Inflammatory Bowel Disease, Hinkle, Ch. 48

NURSING DIAGNOSIS: Disturbed body image Goal: ______

Attainment of a positive self-concept

The patient's lab results show WBC 11,000/mm, Hgb 10.8g/dL, Hct 35%, Na+ 153mEq/L, K+ 4.7mEq/L, BUN 40mg/dL, and Creatinine 1.6mg/dL. The nurse is developing a plan of care for the patient. What nursing diagnosis should the nurse identify as the highest priority? A. Body image disturbance related to diarrhea and weight loss. B. Fluid volume deficit related to diarrhea and decreased fluid intake. C. Imbalanced nutrition: less than body requirements related to decreased intake. D. Hemorrhage related to gastrointestinal blood loss.

B. Fluid volume deficit related to diarrhea and decreased fluid intake.

The patient asks the nurse what caused her IBD. What is the most accurate response for the nurse to make? A. IBD is caused by severe stress. B. IBD is caused by the body's immune system attacking the intestine. C. IBD is an infection of the lining of the digestive system. D. IBD is a genetic disease. Do you have any family members with IBD?

B. IBD is caused by the body's immune system attacking the intestine.

What should the nurse advise the patient about their activity? A. A routine of aerobic exercise at least 3 times a week will decrease the number of exacerbations they experience. B. The patient may maintain activity as tolerate, even during exacerbations. C. IBD will not affect their ability to exercise or engage in their usual activities at all. D. Maintaining bedrest during an exacerbation will shorten the exacerbation.

B. The patient may maintain activity as tolerate, even during exacerbations.

The patient asks why she is not allowed to eat or drink. What is the reason for keeping the patient NPO? A. IBD is caused by food allergies. A period of NPO followed by introducing foods one at a time will help determine which food caused the patient's IBD. B. To provide bowel rest and permit more rapid resolution of the flare-up of symptoms. C. The nurse should call the provider to clarify the order. The patient is dehydrated and has lost weight. The patient should take a high-calorie diet. D. If the symptoms resolve after a day of NPO status, the patient's IBD is UC. If not, the patient's IBD is CD.

B. To provide bowel rest and permit more rapid resolution of the flare-up of symptoms.

______ tablets, which may be prescribed and taken orally three or four times each day, are effective in reducing odor.

Bismuth subcarbonate

Extent of involvement UC:

Continuous

______ is also the procedure of choice in familial adenomatous polyposis.

IPAA

Fistula's, strictures, and perianal abscesses in UC are:

Rare

______ are valuable in distinguishing ulcerative colitis from other diseases of the colon with similar symptoms.

Sigmoidoscopy or colonoscopy and barium enema

Patients with colonic Crohn's disease are also at increased risk of ______.

colon cancer

Ulcerative colitis affects the superficial mucosa of the colon and is characterized by ______.

multiple ulcerations, diffuse inflammations, and desquamation or shedding of the colonic epithelium.

Bleeding occurs as a result of the ______.

ulcerations

The patient should gain ______ daily during parenteral nutrition therapy.

0.5 kg (1.1 lb)

People between ______ of age are at the greatest risk of developing IBD, followed by those between 50 and 70 years of age.

15 and 30 years

The nurse monitors the ileostomy for fecal drainage, which should begin about ______ hours after surgery.

24 to 48

(Restorative proctocolectomy with IPAA) A temporary diverting loop ileostomy that promotes healing of the surgical anastomoses is constructed at the time of surgery and closed about ______ later.

3 months

With IPAA or restorative proctocolectomy, the diseased colon and rectum are removed, voluntary defecation is maintained, and anal continence is preserved. The ileal reservoir decreases the number of bowel movements by ______, from approximately 14 to 20 per day to 7 to 10 per day. Nighttime elimination is gradually reduced to ______ bowel movement.

50%; 1

What should the nurse advise the patient about their diet with IBD? Select all that apply. A. Eat a high-protein, high-calorie diet. B. Avoid milk products. C. Eat a low-carbohydrate diet. D. Eat a low-residue (low-fiber) diet. E. Avoid red meat.

A. Eat a high-protein, high-calorie diet. B. Avoid milk products. D. Eat a low-residue (low-fiber) diet.

As the nurse taking care of the patient, what would be your concerns for the patient regarding her prednisone prescription? Select all that apply. A. Patient education about possible medication side-effects. B. Patient education about how the medication reduces inflammation. C. Patient education about the tests to be conducted before administration. D. Patient education about how the medication cost can be covered. E. Patient education about how to take the medication.

A. Patient education about possible medication side-effects. E. Patient education about how to take the medication.

After 24 hours, the patient's condition has improved. They say that a friend has suggested they consider having surgery. The patient asks if surgery will cure her UC. What is the best response for the nurse to make? A. Removing the entire colon can cure UC. B. No surgery can cure UC, although surgery may decrease your exacerbations. C. Surgery can be used to treat complications of UC, like your toxic megacolon, but not to treat the UC. D. You'll have to discuss that with your provider.

A. Removing the entire colon can cure UC.

Patient is discharged with sulfasalazine (Azulfidine) 1g by mouth Q8h and Prednisone 30mg by mouth daily. What instructions should the nurse include about patient's medications? A. You shouldn't take Azulfidine if you are allergic to aspirin of sulfa. B. You'll need to take predisone for the rest of your life. C. Take the prednisone at bedtime. D. The Azulfidine must be taken on an empty stomach.

A. You shouldn't take Azulfidine if you are allergic to aspirin of sulfa.

NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to avoidance of foods that may cause GI discomfort GOAL: ______

Achievement of an optimal nutritional intake

NURSING DIAGNOSIS: Risk for deficient fluid volume related to anorexia and vomiting and increased loss of fluids and electrolytes from GI tract GOAL: ______

Attainment of fluid balance

NURSING DIAGNOSIS: Sexual dysfunction related to altered body image GOAL: ______

Attainment of satisfactory sexual performance

As the nurse attending the patient, which assessment data do you think are of concern when establishing state of hydration? select all that apply. A. Decrease in bowel sounds B. Dizziness C. Decrease in urine output D. Mucus-filled stools E. Increase in heart rate

B. Dizziness C. Decrease in urine output E. Increase in heart rate

What is most likely explanation for the patient's joint pain with IBD? A. Patients who have one autoimmune disease often develop a second autoimmune disorder. The joint pain is caused by another autoimmune disorder. B. The joint pain is a manifestation of the patient's IBD. C. The joint pain is an attention-seeking device the patient is using to cope with having a chronic disease. D. The joint pain is caused by the patient's decreased activity level.

B. The joint pain is a manifestation of the patient's IBD.

Which of the following factors may contribute to UC? Select all that apply. A. Age B. Smoking C. Stress and anxiety D. Immune system response E. Allergic reactions

C. Stress and anxiety D. Immune system response E. Allergic reactions

A ______ may show bowel wall thickening and fistula formation.

CT scan

The prevalence of ulcerative colitis is highest in ______.

Caucasians and people of Jewish heritage.

Diarrhea and rectal bleeding is common among ______ and ______.

Crohn's disease and Ulcerative colitis

Patient education for IBD include:

Dietary modifications, essential vitamin replacement, and fatty food avoidance.

______ may be used to confirm the diagnosis in Crohn's disease.

Endoscopy, colonoscopy, and intestinal biopsies

With Crohn's disease ______ occur in 50% of patients.

Granulomas

Types of inflammation for CD:

Granulomatous

Vitamin ______ may be prescribed to increase clotting factors.

K

Another procedure involves the creation of a continent ileal reservoir (i.e., ______) by diverting a portion of the distal ileum to the abdominal wall and creating a stoma.

Kock pouch

______ is useful when severe colitis prohibits the use of colonoscopy to determine the extent of inflammation.

Leukocyte tagging

Nursing interventions for IBD include:

Maintaining normal elimination patterns, relieving pain, maintaining fluid intake, maintaining optimal nutrition, promoting rest, reducing anxiety, enhancing coping measures, preventing skin breakdown, monitoring and managing potential complications, and promoting home and community based care.

Patient physiologic care for IBD includes:

Maintenance of electrolyte balance, perineal area care, and good oral hygiene maintenance.

NURSING DIAGNOSIS: Risk for impaired skin integrity related to irritation of the peristomal skin by the effluent Goal: ______

Maintenance of skin integrity

(Chronic IBD) Any foods that exacerbate diarrhea are avoided. ______ may contribute to diarrhea in those with lactose intolerance. ______ and ______ are avoided because both increase intestinal motility. Parenteral nutrition may be indicated.

Milk; Cold foods and smoking

After the NG tube is removed, the nurse offers sips of clear liquids and gradually progresses the diet. ______ and ______, which may indicate intestinal obstruction, must be reported immediately.

Nausea and abdominal distention

Crohn's disease and ulcerative colitis are more prevalent in Jewish people than in any other ethnic group, especially ______.

North American Jews of eastern European descent.

Areas of involvement UC:

Primarily rectum and left colon

Areas of involvement CD:

Primary ileum, secondarily colon

NURSING DIAGNOSIS: Anxiety related to the loss of bowel control Goal: ______

Reduction of anxiety

Development of cancer in UC is:

Relatively common

Patient integrated care for IBD includes:

Reporting of complications, reporting of side-effects, and appropriate dosage adherence.

Manifestations of Ulcerative Colitis disease:

Restricted to the colon, inflammation is continuous, risk for toxic megacolon, and inflammation restricted to mucosa.

______ medications are used to minimize peristalsis in order to rest the inflamed bowel. They are continued until the patient's stools approach normal frequency and consistency.

Sedatives, antidiarrheal, and antiperistaltic

Extent of involvement CD:

Skip lesions

The physician has prescribed an antispasmodic for the patient. What teaching should be provided to prevent related complications?

The nurse should instruct the patient on the signs and symptoms of toxic megacolon: fever, abdominal distention, abdominal cramping and pain, inability to have a bowel movement. Any signs of this serious illness should be immediately reported to the physician.

Types of inflammation for UC:

Ulcerative and exudative

______ is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum.

Ulcerative colitis

NURSING DIAGNOSIS: Deficient knowledge about the surgical procedure and preoperative preparation Goal: ______

Understands the surgical process and the necessary preoperative preparations.

Possible indications for a total colectomy with Kock pouch placement (rather than a restorative proctocolectomy with IPAA) include:

a badly diseased rectum, lack of rectal sphincter tone, or inability to achieve fecal continence post IPAA.

Report complications such as toxic megacolon, the signs of which include:

a decrease in bowel sounds, abdominal cramping and pain, and abdominal distention.

Manifestations of Crohn's disease:

abdominal pain, may occur at any point in the GI tract, inflammation occurs in separate lesions, fistula development, and lesions extend through intestinal wall.

Crohn's disease is usually first diagnosed in ______ but can appear at any time of life.

adolescents or young adults

The nurse obtains a health history to identify the onset, duration, and characteristics of abdominal pain; the presence of diarrhea or fecal urgency, straining at stool (tenesmus), nausea, anorexia, or weight loss; and family history of IBD. It is important to discuss dietary patterns, including the amounts of ______ used daily and weekly. The nurse asks about patterns of______. Allergies and food intolerance, especially ______ intolerance, must be noted. The patient may identify sleep disturbances if diarrhea or pain occurs at night.

alcohol, caffeine, and nicotine-containing products; bowel elimination, including character, frequency, and presence of blood, pus, fat, or mucus; milk (lactose).

As with other patients undergoing abdominal surgery, the nurse encourages those with an ileostomy to engage in early ______. It is important to administer prescribed pain medications as required.

ambulation

Ulcerative colitis patient's may have signs and symptoms of:

anorexia, weight loss, fever, vomiting, and dehydration, as well as cramping, tenesmus, and the passage of 10 to 20 liquid stools each day.

Other biologic therapies recently tested in Crohn's disease include ______ therapy using anti-interleukin (IL)-type drugs (e.g., anti-IL-12).

anticytokine

Elevated ______ antibody levels are common with ulcerative colitis.

antineutrophil cytoplasmic

A recent study suggests that the newer biologics and ______ are more effective for mucosal healing in Crohn's disease versus traditional treatment with methotrexate.

azathioprine

Immunomodulators ______ have been used to alter the immune response. The exact mechanism of action of these medications in treating IBD is unknown. They are used in patients with severe disease who have not responded favorably to other therapies.

azathioprine [Imuran], mercaptopurine [6-MP], methotrexate [MTX], cyclosporine [Neoral]

The most conclusive diagnostic aid for Crohn's disease has classically been a ______ of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.

barium study

The hallmark signs of UC are ______. Also, the stool may contain pus and mucus.

blood diarrhea and symptom-free remission.

There are few dietary restrictions, except for avoiding foods that are high in fiber or hard-to-digest kernels, such as ______, which may result in a stomal obstruction (food blockage) for the person with an ileostomy.

celery, popcorn, corn, poppy seeds, caraway seeds, and coconut

These lesions are not in continuous contact with one another and are separated by normal tissue. Hence, these clusters of ulcers tend to take on a classic "______" appearance.

cobblestone

Fistula's, strictures, and perianal abscesses in CD are:

common

A _______ is performed to assess hematocrit and hemoglobin levels (usually decreased) as well as the white blood cell count (may be elevated). The ESR is usually elevated. Albumin and protein levels may be decreased, indicating malnutrition.

complete blood cell count

(IBD) None of the surgical procedures for Crohn's disease are ______. Ultimately, achievement of remission depends on medical therapy.

curative

Topical (i.e., rectal administration) corticosteroids (e.g., budesonide [Entocort]) are also widely used in the treatment of ______.

distal colon disease

Although its characteristic histopathologic changes can occur anywhere in the GI tract, it most commonly occurs in the ______ and, to a lesser degree, the ascending colon.

distal ileum

Careful stool examination for parasites and other microbes is performed to rule out ______ caused by common intestinal organisms, especially Entamoeba histolytica, C. difficile and Campylobacter, Salmonella, Shigella, and Cryptospora species.

dysentery

Serum ______ levels are monitored daily, and electrolyte replacements are administered as prescribed. Evidence of dysrhythmias or changes in level of consciousness must be reported immediately.

electrolyte

The most common type of small bowel fistula caused by Crohn's disease is the ______ fistula (i.e., an abnormal opening between the small bowel and the skin).

enterocutaneous

(Kock pouch) This procedure eliminates the need for an ______. Approximately 30 cm (11 in) of the distal ileum is reconstructed to form a reservoir with a nipple valve that is created by pulling a portion of the terminal ileal loop back into the ileum. GI effluent can accumulate in the pouch for several hours and then be removed by means of a catheter inserted through the nipple valve.

external fecal collection bag

A positive ______ is the most important independent risk factor for IBD.

family history

Because the inflammatory process is not transmural (i.e., it affects the inner lining only), ______ are uncommon in ulcerative colitis.

fistulas, obstruction, and fissures

Because these patients lose large fluid volumes in the early postoperative period, an accurate record of ______, including fecal discharge, is necessary to help gauge each patient's fluid needs. There may be 1,000 to 2,000 mL of fluid lost each day in addition to expected fluid loss through urine, perspiration, respiration, and other sources.

fluid I&O

Spasm of the ______ causes severe right upper quadrant abdominal pain that can radiate to the back and right shoulder.

gallbladder

The purpose of nasogastric suction is to prevent a buildup of ______ while the intestines are not functioning.

gastric contents

Another intervention being tried for IBD is ______ therapy.

gene

Corticosteroids are used to treat severe and fulminant disease and can be administered orally (e.g., prednisone) in outpatient treatment or parenterally ______ in hospitalized patients.

hydrocortisone [Solu-Cortef]

______ and ______ frequently develop with ulcerative colitis.

hypocalcemia and anemia

An ______—the surgical creation of an opening into the ileum or small intestine (usually by means of an ileal stoma on the abdominal wall)—is commonly performed after a total colectomy (i.e., excision of the entire colon).

ileostomy

For many patients with toxic megacolon, surgery becomes necessary to relieve the effects of the disease and to treat these serious complications; an ______ usually is performed.

ileostomy

(Restorative proctocolectomy with IPAA) The procedure involves connecting the ______ (made from a small intestine segment), and the surgeon connects the pouch to the ______ in conjunction with removing the colon and the rectal mucosa (i.e., total abdominal colectomy and mucosal proctectomy).

ileum to the anal pouch; anus

Medical treatment for both Crohn's disease and ulcerative colitis is aimed at reducing ______ so that healing may take place, improving quality of life, and preventing or minimizing complications.

inflammation, suppressing inappropriate immune responses, providing rest for a diseased bowel

Patients whose CD does not respond to conventional therapy may be given immune system suppressors such as ______.

infliximab (Remicade)

(IBD) A newer surgical procedure developed for patients with severe Crohn's disease is ______. This technique is now available to children and to young and middleaged adults who have lost intestinal function from disease.

intestinal transplant

(IBD) A common procedure performed for strictures of the small intestines is ______, in which the blocked or narrowed sections of the intestines are widened, leaving the intestines intact.

laparoscope-guided strictureplasty

The predominant symptoms of ulcerative colitis include diarrhea, passage of mucus and pus, ______ quadrant abdominal pain, intermittent tenesmus, and rectal bleeding.

left lower

(Chronic IBD) Oral fluids and a ______ diet with supplemental vitamin therapy and iron replacement are prescribed to meet nutritional needs, reduce inflammation, and control pain and diarrhea.

low-residue, high-protein, high-calorie

(IBD) The most common indications for surgery are:

medically intractable disease, poor quality of life, or complications from the disease or its treatment.

Sulfa-free aminosalicylates ______ are effective in preventing and treating recurrence of inflammation.

mesalamine [Asacol, Pentasa]

Antibiotics ______ are used for secondary infections, particularly for purulent complications such as abscesses, perforation, and peritonitis.

metronidazole [Flagyl]

Newer biologic therapies incorporate ______ antibodies, including infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), and natalizumab (Tysabri) for treating Crohn's disease and infliximab for treating ulcerative colitis.

monoclonal

Eventually, the bowel narrows, shortens, and thickens because of ______.

muscular hypertrophy and fat deposits

Toxic megacolon symptoms include fever, abdominal pain and distention, vomiting, and fatigue. If the patient with toxic megacolon does not respond within 24 to 72 hours to medical management with ______ , surgery is required.

nasogastric suction, IV fluids with electrolytes, corticosteroids, and antibiotics

A major issue associated with appropriate pharmacologic treatment of IBD is ______. Patients may suffer a greater chance of disease relapse with severe associated symptoms.

nonadherance

For patients with IBD history, dietary intolerances may persist after the IPAA is formed. Increased stool output, flatulence, and perineal irritation are associated with consumption of ______.

nuts, corn, chocolate, spicy foods, onions, and citrus fruits

If irritation and yeast growth occur, ______ is dusted lightly on the peristomal skin and a pouch with skin barrier is applied over the affected area.

nystatin powder (Mycostatin)

A stool examination is also performed; the result may be positive for ______.

occult blood and steatorrhea

After having a continent ileostomy (kock pouch) foods are reintroduced ______. The nurse assesses the patient's tolerance for these foods and reminds him or her to chew food thoroughly.

one at a time

Patients with IBD also have a significantly increased risk of ______ due to decreased bone mineral density. Corticosteroid therapy may also contribute to the diminished bone density.

osteoporotic fractures

The nurse observes the stoma for color and size. It should be ______ and shiny. Typically, a temporary clear or transparent plastic bag (i.e., appliance or pouch) with an adhesive facing is placed over the ileostomy in the operating room and firmly pressed onto the surrounding skin.

pink to bright red

With ulcerative colitis the stool is _____ for blood, and laboratory test results reveal ______ levels in addition to an elevated ______ count, low ______, and an ______.

positive; low hematocrit and hemoglobin; white blood cell; albumin levels; electrolyte imbalance

Level of involvement UC:

primarily mucosal

Level of involvement CD:

primarily submucosal

If the rectum can be preserved, restorative ______ is the procedure of choice for ulcerative colitis.

proctocolectomy with ileal pouch anal anastomosis (IPAA)

A ______ is usually performed initially to determine whether the rectosigmoid area is inflamed.

proctosigmoidoscopy

Goal for both CD and UC diseases is to:

reduce the inflammation and prevent complications.

(Immunomodulators) These medications are useful in maintenance regimens to prevent ______.

relapses

A ______ is the surgical procedure of choice in cases where the rectum can be preserved in that it eliminates the need for a permanent ileostomy.

restorative proctocolectomy with IPAA

When the dosage of corticosteroids is reduced or stopped, the symptoms of disease may ______. If corticosteroids are continued, numerous ______ may ensue.

return; adverse sequelae

Oral diphenoxylate with atropine can be prescribed to diminish intestinal motility, thereby thickening the stool and assisting in odor control. Foods such as ______ may also thicken stool.

rice, mashed potatoes, and applesauce

The onset of symptoms is usually insidious in Crohn's disease, with prominent ______ quadrant abdominal pain and diarrhea unrelieved by defecation.

right lower

(IBD) Proctocolectomy with ileostomy (i.e., complete excision of colon, rectum, and anus) is recommended when the rectum is ______.

severely diseased

With ulcerative colitis extraintestinal manifestations include:

skin lesions (e.g., erythema nodosum), eye lesions (e.g., uveitis), joint abnormalities (e.g., arthritis), and liver disease.

A ______ may be helpful to distinguish between CD and UC.

small bowel series

If oral foods are tolerated, ______ feedings are given to avoid overdistending the stomach and stimulating peristalsis. The patient must restrict activity to conserve energy, reduce peristalsis, and reduce caloric requirements.

small, frequent, low-residue

Crohn's disease is seen more often in ______.

smokers than in nonsmokers

(Postoperative Care fluid loss) With this loss, ______ are depleted. The nurse monitors laboratory values and administers electrolyte replacements as prescribed. Fluids are administered IV for 4 to 5 days to replace lost fluids.

sodium and potassium

(IBD) When the colon is surgically removed, the patient is considered "cured" in that extraintestinal manifestations:

subside and the disease process is otherwise limited to the colon.

(Surgery toxic megacolon) a ______ may be performed if bowel perforation has not occurred; otherwise, ______ is indicated.

subtotal colectomy; colectomy

Aminosalicylates such as ______ are often effective for mild or moderate inflammation and are used to prevent or reduce recurrences in long-term maintenance regimens.

sulfasalazine (Azulfidine)

The patient should be assessed for tachycardia, hypotension, tachypnea, fever, and pallor. Other assessments address the level of hydration and nutritional status. The abdomen is examined for bowel sounds, distention, and tenderness. These findings assist in determining ______.

the severity of the disease

As Crohn's disease advances, the bowel wall ______ and becomes ______, and the intestinal lumen ______.

thickens; fibrotic; narrows

In ______, the inflammatory process extends into the muscularis, inhibiting its ability to contract and resulting in colonic distention.

toxic megacolon

Complications of ulcerative colitis include ______.

toxic megacolon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue.

Side effects from the infliximab (Remicade) should be explained to each patient, and ______ should be performed prior to the administration of this drug.

tuberculosis screening

A barium enema may show ______ (the cobblestone appearance described earlier), ______, and ______.

ulcerations; fissures, and fistulas

Development of cancer in CD is:

uncommon

To avoid these bouts of crampy pain, the patient tends to limit food intake, reducing the amounts and types of food to such a degree that normal nutritional requirements are often not met. As a result, ______.

weight loss, malnutrition, and secondary anemia occur.

The nurse gives immediate attention to reddened or irritated areas over bony prominences and uses pressure-relieving devices to prevent skin breakdown. Consultation with a ______ nurse (or WOCN; a nurse specially educated in the management of a variety of fecal and urinary diversions) is often helpful.

wound-ostomy-continence (WOC)