Transcript Crohn`s case study

Crohn’s Disease
A Case Study
Isabella Bourke
Jaymie McAllister
Jessica Nemerovsky
NUR 4216
Objectives
• Student will be able to identify causative factors
of Crohn’s Disease
• Student will be able to explain the
pathophysiology of Crohn’s Disease
• Student will learn about the incidence and
prevalence of Crohn’s Disease
• Student will be able to identify an appropriate
nursing diagnosis for a patient with Crohn’s
Disease and possible nursing interventions
What is Crohn’s Disease?
• Genetically linked inflammatory
disorder of GI tract classified as
an inflammatory bowel disease
(Alisa & Siew, 2011)
• Involves all layers of intestinal
wall
• Characteristic skip lesions from
intermittent patterns of
inflammation
• Affects any portion of the GI
tract from mouth to anus
• Causes are not definitively
known
– Combination of heredity,
abnormal immune response,
and imbalance of
gastrointestinal flora
Clinical Manifestations
• Systemic S/S
– Fever, fatigue, joint pain,
mouth sores, fatty liver,
autoimmune hepatitis
• Diarrhea (Osborn, Wraa & Watson, 2009)
– As many as 10-20 bowel
movements per day
• Weight loss
• Abdominal pain
– Right lower quadrant
• Anemia
• Malnutrition
• Deficiency of fat-soluble
vitamins
Diagnostic Procedures
• Endoscopy
(Osborn, Wraa & Watson, 2009)
– Gold standard
• Radiography
– Not favored due to risk of colonic perforation
• Blood tests
– Detect CBC r/t anemia
• Stool sample
– Checks for blood or infectious microbes
• Barium enema
• http://www.youtube.com/watch?feature=player_em
bedded&v=yB-wm2x6woc#!
Pathophysiology
• Chronic inflammation from T-cell
activation leading to tissue injury
• Activation by antigen
presentation results in
unrestrained release of helper
lymphocytes type 1 (Th1)
• Defective regulation of Th1
cytokines such as interleukin (IL) 12 and tumor necrosis factor
(TNF)-alpha stimulate the
inflammatory response
• Nonspecific inflammatory
substances, like platelet activating
factor and free radicals are
released, resulting in direct injury
to intestine (Medscape)
• http://www.youtube.com/watch?
v=obL6OB6My1Y
Incidence & Prevalence
• Men and women equally affected by IBD
– Women, however, more likely to have Crohn’s
Disease
• Crohn’s disease affects every 133 people per
100,000
• Genetic link to Crohn’s Disease
– Chromosome 10
– Chromosome 7
Patient Scenario
• A 22 year old woman presents to the E.R. with a 6 week history of
five loose, non-bloody stools daily, right lower quadrant
abdomnial pain (especially after eating), a twenty pound weight
loss, and bilateral knee and ankle pain. Findings from physical
examination shows a definite and moderately tender 5 cm mass in
the right lower quadrant of her abdomen. Stool culture are
negative for enteric pathogens and blood work results show mild
anemia (Hmg 11.2), with a normal metabolic panel and normal
thyroid stimulating hormones. Radiographic findings show a 10cm
narrowing of the terminal ileum and a separate of bowel loops
around the terminal ileum.
• This patient is then diagnosed with Crohn’s disease. The patient is
started on 5-aminosalcylic acid (5ASA), antibiotics and nutritional
therapy.
Research
• A gap between research exists when looking at antibiotic
treatment for Crohn's disease patients.
• A study by Feller, Huwiler, Schoepfer, Shang, Furrer, and Egger
(2010) determined the effectiveness of long-term antibiotic
treatment in 865 patients with Crohn’s disease.
• This study suggested that “long-term treatment with
nitroimidazoles or clofazimine appears to be effective in patients
with Crohn’s disease.”
• The current antibiotic treatment is Cipro and Flagyl. This study is
level one and found that clofazimine and nitroimidazoles have
been researched and are recommended for long-term antibiotic
treatment. This is important because diarrhea is a very common
and painful symptom in these patients. Antibiotics are known to
cause diarrhea so it is imperative that we use these researched
antibiotics to prevent this as much as possible.
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Treatment Modalities
No current cure
Diet therapy:
– No specific diet is recommended other than a balanced regular diet and
avoidance of triggers
– High fiber can lessen diarrhea and improve rectal urgency
Antibiotics
– Flagyl
– Cipro
Anti-inflammatory drugs
Immune system suppressors
– Azathioprine
– 6-mercaptopurine (6-MP)
Aminosalicylate
– Azulfidine
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Decreases fever, pain, diarrhea and rectal bleeding
Treatment Modalities Continued
• Corticosteroids
– used when traditional therapy does not work
• Antidiarrheals
• Laxatives
• Pain relievers (tylenol)
• Surgery
– Can correct fistulas that may have formed
– Anastomosis of affected portion of GI tract
– Ostomy placement
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("Crohn's disease: Treatment," 2011)
Elijah’s New Ostomy
• http://www.youtube.com/watch?v=eBry_Msq
cVs&feature=player_embedded
Prognosis
• Varies depending on the severity
– Possible to have one episode in a lifetime while
others suffer from chronic episodes
• Rarely the direct cause of death, and many
people live a normal lifespan
• 3 out of 4 people with Crohn’s disease will
end up needing surgical intervention
(SIMON, 2008)
("Crohn's disease:
Treatment," 2011)
Nursing Diagnoses
• Diarrhea related to inflammatory process
(Ackley &
Ladwig, 2011)
• Acute pain related to increased peristalsis
• Imbalanced nutrition related to diarrhea and
altered ability to absorb and digest food
• Risk for fluid volume deficit related to
abnormal loss of fluid from diarrhea
Nursing Interventions
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Assess defecation patterns. Assessment will help direct treatment
If the diarrhea is related to IBS, interventions may include the use of
complementary or alternative treatment such as probiotics. Probiotics enhance
the normal intestinal microflora and decrease symptom of diarrhea
Observe for signs and symptoms of sodium and electrolyte loss (weakness,
abdominal or leg cramps, dysrthmias). Excessive diarrhea causes electrolyte
abnormalities
Monitor intake and output. Dark, concentrated urine is an indication of deficient
fluid volume
With chronic diarrhea, observe for signs and symptoms of malnutrition and
consult with primary care provider for dietary consult and the possibility of
supplemental feeding methods such as TPN.
Provide a readily available bathroom, commode or bedpan at all times
Ensure stringent perianal care for the patient daily and as needed using and a
skin protectant (barrier cream)administral of antidiarrheal medications. At risk
for perineal skin injury
(Ackley & Ladwig, 2011)
Conclusion
• A definitive cure for Crohn’s disease does not currently
exist
• Treatment modalities depend upon the severity and the
progression of the disease
• Research is still being conducted to improve treatment
modalities for Crohn’s disease
• Inflammatory bowel diseases, including Crohn’s,
contribute to a high incidence of colon cancers
• These cancers are almost completely preventable with a
proper diet that consists of bulk forming and low fat foods
• With the exponential rise of obesity in America, it is
important to promote awareness and teach preventative
dietary methods.
NCLEX Question #1
• The nurse is reviewing the record of a female
client with Crohn’s disease. Which stool
characteristics should the nurse expect to
note documented in the client’s record?
– A. Diarrhea
– B. Chronic constipation
– C. Constipation alternating with diarrhea
– D. Stools constantly oozing from the rectum
NCLEX Answer #1
• A!
• Crohn’s disease is characterized by
nonbloody diarrhea of usually not more than
four to five stools daily. Over time, the
diarrhea episodes increase in frequency,
duration, and severity. Options B, C, and D
are not characteristics of Crohn’s disease.
NCLEX Question #2
• The nurse is preparing a client with Crohn’s
disease for discharge. Which of the following
statements indicates that he needs further
teaching?
– A. “Stress can make it worse.”
– B. “Since I have Crohn’s disease, I am not likely to get
colon cancer.”
– C. “I realize I will always have to monitor my diet.”
– D. “I understand there is a high incidence of familial
occurrence with this disease.”
NCLEX Answer #2
• B!
• Persons with Crohn’s disease are at high risk
for the development of colon cancer. The
other options are all correct and do not
indicate a need for further instruction
References
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Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to
planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier.
Ailsa L., H., & Siew C., N. (n.d). Inflammatory bowel disease: Crohn’s disease. Medicine,
39(Gastroenterology Part 3 of 4), 229-236. doi:10.1016/j.mpmed.2011.01.004
Crohn's disease: Treatment and drugs. (2011, August 09). Retrieved from
http://www.mayoclinic.com/health/crohns-disease/DS00104/DSECTION=treatments-and-drugs
Feller, M., Huwiler, K., Schoepfer, A., Shang, A., Furrer, H., & Egger, M. (2010). Long-term antibiotic
treatment for Crohn's disease: systematic review and meta-analysis of placebo-controlled trials.
Clinical infectious diseases, 50(4), 473-480.
Gastrointestinal diseases nclex review questions part 1. (n.d.). Retrieved from
http://www.rnpedia.com/home/exams/nclex-exam/gastrointestinal-diseases-nclex-reviewquestions-part-1
Osborn, K. S., Wraa, C. E., & Watson, A. B. (2009).Medical-surgical nursing, preparation for practice.
(Vol. 1). Prentice Hall.
Simon, H. (2008, December 01). Crohn's disease: Prognosis. Retrieved from
http://www.umm.edu/patiented/articles/who_gets_crohns_disease_000103_5.htm
WebMD, LLC (2012). Medscape For Android (Version 2.2) [Mobile Application Software]. Retrieved
from Google Play Store.