Inflammatory Bowel Disease with Small Bowel Obstruction Case Study (Harding & Snyder Case Study 62): Nursing Guide

How to use this guide: the textbook case and its questions are copyrighted, so they are not reproduced here. Instead, this guide explains the clinical content the case tests and walks through an original practice case with model answers. Use it to study and to check your reasoning, then answer the questions in your textbook in your own words. It is not an answer key.

Inflammatory bowel disease: what the case tests

Inflammatory bowel disease (IBD) is a group of chronic, relapsing inflammatory conditions of the gastrointestinal tract. The two main types are Crohn’s disease and ulcerative colitis. The cause involves an abnormal immune response to gut bacteria in genetically susceptible people, influenced by environmental factors such as smoking (Harding et al., 2023). IBD usually begins in adolescence or young adulthood, so it affects schooling, work, relationships and body image.

When a case involves the small bowel, it is almost always about Crohn’s disease, which can affect any part of the digestive tract but most often the terminal ileum. Transmural inflammation (through the full bowel wall) leads to strictures, fistulas and abscesses. Repeated inflammation and scarring can narrow the bowel enough to cause a small bowel obstruction, and many patients eventually need surgery such as a small bowel resection (Lichtenstein et al., 2025).

Original practice case

Clinical reasoning questions and model answers

1. Explain how Crohn’s disease led to the obstruction.

Chronic transmural inflammation of the ileum causes swelling, then fibrosis (scar tissue). Over years the bowel lumen narrows into a stricture. Food, fluid and gas back up behind the narrowing, the bowel above distends, and fluid shifts into the bowel lumen. This causes colicky pain, distension, vomiting and absent stool or gas. Stopping her maintenance therapy and continuing to smoke both increased inflammation.

2. What do her assessment findings and labs mean?

• High-pitched bowel sounds occur early above an obstruction; later, bowel sounds may become absent.
• Tachycardia, low BP, dry mucous membranes and high BUN show fluid volume deficit from vomiting and fluid trapped in the bowel (“third spacing”).
• Hypokalemia results from vomiting and poor intake. It can worsen ileus and cause dysrhythmias.
• Low hemoglobin and albumin, and weight loss reflect chronic inflammation, blood loss and malnutrition.
• Low-grade fever and elevated CRP reflect active inflammation. A high fever, severe constant pain or peritoneal signs could mean strangulation or perforation, which is a surgical emergency.

3. What are the initial nursing priorities?

1. NPO to rest the bowel.
2. Nasogastric (NG) tube to low intermittent suction to decompress the stomach and bowel and relieve vomiting.
3. IV fluids (isotonic solution) and potassium replacement as ordered. Confirm adequate urine output before giving potassium.
4. Monitor vital signs, intake and output (including NG drainage), daily weight and electrolytes.
5. Assess pain, abdominal girth, bowel sounds and passage of flatus; report signs of strangulation such as sudden severe pain, fever and rising heart rate.
6. Give analgesics and antiemetics as ordered, and provide mouth and nose care while the NG tube is in place.

4. How should the nurse care for the NG tube?

Verify placement per policy (an X-ray confirms initial placement; check the external length marking each shift). Keep the head of the bed elevated at least 30 degrees. Monitor the amount and color of drainage. Irrigate only as ordered. Secure the tube to prevent pressure injury on the nose. Large NG losses remove hydrochloric acid, so watch for metabolic alkalosis, as well as loss of potassium and sodium.

5. The obstruction does not resolve, and Ms. Nair has a small bowel resection with primary anastomosis. What postoperative complications should the nurse watch for?

• Anastomotic leak: fever, increasing abdominal pain, tachycardia, rising WBC and signs of peritonitis, usually several days after surgery.
• Postoperative ileus: distension, nausea and absent flatus. Early ambulation and opioid-sparing pain control help.
• Infection and wound complications, especially with steroid use and malnutrition.
• Venous thromboembolism: IBD increases clotting risk, so prophylaxis and early mobility are important.
• Fluid and electrolyte imbalance and, if a long segment was removed, short bowel syndrome with diarrhea and malabsorption.

If she had needed an ileostomy, the nurse would also assess the stoma (moist and red or pink; dusky or black means poor blood flow), measure high output, protect the skin and support body image and teaching.

6. What nutritional problems are expected after ileal disease or resection?

The terminal ileum absorbs vitamin B₁₂ and bile salts. Removing it can cause B₁₂ deficiency (requiring injections or high-dose replacement), bile acid diarrhea and fat malabsorption with deficiencies of fat-soluble vitamins (A, D, E, K). Ms. Nair is also malnourished, so the team may start enteral nutrition or, if the gut cannot be used for an extended period, parenteral nutrition. A dietitian should help plan a high-calorie, high-protein diet. A low-residue diet may be advised during strictures or flares.

7. What medications might be used, and what are the nursing considerations?

Current guidance supports starting effective advanced therapy early in moderate to severe Crohn’s disease rather than waiting for other drugs to fail, and recommends endoscopic monitoring 6–12 months after surgery to catch recurrence (Lichtenstein et al., 2025). Helping Ms. Nair access affordable biologic therapy, through a social worker or manufacturer assistance program, is a key part of preventing another obstruction.

8. What teaching and psychosocial support does she need?

• Smoking cessation: smoking increases Crohn’s activity and recurrence after surgery. Offer counseling and nicotine replacement.
• Medication adherence and what to do if cost becomes a barrier.
• Warning signs: cramping, vomiting, no stool or gas, fever or blood in the stool.
• Nutrition: small, frequent meals; adequate protein and fluids; supplements as prescribed.
• Emotional health: anxiety and depression are common in IBD. Ask about stress, body image and support, and refer to counseling or support groups.

Sample nursing care plan

Frequently asked questions

Is surgery a cure for Crohn’s disease?

No. Surgery removes damaged bowel, but Crohn’s disease often comes back, usually near the anastomosis. Maintenance therapy and not smoking reduce recurrence.

Why do high-pitched bowel sounds occur early in obstruction?

The bowel above the blockage contracts harder to push contents past it, producing high-pitched, tinkling sounds. As the bowel tires and distends, sounds may disappear.

Why check for tuberculosis before biologics?

Anti-TNF drugs suppress the immune response that keeps latent tuberculosis inactive, so TB can reactivate.

Related reading: abdominal assessment guide, subjective vs. objective nursing data and the nurse as health educator.

Conclusion

An IBD case with small bowel involvement tests whether nurses understand how chronic Crohn’s inflammation becomes a mechanical obstruction, and whether they can manage NG decompression, fluids, electrolytes, nutrition and postoperative risks. Long-term success depends on medication access, smoking cessation and support for a young adult living with a chronic disease.

References

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Harding, M. M., & Snyder, J. S. (2019). Clinical reasoning cases in nursing (7th ed.). Elsevier Mosby.

Lichtenstein, G. R., Loftus, E. V., Jr., Isaacs, K. L., et al. (2025). ACG clinical guideline: Management of Crohn’s disease in adults. American Journal of Gastroenterology, 120(6), 1225–1264. https://doi.org/10.14309/ajg.0000000000003465