Interactive Tutorial: Inflammatory Bowel Disease/ Practice & Learn

What are the two forms of inflammatory bowel disease?

1. Crohn's disease: affects any part of the gastrointestinal tract from the mouth to the anus.

2. Ulcerative colitis: affects the large intestine &, rarely, the small intestine.

What is Inflammatory Bowel Disorder?

Both Ulcerative Colitis (UC) & Crohn's Disease (CD) are inflammatory conditions of the Gl tract that are most often initially diagnosed in young adults, age 15 to 40, and are usually present with diarrhea and weight loss.

Crohn's disease vs Ulcerative Colitis

Crohn's Disease:

Abdominal pain

Occurs at any point in the Gl tract

Inflammation occurs in separate lesions

Fistula development

Lesions extend through the intestinal wall

Abdominal pain, especially in the right lower quadrant.

Frequently involves the terminal ileum & /or ascending colon Manifests in distinct lesions, & involves the entire thickness of the intestinal wall.

Ulcerative Colitis:

Rectal involvement

Restricted to the colon

Inflammation is continuous

Risk for toxic megacolon

Inflammation restricted to the mucosa

The diarrhea of UC is more likely to be bloody;

Explanation:

Both UC & CD are inflammatory conditions of the Gl tract that are mostly diagnosed in young adults, aged 15 to 40 & present with diarrhea.

Describe the pathophysiology relevant to the development of Crohn's disease.

Crohn's disease can affect the gastrointestinal tract from the mouth to the anus. It can affect either gender equally and is most prevalent in individuals between 20 to 40 years of age, with a second peak in those aged 55 to 65 years.

- difficult to diagnose, & symptoms may become confused with irritable bowel syndrome.

It is slow & progressive in nature with periods of remission & exacerbation.

- no exact known cause but is theorized to be an immune disorder: the immune system responds to a virus or bacteria in the gastrointestinal tract. Other potential causes may be genetic factors (most often a sibling or parent suffers from the disease), allergies, & infections, and smoking.

Stages of Crohn's disease

1. The lymph nodes enlarge

2. Lymph flow is obstructed

3. Peyer's patches become more prominent

4. Fibrosis occurs

5. Inflammation of the serous membrane develops

6. Adhesions develop

Lymphatic obstruction causes edema, mucosal ulceration, fissures, abscesses, &, sometimes, granulomas.

Mucosal ulcerations are called skipping lesions because they are not continuous (as in ulcerative colitis)

Peyer's patches, the oval, elevated patches of closely packed lymphoid follicles present on the lining of the small intestine, are aggravated by inflammation & become more prominent.

Fibrosis occurs, thickening the bowel wall & causing stenosis, or narrowing of the lumen.

Inflammation of the serous membrane (serositis) develops.

Inflamed bowel loops adhere to other diseased or normal loops.

• Diseased bowel segments become interspersed with healthy ones.

Diseased parts of the bowel become thicker, narrower, & shorter & can lead to the formation of strictures.

Pathophysiology of Ulcerative Colitis

- affects the large intestine &, rarely, the small intestine.

- cause of ulcerative colitis: unknown

- the disease is linked to genetic factors, immune-system response to a virus or bacteria, autoimmune reactions, & allergic reactions to food, milk, or other substances that release inflammatory histamine in the bowel.

- Although emotional stress & anxiety can contribute to the aggravation of symptoms, they are not the primary cause of the disease.

The disease process of ulcerative colitis begins in the rectum & lower portion of the colon & may spread to other areas in a continuous manner.

Ulceration ensues with resulting bleeding, hemorrhage, & exudative inflammation.

Abscess formation in the mucosa drains purulent pus, necrosis, & ulceration. Next, sloughing occurs, causing blood- & mucus-filled stools.

As ulceration progresses, the structure of the colon changes. Initially, the colon's mucosal surface becomes dark, red, & velvety.

Abscesses form & coalesce into ulcers, & necrosis of mucosa occurs. As abscesses heal, scarring & thickening may appear in the bowels' inner muscle layer. Granulation tissue replaces the muscle layer, & the colon narrows, shortens, & loses its pouches.

Crohn's vs. Ulcerative Colitis: Type of inflammation

Crohn's Disease: Granulomatous

Ulcerative Colitis: Ulcerative and exudative

Level of involvement

Crohn's Disease: Primarily submucosal

Ulcerative Colitis: Primarily mucosal

Extent of involvement

Crohn's Disease: Skip lesions

Ulcerative Colitis: Continuous

Areas of involvement

Crohn's Disease: Primarily ileum, secondarily colon

Ulcerative Colitis: Primarily rectum and left colon

Diarrhea & Rectal bleeding

Crohn's Disease: Common

Ulcerative Colitis: Common

Fistulas, Strictures & Perianal Abscesses

Crohn's Disease: Common

Ulcerative Colitis: rare

Cancer

Crohn's Disease: Uncommon

Ulcerative Colitis: Relatively common

Crohn's Disease versus Ulcerative Colitis: Self-Assessment Exercise

The pathophysiology of Crohn's disease & ulcerative colitis is different.

Can you identify their pathophysiologic features?

Adhesions develop.

Abscesses are formed in the mucosa.

Complications related to fistulas often develop.

Granulomas are formed, leading to a cobblestone appearance.

The lower portion of the colon is affected.

Any part of the gastrointestinal tract is affected.

Exudative inflammation develops.

Crohn's Disease: Adhesions develop; Any part of the gastrointestinal tract is affected; Complications related to fistulas often develop; granulomas are formed, leading to a cobblestone appearance.

Ulcerative Colitis: The lower portion of the colon is affected; Exudative inflammation develops; Abscesses are formed in the mucosa.

Clinical Manifestations of Cohn's Disease

The symptoms of Crohn's disease are dependent upon the section of the gastrointestinal tract that is affected as well as the severity of the inflammation. Clinical manifestations may be mild & nonspecific; they do not always follow the same pattern for each patient.

The most common symptoms are diarrhea & cramping due to the inability of the large intestine to absorb excess fluid. This creates a loss of water & sodium. Loose, watery stools can occur up to 12 times per day in the active phase of the disease.

Right lower quadrant pain is also a common complaint but patients may have other abdominal complaints as well, such as tenderness upon palpation, nausea, & flatulence. Low-grade fever, anorexia, & weight loss may occur related to the inflammatory response in the intestine & can prevent the absorption of essential vitamins and minerals. The digestive process can also be altered.

Although bleeding is not always associated with Cohn's disease, there may be blood observed in stools due to intestinal inflammation and stool passage.

Other clinical manifestations arise from the complications of Crohn's disease, such as anal or rectal fissures, which can cause pain and bleeding. Fistulas may also develop.

Crohn's disease can also affect other parts of the body, such as the joints, eyes, skin, & liver.

Assessment of Crohn's Disease

Lab tests may reveal an elevated WBC count due to an increased inflammatory reaction, elevated erythrocyte sedimentation rate, electrolyte imbalance, & a decrease in hemoglobin related to anemia.

A barium enema should be used in conjunction with a colonoscopy. While this does not allow direct visualization of the colon, it may show the string sign, which is segments of stricture separated by normal bowel.

Sigmoidoscopies and colonoscopies allow direct visualization of the colon and the ability to take a biopsy to confirm the diagnosis and rule out ulcerative colitis.

An upper Gl series may be ordered to determine the location in the ileum, which cannot be determined by colonoscopy, and a CT scan may be used to detect complications such as fistulas, intestinal obstructions, or abscess formations.

String Sign: A characteristic sign of Crohn's disease that is shown on a small bowel series. This sign represents a narrowed lumen of the intestine that is often the cause of intestinal obstruction, pain & diarrhea.

Medical Management of Crohn's Disease

Lifestyle changes may be suggested, including rest & a diet low in fiber, which will help decrease the number of stools, & free of dairy, which will help with lactose intolerance. Vitamin supplements are helpful for the replacement of vitamins lost through a lack of absorption.

Drug therapy, the goal of which is to suppress inflammation & allow for healing without complications, may vary related to individuals' tolerance of the therapy and its effectiveness.

Medications:

Aminosalicylates, sulfasalazine (Azulfidene)

Mesalamine (Asacol, Rowasa [enema form, for Crohn's disease in the lower bowel)

Sulfasalazine (in those patients who do not have a sulfa allergy)

Corticosteroids:

Corticosteroids such as prednisone can reduce inflammation and relieve diarrhea, pain, and bleeding, though side effects from short- and long-term use of steroids exist.

Antibiotics:

metronidazole (Flagyl) or ciprofloxacin may also be used.

Antidiarrheals:

combination drugs consisting of diphenoxylate & atropine may help control diarrhea but are not used in patients with significant bowel obstruction because they decrease intestinal motility.

Opioids

control pain and diarrhea but also can cause slowing of intestinal motility and should not be used in patients who have a bowel obstruction.

Patients whose Crohn's disease does not respond to conventional therapy:

- may be given immune system suppressors such as IntuXImab (Remicade). Remicade Is an anti-tumor necrosis factor agent that removes the tumor necrosis factor from the bloodstream to prevent inflammation of the gastrointestinal tract. There have been very tavorable results from Remicade, and it can be used in conjunction with other medications, such as steroids, to control Crohn's symptoms.

However, Remicade is very costly and may not be covered by some insurance plans. Further, there are some unfavorable side effects from the immunosuppressive actions that should be explained to each patient, and tuberculosis screening should be performed prior to the administration of this drug.

Surgery

necessary if bowel perforation, massive hemorrhage, fistula formation, or intestinal obstruction develops.

A colostomy with an ileostomy may be performed in those patients with extensive disease in the large intestine & rectum.

For patients who are unable to tolerate solid foods or liquids due to excessive diarrhea, total parenteral nutrition (or TPN) may be initiated for nutritional support. A central venous catheter would be inserted by the surgeon to begin therapy; TP should never be infused through a peripheral intravenous line.

The medical management of ulcerative colitis is very similar to that o Crohn's disease because the goal for both diseases is to reduce Inflammation and prevent complications

Supportive measures include rest, including resting the gastrointestinal tract, and fluid and electrolyte replacement.

TPN may be used to rest the GI tract, decrease stool volume, and restore a positive nitrogen balance.

Pharmacological therapy is also used.

Adrenocorticotropic hormone Entocort -examples are prednisone (Deltasone), prednisolone (Prelone), hydrocortisone (Solu-corter), and budesonide (Entocort EC).

Sulfasalazine: To decrease inflammation. and as an antimicrobial (in those patients who do not have a sulta allergy) Mesaline

Mesaline Suppositories or enemas: if inflammation is confined to lower part of colon

Antispasmotics: May be used for patients who still have diarrhea even with well-controlled ulcerative colitis.

Note that caution should be used when administering

antispasmotics if symptoms of toxic megacolon develop, which may occur due to the decrease in intestinal motility.

Immunomodulatory Agents: Examples are azathioprine and

6-mercaptopurine; used for frequent exacerbations that are not controlled with continuous steroid therapy.

Cyclosporine: for more severe form of ulcerative colitis

If medical management is unsuccessful or the patient develops toxic megacolon, surgery, such as a proctocolectomy and ileostomy, may be an option. These procedures may be reversed at a future date.

The medical management of ulcerative colitis is very similar to that of Crohn's disease. What do you think is its goal?

O To reduce inflammation and prevent complications.

O To prevent immediate surgery.

O To prepare the patient for immediate surgery.

O To prevent the usage of Remicade, a very costly treatment that may not be covered by some insurance plans.

To reduce inflammation and prevent complications.

The general goal of drug therapy is to suppress inflammation, thereby allowing for healing without complications.

If medical management is unsuccessful or the patient develops toxic megacolon, surgery, such as a proctocolectomy and ileostomy, may be an option. Patients whose Crohn's disease does not respond to conventional therapy may be given immune system suppressors such as infliximab (Remicade). Prescribing Remicade is a part of medical management.

Nursing Management: Crohn's Disease & Ulcerative Colitis

The nursing management for Crohn's disease and for ulcerative colitis is similar.

Education about the changes in lifestyle that will be needed to control the symptoms of the disease will include dietary modifications to decrease inflammation and therefore control diarrhea.

Foods high in fiber, dairy, spicy foods, and fatty foods should be avoided since they tend to irritate intestinal mucosa. Patients should be advised to avoid carbonated beverages since they increase intestinal motility.

Replacement of essential vitamins should be encouraged due to a decrease in the absorption of vitamins such as calcium & Vitamin D. Vitamin B12 may be replaced by injection related to alteration or loss of intrinsic factors.

Nursing Management: Cohn's Disease and Ulcerative Colitis

Fluid & Electrolyte Balance

Maintaining fluid and electrolyte balance is essential and requires accurate measurement of intake and output.

TPN

TP is used for those patients with the inability to tolerate oral food and fluids.

Monitor the central line site for signs and symptoms of infection.

Use aseptic technique when changing the dressing site.

Care of Perineal Are:

Loose, watery stools require vigilant care of the perineal area.

Cleanse the area around the perineum with mild soap and water after each bowel movement. Warm sit baths may also be comforting.

Hemoglobin and hematocrit

should be monitored with the administration of blood transfusions if required.

Oral hygiene

Good oral hygiene should be maintained for those patients who are unable to take food or fluids by mouth.

Pressure mattresses

Alternating pressure mattresses helps to prevent skin breakdown.

Nursing Management: Cohn's Disease and Ulcerative Colitis

The nurse plays an important role in coordinating the efforts of all healthcare team members.

Instruct the patient on the importance of adhering to the prescribed medication regimen and the importance of not stopping or skipping doses of the drugs prescribed.

Inform the patient of the side effects of the drugs used for treatment, including the immunosuppressive medications. Fever, pain, rash, or blood in the stool should be reported immediately to the physician. Remember that steroid use can mask the signs and symptoms of infections.

Report complications such as toxic megacolon, the signs of which include a decrease in bowel sounds, abdominal cramping and pain, and abdominal distention.

Report signs of intestinal obstruction, such as nausea and vomiting (the vomit may smell like stool & have fecal material present), a decrease in bowel sounds, and abdominal cramping and pain.

Place emphasis on the importance of screenings for early intervention to promote better outcomes, since patients with ulcerative colitis are at risk for the development of colon cancer.

Assist patients in finding a support group.

Nursing Management: Self-Assessment Exercise

The nursing management for inflammatory bowel disease comprises different types of tasks. Can you identify the types?

Dietary modifications

Maintenance of electrolyte balance

Appropriate dosage adherence

Essential vitamins replacement

Fatty food avoidance

Good oral hygiene maintenance

Reporting of complications

Reporting of side-effects

Perineal area care

Patient Education: Dietary modifications; Essential vitamins replacement; Fatty food avoidance.

Physiologic Care: Maintenance of electrolyte balance: Perineal area care; Good oral hygiene maintenance.

Integrated Care: Reporting of complications;

Signs and Symptoms of Cohn's Disease: Self-Assessment Exercise

For each statement about Crohn's disease below, choose "True" or "False."

Statement

Every patient diagnosed with Crohn's disease has similar symptoms.

Intestinal inflammation may cause bleeding in stools.

Weight loss is the most common symptom of the disease.

In the active phase of the disease, a feeling of urgency with an inability to

defecate may be present.

The digestive process often gets altered for patients with Crohn's disease.

The disease may cause a crack or tear in the mucosa of the rectum.

Every patient diagnosed with Crohn's disease has similar symptoms. False

Intestinal inflammation may cause bleeding in stools. True

Weight loss is the most common symptom of the disease. False

In the active phase of the disease, a feeling of urgency with an inability to defecate may be present. False

The digestive process often gets altered for patients with Crohn's disease. True

The disease may cause a crack or tear in the mucosa of the rectum. True

Clinical Manifestations of Ulcerative Colitis

As with Crohn's disease, the symptoms of ulcerative colitis will vary with the degree of inflammation present & the location.

The hallmark signs of ulcerative colitis are bloody diarrhea and symptom-free remissions.

Also, the stool may contain pus & mucus.

Other signs may be vague, such as fatigue, fever, malaise, anorexia, nausea, and vomiting. A feeling of urgency with an inability to defecate (tenesmus) may be present as well as spasticity of the rectum & anus.

Assessment of Ulcerative Colitis

If the disease extends from the rectum through the sigmoid colon, flexible sigmoidoscopy may be useful to determine the extent of inflammation & allow biopsies to confirm the diagnosis.

A colonoscopy will allow direct visualization of the colon up to the ileocecal valve & determine the extent of the disease. It will also evaluate the Formation of strictures & pseudopolyps

A barium enema may be useful in conjunction with the colonoscopy or flexible sigmoidoscopy to assess for strictures and masses, and small bowel series may also help to distinguish between Crohn's disease & ulcerative colitis.

Lab Tests: Ulcerative Colitis

Lab studies are nonspecific and may indicate the presence of infection or inflammation, such as an elevated white blood cell (WBC) count and an elevated erythrocyte sedimentation rate.

Electrolyte imbalance caused by diarrhea may be detected from sodium and potassium levels.

Anemia related to blood loss may be necessary.

Signs and Symptoms of Ulcerative Colitis Disease: Self-Assessment Exercise

For each statement about ulcerative colitis disease below, choose "True" or "False."

The major symptoms of ulcerative colitis are bloody diarrhea & symptom-

free remissions

The patient may feel urgency with an inability to defecate.

The symptoms of ulcerative colitis depend on the stage of the disease.

The stool may contain pus & mucus

Flatulence is one of the major symptoms.

Fistulas may easily become infected & lead to abscess formation.

The major symptoms of ulcerative colitis are bloody diarrhea & symptom-free remissions. True

The patient may feel urgency with an inability to defecate. True

The symptoms of ulcerative colitis depend on the stage of the disease. False

The stool may contain pus and mucus. True

Flatulence is one of the major symptoms. False

Fistulas may easily become infected & lead to abscess formation. False

Nursing Diagnosis for inflammatory bowel disease

Deficient fluid volume related to diarrhea.

Impaired nutrition, less than body requirements related to an inability to tolerate solid foods, nausea.

Diarrhea related to the inflammatory process

Risk for impaired skin integrity related to diarrhea and malnutrition.

Risk for infection related to the administration of immunosuppressive medications.

Hopelessness related to chronic illness.

Activity intolerance related to fatigue and malaise.

Case Study 1: Patient with Severe Diarrheal Symptoms

Angela Carson is a 26-year-old white female. She is an elementary school teacher and just began a new school year learning second grade.

About a week after the school year began. she began having several bouts of loose, watery stool up to 6 times a day that was preceded by cramping. She has a vague discomfort in the right upper quadrant of her abdomen that worsened as the week progressed. She attributed the symptoms to a "flu" that has been going around with the children. and she has tried to manage the symptoms with an antidiarrheal that she bought over the counter. After 10 days of these disturbing symptoms, she presents to her family physician.

The nurse obtains her vital signs:

BP 104/62 lying, BP 90/50 sitting, BP 82/48 standing

Pulse 102 lying, Pulse 110 sitting, Pulse 112 standing

Respirations 18

Temperature 99.8°F oral

Her skin Is warm and dry. turgor is poor: mucous membranes are pale and ary: bowel sounds are hyperactive in al Tour quadrants and there is tenderness upon palpation in the right upper quadrant of the abdomen.

After a history and physical. the physician refers her to the gastroenterologist for a colonoscopy, which reveals inflammation of the cecum in a skipped pattern. Biopsies are taken for diagnostic confirmation.

Based on Ms. Carson's signs and symptoms presented in the case study, identify the disease she is suffering from.

Flu

Diarrhea

Ulcerative colitis

Crohn's disease

Crohn's disease

The type of inflammatory disease presented in this case study is Crohn's disease. The clinical manifestations related to this diagnosis are frequent loose, watery diarrhea several times a day, right upper quadrant pain, signs and symptoms of dehydration (orthostatic changes in vital signs and poor skin turgor, and dry, pale mucous membranes), and skipped pattern inflammation observed on the colonoscopy.

As the nurse caring for Ms. Carson, what do you think is a priority nursing diagnosis with the clinical manifestations presented by her?

Impaired nutrition

Deficient fluid volume

Activity intolerance

Hopelessness related to illness

Deficient fluid volume

A priority nursing diagnosis with the clinical manifestations presented would be deficient fluid volume related to the frequent loose watery stools as evidenced by the orthostatic vital sign changes, such as poor skin turgor and dry, pale mucous membranes. Activity intolerance related to the inability to tolerate solid foods, the risk for impaired skin integrity related to diarrhea and malnutrition, and a sense of hopelessness are some of the other nursing diagnoses.

However, these are not of the foremost priority.

As the nurse attending Ms. Carson, which assessment data do you think are of concern when establishing the state of hydration? Select all that apply.

Choose all that apply.

Dizziness

Mucus-filled stools

Decrease in urine output

Decrease in bowel sounds

Increase in heart rate

Dizziness; Decrease in urine output; Increase in heart rate.

State of hydration in Cohn's disease can be assessed by dizziness, an increase in heart rate, a decrease in urine output, skin appearance and texture, fatigue, weakness, irritability, delirium, extreme thirst, a decrease in blood pressure, lab values with electrolyte disturbance. A decrease in bowel sounds is a sign of intestinal obstruction. Mucus-filled stools are a symptom of ulcerative colitis.

Now that you understand Ms. Carson's condition, what other lab studies do you think the physician will order and why?

Select the diagnostic test with the rationale for ordering it.

Diagnostic Test

Barium enema

Sigmoidoscopy

Upper Gl series

CT scan

Barium enema: To view segments of strictures separated by normal bowel.

Sigmoidoscopy: To aid in biopsy for confirmation of diagnosis.

Upper Gl series: To determine the location in the ileum

CT scan: To detect complications such as fistulas, intestinal obstructions, or abscess formations.

Case Study 2: Patient with Ulcerative Colitis

Carol Pennick is a 34-year-old white female who works in the surgical services department of a local hospital. She has a history of ulcerative colitis and has been symptom-free for approximately one year. Six days ago she was assisting with a surgical procedure & felt as though she had to defecate. She excused herself, went to the bathroom, & was unable to have a bowel movement; all that was evacuated was some bloody mucus but no stool. She realized that she may be having a recurrence of ulcerative colitis & decided to call for an appointment to see her gastroenterologist. He scheduled her for a flexible sigmoidoscopy in the office two days later.

The results from her flexible sigmoidoscopy revealed an exacerbation of her ulcerative colitis. Her erythrocyte sedimentation rate was elevated as well as her white blood cell count. Her gastroenterologist prescribed prednisone 40 mg by mouth once a day. He requested that she maintain a diet of clear liquids & gave her diphenoxylate to be used for three days only.

Stress and anxiety; Immune system response; Allergic reactions.

Contributing factors may include genetic predisposition, immune system response to viruses or bacteria, and allergic reactions to food, milk, or other substances. Also contributing may be emotional stress and anxiety. There may be a link between smoking cigarettes and Crohn's disease. Age is also a factor that contributes to Crohn's disease, not ulcerative colitis.

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

Choose all that apply.

Counsel the patient to report dizziness or blurred vision.

Caution patient to avoid exposure to high temperatures.

Counsel the patient to report euphoria.

Counsel patient on dry mouth relief.

Counsel patient to report dizziness or blurred vision; Caution patient to avoid exposure to high temperatures; Counsel patient on dry mouth relief.

As the nurse taking care of Ms. Pennick, what would be your concerns for the patient regarding her prednisone prescription?

Choose all that apply.

Patient education about how the medication reduces inflammation.

Patient education about how to take the medication.

Patient education about the tests to be conducted before administration.

Patient education about how the medication cost can be covered.

Patient education about possible medication side effects.

Patient education about how to take the medication & possible side effects

Some of the side effects of adrenocortical steroid use are night sweats, increased hunger, emotional lability, fat pad growth on the upper back, excess hair growth on the face, moon face, and weight gain.

Patients need to adhere strictly to the medication regimen & should take the medication with food.

Corticosteroids such as prednisone can reduce inflammation & relieve diarrhea, pain, and bleeding, though side effects from short-term and long-term use of steroids exist. However, it is not the nurse's duty to tell the patient about how the medication reduces inflammation, or how the cost can be covered. Administration of prednisone does not require any tests to be performed prior to it.

What do you think is a possible reason for the physician requesting that Ms. Pennick maintain a clear liquid diet?

To prepare the patient for surgery

To decrease the number of stools

To give the Gl tract a rest

To facilitate the action of Remicade

To give the Gl tract a rest

Resting the gastrointestinal tract is a part of the medical management of ulcerative colitis aimed at reducing inflammation and preventing complications. A clear liquid diet ensures minimal gastrointestinal disturbance. A diet of solid foods may irritate the intestinal mucosa by increasing the production of digestive enzymes. The action of Remicade, the number of stools, and surgery do not have any relation to a clear liquid diet.

The reason for Ms. Pennick's symptoms is not clear in the case. Which of the following factors may have contributed to her ulcerative colitis?

Choose all that apply.

Stress & anxiety

Immune system response

Smoking

Allergic reactions

Age

Stress & anxiety

Immune system response

Allergic reactions

Contributing factors may include genetic predisposition, immune system response to viruses or bacteria, and allergic reactions to food, milk, or other substances. Also contributing may be emotional stress and anxiety. There may be a link between smoking cigarettes and Crohn's disease. Age is also a factor that contributes to Crohn's disease, not ulcerative colitis.

Part 1: Hospital Admission (Practice & Learn: Inflammatory Bowel Disease)

Anita Hoffman, a 32-year-old woman, is admitted to the medical/surgical unit with a 4-month history of diarrhea & abdominal pain that has become much worse over the past 3 days. Earlier, she had been diagnosed with irritable bowel syndrome (IBS). The pain occurs before bowel movements and is crampy. Over the past 4 months, she has lost 11 lbs. She is admitted with a diagnosis of possible inflammatory bowel disease (IBD).

Ms. Hoffman reports very little oral intake over the past 3 days due to diarrhea & loss of appetite.

Vital Signs

On admission, her temperature is 37.6°C (99.7°F), blood pressure is 96/54 mm Hg, heart rate is 102 bpm, and respiratory rate is 14.

Ms. Hoffman asks the nurse what caused her IBD. What is the most accurate response for the nurse to make?

"IBD is an infection of the lining of the digestive system."

"IBD is a genetic disease. Do you have any family members with IBD?"

"IBD is caused by severe stress.

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

"BD is caused by the body's immune system attacking the intestine."

Although there are many gaps in our understanding of the causes of IBD, it is thought to be an autoimmune process. There is a familial tendency to IBD. However, although research has identified genes that predispose to IBD, not all persons with those genes will develop IBD.

Stress may influence exacerbations

Part 2: Hospital Treatment

Ms. Hoffman remains in the medical/surgical unit.

Ms. Hoffman's lab results show WBC 11,000 /mm, Hgb 10.8 g/dL, Hct 35%, Na+ 153 mEq/L, K+ 4.7 mEq/L, BUN 40 mg/ dL, and creatinine 1.6 mg/dL.

The provider's orders include IV fluids & NPO status, & methylprednisolone (Solu-Medrol) 40 mg IV every 6 hours.

The nurse is developing a plan of care for Ms. Hoffman. What nursing diagnosis should the nurse identify as the highest priority?

a. Hemorrhage related to gastrointestinal blood loss.

b. Imbalanced nutrition: less than body requirements related to decreased intake

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

d. Body image disturbance related to diarrhea and weight loss.

Fluid volume deficit related to diarrhea and decreased fluid intake.

Increased BUN, creatinine, & Na+ levels, decreased blood pressure & tachycardia indicate fluid volume deficit (FVD). Continuing diarrhea puts Ms. Hoffman at risk for the FVD worsening. Hemorrhage is not a nursing diagnosis. The Hgb level is slightly below normal, but not low enough to suggest hemorrhage. IBD often causes anemia due to malnutrition and anemia of chronic disease. Body image disturbance is a common problem for patients who have IBD, but FVD is a higher priority. Imbalanced nutrition that is less than body requirements does apply to Ms. Hoffman, but FVD is a higher priority.

Ms. Hoffman asks why she is not allowed to eat or drink. What is the reason for keeping Ms. Hoffman's NPO?

a. The nurse should call the provider to clarify the order. Ms. Hoffman is dehydrated and has lost weight. She should take a high-calorie diet.

b. If the symptoms resolve after a day of NPO status, Ms. Hoffman's IBD is UC. If not, her IBD is CD.

c. IBD is caused by food allergies. A period of NPO followed by introducing foods one at a time will help determine which food caused her IBD.

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

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

Bowel rest is an important part of the management of flare-ups of IBD, especially CD. Bowel rest decreases symptoms and helps in decreasing the inflammation in CD.

Although lactose intolerance is common in patients who have IBD it is not caused by food allergies or ingesting particular foods. Dehydration and malnutrition are common in IBD; both are a problem for Ms. Hoffman.

However, bowel rest is essential during the flare-up. Fluids, and possibly nutrition, will need to be given by IV for a time. Bowel rest is more helpful in CD than UC, but it is not a diagnostic test.

Part 3: Hospital Discharge

Ms. Hoffman's diarrhea slows over the next few days and a diet is gradually introduced. She is ready to be discharged. She is scheduled to have a colonoscopy as an outpatient to determine the type & extent of her

IBD. The nurse reviews discharge instructions with Ms. Hoffman.

Meds: Her provider prescribes sulfasalazine (Azulfidine) 1 g by mouth every 8 hours & prednisone 30 mg by mouth daily.

Which instructions should the nurse include about Ms. Hoffman's medications?

a. "The Azulfidine must be taken on an empty stomach."

b. "Take the prednisone at bedtime."

c. "You'll need to take the prednisone for the rest of your life."

d. "You shouldn't take Azulfidine if you are allergic to aspirin or sulfa drugs."

"You shouldn't take Azulfidine if you are allergic to aspirin or sulfa drugs.

Sulfasalazine (Azulfidine) is considered a disease-modifying anti-rheumatic drug (DMARD)

Sulfasalazine contains sulfa and salicylate. Cross-allergies with other sulfa-containing drugs and aspirin are possible. Corticosteroids, including prednisone, are used for the shortest time possible. Once the exacerbation is controlled, corticosteroids are tapered off. Sulfasalazine should be taken with or after food to minimize Gl upset. Corticosteroids should be taken in the morning to coincide with the body's normal secretion of cortisol.

What should the nurse advise Ms. Hoffman about her diet?

Choose all that apply.

a. Avoid milk products

b. Avoid red meat

c. Eat a low-residue (low-fiber) diet

d. Eat a low-carbohydrate diet

e. Eat a high-protein, high-calorie diet

Eat a high-protein, high-calorie diet

Eat a low-residue (low-fiber) diet;

Avoid milk products.

Patients with IBD, especially CD, are often malnourished due to decreased intake &, in the case of CD, poor absorption of nutrients. A high-protein, high-calorie diet helps meet nutritional needs. A low-residue diet often decreases the amount of diarrhea.

Many patients who have IBD are lactose intolerant. Until Ms. Hoffman's lactose tolerance is determined, she should avoid milk products. Meat does not increase the symptoms or inflammation. Many patients who have IBD are anemic; meat contains both iron & protein, which are beneficial. A low-carbohydrate diet does not aid in the management of IBD.

What should the nurse advise Ms. Hoffman about her activity?

a. A routine of aerobic exercise at least 3 times a week will decrease the number of exacerbations she experiences.

b. IBD will not affect her ability to exercise or engage in her usual activities at all.

c. She may maintain activity as she tolerates it, even during exacerbations.

d. Maintaining bedrest during an exacerbation will shorten the exacerbation.

She may maintain activity as she tolerates it, even during exacerbations.

Although anemia and fatigue may impact the ability of patients who have IBD to participate in activities, they may continue activity as tolerated, even during exacerbations. Bedrest will not shorten an exacerbation. IBD often causes anemia and fatigue. Those effects, plus diarrhea that is often unpredictable and urgent, often impair the ability of patients who have IBD to engage in activities.

Part 4: Hospital Admission

Ms. Hoffman was diagnosed with ulcerative colitis based on colonoscopy results. A year later, Ms. Hoffman is again admitted to the medical/surgical unit. Despite adjustments in her medications, she has been having increasing exacerbations with bouts of diarrhea, often bloody.

On admission, she reported bloody, loose stools 8 to 10 times per day. Her weight was down 15 lbs from the previous admission. She also reports aching pain in her hips & knees.

After admission, Ms. Hoffman develops a fever of 39°C (102.4°F).

Her BP is 89/51 mm Hg and her pulse is 123 bpm.

Her abdomen is distended & bowel sounds are absent.

A CBC shows a WBC of 13,200 / mm, Hgb 8.4 g/dL, and Hct 25%. The provider orders an abdominal radiograph.

What complication of UC might Ms. Hoffman be experiencing?

Choose all that apply.

a. Liver disease

b. Osteoporosis

c. Toxic megacolon

d. Perforated colon

Toxic Megacolon

Rare but life-threatening complication of IBD

What hallmarks might indicate a diagnosis of toxic megacolon?

Choose all that apply.

Dilation of the colon

Hypotension

Hypertension

Lack of abdominal distension

Tachycardia

Electrolyte imbalance

Altered mental state

Hyperactive bowel sounds

Dilation of the colon

Hypotension

Tachycardia

Electrolyte imbalance

Altered mental state.

Hallmarks of toxic megacolon are dilation of the colon and signs of systemic toxicity such as hypotension, tachycardia, electrolyte imbalances, and altered mental status. Toxic megacolon is treated with bowel rest, antibiotics, and nasogastric suction. Perforation may occur, and if it does, surgery is usually required.

What is the most likely explanation for Ms. Hoffman's joint pain?

a. The joint pain is an attention-seeking device Ms. Hoffman is using to cope with having a chronic disease.

b. The joint pain is a manifestation of Ms. Hoffman's IBD.

c. The joint pain is caused by Ms. Hoffman's decreased activity level.

d. Patients who have one autoimmune disease often develop a second autoimmune disorder. The joint pain is caused by another autoimmune disorder.

The joint pain is a manifestation of Ms. Hoffman's IBD.

IBD can cause a number of problems outside of the gastrointestinal tract, including arthritis, uveitis, sclerosing cholangitis, gallstones, and kidney stones. This is not considered to be a separate disorder, but a complication of the IBD. Arthritis is a complication of IBD, not of inactivity. There is no evidence of "attention seeking."

A patient's reports of pain must be accepted as genuine.

After 24 hours, Ms. Hoffman's condition has improved. She says that a friend has suggested she consider having surgery. She 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."

"Removing the entire colon can cure UC"

Total colectomy is curative for UC. Surgery is sometimes required to treat complications that may occur with UC, but it is also used to treat and cure UC. Telling the patient to speak with her physician is non-therapeutic. The nurse may provide general information about surgery, although specific questions about a planned procedure should be referred to the surgeon.