Crohn's disease

Nursing Considerations-Nursing Diagnoses

Acute pain Diarrhea Disturbed body image Imbalanced nutrition: Less than body requirements Ineffective coping Risk for ineffective gastrointestinal tissue perfusion Risk for deficient fluid volume Risk for impaired skin integrity Risk for injury

Treatment-Diet

Avoidance of foods that worsen diarrhea Avoidance of raw fruits and vegetables if blockage occurs Adequate caloric, protein, and vitamin intake Parenteral nutrition, only if necessary Decreased fat for fat malabsorption

Nursing Considerations-Associated Nursing Procedures

Blood pressure assessment Fecal occult blood tests IV bag preparation IV bolus injection IV catheter insertion Intake and output assessment Intramuscular injection Nutritional screening Oral drug administration Pain management Pressure ulcer prevention Pulse assessment Relaxation and stress management techniques Respiration assessment Temperature assessment Weight measurement

Treatment-Medications

Corticosteroids, such as predniSONE Sulfasalazine or mesalamine Proton pump inhibitor, such as omeprazole or sucralfate, for gastroduodenal symptoms (epigastric pain, nausea, postprandial vomiting) Mesalamine or hydrocortisone enema for tenesmus or bleeding Metronidazole for perirectal disease with fistulae Azathioprine or mercaptopurine if the patient relapses while on or doesn't respond to predniSONE Infliximab or adalimumab for symptomatic fistulae that fail to heal with therapy and for joint, eye, and extraintestinal manifestations Loperamide hydrochloride for diarrhea control Budesonide topically or orally as an alternative to predniSONE in patients needing long-term steroid therapy Methotrexate I.M. weekly as an alternative to azathioprine or mercaptopurine CycloSPORINE for fistula closure if other methods have been ineffective Vitamin supplements, such as folic acid Antibiotics, such as metronidazole or ciprofloxacin, to treat active disease Triamcinolone acetonide for symptomatic relief of oral lesions I.V. fluid replacement for significant fluid volume loss

Overview-Pathophysiology

Crohn's disease involves slow, progressive inflammation of the bowel or digestive tract. Focal infiltration occurs, leading to ulceration of the superficial mucosa and progressing to the deep mucosa producing granulomas. Granulomas extend through all the mucosal layers and into the regional lymph nodes. Neutrophils infiltrate the area, forming crypt abscesses, ultimately destroying the crypt and leading to colonic atrophy. Lymphatic obstruction is caused by enlarged lymph nodes. Edema, mucosal ulceration, fissures, and abscesses occur. Elevated patches of closely packed lymph follicles (Peyer's patches) develop in the small intestinal lining. Fibrosis occurs, thickening the bowel wall and causing stenosis. Inflamed bowel loops adhere to other diseased or normal loops. The diseased bowel becomes thicker, shorter, and narrower.

Overview-Incidence

Crohn's disease occurs more often in females than in males. In the United States, the disease is more common in Whites than in African Americans or Asians. Onset usually occurs between ages 15 and 30, with another peak between ages 60 and 80.

Overview-Causes

Exact cause unknown; idiopathic Immune related Lymphatic obstruction and infection among contributing factors

Overview-Complications

Fistulae (perirectal, cutaneous, enterovaginal, and enterovascular) Extraluminal disease of the skin, uveal tract, joints, and biliary tract Colon perforation Toxic megacolon Gallstones Osteoporosis (more frequent and severe with chronic steroid use) Malabsorption, leading to vitamin deficiencies Abscess Colon cancer (increased risk) Hemorrhage

Assessment-History

Gradual onset of signs and symptoms, marked by periods of remission and exacerbation Fatigue and weakness Chronic intermittent fever, flatulence, nausea Steady, colicky, or cramping abdominal pain that usually occurs in the right lower abdominal quadrant Diarrhea that may worsen after emotional upset or ingestion of poorly tolerated foods, such as milk, fatty foods, and spices Weight loss Anorexia

Overview-Risk Factors

History of allergies Immune disorders Genetic predisposition (15% of patients have a first-degree relative with inflammatory bowel disease) High protein levels of tumor necrosis factor History of smoking Use of oral contraceptives or nonsteroidal anti-inflammatory drugs

Treatment-Surgery

Indicated for acute intestinal obstruction Colectomy with ileostomy Stricturoplasty Surgical drainage of perirectal abscesses Surgical repair of recurrent fistulae if other treatments are unsuccessful

Overview

Inflammatory bowel disease that can affect any part of the GI tract from the mouth to the anus but commonly involves the terminal ileum (60% of cases involve the terminal ileum; 15% to 20%, the colon; and 10%, only the proximal small bowel) Extends through all layers of the intestinal wall May involve regional lymph nodes and mesentery

Diagnostic Test Results-Laboratory

Occult blood in stools may be present. Hemoglobin (Hb) level and hematocrit may be decreased. White blood cell count may be increased. Erythrocyte sedimentation rate and C-reactive protein may be elevated Serum potassium, calcium, and magnesium levels may be decreased. Hypoalbumenia from intestinal protein loss may occur. Vitamin B12 and folate deficiency may occur. Antiglycan antibody titer is elevated. Perinuclear antineutrophil cytoplasmic antibody test is negative, and anti-S cerevisiae antibody test is positive.

Assessment-Physical Findings

Possible soft or semiliquid stool, usually without gross blood Right lower abdominal quadrant tenderness or distention Possible abdominal mass, indicating adherent loops of bowel Hyperactive bowel sounds Bloody diarrhea Perianal and rectal abscesses Arthritis of large joints (extraintestinal disease) Uveitis, iritis, episcleritis (eye involvement) Oral ulcerations

Nursing Considerations-Nursing Interventions

Provide emotional support to the patient and his family; allow the patient and his family to verbalize their fears and concerns in light of the chronic nature of the disease. Provide honest, consistent answers and explanations. Encourage patient participation in care and decision-making to foster the patient's sense control over situation. Assess bowel elimination patterns, including frequency and stool characteristics; check stools for occult blood. Provide meticulous skin care, especially after each bowel movement; ensure that patient has ready access to bathroom facilities or a commode. Schedule patient care to include rest periods throughout the day; cluster nursing activities to avoid overtaxing the patient. Encourage the use of energy conservation measures Assist with dietary modifications. Suggest options for foods to include and avoid based on the patient's likes and dislikes. Give prescribed medications, such as predniSONE, sulfasalazine or mesalamine; expect to start predniSONE at the same time as sulfasalazine or mesalamine. Provide comfort measures such as warm sitz baths. Obtain daily weights. Encourage fluid intake; check skin turgor and mucous membranes for moisture. Assess abdomen, including abdominal girth; auscultate bowel sounds for changes. Offer non-irritating foods and fluids if the patient experiences oral ulcerations. Obtain specimens for laboratory testing, such as complete blood count (CBC), liver function tests, and vitamin levels. Prepare the patient and his family for possible surgery, such as drainage of abscesses, repair of fistulae, or colectomy with ostomy.

Treatment-Activity

Reduced during acute disease Physical and emotional rest

Patient Teaching-Discharge Planning

Refer the patient and his family to a local chapter of the Crohn's and Colitis Foundation of America. Refer the patient to a smoking-cessation program, if appropriate. Refer the patient to an enterostomal therapist, if indicated.

Treatment-General

Stress reduction Sitz baths for perirectal disease

Diagnostic Test Results-Imaging

Upper GI and small bowel X-rays may show an irregular mucosa, ulceration, and stiffening. Barium enema reveals the string sign (segments of stricture separated by normal bowel) and may also show fissures, fistulae, and narrowing of the lumen. Computed tomography scanning may show thickening of the bowel wall, strictures, dilation, abscess cavities, and fistulae.

Diagnostic Test Results-Diagnostic Procedures

Upper endoscopy, sigmoidoscopy, and colonoscopy show patchy areas of inflammation and may also reveal the characteristic coarse irregularity (cobblestone appearance) of the mucosal surface. Biopsy reveals granulomas in up to 50% of all specimens.

Nursing Considerations-Monitoring

Vital signs Fluid balance Intake and output Abdominal distention Bowel sounds Stool, including amount, characteristics, episodes of diarrhea and their frequency Daily weight Nutritional status Serum electrolyte levels, Hb level, and ESR Stools for occult blood Signs and symptoms of infection or obstruction

Patient Teaching-General

disorder; diagnosis, such as ordered diagnostic tests and pretest guidelines; and treatment, including diet, medications, and chronicity of the disorder signs and symptoms of recurrence, such as an increase in abdominal discomfort, diarrhea, frank blood in stool, and abnormal drainage potential complications, including the need to notify a practitioner if any occur prescribed medication therapy, including drugs, dosages, rationales for use, schedule of administration, and possible adverse reactions, including cushingoid syndrome with predniSONE and the need to taper steroids gradually importance of adhering to the prescribed medication regimen to control the disorder need for follow-up laboratory testing, such as CBC to evaluate for anemia and evidence of inflammation, yearly liver function tests, and folate and vitamin B12 levels for those with ileal disease or resection skin care measures, including perianal hygiene measures and sitz baths if indicated importance of adequate rest, both physical and emotional ways to identify and reduce sources of stress prescribed dietary changes, including foods to avoid or include and the need to monitor weight for changes need to avoid nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, which can make disease worse importance of regular exercise possible need for surgery if recurrences occur or medications fail to control the disorder (be sure to explain that surgery is palliative not curative) importance of adhering to follow-up, including regular visits every 3 to 6 months if condition is stable, possible endoscopy for changes in signs and symptoms, and surveillance colonoscopy beginning 8 years after initial diagnosis and then every 1 to 3 years.

Nursing Considerations-Expected Outcomes

express feelings of comfort and decreased pain regain normal intestinal function express positive feelings about self maintain adequate caloric intake exhibit adequate coping mechanisms and seek appropriate sources of support exhibit signs of adequate GI perfusion maintain normal fluid volume maintain skin integrity remain free from injury.