CROHN'S DISEASE

CROHN'S DISEASE

1. WHAT IS CROHN'S DISEASE?

   • It most commonly involves the lower part of the ileum, ileocecal region or the colon (Lewis, 2014).
   • It is an inflammatory condition of unknown ethology which may involve the whole digestive tract from the oral cavity to the anus (Morrison, 2008).
   • It is an irritable bowel condition that occurs mostly in people ages 15 - 30 (Chastang, 2015).
     • There is a slightly higher incidence in women (Lewis, 2014)
     • There is an increased prevalence in Caucasians and Jews of eastern european descent (Chastang, 2015).
     • In older adults the morbidity and mortality rates are higher because of other chronic problems that may be present (Lewis, 2014)
   • Crohn's disease is an autoimmune disease that causes chronic inflammation of the GI tract (Evans, 2016).

2. CLINICAL MANIFESTATIONS

   • Hyperactive bowel
   • Vital signs
     • Pain
       • Abdominal cramping and tenderness (Lewis, 2014)
         • Around umbilicus and lower right quadrant (Lewis, 2014).
       • Onset
       • Provoking
       • Quality
       • Radiating
       • Severity
       • Time
     • Increased temperature
       • Febrile
     • Increased pulse
     • Increased respirations
     • Increased blood pressure
   • Anxiety
   • Depression
   • Depend largely on the anatomical site of involvement, the extent of the disease process, and the presence or absence of complications (Lewis, 2014).
   • Nausea/Vomiting
     • Malnutrition
       • Dehydration
       • Anemia
     • Electrolyte imbalances
   • Fatigue
   • Abdominal distension
   • Increased peristalsis
     • Malabsorption
       • Stearrhoea
       • Weight loss
       • Diarrhea
         • Usually non-bloody
         • Perianal fissures
       • Vitamin deficiency
   • Fistula
   • Abscess

3. DIAGNOSTIC STUDIES

   • CT scan
   • Lab work
     • WBC count
     • Potassium levels
     • May determine electrolyte disturbances (Lewis, 2014)
     • May determine the presence of anemia.
   • Fecal analysis
   • Barium studies
     • Useful in determining location and extent of the disease (Lewis, 2014).
       • Determine the degree of ill involvement.
     • May reveal cobblestoning of the mucosa
     • May reveal stricture formation in the ileum (string sign)
     • May reveal fistulas
     • May reveal areas of abnormal and normal mucosa
   • Radiological studies
   • Endoscopic studies
     • Colonoscopy/ Endoscopy/ Sigmoidoscopy
       • Useful in detecting early mucosal changes as patchy inflammation, small ulcerations and skip areas that may not be seen radiologically.
       • Capsule endoscopy may be used to diagnose the small intestine (Lewis, 2014)
   • Biopsy
     • Determine the presence of granulomas (Lewis, 2014)
       • Granulomatous intestinal inflammation (Copsted, 2013)
   • Thorough history and physical examination, to establish clinical signs and symptoms (Lewis, 2014)

4. COLLABORATIVE CARE/ TREATMENT

   • Drug Therapy
     • More information on Medications Node
   • Nutritional Therapy
     • Parenteral nutrition
       • May be given to patients with severe disease, small bowel fistulas, or short bowel syndrome (Lewis, 2014).
         • It is given before and after surgery to promote wound healing, reduce complications and hasten recovery.
     • Elemental diet
       • Diet is high calorie, high-nitrogen, fat-free, no-residue substrate (Lewis, 2014)
         • Absorbed in the proximal small bowel.
         • Can be given during an acute exacerbation.
     • Low in residue, roughage and fat but high in calories and protein (Lewis, 2014).
       • High fat diets are poorly tolerated because of the loss of absorbing mucosa and altered bile salt metabolism and absorption.
       • Acidic, fried and pickled foods should be avoided (Morrison, 2008).
     • Milk and milk products may be exclude from the diet (Lewis, 2014).
       • Lactose may not be adequately digested because of the inability of the damaged intestinal mucosa to produce sufficient amounts of lactase.
     • Small frequent meals are encouraged (Morrison, 2008)
   • Surgical Therapy
     • Used in patients with severe symptoms that are unresponsive to therapy and in those with life-threatening complications (Lewis, 2014).
       • 50% of patients will require surgery within ten years (Morrison, 2008)
       • 80% of patients will require surgery within twenty years (Morrison, 2008).
     • Indications include drainage of abdominal abscess, failure to respond to conservative therapy, fistulas, intestinal obstruction, inability to decrease corticosteroids, massive hemorrhage, perforation, secondary hydronephrosis, severe anorectal disease and suspicion of carcinoma.
       • Early ambulation encouraged to facilitate return of bowel function and prevent the formation of venous thromboemoli (Morrison, 2008).
   • The goal is to control the inflammatory process, relieve symptoms, correct metabolic and nutritional problems, and promote healing (Lewis, 2014).
   • Support (Meize-Grochowski, 1991)
     • Develop trusting relationship with patient
     • instill a sense of confidence in patient by helping control odors and leakage
       • help with a diet plan that suits patients lifestyle
     • refer to social services or counselor for further for further interventions
     • Encourage expression of sexual councerns
     • provide consistent colostomy care and encourage patient in helping
   • Patient education (Lewis,2014)
     • Proper stoma care
       • Educate patient on the type of colostomy and location
       • empty pouch or replace bag when not more that 1/3 full
       • Always properly assess appearance of stoma and surrounding skin
       • Good skin care and stoma care is important to maintain skin integrity
   • Diet (Cope, 2014)
     • Monitor ins and out of patient when in the hospital
     • Refer to dietition for dietery management
     • weigh daily
     • Educate patient on types of food that helps odor
   • Surgery (Cronin,2011)
     • stricturoplasty
       • Opens up narrowed areas, no intestine is remmoved
     • Colectomy
       • Severe cases, colon is removed
     • Proctocolectomy
       • Severe cases, both colon and rectum is removed
     • Bowel resection
       • Removes diseased part, corrects fistulas

5. MEDICATIONS

   • Opioids
     • Via PCA 1-2 days post-op (Morrison, 2008)
     • Oral forms third day post-op (Morrison, 2008)
   • Immunosuppressants
     • Prevention of recurrence after surgery (Morrison, 2008)
     • i.e. azathioprine (Imuran), cyclosporine (Neoral)
   • Immunomodulators
     • Inhibit the cytokine tumour necrosis factor a (TNF-a) (Lewis, 2014)
     • i.e. infliximab (Remicade), adalimumab (Humira)
   • Antibody therapy
     • Treats acute flares (Morrison, 2008)
     • Maintenance after surgery (Morrison, 2008)
   • i.e. Cholecystaramine
     • Treats diarrhea due to bile salts overflow (Morrison, 2008)
   • Hematinic's and vitamins
     • Corrects iron deficiency anemia and promotes healing (Lewis, 2014)
       • i.e. oral iron, iron injections
       • Vitamin B12
         • Avoid megablastic anemia (Morrison, 2008)

6. NURSING MANAGEMENT

   • Promote rest
   • Diet management
     • Encourage patient to keep a food journal to help eliminate all food that trigger adverse events (Morrison, 2008)
     • Increased fluid intake to prevent dehydration (Morrison, 2008)
     • Assess for signs of malnutrition (Lewis, 2014)
     • Record daily weights to evaluate nutritional response and response to treatment (Lewis, 2014)
   • Perianal care
     • Monitor frequency and characteristic of stools to evaluate effectiveness of therapy and dietary restrictions (Lewis, 2014)
     • Assess skin for signs of breakdown to ensure early intervention.
     • Cleanse perianal area after each bowel movement with warm water or perianal skin cleanser and dry thoroughly to remove stool, provide comfort and prevent skin breakdown.
     • Provide sits bath for comfort and hygiene, apply barrier cream.
   • Drug Therapy
     • Teach patient signs and symptoms to report
   • Stress and anxiety management
     • Encourage open discussions of feelings about diagnosis to demonstrate acceptance and concern for patient and allow verbalization of concerns (Lewis, 2014).
     • Explain disease treatments, diagnostic tests and drugs because understanding may reduce anxiety.
     • Provide privacy to reduce embarrassment and anxiety associated with frequent bowel movements.
     • Utilize listening skills
   • Teach patient signs and symptoms of recurrence of disease
   • Pain Management (Cronin,2011)
     • Monitor pain levels regularly, when administering medication always monitor for therapeutic effect
     • Administer pain medication before wound care, to make patient fell comfortable
     • properly asses wound for inflammation, discoloration, assess discharge or drainage.

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