TABLE OF CONTENTS

I. INTRODUCTION ....................................................................................................................... 2 OBJECTIVES ............................................................................................................................. 5

II. DEFINITIONS OF THE DISEASE ........................................................................................... 6

III. ANATOMY & PHYSIOLOGY ............................................................................................... 7

IV. SYMPTOMATOLOGY ......................................................................................................... 16

V. ETIOLOGY ............................................................................................................................. 19

VI. PATHOPHYSIOLOGY ......................................................................................................... 22

VII. DIAGNOSTIC TESTS .......................................................................................................... 26

VIII. MEDICAL MANAGEMENT.............................................................................................. 28

IX. SURGICAL MANAGEMENT .............................................................................................. 32

X. NURSING CARE PLANS....................................................................................................... 34 Nursing Care Plan No.1 ............................................................................................................ 34 Nursing Care Plan No.3 ............................................................................................................ 39 Nursing Care Plan No.4 ............................................................................................................ 43 Nursing Care Plan No.5 ............................................................................................................ 47

XI. BIBLIOGRAPHY................................................................................................................... 49

I. INTRODUCTION

Regional enteritis or commonly known as Crohn's disease, is a chronic inflammatory disease of the intestine primarily in the small and large intestines but which can occur anywhere in the digestive system between the mouth and the anus. MediceneNet (2011, April 5). It was named after Burrill Crohn who described the disease in 1932. The disease usually affects persons in their teens or early twenties. It tends to be chronic, recurrent with periods of remission and exacerbation. In the early stages, it causes small scattered shallow crater-like areas (erosions) called aphthous ulcers in the inner surface of the bowel. With time, deeper and larger ulcers develop, causing scarring and stiffness of the bowel and the bowel becomes increasingly narrowed, leading to obstruction. Deep ulcers can puncture holes in the bowel wall, leading to infection in the abdominal cavity (peritonitis) and in adjacent organs. When only the large intestine (colon) is involved, the condition is called Crohn's colitis. When only the small intestine is involved, the condition is called Crohn's enteritis. When only the end of the small intestine (the terminal ileum) is involved, it is termed terminal ileitis. When both the small intestine and the large intestine are involved, the condition is called Crohn's enterocolitis (or ileocolitis). Pain, diarrhea, vomiting, fever, and weight loss can be symptoms. Crohn's disease can be associated with reddish tender skin nodules, and inflammation of the joints, spine, eyes, and liver. Diagnosis is by barium enema, barium x-ray of the small bowel, and colonoscopy. Treatment includes medications for inflammation, immune suppression, antibiotics, or surgery. The disease is also called granulomatous enteritis. MediceneNet (2011, April 5). Crohn's disease is a life-long illness. The severity of the disease can vary, and a patient can experience periods of time when the disease is not active and he or she is symptom free. However, the complications and risks of Crohn's disease tend to increase over time. Well over 60% of all patients with Crohn's disease will require surgery, and about half of these patients will require more than one operation over time. About 5-10% of all Crohn's patients will die of their disease, primarily due to massive infection. Farlex (2011). About 35% of Crohn's disease cases involve the ileum alone (ileitis); about 45% involve the ileum and colon (ileocolitis), with a predilection for the right side of the colon; and about 20% involve the colon alone (granulomatous colitis), most of which, unlike ulcerative colitis (UC), spare the rectum. Occasionally, the entire small bowel is involved (jejunoileitis). The

stomach, duodenum, or esophagus is clinically involved only rarely, although microscopic evidence of disease is often detectable in the gastric antrum, especially in younger patients. In the absence of surgical intervention, the disease almost never extends into areas of small bowel that are not involved at first diagnosis. There is an increased risk of cancer in affected smallbowel segments. Patients with colonic involvement have a long-term risk of colorectal cancer equal to that of UC, given the same extent and duration of disease. The Merck Manual Professional (2010) According to the National Institute of Allergy and Infectious Diseases (NIAID), a division of the US Department of Health and Human Services that accumulates and publishes the statistics for Crohns disease and other health problems, one in 500 people suffer from Inflammatory Bowel Disease (IBD), the group of diseases that includes Crohns syndrome and ulcerative colitis. The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) reports similar numbers. Approximately 544,000 people suffer from IBD in the United States. Weissheiss (2011, April 11). Worldwide, there are typically three or four new cases per 100,000 people reported annually. There are also currently 90,000 people living with Crohn's disease in the U.K. There are more than 8,000 new cases every year and research has shown that the number of people with Crohn's disease has been rising, particularly among young people. Crohn's disease affects about one in 1,000 people and affects between 400,000 and 600,000 people in North America. It may run in families with 20% of people diagnosed with the disease having a blood relative with some form of inflammatory bowel disease. It is usually diagnosed between the ages of 20 to 30, although people of all ages can suffer from Crohn's. People of Jewish heritage have a greater risk of developing the disease while people of African American heritage have less of a risk. If a certain person has a Crohn's disease that affects his large bowel (colon), he will surely have the higher risk of developing bowel cancer. One in 20 people with Crohn's disease will develop bowel cancer in the 10 years after their condition is diagnosed. St. Marks Foundation (2011, January 27) In Asian countries, Crohns disease was also present. According to research conducted by the US Census Bureau of 2006, it is said that China rank as one of the country having the highest prevalence with 2,387,587cases out of an estimated population of 1,298,847,6242; while Macau rank as the lowest prevalence among Asian countries with 818 number of cases out of an

estimated population of 445,2862. Philippines rank at number 7 with 158,532 numbers of cases out of an estimated population of 86, 241, 6972, following the Indonesia at number 6 with 438,332 cases out of an estimated population of 238, 452, 9522. Cure Research (2010, March 2)

Significance of the study: This case study will allow me and all the student nurses to understand more about Regional Enteritis or the so-called Crohns disease. In order for us to have an additional idea about the said disease, its process, signs & symptoms, medical & surgical treatments and its appropriate nursing managements; and in order for us also to apply it among our patients experiencing this kind of disease.

OBJECTIVES

General Objectives:

This case study tends to enhance my capability and knowledge as student nurses about the Regional Enteritis or Crohns disease; in order for me to apply what I have learned during NCM 103 discussions and be prepared in times of encountering patients experiencing this disease.

Specific objectives:

This case study specifically aims: To present the different definitions of the disease according to different sources; to review the anatomy and physiology of the involved organs and system; to identify the symptomatology and etiology of the chosen disease; to trace the pathophysiology of the disease; to identify and define the appropriate diagnostic tests; to identify the different medical and surgical managements; to present nursing care plans regarding about the different manifestations; and to list down all the trusted references used in this case study.

II. DEFINITIONS OF THE DISEASE Regional Enteritis (Crohns Disease) Also known as Crohns disease; It is an ongoing disorder that causes inflammation of the digestive tract, also referred to as the gastrointestinal (GI) tract. Crohns disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum. The swelling extends deep into the lining of the affected organ. The swelling can cause pain and can make the intestines empty frequently, resulting in diarrhea. National Digestive Diseases

Information Clearinghouse (NDDIC) (2006, February)

An inflammatory bowel disease (IBD). It causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea and even malnutrition. Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people. Mayo Clinic Staff (2011, August 9)

Causes inflammation of the digestive system. It is one of a group of diseases called inflammatory bowel disease. The disease can affect any area from the mouth to the anus. It often affects the lower part of the small intestine called the ileum. NIH: National Institute of Diabetes and Digestive and Kidney Diseases (2010, December 13)

An inflammatory condition that affects the digestive tract - including the mouth, esophagus, stomach, small and large intestine, and anus. It can affect any portion of the digestive tract, but is most common in the ileum - the lowest portion of the small intestine, where it connects with the large intestine. Slowik G. MD FRCS., (2011, June 11)

An idiopathic disease of small intestine (60%), the colon (20%), or both. It involves all the layers of the bowel but most commonly involves the terminal ileum. It is a slowly progressive and recurrent disease with predominant involvement of multiple regions of the intestine with normal sections between. Igantavicius & Workman (2006)

III. ANATOMY & PHYSIOLOGY The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in thedigestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.

The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces).

In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms

of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialized functions, the entire tract has a similar basic structure with regional variations.

The wall is divided into four layers as follows: Mucosa The innermost layer of the digestive tract has specialized epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and esophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner

lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen.

Submucosa The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa.

Muscularis externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibers separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen.

Serosa/mesentery The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.

Individual components of the gastrointestinal system Oral cavity The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialised sensors known as papillae. Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva, starts the process of digestion of complex carbohydrates. The final function of the oral cavity is absorption

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of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and oesophagus via the action of swallowing.

Salivary glands Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini secrete their contents into specialised ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands secretes saliva with slightly different compositions.

Parotids The parotid glands are large, irregular shaped glands located under the skin on the side of the face. They secrete 25% of saliva. They are situated below the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can be easier felt when one clenches their teeth. The parotids produce a watery secretion which is also rich in proteins. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break down complex carbohydrates.

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Submandibular The submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor of the mouth, in a groove along the inner surface of the mandible. These glands produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant.

Sublingual The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor of the mouth. They produce approximately 5% of the saliva and their secretions are very sticky due to the large concentration of mucin. The main functions are to provide buffers and lubrication.

Oesophagus The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a transport medium between compartments.

Stomach The stomach is a J shaped expanded bag, located just left of the midline between the oesophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the oesophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J. This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when

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food enters. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: 1. The short-term storage of ingested food. 2. Mechanical breakdown of food by churning and mixing motions. 3. Chemical digestion of proteins by acids and enzymes. 4. Stomach acid kills bugs and germs. 5. Some absorption of substances such as alcohol. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins.

Small intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileocaecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction.

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The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions.

Large intestine The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces.

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The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate fecal matter as it solidifies. The functions of the large intestine can be summarized as: 1. The accumulation of unabsorbed material to form feces. 2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas. 3. Reabsorption of water, salts, sugar and vitamins.

Liver The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and oestrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act.

Gall bladder The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food.

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Pancreas Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to the gastrointestinal tract. It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food. These are secreted in an inactive form to prevent digestion of the pancreas itself. The enzymes become active once they reach the duodenum.

Virtual medical centre (2006, January 30)

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IV. SYMPTOMATOLOGY SYMPTOM

JUSTIFICATION

Crampy abdominal (belly area) pain

Abdominal pain is pain that you feel anywhere between your chest and groin. This is often referred to as the stomach region or belly. Pain may be generalized, meaning that it is present in more than half of your belly. This is more typical for a stomach virus, indigestion, or gas. If the pain becomes more severe, it may be caused by a blockage of the intestines. Medline Plus Encyclopedia (2011)

Cramp-like pain is usually not serious, and is more likely to be due to gas and bloating. It is often followed by diarrhea. More worrisome signs include pain that occurs more often, lasts longer (more than 24 hours), or has a fever with it. Medline Plus Encyclopedia (2011)

Fever & Fatigue

Individuals suffering with Crohn's disease may experience low-grade fevers and an overall feeling of fatigue. Chronic fatigue often accompanies severe diarrhea and may indicate dietary deficiencies. High or persistent fevers may indicate an infection. Knudson, J. (2011)

Loss of appetite

An inflamed intestine as in the case with Crohn's Disease is less able to fully absorb and digest the nutrients from food. Depending on how severe the small intestine has been injured by inflammation, vital nutrients as well as unabsorbed bile salts, may travel into thelarge intestine to a varying degree. This is why many Crohn's patients dont have much of an appetite and are normally malnourished. Crohns Disease & Living Probiotics (2011)

Pain with passing stool (tenesmus)

Pain with passing stool (tenesmus) Tenesmus is the feeling that you constantly need to pass stools, even though your bowels are already empty. It may involve straining, pain, and cramping. Medline Plus Encyclopedia (2011)

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SYMPTOM

JUSTIFICATION

Persistent,

Diarrhea is a common symptom of Crohn's disease. The diarrhea may be mild, or frequent and chronic. Some people with Crohn's disease may have symptoms diminish and reoccur without warning. The diarrhea may be accompanied by blood in the stool. In severe cases, rectal bleeding may not be associated with passing stool and may lead to anemia or other complications if not treated. Knudson,J.( 2011)

watery diarrhea & bleeding

Unintentional weight loss

Unintentional weight loss is a decrease in body weight that is not voluntary. In other words, you did not try to loss the weight by dieting or exercising. Medline Plus Encyclopedia (2011) Some people who are suffering from Crohn's disease have also experienced weight loss. This is partly due to the fewer calories consumed when a person loses his appetite, but also a result of the way in which the digestive system works--food may not be properly absorbed into the system as would be seen in someone without the condition George, D. (2011)

Bowel Obstruction

Crohn's disease inflames the intestine, causing it to swell; when combined with scarring often associated with ulcers; it may cause an obstruction of the bowel. Stomach pain, bloating and vomiting are common symptoms of a bowel obstruction. Anti-inflammatory medication often reduces swelling and relieves the obstruction, but severe cases may require surgical intervention. Knudson, J. (2011)

Fistulas (usually around the rectal area, may cause draining of pus,

A fistula is an abnormal connection between an organ, vessel, or intestine and another structure. Fistulas are usually the result of injury or surgery. It can also result from infection or inflammation. Inflammatory bowel

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SYMPTOM mucus, or stools)

JUSTIFICATION disease, such as ulcerative colitis or Crohn's disease is an example of a disease that leads to fistulas between one loop of intestine and another. Injury can lead to fistulas between arteries and veins. Medline Plus Encyclopedia (2011)

Liver inflammation

Fatty liver disease is the most common form of liver inflammation in Crohn's disease patients, according to the Crohn's & Colitis Foundation of America. Fatty liver disease is caused by the accumulation of fat in the liver. This is because of an abnormality in the liver's metabolism. Fatty liver disease is easily treated, often by the prescription of steroids. Gorman, F. (2011)

- Fatty Liver Disease

- Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a disease that causes severe inflammation of the liver and bile ducts. According to studies cited in the Postgraduate Medical Journal, primary sclerosing cholangitis can occur in up to 4 percent of Crohn's disease patients. Surgery or a liver transplant may be needed to overcome this disease. Gorman, F. (2011)

Complications involving the eyes, mouth, skin and joints:

These complications may be caused by immunologic response, microbiologic concomitants, genetic

interrelationships, or unknown reasons. Chen, J. PhD, PharmD, OMD, Lac, (2000)

Eyes episcleritis Mouth - aphthous Stomatitis Skin - erythema nodosum, pyoderma gangrenosum and pustular lesions Joints - arthritis of the

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SYMPTOM larger joints such as the knees, ankles, hips and elbows

JUSTIFICATION

V. ETIOLOGY PREDISPOSING FACTORS Age Regional Enteritis or Crohns disease affects all ages. American Family Physician (August 2003) Crohn's disease usually begins before age 35, with peak incidence between 14-24 years old. Chen, J. PhD, PharmD, OMD, Lac, (2000) Gender Regional Enteritis or Crohns disease affects the two genders, but it is more common in women than in men. Knutson, D. M.D., Greenberg, G. M.D., & Cronau, H. M.D., (2003, August 15) Race Regional Enteritis or Crohns disease affects all races, but it is more common in whites than in blacks & in Jewish than in non-Jewish persons. Knutson, D. M.D., Greenberg, G. M.D., & Cronau, H. M.D., (2003, August 15) Family History Brothers, sisters, children, and parents of persons with IBD, including Crohn's disease, are more likely to develop the disease themselves. About 10% to 20% of people with Crohn's disease have at least one other family member who also has the disease. And the disease is more common in certain ethnic groups, such as people of Jewish descent and whites. Is this tendency toward IBD and Crohn's disease passed genetically? Scientists have identified a gene linked to Crohn's disease. This gene helps the body decide how to react to certain JUSTIFICATION

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PREDISPOSING FACTORS

JUSTIFICATION

microbes. If the gene has changed or mutated in some way, your body's reaction to microbes may also be different from the normal reaction. Over time, IBD or Crohn's disease may develop. People with Crohn's disease have this mutated gene twice as often as people who do not have the disease. WebMD (February 2010)

PRECIPITATING FACTORS Environment

JUSTIFICATION

Environmental factors may help trigger Crohn's disease. These environmental factors may include any of the following: substances from something you've eaten, microbes such as bacteria or viruses, cigarette smoke & other substances that are yet unknown Environmental factors may contribute to Crohn's disease in one of these two ways: 1. They may trigger an immune system response. Once started, the response cannot stop. 2. They may directly damage the lining of the intestines. This may cause Crohn's disease to begin or to speed up. WebMD (February 2010) Among people with Crohns disease, smoking is linked with a higher rate of relapse, repeat surgery, and the need for drug therapy. Women have a higher risk of relapsing and needing surgery and treatment than men whether they are current or former smokers. Why smoking increases the risk of Crohn's disease is unknown, but some researchers believe that smoking might lower the intestines defenses, decrease blood flow to the intestines, or cause immune system changes that result in inflammation. National Digestive Diseases Information Clearinghouse (NDDIC) (February 2006)

Smoking

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PRECIPITATING FACTORS Abnormal activation of the immune system

JUSTIFICATION

Activation of the immune system in the intestines appears to be important in IBD. The immune system is composed of immune cells and the proteins that these immune cells produce. Normally, these cells and proteins defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is an important mechanism of defense used by the immune system.) Normally, the immune system is activated only when the body is exposed to harmful invaders. In individuals with IBD, however, the immune system is abnormally and chronically activated in the absence of any known invader. The continued abnormal activation of the immune system results in chronic inflammation and ulceration. MedicineNet.com (2011)

Infections

The cause of Crohn's disease is unknown. Some scientists suspect that infection by certain bacteria, such as strains of mycobacterium, may be the cause of Crohn's disease. To date, however, there has been no convincing evidence that the disease is caused by infection per se. MedicineNet.com (2011)

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VI. PATHOPHYSIOLOGY PREDISPOSING FACTORS Age Gender Race Family History PRECIPITATING FACTORS Environment Smoking Abnormal activation of the immune system Infections

Inflammation

Appearance of small, scattered, shallow, crater-like ulcerations (erosions) on the inner surface of the bowel (ileum & ascending colon)

Tiny focal aphthous ulcers

Develop into deep longitudinal & transverse ulcers with intervening mucosal edema

Creates a characteristic of: Cobblestoned appearance bowel

S/s: Persistent watery diarrhea & bleeding

Transmural spread of inflammation

Lymph edema

Thickening of the wall & mesentery

Mesenteric fat extends to the serosal surface of the bowel

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Mesenteric lymph nodes enlarge

Extensive inflammation

Hypertrophy of the muscularis mucosae, fibrosis & stricture formation

Bowel obstruction

Cessation of flow of the contents into the intestine

Digesting food, fluid & gas from the stomach & small intestine cannot pass the colon

S/s: Severe abdominal cramps, nausea, vomiting & abdominal distention

Fecal Stasis

Deep ulcers developed

Puncture holes in the bowel

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Creating a tunnel between intestine & adjacent organs

A channel (fistula) is formed

Ulcer tunnel reaches an adjacent empty space inside the abdominal cavity

Fistula between intestine & bladder (Entericventricular fistula

Fistula between colon & vagina (colonic-vaginal fistula)

Fistula from intestine to anus (anal fistula)

Bacteria from within the bowel will spread

Collection of infected pus is formed (abdominal abscess)

Frequent UTI & passage of gas & feces during urination

Gas & feces emerge through the vagina

Discharge of mucous & pus from the fistulas opening around the anus

S/s: tender abdominal, high fever & abdominal pain

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IF TREATED

IF NOT TREATED

Nursing Management: Maintaining normal elimination pattern. Relieving pain. Maintaining fluid intake. Promoting rest Reducing anxiety Enhancing coping measures Preventing skin breakdown on the perianal skin Monitoring & managing potential complications

Medical Management: Anti-inflammatory Drugs Cortisone or steroids Immune System Suppressors Antibiotics Antidiarrheals & fluid replacement Surgical Management: Total Colectomy with ileostomy Continent Ileostomy Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

Electrolyte imbalance Metabolic Disorders Digestive Tract Cancer Sepsis

DEATH

Prevention of complications

God / Fair Prognosis

Andrew, H. A., Lewis, P., Allan, R. N., (1988, Nov. 28), Medicine Net (2011) Scachar, D., Walfish, A. E., (2010, Feb.), Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010)

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VII. DIAGNOSTIC TESTS TEST Complete Blood Count (CBC) DESCRIPTION & RESULT A test done to determine the complete blood count of an individual. An elevated white blood cell counts and sedimentation rates result, both of which suggest infection or inflammation. Other blood tests may show low red blood cell counts (anemia), low blood proteins, and low body minerals, reflecting loss of these minerals due to chronic diarrhea. MedicineNet (2011) Stool Examination A stool sample is taken and examined for blood, infectious organisms, or both. Health Central (March 2007) Barium X-ray study A test used to define the distribution, nature, and severity of the disease. Barium is a chalky material that is visible by X-ray and appears white on X-ray films. When barium is ingested orally (upper GI series) it fills the intestine, and pictures (X-rays) can be taken of the stomach and the small intestines. When barium is administered through the rectum (barium enema), pictures of the colon and the terminal ileum can be obtained. Barium X-rays can show ulcerations, narrowing, and, sometimes, fistulae of the bowel. MedicineNet (2011) It shows a STRING SIGN on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010) Colonoscopy Direct visualization of the rectum and the large intestine can be accomplished with flexible viewing tubes (colonoscopes).Colonoscopy is more accurate than barium X-rays in detecting small ulcers or small areas of inflammation of the colon and terminal ileum. Colonoscopy also allows for small tissue samples (biopsies) to be taken

27

TEST

DESCRIPTION & RESULT and sent for examination under the microscope to confirm the diagnosis of Crohn's disease. Colonoscopy also is more accurate than barium X-rays in assessing the degree (activity) of inflammation. MedicineNet (2011)

Computerized axial tomography (CAT or CT) scanning

A computerized X-ray technique that allows imaging of the entire abdomen and pelvis. It can be especially helpful in detecting abscesses. MedicineNet (2011) A CT scan may show bowel wall thickening & fistula formation. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010)

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging is another advanced imaging technique that may be useful for detecting abscesses and other injuries related to Crohn's disease in the pelvis. A variant called magnetic resonance spectroscopy (MRS) may prove to be useful for differentiating between Crohn's disease and ulcerative colitis. Health Central (2007)

Video capsule endoscopy(VCE)

For video capsule endoscopy, a capsule containing a miniature video camera is swallowed. As the capsule travels through the small intestine, it sends video images of the lining of the small intestine to a receiver carried on a belt at the waist. The images are downloaded and then reviewed on a computer. The value of video capsule endoscopy is that it can identify the early, mild abnormalities of Crohn's disease. Video capsule endoscopy may be particularly useful when there is a strong suspicion of Crohn's disease but the barium X-rays are normal. In a prospective blinded evaluation, video capsule endoscopy was demonstrated to be superior in its ability to detect small bowel pathology missed on small bowel radiographic studies and CT exams. Video capsule endoscopy should not be performed in patients who have

28

TEST

DESCRIPTION & RESULT obstruction of the small intestine. The capsule may get stuck behind the obstruction and make the obstruction worse. MedicineNet (2011)

Sigmoidoscopy

Sigmoidoscopy, which is used to examine only the rectum and left (sigmoid) colon, lasts about 10 minutes and is done without sedation. It may be mildly uncomfortable, but it is not painful. This is performed to determine whether the rectosigmoid area is inflamed. Health Central (2007) &

Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010)

Results may be unremarkable unless accompanied by perianal fistulas. Smeltzer, S., Bare, B., Hinkle, J., & Cheever,

K.(2010)

VIII. MEDICAL MANAGEMENT DRUG Aminosalicylates (Oral) Sulfasalazine (Azulfidine) Converted in colon to Assess for allergy to sulfonamides or aspirin. sulfapyridine & 5- Monitor for common side effects: anorexia, nausea & vomiting, headache. may Teach patient to: antieffect, through - Take in divided doses. - Take with full glass of fluid or with food. - Maintain liberal fluid intake (2.5-3 L/day). - Report skin rash or other adverse effects. Monahan, Sands, Neighbors, Marek & Gren (2007) Olsalazine (Dipentum) As above without Monitor for common side effects as above and for mild to moderate diarrhea. Teach patient to: - Take in divided doses. aminosalicylic acid (5ASA), exert inflammatory possibly prostaglandin inhibition. which ACTION NSG. INTERVENTIONS

antibacterial action of sulfapyridine.

29

DRUG

ACTION

NSG. INTERVENTIONS - Take with full glass of fluid or with food. - Maintain liberal fluid intake (2.5-3 L/day).

Monahan, Sands, Neighbors, Marek & Gren (2007) Balsalazide (Coloazal) Prodrug 5-ASA Teach patient to: - Take with a full glass of water. - Stop drug & see physician if signs of allergy or worsening colitis occur. - Continue taking but consult physician if headache, nausea & vomiting, fatigue,

connected to carrier by an A20 bond Colon bacteria break bond, releasing active 5-

ASA with action as above.

stomach, or joint pain occurs. Monahan, Sands, Neighbors, Marek & Gren (2007) Teach patient to: - Take in divided doses.
- Maintain liberal fluid intake (2.5-3 L/day).

Mesalamine (Asacol, Pentasa)

Same as olsalazine

- Swallow tablets whole, do not chew or break outer coating. Monahan, Sands, Neighbors, Marek & Gren (2007) Aminosalicylates (Rectal) Mesalamine in suspension for retention enema Mesalamine suppository Corticosteroids (Oral or IV) Prednisolone Potent systemic anti- Teach patient to: As above Administer enema while patient is positioned on left side, & teach patient to retain as long as possible. Monahan, Sands, Neighbors, Marek & Gren (2007)

30

DRUG Prednisone

ACTION inflammatory action.

NSG. INTERVENTIONS - Take with food or fluid. - Monitor weight gain; asses for edema. - Have blood pressure checked regularly. - Be alert to signs of infection & report promptly. - Be aware that mood swings occur commonly. - Do not change dose or schedule or abruptly discontinue drug. - Maintain good personal hygiene; keep perianal area clean & dry. Monahan, Sands, Neighbors, Marek & Gren (2007)

Corticosteroids (Rectal) Hydrocortisone Intrarectal foam (Cortifoam) -Retention enema (Cortenema) Budesonide enema As above, Monahan, Sands, Neighbors, Marek & Gren (2007) rapid Administer enema while patient is positioned on left side, & teach patient to retain as long as possible. Perform other interventions as above; side effects should be less. Monahan, Sands, Neighbors, Marek & Gren (2007) Immune Modifiers 6-Mercaptopurine Potent systemic Teach patient to: of response; - Report any signs of infection. - Be alert to easy bruising. As above As for oral or IV corticosteroids.

presystemic metabolism minimizes absorption.

(6-MP, Purinethol) suppression immune

31

DRUG

ACTION may take 4-6 mo for full effect

NSG. INTERVENTIONS - Return for laboratory work as scheduled. - Maintain liberal daily fluid intake (2.5-3 L/day) - Take with food or after meals. Monahan, Sands, Neighbors, Marek & Gren (2007) As above Monahan, Sands, Neighbors, Marek & Gren (2007) Oral solution may be mixed in glass & given with milk or orange juice at room temperature; avoid refrigeration. Teach patient to: - Monitor blood pressure - Report hematuria or any change in urinary function. Monahan, Sands, Neighbors, Marek & Gren (2007)

Azathiopine (Imuran)

As above

Cyclosporine (Sandimmune)

As above; effects seen after several days

Monoclonal Antibodies Infliximab (Remicade) Binds to tumor Monitor for infusion-related problems: pruritis, hypotension, dyspnea, headache, fatigue. Teach patient to promptly report any signs of infection. Monahan, Sands, Neighbors, Marek & Gren (2007) Antibiotics Metronidazole (Flagyl) Teach patient to: - Report side effects: diarrhea, peripheral neuropathies, strong metallic taste.

necrosis factor-alpha, blocking its activity & decreasing inflammation.

32

DRUG

ACTION

NSG. INTERVENTIONS - Avoid alcohol use; alcohol use with drug can cause disulfiram (Antabuse) reaction. Monahan, Sands, Neighbors, Marek & Gren (2007)

IX. SURGICAL MANAGEMENT TYPE OF SURGERY Total Colectomy with Ileostomy DESCRIPTION An Ileostomy, 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 (ie, excision of the entire colon). It allows for drainage of fecal matter (ie, effluent) from the ileum to the outside of the body. The drainage is liquid to unformed and occurs at frequent intervals. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010) Continent Ileostomy Another procedure involves the creation of a continent ileal reservoir (ie, Kock pouch) by diverting a portion of the distal ileum to the abdominal wall and creating a stoma. This procedure eliminates the need for an external fecal collection bag. Approximately 30cm 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. Possible indications for a total colectomy with Kock pouch placement (rather than restorative proctocolectomy with IPAA) include a badly diseased rectum, lack of retal sphincter tone, or inability to

33

TYPE OF SURGERY

DESCRIPTION achieve fecal continence post-IPAA. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010)

Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

A restorative proctocolectomy with IPAA is the surgical procedure of choice in cases where the rectum can be preserved in that it eliminates the need for a permanent ileostomy. It establishes an ileal reservoir that functions as a new rectum & anal sphincter control of elimination is retained. The procedure involves

connecting the ileum to the anal pouch (made from a small intestine segment), & the surgeon connects the pouch to the anus in conjunction with removing the colon & the rectal mucosa (ie, total abdominal colectomy & mucosal proctectomy). A temporary diverting loop ileostomy that promotes healing of the surgical anastomoses is constructed at the time of surgery & closed about 3 months later. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.(2010)

X. NURSING CARE PLANS Nursing Care Plan No.1 ASSESSMENT Objective cues: - Hyperactive Diarrhea related to the Within 8 hours span NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: - Restrict solid food intake as After 8 hours span of indicated. This is to provide care, patient was able to: & normal rest for the stomach & - Reestablish & maintain normal dietary pattern of bowel functioning as evidenced by a formed, soft stool. - State a relief from cramping & less diarrhea; with pain scale of 4 noted. - Verbalize understanding of causative factors & rationale for treatment regimen. - Demonstrate
34

EVALUATION

Bowel sounds inflammatory process of care, patient will: during auscultation - Frequency of at least loose three liquid SCIENTIFIC BASIS: Large volume diarrhea is caused by a of secondary to regional enteritis. - Reestablish maintain

decreases peristalsis. - Provide changes intake. This is to avoid foods /substances that could in

pattern of bowel functioning evidenced by as a

stools per day - Urgency - Grimaced face - Guarding movement

formed, soft stool. - State relief from cramping & less or no diarrhea;

precipitate diarrhea. - Limit caffeine & high fiber foods; avoid milk & fruits. This could stimulate the bowel & may increase peristalsis. - Promote the use of relaxation techniques (e.g., progressive

hypersecretion

water& electrolytes by at the intestinal mucosa.

with pain scale of 4-1 as mild pain to 0 as no pain at all. - Verbalize understanding causative & of

the abdominal This secretion occurs area. in response to the pressure by food

- Pain scale of 8 osmotic out of 10; with exerted 0 as no pain, 1- nonabsorbed

relation

exercises

&

factors for

visualizations). To decrease stress/ anxiety.

4 as mild pain, particles in the chyme

rationale

ASSESSMENT 5-8

NSG. DIAGNOSIS

OBJECTIVE treatment regimen. - Demonstrate appropriate behavior to assist with resolution of causative factors

INTERVENTIONS - Encourage oral intake of fluids containing electrolytes such as juices, bouillon, or commercial preparations. To replace fluid loss. - Assist patient as needed with pericare after & each To bowel prevent skin

EVALUATION appropriate behavior to assist with resolution of causative factors (e.g., avoidance of irritating foods) - Maintain a rectal area free of irritation.

as or to direct irritation of mucosa. is & the

moderate pain the and 9-10 as Peristalsis pain increased,

severe felt.

transit time through the intestine is

significantly decreased. Increase

(e.g., avoidance of irritating foods) - Maintain a rectal area free of

movement. irritation integrity. - Apply

peristalsis may also result inflammation mucosal from as cells

maintain

-GOAL METlotion/ointment skin

irritation.

barrier as needed. To prevent skin breakdown. DEPENDENT: - Administer IV fluids with doctors order. To promote treatment of fluid loss. - Administer antidiarrheals with doctors order. To decrease gastrointestinal motility &

hypersecrete water in the presence of

infectious Severe cramping,

organism. abdominal Tenesmus

(persistent spasm) of the anal area,

abdominal distention, & borborygmus (loud

minimize fluid losses.

35

ASSESSMENT

NSG. DIAGNOSIS bowel sounds) may also occur. Monahan, Sands, Marek (2007) Neighbors, & Green

OBJECTIVE

INTERVENTIONS COLLABORATIVE: - Use standard precautions when caring for clients with diarrhea; use of gloves and proper hand washing. To prevent spread of infectious diarrhea. - Obtain stool specimens as

EVALUATION

ordered. To either rule out or diagnose an infectious process.

36

Nursing Care Plan No. 2 ASSESSMENT Objective cues: - Distraction behavior (moaning, crying, pacing & restlessness) - Guarding SCIENTIFIC BASIS: Large volume diarrhea caused by a of Acute pain related to Within 20 min. span increased peristalsis & of care, patient will be GI inflammation. able to: - Report pain is relieved as evidenced by having a pain scale of 0 out of 10. - Follow prescribed pharmacologic regimen. - Verbalize methods that provide relief. - Demonstrate use of relaxation skills & diversional activities. NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: - Provide comfort the patient some After 20 min. span of (e.g., care, patient was able to: - Report pain is relieved as evidenced by having a pain scale of 0 out of 10. - Follow prescribed pharmacologic regimen. - Verbalize methods that provide relief. - Demonstrate use of relaxation skills & diversional activities. EVALUATION

measures

change of position & use of heating pad applied into the abdomen). This is to

provide comfort and alleviate the pain felt. - Encourage use of diversional activities (e.g., T.V/ radio & socialization with others). To divert attention from pain to other activities providing comfort & alleviate pain. - Teach patient a specific

behavior on the is abdominal area. - Facial mask of pain (eyes lack luster, beaten look, fixed or scattered movement, grimace) - Diaphoresis - Increase BP & PR

hypersecretion

water& electrolytes by the intestinal mucosa. This secretion occurs in response to the osmotic pressure exerted by food

nonabsorbed

particles in the chyme or to direct irritation of the mucosa. Peristalsis is increased, & the transit time through the

relaxation strategy (e.g., slow, rhythmic breathing or deep breath). Breathing exercises relaxes the body, alleviating pain & promoting relief
37

-GOAL MET-

ASSESSMENT - Papillary dilatation - Increased or decreased respiratory rate - Self-focusing

NSG. DIAGNOSIS intestine is significantly decreased. peristalsis result inflammation mucosal Increase may also from as cells

OBJECTIVE

INTERVENTIONS - Encourage adequate rest

EVALUATION

periods. To prevent fatigue. DEPENDENT: - Administer anti-inflammatory drugs with doctors order. Anti-inflammatory drugs

- A pain scale of hypersecrete water in 8 out of 10; the presence of

reduce the inflammation of the bowel, relieving pain. - Administer anti-cholinergic or antispasmodic medications

with 0 as no infectious pain, 1-4 as Severe

organism. abdominal Tenesmus

mild pain, 5-8 cramping, as

such as propantheline bromide 30 minutes before meal as prescribed. To decrease intestinal motility.

moderate (persistent spasm) of anal area, distention,

pain and 9-10 the

as severe pain abdominal felt.

& borborygmus (loud bowel sounds) may

also occur. Monahan, Sands, Neighbors,

Marek & Green (2007)

38

Nursing Care Plan No.3 ASSESSMENT Objective cues: - Vomiting 3 times or more a day. - Frequent defecation with 3 or more loose liquid stools per day. - Dry skin and mucous membranes - Decreased skin turgor - Weakness - Thirst - Sudden weight loss - Increased hematocrit: SCIENTIFIC BASIS: Inflammation of the mucosal cells is the major cause of triggering these symptoms to appear. Anorexia or loss of appetite is one of the systemic symptoms because of inflammation. It causes deficient Deficient fluid volume related to anorexia, nausea & diarrhea secondary to regional enteritis. Within 3-day shifts span of care, patient will be able to: - Maintain volume at fluid a NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: - Provide frequent oral hygiene, at After 3-day shifts least twice a day & explain its span of care, patient purpose to the patient. Oral was able to: hygiene decreases unpleasant - Maintain volume at fluid a EVALUATION

tastes in the mouth and allows the client to respond to the sensation of thirst. - Provide fresh water & oral fluids preferred by the client (distribute over 24 hours [e.g., 1200 ml on days, 800 ml on evenings, & 200 ml on nights]); provide prescribed diet; offer snacks (e.g., frequent drinks, fresh fruits, fruit juice). The oral route is preferred for maintaining fluid balance.

functional level as evidenced by

functional level as evidenced individually adequate urinary by

individually adequate urinary (<30mL/hr) normal output with specific

output (<30mL/hr) with specific normal gravity,

gravity, stable vital signs, moist mucous membranes & good skin turgor. - Verbalize understanding of

stable vital signs, moist mucous &

membranes good skin turgor. - Verbalize understanding causative

Distributing the intake over the entire 24-hour period & providing snacks & preferred beverages

causative factors & purpose of individual

of

factors
39

ASSESSMENT <0.39 - 0.50 - Decreased urine output: >30 mL/hr (or 720mL/day) - Increased urine concentration as evidenced by dark-colored urine. - Elevated urine specific gravity: <1.010-1.030 - Increased body temperature: <36.5C 37.5C - Increased pulse rate: <60-100 bpm - Decreased

NSG. DIAGNOSIS fluid volume because of the inability to acquire nutrients & electrolytes needed by the body. On the other hand, nausea is a subjective sensation of an impending urge to vomit. The vomiting center, located in the medulla adjacent to the respiratory & salivary controls centers, can be stimulated directly by both the vagus nerve & sympathetic

OBJECTIVE therapeutic interventions medications. - Demonstrate measures that can be taken to treat fluid volume loss. &

INTERVENTIONS increases the likelihood that the client will maintain the prescribed oral intake. - Instruct patient to avoid solid foods & high in fiber; & to decrease intake of milk products. These measures allow the bowel to rest preventing vomiting & diarrhea. - Assist the client with ambulation if postural hypotension is present. Postural hypotension can cause dizziness, which places the client at higher risk for injury. - Watch trend in output for 2-3 days; include all routes of intake & output & note color & specific gravity of urine. Monitoring for trends for 2-3 days gives a more valid picture of the clients

EVALUATION & purpose of

individual therapeutic interventions medications. - Demonstrate measures that can be taken to treat fluid volume loss. &

-GOAL MET-

hydration status than monitoring

40

ASSESSMENT blood pressure: >110/70-120/80 mmHg

NSG. DIAGNOSIS nervous system. Receptors can be found throughout the GI tract & the internal organs that, when triggered by spasm or inflammation, can directly produce vomiting. It causes deficient fluid volume since more nutrients and electrolytes were excreted from the body via vomiting; same also a diarrhea; which excretes a watery loose stools frequently resulting

OBJECTIVE

INTERVENTIONS for a shorter period. - Monitor vital signs every 15 minutes to 1 hour for the unstable clients (every 4 hours for the stable client). This is to monitor the health of the patient, if it is progressing or not. DEPENDENT: - Hydrate the client with ordered intravenous prescribed. hydration. - Provide oral replacement therapy as ordered & tolerated with a hypotonic glucose-electrolyte (IV) solutions To as

EVALUATION

maintain

solution. Provide small, frequent quantities of slightly chilled

solutions. Maintenance of oral intake stabilizes the ability of the intestines to digest & absorb nutrients; glucose electrolyte
41

ASSESSMENT

NSG. DIAGNOSIS to fluid loss. Monahan, Sands, Neighbors, Marek & Green (2007)

OBJECTIVE

INTERVENTIONS solutions absorption increase while net fluid

EVALUATION

correcting

deficient fluid volume. A study demonstrated that decreasing the osmolality of standard glucoseelectrolyte oral replacement

solutions improves the absorption of water, & stool volume. - Administer medications such as antiemetics & antidiarrheals with doctors order. To prevent vomiting & diarrhea. COLLABORATIVE: - Consult physician if signs & symptoms of deficient fluid

volume persist or worsen. Prolonged deficient fluid volume increases the risk for development of complications, including shock, multiple organ failure, & death.

42

Nursing Care Plan No.4 ASSESSMENT Objective cues: - Lack of interest High risk for in food. - Satiety immediately after food. - Abdominal cramping with a pain scale of 8 SCIENTIFIC out of 10; with 0 BASIS: as no pain, 1-4 Some people who as mild pain, 5- are suffering from 8 as moderate Crohn's pain and 9-10 as have severe pain felt. - Body weight 20% or more under ideal. - Unintentional disease also imbalanced nutrition, less than body requirements, Within 3 days shifts span of care, patient will be able to: - Prevent & demonstrate progressive weight gain toward goal. - Display free signs of malnutrition as reflected in defining characteristics. - Verbalize understanding of causative factors and necessary interventions. - Demonstrate NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: - Determine whether patient prefers / Within ___ span of tolerates more calories in a care, patient was able EVALUATION

particular meal. Determining the to: patients preference enhances the appetite to eat. - Use flavoring agents (e.g., lemon & herbs) if salt are restricted. This is to give flavor on the patients food, preventing nausea & vomiting. - Avoid gas-forming foods, hot/cold foods. Spicy, caffeinated beverages, milk products, & the like. These foods can cause intolerances and may also increase gastric motility. - Limit fiber/bulk. This could lead to an early satiety. - Promote pleasant, relaxing environment, including socialization when possible. A clean & relaxing - Demonstrate progressive weight gain toward goal. - Display free signs of malnutrition as reflected in defining characteristics. - Verbalize understanding of causative factors and necessary interventions. - Demonstrate behavior changes to regain &
43

ingesting related to dietary restrictions, nausea, & malabsorption.

experienced weight loss. This is partly due to the fewer calories consumed when a person loses

ASSESSMENT weight loss. - Poor muscle tone - Hyperactive bowel sounds - Frequent defecation with 3 or more loose liquid stools per day.

NSG. DIAGNOSIS his appetite, but

OBJECTIVE behavior changes to regain & maintain appropriate weight.

INTERVENTIONS environment together with a companion at mealtime encourages nutritional intake. - Prevent/minimize odors/sights that may unpleasant have a

EVALUATION maintain appropriate weight.

also a result of the way in which the digestive works--food not be system may

properly

negative effect on appetite. Unpleasant odors & sights could stimulate the vomiting center

-GOAL MET-

absorbed into the system as would be seen in without someone the

resulting to a feeling of nauseated then later vomit. - Provide oral care before/after meals. Good oral hygiene enhances appetite; the condition of the oral mucosa is critical to the ability to eat. The oral mucosa must be moist, with adequate saliva production to facilitate & aid in the digestion of food. - Promote adequate fluid intake. May want to limit fluids 1 hour prior to meal to decrease possibility of
44

- Pale conjunctiva condition. & mucous membranes George, D. (2011).

ASSESSMENT

NSG. DIAGNOSIS

OBJECTIVE

INTERVENTIONS early satiety. - Weigh the patient everyday and prn. This is to have a proof of an effective nursing care rendered. DEPENDENT: - Provide diet modifications as

EVALUATION

indicated. For example: - Increase CHON, CHO, calories. - Small feedings with snacks (easily digested snacks) - Mechanical feedings - Appetite stimulants (e.g., wine) if indicated. - Dietary supplements. Modification in feedings provides the appropriate nutrients needed by the body depending on the condition of the patient. Some of the diets also facilitate a rapid absorption in the GI tract.
45

soft,

liquefied

tube

ASSESSMENT

NSG. DIAGNOSIS

OBJECTIVE

INTERVENTIONS - Administer pharmaceutical agents as indicated: - Digestive drugs/enzymes - Vitamin - Medications anticholinergics, antidiarrheals) Drugs facilitate a direct target of healing. COLLABORATIVE: - Consult dietitian/nutritional team as indicated. To have further (e.g., antacids, antiemetics,

EVALUATION

knowledge about the appropriate foods for the patients condition.

46

Nursing Care Plan No.5 ASSESSMENT Objective cues: - Abnormal heart rate or blood pressure response High risk for activity intolerance related to generalize Within 8 hours span of care patient will be able to: - Participate willingly necessary in or NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: - Monitor vital signs, watching for After 8 hours span of dramatic changes in blood care, the patient was able EVALUATION

pressure, heart & respiratory rate; to: and/or pallor, cyanosis, VS & - Participate willingly in necessary or

- Pallor skin color weakness - Cyanotic nail beds - Dry lips & skin - Low grade fever SCIENTIFIC - Frequent defecation with watery loose stools - Has a musculoskeletal function status of 3 out of 5; with 1 completely BASIS: Individuals suffering Crohn's may with disease experience secondary to regional enteritis.

confusion.

monitoring

provides a baseline data for the planned activity.

desired activities. - Report a measurable increase in activity intolerance - Demonstrate a decrease in physiologic signs of intolerance as evidenced by the vital signs taken in within normal range.

desired activities. - Report measurable increase in activity intolerance - Demonstrate decrease a in a

- Increase exercise/activity levels gradually; teach energy

conserving methods such as rest for 3 minutes during a 10-minute walk and so forth. This provides the patient a time to exercise & relax at the same time conserving energy in the right manner. - Plan care with rest periods

physiologic signs of intolerance as evidenced by the vital signs taken in within range. normal

low-grade fever and an overall feeling of fatigue. fatigue Chronic often

between activities. This is to reduce & prevent chronic fatigue.

-GOAL MET-

accompanies severe

47

ASSESSMENT independent 2 requires help of equipment to assist self. 3 requires help or supervision of others 4 requires help from other persons. 5 completely dependent.

NSG. DIAGNOSIS diarrhea and may indicate deficiencies. George, D. (2011). dietary

OBJECTIVE

INTERVENTIONS - Involve patient in planning of activities. This allows the patient to be encouraged & be willing to participate since he/she already knew the activities to be done. - Assist the patient during the activities & provide with assistive devices such as walker or

EVALUATION

wheelchair. This is to protect the patient from injury. DEPENDENT: - Provide/monitor supplemental use oxygen of with

doctors order. This is to provide the client a proper oxygenation for dyspnic episodes.

48

49

XI. BIBLIOGRAPHY Ackley, B., Ladwig, G. (2006), Nursing Diagnosis Handbook, A Guide to Planning Care; Seventh Edition; Singapore; Elsevier Pte Ltd. Andrew, H. A., Lewis, P., Allan, R. N., (1988, Nov. 28), Mortality in Crohns Disease A Clinical Analysis, QJM: An International Journal of Medicine, Vol. 71, Issue 2; Retrieved Sept. 25, 2011 from http://qjmed.oxfordjournals.org/content/71/2/399.abstract. Chen, J. PhD, PharmD, OMD, Lac, (2000, November.), Crohns Disease; Retrieved Sept. 25, 2011 from http://acupuncturetoday.com/mpacms/at/article.php?id=27652. Crohns Disease & Living Probiotics (2011); Retrieved Sept. 16, 2011 from http://www.crohnsdisease-probiotics.com/crohns-disease-diet.html. Cure Research (2010, March 2); Statistics by Country for Crohns Disease; Retrieved Sept. 16, 2011 from http://cureresearch.com/c/crohns_disease/stats-country.htm. (1993), Nurses Pocket Guide: Nursing Diagnoses with

Doenges, M., Moorhouse, M.F.

Interventions; Fourth Edition; Philadelphia; F. A. Davis Company. Farlex, (2011), The Free Dictionary; Crohns Disease; Retrieved Sept. 6, 2011 from http://medical-dictionary.thefreedictionary.com/Crohn's+disease. George, D. (2011); Symptoms of Crohns Disease; Retrieved Sept. 16, 2011 from Symptoms of Crohn's Disease | eHow.com http://www.ehow.com/facts_4828904_symptoms-crohns-

disease.html#ixzz1YA5FKZty. Gorman, F. (2011), Liver Inflammation in Crohns Disease; Retrieved Sept. 22, 2011 from Liver Inflammation in Crohn's Disease | eHow.com http://www.ehow.com/facts_5934851_liverinflammation-crohn_s-disease.html#ixzz1YA39lXHU.

50

Knudson, J., ( 2011), How Does Crohns Disease Affect the Body?, Retrieved Sept. 16, 2011 from http://www.ehow.com/how-does_4965355_crohns-disease-affect-body.html.

Knutson, D. M.D., Greenberg, G. M.D., & Cronau, H. M.D., (2003, August 15), Management of Crohn's DiseaseA Practical Approach; Retrieved Sept. 22, 2011 from

http://www.aafp.org/afp/2003/0815/p707.html. Mayo Clinic Staff (2011, August 9), Crohns Disease; Retrieved Sept. 15, 2011 from http://www.mayoclinic.com/health/crohns-disease/DS00104. MedicineNet.com (2011); Crohns Disease Symptoms, Causes, Treatment; Retrieved Sept. 25, 2011 from http://www.medicinenet.com/crohns_disease/article.htm. MedicineNet.com: We Bring Doctors Knowledge to you, (2011, April 27), Regional Enteritis; Retrieved Sept. 6, 2011 from http://www.medterms.com/script/main/art.asp?articlekey=5280. MedicineNet.com: We Bring Doctors Knowledge to You (2011), Retrieved Sept. 25, 2011 from http://www.medicinenet.com/crohns_disease/article.htm.

Medline

Plus

Encyclopedia

(2011),

Retrieved

Sept.

15,

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