# A nurse is caring for a client with Crohn's disease who is experiencing an acute exacerbation. Which action is of the highest priority for this client?

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## 문제

A nurse is caring for a client with Crohn's disease who is experiencing an acute exacerbation. Which action is of the highest priority for this client?

A 28-year-old client with Crohn's disease is admitted to the medical unit with severe abdominal cramping, bloody diarrhea (8-10 stools per day), and a low-grade fever. The client reports fatigue and has lost 15 pounds over the past month.

## 보기

1. Administer prescribed corticosteroids to reduce inflammation
2. Provide a low-residue diet to rest the bowel
3. Monitor fluid and electrolyte balance **✔ 정답**
4. Assess for signs of fistula formation

**정답: 3**

## 해설

Monitoring fluid and electrolyte balance is the priority due to severe diarrhea causing dehydration and electrolyte imbalances. Other options address inflammation, diet, or complications but are less urgent.

## 심화 해설

Clinical Context and Priority Setting

In an acute exacerbation of Crohn's disease, the client presents with a cluster of high-risk findings: severe abdominal cramping, high-volume bloody diarrhea (8-10 stools per day), low-grade fever, significant weight loss (15 pounds over one month), and fatigue. When prioritizing care using the ABC (Airway, Breathing, Circulation) framework and Maslow's hierarchy, the most immediate threat to physiological integrity is fluid volume deficit and electrolyte derangement. The primary pathophysiological process involves transmural inflammation of the gastrointestinal tract, which impairs the colon's ability to reabsorb water and electrolytes. Combined with the high output from 8-10 episodes of bloody diarrhea daily, this creates a rapid pathway to hypovolemia, hemodynamic instability, and potentially life-threatening cardiac arrhythmias from electrolyte shifts. While all listed options are valid components of care, the nurse must first address the risk that poses the most immediate danger to survival.

Why Monitoring Fluid and Electrolyte Balance is the Priority

The rationale for prioritizing fluid and electrolyte monitoring is directly supported by the documented consequences of gastrointestinal pathology in Crohn's disease. According to the review on gastrointestinal fistulas, a known complication of Crohn's, the clinical presentation can cause dehydration, electrolyte imbalance, and malnutrition, leading to increased morbidity and mortality [2]. Although this reference focuses on fistulas, the mechanism of loss—excessive fluid and electrolyte depletion through the GI tract—is identical in a severe flare with profuse diarrhea. The client's report of fatigue is a key clinical cue that may indicate hypokalemia or hyponatremia, while the low-grade fever increases insensible fluid loss, compounding the deficit. A nurse's highest priority assessment is to monitor intake and output, daily weight, vital signs (specifically orthostatic hypotension and tachycardia), and serum electrolyte levels to detect and manage these shifts before they progress to hypovolemic shock.

Analysis of Other Options

The remaining options are essential but secondary in the acute phase. Administering prescribed corticosteroids (Option 1) is a cornerstone of medical management to reduce the inflammatory cascade in the intestinal mucosa. However, pharmacologic intervention is a dependent nursing action and does not take precedence over the independent, immediate assessment of a life-threatening physiological imbalance. Providing a low-residue diet (Option 2) is a strategy to rest the bowel by reducing fecal bulk and mechanical stimulation. Yet, during a severe exacerbation, the client may be placed on NPO (nothing by mouth) status or require exclusive enteral nutrition, and dietary modification is a supportive measure rather than an emergent one. Assessing for signs of fistula formation (Option 4) is a critical surveillance activity given that perianal abscesses and fistulizing disease are common complications, as noted in the case report of an adolescent with a history of perianal abscess surgery . This assessment addresses long-term disease progression and complication management, not the immediate, minute-to-minute risk of circulatory collapse from massive fluid loss.References (research sources)

- [2]Gastrointestinal Fistulas-What Gastroenterologists Need to Know in 2025.Research articleAhmed M. (2025) · DOI: 10.1155/cjgh/6210421

## 임상 시나리오

Managing Acute Crohn's ExacerbationPrioritizing Fluid and Electrolyte Monitoring
For a client with high-volume bloody diarrhea (8-10 stools/day), the priority is to prevent hypovolemic shock and fatal arrhythmias. Immediately monitor intake and output, daily weight, and serum electrolytes (especially potassium and magnesium).

Assess for signs of fluid volume deficit: tachycardia, hypotension, orthostasis, dry mucous membranes, and decreased skin turgor. Match ongoing losses with appropriate IV fluid replacement, typically with isotonic crystalloids.

CautionDo not delay fluid resuscitation to administer corticosteroids or initiate dietary changes. While these are important, they are secondary to stabilizing the client's hemodynamic status. Recheck electrolyte levels frequently during replacement to avoid overcorrection.

## 핵심 개념

- **Transmural Inflammation** — Inflammation affecting all layers of the bowel wall, characteristic of Crohn's disease, which impairs absorption and can lead to complications like fistulas.
- **Hypovolemia** — A state of decreased blood plasma volume, often caused by fluid loss from severe diarrhea, leading to poor tissue perfusion and potential shock.
- **Low-Residue Diet** — A diet limiting fiber and other foods that increase bowel activity and stool bulk, used to rest the bowel during acute exacerbations of inflammatory bowel disease.
- **ABC Framework** — A prioritization method in nursing that addresses Airway, Breathing, and Circulation first, placing hemodynamic stability from fluid balance as a critical 'Circulation' concern.
- **Electrolyte Derangement** — An imbalance of critical minerals like potassium and sodium in the blood, which can result from severe diarrhea and lead to cardiac arrhythmias and neurological issues.

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