Lucy Stephens is a 35-year-old part-time shop assistant who lives in a private house in the Burroughs, with her husband and four young children.
Lucy has suffered from Chron’s disease since the age of 15 and has been managing the condition with medications well. After the birth of her twins a year ago, Lucy has had more difficulty managing Chron’s and has been in and out of hospital with abdominal pain, diarrhoea, and weight loss. She is currently taking a combined oral contraceptive pill to ensure she does not become pregnant again whilst she is unwell.
Part A:
Lucy has recently been diagnosed with a rectovaginal fistula after reporting to her consultant that she is passing small amounts of faeces and gas vaginally. Lucy also reported suffering from moderate pain and excoriation in the vulva. The consultant has told Lucy that this is going to be a long-term problem and would like to initially manage the rectovaginal fistula conservatively with antibiotics and infliximab, before considering surgery. Lucy was also commenced on oral morphine 10mg every four hours for the pain and cavilon cream twice a day for the excoriated skin. She has been prescribed a course of prednisolone to manage her symptoms. The consultant has arranged for the community nurse to review Lucy’s skin, as she is having difficulty leaving the house to see the practice nurse.
As a community nurse, you have been asked to go and assess Lucy and complete a care plan for her needs in the community. When you meet Lucy, she is very tearful and tells you she can’t leave the house as she can’t manage the faecal leaking or smell, as the sanitary towel she is using is not working. She says this inability to leave the house is causing problems with her husband who is trying to be supportive, but he is having to take the children to school and work extra hours as Lucy cannot currently work.
Lucy reports that she is having difficulty mobilising short distances, due to severe pain in the vulva area even though she is taking the oral morphine as prescribed and 1 gram of paracetamol twice a day. The skin around her vulva has not improved since the cream and washing the area is extremely painful.
You also notice that Lucy appears pale, and her clothes are ill-fitting. She explains that she has lost approximately a stone and a half in the last year, and she wants to eat but struggles with what to eat as she is conscious that some foods seem to increase her faecal output and pain. She also is struggling to find time to prepare food with caring for the children as well the pain from mobilising so she has tended to make ‘fast food’ that the children like. You check Lucy’s vital signs including her temperature and all are within normal parameters.
Lucy reports that she constantly feels exhausted. Her husband has tried to help her through the night with the twins but he is also struggling to cope with the extra hours he is needing to work. Lucy is sometimes sleeping on the sofa as she is conscious of the smell and leakage whilst her husband is sleeping and does not want to disturb him further.
Part B:
Lucy has been trying to heal her rectovaginal fistula in the community for the last five months. The fistula has not healed, and Lucy has now been scheduled for a rectovaginal fistula repair. The surgeon also informed Lucy that she may require an ileostomy formation to help the damaged tissue