background is another risk factor, and as per the person-centred care approach, the care providers should consider that risk while designing a treatment plan for the patient. This person-centred care approach as a whole can improve the health outcomes of patients.

Involvement of a Multidisciplinary team in the case of Sky

Managing Sky's complex fluid balance requires coordinated multidisciplinary input beyond nursing intervention alone. Her presentation demands specialist knowledge from various healthcare professionals.

Medical Team Involvement

Sky's Crohn's disease is mostly managed by the surgical team, who also have a direct influence on fluid losses from vomiting and bloody diarrhoea. Their knowledge directs suitable fluid replacement plans and keeps an eye out for electrolyte imbalances. While consultant supervision guarantees treatment appropriateness, junior physicians usually oversee daily fluid prescriptions.

Consultation with a Pharmacy

Knowledge of pharmaceuticals becomes essential in light of Sky's past medication use and current prescriptions. Her usage of cannabis may have an impact on pharmaceutical interactions, while her prednisolone therapy impacts her fluid retention patterns. Pharmacists recommend the best times to take analgesics and antiemetics to prevent worsening fluid loss (SCIE, 2022).

Dietetic Input

Although not explicitly mentioned in Sky's immediate care, dietary involvement would typically occur following acute stabilisation. Her learning difficulties require simplified dietary education regarding fluid intake, maintenance, and Crohn's dietary management. Social Work Involvement Sky's abandonment by family and nomadic lifestyle necessitates social work assessment (SCIE, 2022). These professionals coordinate discharge planning, ensuring appropriate community support exists for ongoing fluid balance monitoring. Their cultural understanding of Travelling Communities proves invaluable.

Psychological support

Sky’s aggressive behaviour and confusion suggest psychiatric involvement as a medical intervention to ensure her mental health and well-being. In such a scenario, mental healthcare professionals can address underlying trauma whilst ensuring therapeutic compliance for essential treatments. This collaborative approach can ensure comprehensive care where the focus has been given solely to meeting the physical and psychological needs of Sky.

Discharge Planning for Sky

Evaluation of Nursing Care Effectiveness and Discharge Planning for Fluid Balance

The nursing care delivered for Sky's fluid balance management demonstrates mixed effectiveness, complicated by her challenging presentation and complex social circumstances.

Care Effectiveness Analysis

Initial fluid replacement attempts failed when Sky removed her intravenous cannula, highlighting inadequate therapeutic relationship establishment. This represents a significant care delivery failure - nurses must build trust before implementing invasive procedures, particularly with vulnerable adolescents (Seixas et al., 2021). Sky's continued oliguria and dehydration symptoms suggest insufficient hydration restoration.

However, recognising the severity through systematic monitoring shows appropriate clinical judgement. Hourly observations would typically identify deterioration patterns, though Sky's non-compliance creates monitoring challenges (Raus et al., 2020). The documentation set up by the nursing team appears thorough, providing essential information for medical decision-making.

Missed Opportunities

Several care elements warrant criticism. Sky's learning difficulties weren't adequately addressed through simplified explanations about treatment necessity. Cultural sensitivity regarding her Travelling Community background appears lacking, contributing to her distress and non-cooperation (Viken et al., 2021). Pain management seems inadequate given her continued discomfort despite morphine administration.

Discharge Planning Considerations

Discharge planning for fluid balance management presents enormous challenges given Sky's circumstances (Schoeber et al., 2022). Her family abandonment eliminates typical support networks, whilst her nomadic lifestyle complicates follow-up arrangements (Oxford Academic, 2024). Previous poor compliance with medical interventions suggests likely treatment discontinuation post-discharge.

Effective planning requires social work involvement to establish temporary accommodation with healthcare access. Community nursing input becomes essential for ongoing monitoring, though tracking mobile populations proves difficult (Raus et al., 2020). Simplified written instructions about recognising dehydration signs suit her learning difficulties.

The ultimate discharge plan must acknowledge realistic outcomes rather than ideal scenarios. Sky's historical pattern suggests probable re-admission unless significant social support mechanisms develop. Pragmatic planning focuses on harm reduction and emergency contact information rather than perfect compliance expectations.

Conclusion

Given Sky's Traveller heritage and recent family abandonment, her case exemplifies a potentially fatal Crohn's disease flare that is exacerbated by extreme dehydration, potential sepsis, and psychological fragility. Even with timely multidisciplinary intervention, which includes the involvement of medical professionals, nurses, chemists, dietitians, and social workers, persistent issues, including non-compliance, insufficient pain management, and a lack of adaptation to her cultural and educational needs, still exist. Her declining mental health and physical symptoms necessitate immediate, person-centred care, and the MUST score confirms a significant nutritional risk. In order to maximise Sky's immediate survival and long-term health results, it is imperative that she receive compassionate, coordinated, and culturally aware care, as demonstrated by her complex presentation.

References

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Oxford Academic (2024) 'Considerations in Paediatric and Adolescent Inflammatory Bowel Disease', Journal of Crohn's and Colitis, 18(Supplement_2), pp. ii31–ii45. Available at: https://academic.oup.com/ecco-jcc/article/18/Supplement_2/ii31/7848695 (Accessed: 13 June 2025).

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