NSG 202: week 2 (Professionalism, IBS, UC, Crohn's)

Professionalism

• Refers to the attributes and behaviors of a nurse as a representative of the profession and as a health care professional.

• you’re representing where you work 

Ethics

• Refers to considering what is "right or wrong" when using clinical judgement to make ethical decisions.

• Ethics = doing the right thing 

  • component of professionalism 

  • in order to be a professional you have to have ethics 

Professional Identity

• Refers to an individual's comprehension of themselves as a discrete, separate entity.

• a sense of oneself in relation to others that’s influenced by characteristics, norms, values or expected values, of the nurse

Attributes of Professional Identity

• Doing = the skills

  • the technical or functional part of professionalism 

• Being 

  • adopting attitudes & behaviors that reflect our profession

• Acting Ethically

  • doing the right thing from a societal view & from a professional perspective 

• Flourishing

  • having transformational growth; when you grow in your profession
    
    

• Changing Identities

  • you have multiple identities

    • you’re you, you represent your school, you represent your workplace, you’re someone’s loved one, etc. 

    • we have lots of identities to ourselves  

Attributes of Professional Identity: Doing

• Doing = the skills

  • the technical or functional part of professionalism 

Attributes of Professional Identity: Being

• Being 

  • adopting attitudes & behaviors that reflect our profession

Attributes of Professional Identity: Acting Ethically

• Acting Ethically

  • doing the right thing from a societal view & from a professional perspective 

Attributes of Professional Identity: Flourishing

• Flourishing

  • having transformational growth; when you grow in your profession

Attributes of Professional Identity: Changing Identities

• Changing Identities

  • you have multiple identities

    • you’re you, you represent your school, you represent your workplace, you’re someone’s loved one, etc. 

    • we have lots of identities to ourselves  

Nursing Attributes Involving Ethics: Autonomy

• Autonomy = Autonomy refers to freedom from external control. In healthcare, this concept primarily applies to respecting patients' independence and their right to make their own decisions about their care. 

  • Even when patients cant make their own decisions, we are ethically obligated to protect &  advocate on their behalf 

  • acting autonomously you’re going to advocate for that patient 

Nursing Attributes Involving Ethics: Beneficence

• Beneficence = doing good for the patient 

Nursing Attributes Involving Ethics: Nonmaleficence

• Nonmaleficence = Preventing Harm; making sure that we keep our patients safe

Nursing Attributes Involving Ethics: Fidelity

• fidelity = promise that you’ll follow through your care 

Nursing Attributes Involving Ethics: Veracity

• veracity = being obligated to tell the truth 

Nursing Attributes Involving Ethics: Social Justices

• social justices = being equal and fair with all patients

Roles of Professional Nurses that Involve Ethics

• you want to practice with compassion & respect 

• you’re committed to your patient 

• you advocate for the rights & safety of your patient 

• you’re responsible & accountable for good nursing practice 

  • you’re accountable for your errors; you have to own it 

• Continue growth & education 

• you need to collaborate & be a team player

Attributes of a Healthcare Professional

• altruism = selfless concern for the well-being of others

Examples in Use of Ethics in Nursing

• Advance Directives

  • make sure that the patient can make informed decisions 

    • we don’t tell patients what to do, it’s their decision

• Informed Consent

  • they know what the risks are; they know what’s going to happen, & they’ve signed them. You need to make sure they understand them 

• Policy development

  • Policy development depends on where you work 

• Withdrawing life support

  • Withdrawing life support: all we can do is educate the patient & family 

• Aggressive Treatment Options

  • Aggressive treatment options: not your decision, you need to advocate for your patient 

How Nurses Describe a “Professional Nurse”

•  The best professional nurses are:

  • Highly experienced

  • Well-educated, with a minimum of a
    bachelor’s degree

  • Certified in a specialty area

  • Innovative 

  • Confident 

  • Passionate about nursing

How Patients Describe a “Professional Nurse”

• Patients view a professional nurse as someone who has 

  • Good interpersonal skills 

  • Critical thinking ability 

  • Empathetic, caring practices

Engagement in Profession

• Involvement in local committees or organizations related to nursing

• Involvement in state and/or national nursing organizations

• Mentorship

• Maintain Necessary Qualities

Interrelated Concepts for Professionalism

Interrelated Concepts for Ethics

Nurse Well-Being

Elimination Interrelated Concepts

Irritable Bowel Syndrome (IBS)

• very common

• GI disorder characterized by abdominal pain & changes in bowel habits

• it can cause discomfort 

• it can affect someone’s quality of life, but it doesn’t cause permanent damage internally 

• can be constipation or diarrhea 

• it can be chronic

• it can reoccur 

• IBS & IBD are not the same

Irritable Bowel Syndrome Facts

• Can be chronic or recurrent diarrhea, constipation, abd pain & bloating

• Effects 10% - 15% of people in the US

• Fried foods, caffeine, carbonation, dairy, ETOH, fake sugars 

• Common w/ hx of bowel infections

• 2x more common  in women vs men

• you always feel like you have the urge to go 

• IBS is mostly psychosocial 

  • stress is what drives this

  • it may be genetic or hormonal

  • it is also intermittent (or could be chronic)

IBS Classifications

• Long-term that is managed but not curable

• No permanent damage to intestines

Psychosocial Factors in IBS

• Psychologic stressors are associated with development and exacerbation of IBS

  • Anxiety

  • Stress

  • Panic disorder

  • Depression

• IBS can lead to additional stress

IBS Labs & Assessments

• H & P:

  • Talk to the patient about their concerns

    • get them to ask questions

    • connect patient with a social worker so that they can control their stress

      • you do not need a doctor to write an order for a social worker, you can write one yourself 

      • stress management may help the symptoms go away or it may lessen symptoms

  • Questions you would need to ask: 

    • bowel patterns

    • stool characteristics

    • pain

    • diet 

      • diet that may promote IBS

        • dairy, gluten, alcohol, caffeine, fake sugars  

    • recent travels

    • medications

    • Usually IBS doesn’t affect their weight since they don’t have it often enough for it to affect their weight

      • it may not even affect their nutritional status

    • You’d want to do an abdominal focus assessment 

      • IAPP

• CBC - WBC:

  • CBC

    • we want to look at that WBC so that we can rule out any inflammation or infection

• Serum albumin:

  • Serum Albumin

    • we need to check serum albumin to monitor malabsorption

      • we need protein for healing and for medication absorption

• ESR, CRP

  • tell us that there is inflammation in our body

• Stools for occult blood

  • we also want to look in the stool for occult blood 

    • this may be from a GI bleed, hemorrhoids, excoriations, etc

    • you need to take a look at the tissue in that area 

  • MAY ALL BE NORMAL!

  • we want to do a stool specimen so that we can rule out infections

• Hydrogen breath test

  • npo 12 hrs

  • tests for malabsorption

  • if patient has a problem with malabsorption, they will have a high hydrogen breath test

  • patient ingests a whole bunch of lactulose 

  • they run the test every 20 minutes for every one - two hours 

• F&E

  • we need to make sure that they are balanced

Treatment other than meds:

• Self care management & stress management

• Dietary teaching

  • we need to teach the patient to avoid irritating foods (lactulose, dairy, gluten, etc.), to rule out that the abdominal issues isn’t caused by their diet. 

• Complementary therapy (stress reducer)

• Dietary fiber (30-40 g each day)

  • if the patient isn’t getting enough fiber we only recommend that the patient increases it by 20g a day at a time 

    • if you do it too quickly it’ll promote gas, which may be really painful 

• 8-10 glasses of water per day

• Probiotics or peppermint oil caps 

  • to help with s/s

Meds Used For IBS-D

• Imodium (loperamide)

• Rifaximin is an antibiotic that may cause constipation

• Alosetron (Lotronex), only for women

Meds Used For IBS-C

• Linzess (linaclotide)

  • Take Linzess once daily about 30 minutes before breakfast on an empty stomach

  • Linzess is contraindicated in:

    • Patients with GI obstruction

    • Children younger than 17 years of age

  • Why It's Effective for IBS-C

    • Unlike simple laxatives that only address constipation, Linzess offers a dual benefit—it not only helps with bowel movements but also provides pain relief from the cramping and abdominal discomfort that often accompanies IBS-C . This makes it particularly valuable for IBS patients who experience both constipation and pain.

    
    

• Lubiprostone (Amitiza)

  • is a chloride channel activator indicated for treating chronic idiopathic constipation and constipation-predominant IBS (IBS-C) in women 18 years of age and older 

    • Take with food and water 
      
      

Meds used with any IBS

• Metamucil (psyllium hydrophilic mucilloid) is a bulk-forming laxative that can effectively treat both constipation and diarrhea due to its unique hydrophilic (water-retaining) properties.

  • you can always do metamucil but you need to make sure that you increase your fluids

  • you can also take imodium, but you need to make sure that the diarrhea isn’t caused by an infectious agent, so we need to do a stool culture first. 

• How It Works for Both Conditions

  Bulk-forming laxatives increase water absorption, which results in greater total volume (bulk) of the intestinal contents. The hydrophilic properties help prevent both dry, hard stools AND liquid stools.

  
  

• For Constipation (IBS-C):

  • Psyllium is generally taken at mealtimes with a glass of water 

  • It absorbs water to soften hard stools and add bulk, making them easier to pass 

  • It produces normal, formed stools 

  
  

• For Diarrhea (IBS-D):

  • Psyllium can be used as a treatment option alongside antidiarrheal agents like loperamide 

  • Natural bran and commercial preparations of psyllium are inexpensive and effective treatments for mild diarrhea 

  • The bulk-forming action absorbs excess water in liquid stools, helping to form more solid stool 

• Bentyl = helps with cramping 

  • antispasmodic 

• Levsin (Hyoscyamine Sulfate)

  • antispasmodic

  • Levsin is the brand name for hyoscyamine, an anticholinergic medication used to treat various gastrointestinal conditions. It works by reducing muscle spasms in the digestive tract and decreasing stomach acid production.

Inflammatory Bowel Disease

• On the basis of clinical manifestations, 

  IBD is classified as either:

  • Ulcerative Colitis

  • Crohn’s

• Over 3 million people have IBD

  • split half-half for which have Crohn’s and UC

Ulcerative Colitis

• Inflammation and ulceration of the colon and rectum

  • inflammation first, usually goes from the rectum all the way up 

Crohn’s

• Inflammation of any segment of the Gl tract from mouth to anus

  • any segment can become inflamed

    
    

• most commonly affects the terminal ileum

Inflammatory Bowel Disease: Pattern of Inflammation

• Inflammation patterns differ between Crohn’s disease and ulcerative colitis

  • we can check the pattern of inflammation by doing a colonoscopy

• Chronic disorders

  • both chronic disorders 

  • Patients suffer mild to severe acute exacerbations that occur at unpredictable intervals over their lifetimes

    • they can occur regularly or irregularly 

• Important to get a good history and physical assessment

• Ulcerative Colitis only involves the mucosal layer, Crohn’s is transmural (it can go through all of the layers and can occur everywhere).

IBD Clinical Manifestations

• Diarrhea

• Bloody stools (more common with UC)

• Weight loss (more common in Crohn’s)

  • Crohn’s = nooks and crannies; stuff gets stuck, stuff doesn’t get absorbed, nothing to absorb nutrients 

• Abdominal pain

• Fever

• Fatigue

• Monitor pt for whatever stools theyre having; diarrhea, bloody, etc

• monitor for any weight loss or pain that they may be experiencing 

• low grade fever because of inflammation

• we need to make sure that we’re listening 

  • and we’re doing a good focused abdominal assessment 

  • we won’t hear bowel sounds 24-48 hours after surgery 

IBD Complications

• Hemorrhage/perforation

  
  

• Abscess formation

  
  

• Toxic megacolon

• Intestinal malabsorption

• Nonmechanical bowel obstruction

  
  

• Fistulas

  
  

• Colorectal cancer

IBD Complications: Hemorrhage/Perforations

• Lower GI bleed r/t erosion of bowel wall

IBD Complications: Abscess Formation

• Pockets of infection develop in the ulcerated bowel lining

• Abscess formation seen a little more commonly with crohn’s 

IBD Complications: Toxic Megacolon

• Massive dilation of the colon

• rare but life threatening condition. large intestine dilates & it dilated over 1 - 3 days, so as the colon expands it isn’t able to perform peristalsis, the empty space bloats up with gas. As gas and stool build up, the colon may rupture 

  • this condition may even lead to peritonitis, hemorrhaging, and sepsis

  • very life threatening 

  • anyone with toxic megacolon is at risk for perforation; patient may even need an emergency colectomy 

  • more commonly seen with ulcerative colitis because that mucosal wall is so weak 

  • if the patient hemorrhages they can become anemic; may even need blood transfusions & iron supplements (iron can be constipating)

IBD Complications: Intestinal Malabsorption

• Nutrients cannot be absorbed in diseased bowel – anemia / malnutrition result – mostly in Crohn’s

• with IBD you should also be considering extra intestinal issues: Flare up arthritis, liver disease, biliary disease, oral lesions, skin lesions, eye issues, osteoporosis 

  • due to malabsorption

IBD Complications: Nonmechanical Bowel Obstruction

• Obstruction from toxic megacolon or cancer

IBD Complications: Fistulas

• Crohn’s pts get these r/t transmural bowel

IBD Complications: Colorectal Cancer

• Pt with UC > 10 yrs run risk

Anatomy of the small intestines

• Duodenum

• Jejunum

• Ileum

• DJI

Anatomy of the large intestine

• Cecum

• Ascending Colon

• Transverse Colon

• Descending Colon

• Sigmoid Colon

• Rectum

UC vs Crohn’s Intestines

• Crohn’s = you still may get some nutrition because you still have some good bowels 

  
  

• UC = starts at the rectum and keeps progressing upward; you don’t absorb anything from a bowel that’s inflamed. The higher that it progresses, the more problems that you’re going to have.

  
  

• UC mainly affects the large intestines, we have to worry abt Crohn’s more with the small intestines  

  
  
  

Ulcerative Colitis Facts

• May occur at any age

• Cause unknown

• Onset peaks usually between ages 20 - 35 

  • due to an increase in stress levels (stress aggravates the disease but doesn’t cause it)

• Equally affects both sexes

• Remissions and exacerbations

  • Goal of treatment: keep it in remission & have less frequent exacerbations

• Thought to be genetic for some

  • may be a mix of genetics, autoimmune dysfunction, & environmental factors (like stress)

Ulcerative Colitis Pattern of Inflammation

• A disease of the mucosal layer of colon and rectum

  • mucosal layer is the innermost layer of the bowel
    
    

• Usually starts in the rectum and moves in a continual manner toward the cecum

Healthy Colon vs. Ulcerative Colitis

• the mucosa becomes hyperemic (a lot of blood flow)

  • may be the reason why a lot of patients may have blood in their stool

  • it gets very edematous, red, & irritated 

Ulcerative Colitis Clinical Manifestations

• Bloody diarrhea with pus

• Large fluid and electrolyte losses

• Can have small erosions, ulcers, abscesses & tenesmus

  • tenesmus = really feeling the urge that you need to go; you never feel like you’ve finished going due to feeling all of the swelling in there

• Can lead to narrowed colon, possible bowel obstruction

• Severity is classified

• Breakdown of cells results in protein loss through stool

• At risk: diet of high animal fats and sugar and low fruits and vegetables

Ulcerative Colitis Classified Severity: Mild

• <4 stools a day, w/ or w/o blood, still asymptomatic, labs still look normal

Ulcerative Colitis Classified Severity: Moderate

• >4 stools, w/ or w/o blood, minimally symptomatic, ESR & CRP may be elevated

Ulcerative Colitis Classified Severity: Severe

•  >6 absolutely bloody stools, tachycardic, fever, could become anemic, probably have pain, Inflammation labs are definitely going to be elevated 

Ulcerative Colitis Classified Severity: Fulminant

• >10 bloody stools, Patient has for sure bloody stools, worse symptoms, anemia so bad may need transfusion, we need to watch these patients very closely, the cells within that bowel are going to break down, loss of protein, 

  
  

• if they have a diet high in animal fat, high sugar, low fruits & vegetables (low fiber) they are going to be more at risk 

Ulcerative Colitis: Severe Clinical Manifestations

• Dehydration

  • Dehydration can occur from having diarrhea or because patient doesn’t want to eat or consume anything

    • we want to make sure that our patient is getting good food and nutrition

    • we can also check the urine’s specific gravity and osmolality to check for dehydration 

• Anemia

  • we have to check blood count

• Fever

• Tachycardia

Ulcerative Colitis History Assessment

• we need a good history 

  • how long have they had this problem?

  • have they been treated for it before?

  • family hx?

  • look for nutrition history

  • whats their elimination pattern

  • if its UC we need to know which level its at

  • any abdominal pain?

  • Have they recently used any NSAIDs

    • can put you at risk for gastric bleeding 

    • any other meds that may cause the problem

  • Surgery history 

Ulcerative Colitis Physical Assessment

• first you need to perform a focused abdominal assessment 

  • you need a good focus assessment on the abdomen 

• you can also check for dehydration by looking for tenting 

  • look for extraintestinal symptoms like lesions, sores, or fissures in the mouth 

    • arthritis, mouth sores, vision issues, skin issues, pain in the joints, etc. 

    • due to malabsorption

  • is there any increase in stress that may be causing an exacerbation

  • patient may have excoriations in the perineal area so we may have to be using barrier cream

Ulcerative Colitis Psychosocial Assessment

• What kind of support system do they have?

• are they diagnosed with depression or anxiety?

• Any recent life events; whether good or bad major life events can become stressful

Ulcerative Colitis Testing

• Labs

  • CBC for Hgb/Hct/WBC

    • Hemoglobin and Hematocrit would tell us about whether theyre anemic 

    • 
      

  • Albumin for protein loss

  • Electrolytes (Na, K, chloride)

  • ESR and CRP

  
  

• Imaging

  • MRE

    • Magnetic resonance enterography 

      • they can look at bowel movements, wall, mesentery, and the surrounding area 

      • patients have to fast 4-6 hours before they get that test & there is a contrast medium that they have to drink, so we need to ask the patient about allergies

  • EGD and/or Colonoscopy and/or CT

    • Colonoscopy 

      • usually every 10 years, unless there's another reason why you would be getting it more often (family history, polyps, etc.)

      • patient has to drink prep beforehand 

        • most people don’t want to drink all of it

  • Barium enema

    • also used to diagnose UC vs Crohn’s 

    • this will help see mucosal patterns or alterations

Colonoscopy

• Colonoscopy allows for examination of the entire large intestine and it’s lumen all the way up until the most distal part of the ileum 

  • tells us the extent of the inflammation, if there's any ulcerations, polyps, strictures, the doctor can get a biopsy from this as well; can rule out cancer, 

  • you need to drink all of your prep, until you’re passing clear liquid; you can’t have any stool

  • after the procedure you will be having a lot of gas because they put some in during the procedure to help distend things so that they can get a good look around 

  • remember to tell your patient to pass gas before they go home so that they’re not hurting later on. 

• EGD goes the other way (upper GI tract)

• 
  

UC Priority Collaborative Problems

• Frequent bloody diarrhea

  • Leads to fluid/electrolyte imbalances, anemia, and skin breakdown

  • you wouldn’t want to put a brief onto a patient with excessive stools; that can lead to skin breakdown

    • if a patient is incontinent you can put pads or a commode for the patient

• Abdominal pain and cramping

  • Often worsens before bowel movements, affecting comfort and mobility

  • if pt has abdominal pain & cramping we would want to see if we can do anything about that to promote comfort. 

• Fluid volume deficit

  • Due to excessive diarrhea and potential bleeding

  • we need to hydrate our patients 

    • if the patient is unable to drink fluids we may need to get an order for an IV

• Electrolyte imbalances

  • Especially hypokalemia, hyponatremia, from stool loss

  • look for trends, call the doctor and show them if anything looks off

  • sometimes we have to call the doctor for them to check those critical values

• Nutritional deficiencies

  • Due to malabsorption, anorexia, and dietary restrictions

• Anemia

  • From chronic blood loss in the stool

• Fatigue

  • Caused by poor nutrition, anemia, and chronic inflammation

  •  pts are going to be tired from diarrhea, fluid volume loss, from potential anemia

• Weight loss

  • Related to inadequate intake and malabsorption

  • can be from excessive diarrhea or from a fear of intake becoming diarrhea so the pt may not be eating 

  • in the hospital we will be doing daily weights, & when they get home they will be weighing themselves a couple times a week 

• Risk for impaired skin integrity

  • Especially in the perianal area from frequent, loose stools

• Psychosocial stress / anxiety

  • Due to chronic disease burden, urgency, and fear of flare-ups

• Risk for infection

  • Related to mucosal breakdown and immunosuppressive therapies

• Medication side effects

  • From corticosteroids 5-ASA’s & immunosuppressants

• Risk for bowel perforation or toxic megacolon

  • In severe or fulminant UC cases

  • Tell tale assessment of a perforation or peritonitis 

    • rigid-boardlike abdomen 

    • IAPP

Ulcerative Colitis Nutritional Issues

• Watch fruits & vegetables, if we have to give them then they have to be in small amounts
  
  

• Ulcerative Colitis 

  • best diet after being diagnosed with UC is a low residue diet 

  • bc the GI tract is irritated 

  • avoid high fiber, you don't want stool to move through too quickly 
    
    

• watch caffiene 

Fruits & Vegetables with high fiber:

• Examples of fruits with high fiber: bananas, apples, berries, avocados, etc. 

• Examples of vegetables with high fiber: most of them: carrots, potatoes, broccoli 

  • broccoli causes a lot of gas that may be irritating to the patient's stomach 

Low Residue Diet

• very refined grains, well cooked vegetables, very ripe fruit, limited dairy & fats, high protein, high good calories, watch fiber

• Refined Grains

  • Breads and Baked Goods:

    • White bread

    • White sandwich buns and rolls

    • Most crackers

    • Flour tortillas

    • Pretzels

    • Pancakes and waffles made with white flour

    
    

  • Cereals and Grains:

    • White rice

    • Enriched pasta (regular pasta made from white flour)

    • Most cold cereals (unless labeled "whole grain")

    • Cream of Wheat

    • Grits (unless whole grain)

    
    

  • Other Products:

    • White flour (all-purpose flour)

    • Cornbread made with degermed cornmeal

    • Biscuits

    • Muffins made with white flour

    • Pizza crust made with white flour

    • Bagels made with white flour

Collaborative Care IBD Drug Therapy

• Drugs are chosen based on severity and location of inflammation:

  • Step-down approach

    • Step down: this is when the patient’s condition is very severe or fulminate, we start with the heavy hitters to stop over reaction & then take it down as long as they have control, if they lose that control were going to have to go back up. 

    • Uses stronger meds first 

  • Step-up approach

    • Step up: we gradually increase med dosages until we see that it’s working

    • Uses less toxic therapies first

    • More toxic meds are started when initial therapies do not work.

UC Drug Therapy

• Goals of drug treatment are to induce and maintain remission

  • 5-Aminosalicylates (5-ASA)

  • Glucocorticoids

  • Immunosuppressants

  • Antibiotics

  • Biologic response modifiers (BRM’s) 

      -  aka immunomodulators & different strengths

5-Aminosalicylate (5-ASA)

• sulfasalazine (Azulfidine)

  • Need folic acid supplements with sufasalazine

• mesalamine  (Asacol & Pentasa)

  • Some 5-ASAs come as a topical; we can apply them rectally right on the area of inflammation

    • tolerated a little better than the sulfasalazine

    • may come in an enema form or suppository 

      • fewer side effects 

      • doesn’t go through first-pass effect

      • works right on the tissue

5-Aminosalicylate (5-ASA) Nursing Considerations

• Decreases GI inflammation

  - Effective in achieving and maintaining remission

  - For mild to moderately severe attacks

  - Takes 2-4 weeks to work

  • Although these meds take a long time to work you can’t stop taking them abruptly you would have to ween off of them 

    
    

    • turns skin & urine orange or yellow 

    
    

    • can decrease the immune system

      • we need to do proper teaching to make sure that the patient doesn’t end up with an infection

        • proper hand hygiene, watch large crowds, teach signs and symptoms of an infection, report fever or signs of infection

    
    

    • Doesn't work for severe or fulminate 

• you need to check order to see whether or not you may crush a med, if you aren’t sure then call pharmacy and ask! 

• if the med can’t be crushed & your patient can’t take it then call the physician and ask for the route to be changed 

Glucocorticoids

• prednisone/Prednisolone

• budesonide – works specific in bowel/fewer systemic issues

• Used for acute flare up/exacerbation

• Must be tapered off

  • must be tapered off before surgery 

• we want to give these for the shortest amount of time

  • we want to avoid side effects associated with long term use

  • any corticosteroid has to be tapered down when you take it 

  • if the patient is going into surgery they may have to taper off of these

• if they have rectal inflammation they can get a rectal enema or suppository with some of these as well 

Biologic Response Modifiers (Immunomodulators):

• infliximab (Remicade)

  • infliximab (Remicade) is given IV 

    
    

• adalimumab (Humira)

• Alters immune response

• To induce and maintain remission

• Watch for s/s of infections

  • Patients on Immunomodulators have to watch for s/s like cough, fever, dyspnea, any signs of infections. 

  • we need to monitor their CBC when they’re on this medication. 

  • this medication may also take a while to work 

  • these medication are used for more long term maintenance of remission rather than acute.

• contraindicated with cancer, heart disease, or multiple sclerosis 

  • they can not take this medication

UC Collaborative Care

• Nutritional therapy

  • If pt has severe or fulminante UC we would expect to see the patient to be put in an NPO diet to give their bowels a rest. 

    • we need to stop feeding the patient and call the physician to see how they would like for them to progress 

    • we may have to get an order for TPN

    • sometimes they may be given elemental nutrition like the protein drinks, (example: ensure) depends on the patient. 

• Rest

• Complimentary and Integrative Health

• Surgery 

  • if the patient gets toxic megacolon, hemorrhaging, bowel perforation, cancer 

    • the patient may need to have surgery.

  • patient may need to be NPO, call physician & ask 

    • give patients pre-op antibiotics for abdominal surgery 

    • if you don’t see an order for antibiotics then you would want to ask 

  • Temp or perm ileostomy

Restorative proctocolectomy with ileo pouch & anal anastomosis (RPC-IPAA)

• Chronic Ulcerative Colitis: Surgical Therapy

• Gold Standard in UC

  • Laparoscopic

  • 2 stage procedure

    • 1st surgery

      • remove the colon, most of the rectum, the anas & the sphincter

      • they form an internal pouch (called a j pouch sometimes), & that’s connected to the anas, 

      • they have a temporary ileostomy created through the abdominal wall to give the bowels a rest & let the anastomosis heal,

      
      

    • 2nd surgery 

      • once the first surgery is all healed they come back for their second one

      • they take out the ileostomy and close it up, & direct the stool towards the new reservoir. 

      • abt 1-2 months later depending on when the patient heals, age, etc.

  
  

  • usually patient can gain continence after this procedure. 

  • After the second stage, after they’ve reconnected their bowels, at first when they’re having their stools it’s probably going to burn due to all of the gastric acid in it, since its not being absorbed as well by the ileum since it just got redirected. 

  
  

  • we want to omit any foods that cause odor or gas

    • cabbages, broccoli, beans

  
  

  • omit foods that are hard to digest 

    • corn & nuts 

  
  

• patient may also have some body image issues after receiving an ileostomy 

Foods that cause blockage

• nuts, corn, popcorn, coconuts, mushrooms, stringy vegetables, and foods with skins and casings

Foods that may help thicken stool

• bananas, cheese, pasta, rice, yogurt, applesauce, potatoes

Constipating Foods

• Cheese, lean meat, eggs, pasta

Foods with Laxitative affects

• fruits and vegetables, bran, chocolate, alcohol, coffee

Gas Producing Foods

• onions, cabbage, beans, cauliflower, broccoli

Total proctocolectomy with permanent ileostomy

• Chronic Ulcerative Colitis: Surgical Therapy

• this can be considered curative for UC

• a total colectomy may be curative  

  
  
  

• this will be done for patients who may not be a candidate for Restorative proctocolectomy with ileo pouch & anal anastomosis (RPC-IPAA)
  
  

• they remove the colon, the rectum, the anas, they surgically close the anas 
  
  

• bile salts & a lot of enzymes are in stool, so if they have a stoma you have to watch the skin around the stoma site very carefully

  • you dont want the stoma site to break down because of those bile salts & enzymes 
    
    

• this is very life changing for a patient, so we need to listen to the patient

  • this surgery may cause a lot of body image issues

  • we need to make sure that the physician answers all of our pts questions. 
    
    

• stoma bags have to be changed frequently 
  
  

• about 1-4 days will be spent at the hospital, depending on whether or not it’s done laparoscopically or opened.  

Ileostomy

• if the stoma looks pale or dark bluish then that would be concerning 

• we need to watch the pts stoma and make sure it’s nice & healthy 

• Opening from ileum thru abdominal wall

  --TX ulcerative colitis & crohn's disease

• they have to empty this every two hours while they’re awake, right before bed, & right when they wake up. 

Ileostomy Post Operative Care

• Output may be as high as 1500-2000 mL per 24 hours

  • it may take 24 hrs for it to start draining once its put on

    • once it’s draining we need to make sure we replace that fluid

    • at least 500 mls of fluid daily if it’s not contraindicated 

      • may be contraindicated in patients with kidney or heart failure.

  • watch your patient for dehydration

    • a lot of output initially comes out 

• Observe for hemorrhage, abdominal abscess, small bowel obstruction, dehydration

  
  

• Initial drainage will be liquid

  • At first the liquid that’s going to be coming out will be dark green (bc of bile) w/wo blood, but as time goes on and the body becomes more assimilated to the change it’ll get pastier, yellowish green or yellowish brown.

  • initially the fluid will come out smelling sweet, if it smells nasty there’s a problem. 

    • there could be an infection

  • It takes about a week for waste to get to the point to where it’s not just clear liquid coming out and for it to start forming 

    • during that time the patient may need some antidiarrheals 

    • watch diet

      • foods that aren’t easily as digested

    
    

• Stoma care imperative

  • Patient is also at risk for infection so you have to watch out for that. 

    
    

• May have temporary NGT (not with MIS)

  • Make sure NGT is patent & working 

    
    

• Monitoring of stoma viability and peristomal skin integrity

  • remember to watch their skin

    • apply their skin barrier

    • keep their skin clean 

      • clean it very gently with a mild cleanser, rinse well, pat dry, dry thoroughly, moisture barrier ointment may be used & you might need a perineal pad at first

• ileostomy drains frequently so the patient needs to wear their pouch 24/7 even when theyre going to bed 

Crohn’s Diet before vs after diagnosis

• high fiber, fruits, & vegetables intake are associated with a decreased risk in getting crohn’s

  • good diet before being diagnosed with crohn’s 

  • decrease the risk 

  • Once you’re diagnosed with Crohn’s you would want to switch to a low fiber diet, because we don’t want stool to be coming out too fast

• Vitamin B12

Crohn’s Disease Facts

• Transmural

  • goes through multiple layers of the bowel

• Can occur anywhere in the GI tract

  • Skip Lesions

• Occurs most commonly in the small intestine, terminal ileum and colon

• Progressive 

• Remissions and exacerbations

• Often exacerbated by bacterial infection

Skip Lesions

• Skip lesions

  • Seen in Crohn’s

  • Segments of normal bowel that are present between diseased portions

  • Results in a cobblestone appearance

Regular Bowel vs Bowel with Crohn’s Disease

• stuff may get stuck between the “nooks & crannies”

Crohn’s Disease Pattern of Inflammation

• Inflammation through entire wall

  
  

• Microscopic leaks

  • this can allow bowel content to go to places where it’s not supposed to be in

    
    

• Bowel contents into peritoneal cavity

  
  

• Abscesses

  • things get stuck in the nooks & crannies, which leads to an infection and to another problem

    
    

• Peritonitis

Crohn’s Disease: Fistulas

• Fistulas = opening or tract between two structures 

  • not supposed to be there 

  • occur due to those “nooks & crannies” & erosion

• Fistulas can develop: 

  • Between adjacent areas of bowel

  • Between bowel and bladder

    • you may see stool in their urine 

    • if a patient has a diagnosis of Crohn’s and is coming in with a UTI, you would assume that they have a fistula between their bowel and their bladder

  
  

  • Between bowel and vagina

    • you may see stool coming out in discharge

  
  

  • Can form a tract through the skin to the outside of the body

    • stool can leak through the skin

• Because these patients are at a high risk for fistulas, they are at a high risk for abscesses and sepsis 

  • we need to watch WBCs

Crohn’s Disease Clinical Manifestations

• Diarrhea w/wo blood

• Steatorrhea

  • grey-fatty stools usually due to a gallbladder issue 

• Nutrition & hydration issues

• F & E Imbalance

• Anemia ( iron deficient and/or B-12 deficient)

  • Patients with Crohn’s are more prone to having a vitamin B12 deficiency because Crohn’s targets the terminal ileum, which is where we process our B12 

Crohn’s Assessment

• Same assessment as UC

• you need to get a good history

• bowel patterns, nutrition history, pain history, infection history

Crohn’s Disease Complications

• Nutritional problems

  • Cobalamin are absorbed exclusively in terminal ileum

  • Poor nutrition = delayed healing 

  • TPN

  • Low iron absorption if blood loss

Iron Deficient Anemia – What does it look like?

• Iron deficient anemia

  • Common with UC

    • you can have it with crohn’s but it’s more common with UC 

  • R/T GI bleeding

    • they can’t absorb iron because of the inflammation & they also can’t absorb iron because they’re bleeding 

  • patients may have very small immature red blood cells 

    • could also affect their oxygenation

  
  

• Signs & Symptoms

  • Weakness

  • Pallor

  • Fatigue

  • Reduced activity intolerance

  • Fissures at corner of mouth

  
  

• Labs

  • CBC for Hgb/Hct

  • Serum iron

  • Ferritin

  • Total iron-binding capacity (TIBC)

Megaloblastic Anemia

• Vitamin B12 deficiency or malabsorption issue due to the terminal ileum being inflamed. Could also be a problem with bone marrow; unusually large abnormal immature red blood cells, so they can’t do their job.

• We usually give B12 by injections because of the malabsorption  

Diagnostic Studies for Crohn’s

• Labs:

  • CBC for Hgb/Hct/WBC

  • Albumin for protein loss

  • Electrolytes (Na, K, chloride)

  • ESR and CRP

  • Folic Acid

  • Vitamin B-12

  • WBC in urine r/t fistula

• Imaging:

  • X-ray

  • MRE

  • Colonoscopy

• same thing as UC, but we just added folic acid and vitamin B12 

• in early Crohn’s it is very similar to IBS, which is why you have to go through a lot of testing 

Crohn’s Priority Collaborative Problems

• Abdominal pain and cramping

  • Often in the right lower quadrant, worsens after meals.

• Chronic diarrhea

  • May be non-bloody or bloody, often accompanied by urgency.

• Weight loss and malnutrition

  • Due to decreased intake, malabsorption, and increased metabolic demands.

• Fatigue

  • Linked to anemia, chronic inflammation, and poor nutrition.

• Anemia

  • From chronic blood loss, iron deficiency, and vitamin B12 malabsorption (especially with terminal ileum involvement).

• Fluid and electrolyte imbalances

  • From persistent diarrhea and reduced oral intake.

• Fever and low-grade systemic inflammation

  • From ongoing immune activation.

•  Perianal disease

  • Fissures, fistulas, abscesses, and skin tags.

• Fistulas and strictures

  • Due to transmural inflammation—can lead to bowel obstruction or infections.

• Risk for bowel obstruction

  • Caused by strictures or scar tissue from chronic inflammation.

•    Skin breakdown / impaired skin integrity

  • Especially in perianal or fistula areas

•    Psychosocial issues

  • Depression, anxiety, and social isolation due to unpredictable symptoms.

•    Medication side effects

  • From steroids (Cushingoid effects), immunosuppressants, and biologics (risk of infection).

•    Risk for colon cancer (long-term)

  • Especially with disease duration >10 years, though risk is lower than UC.

Collaborative Care for Crohn’s

• Goals of treatment

  • Rest the bowel

  • Control inflammation

  • Combat infection

  • Correct malnutrition 

  • Alleviate stress

  • Relieve symptoms

  • Improve quality of life

• we don’t know what causes crohn’s so we treat the inflammation

• we want to keep the patient in remission with less exacerbation

• Surgery isn’t recommended to treat Crohn’s, since it will eventually just form again 

  • then you get short bowel syndrome 

Collaborative Crohn’s Drug Therapy

• Goals of drug treatment are to induce and maintain remission

  • 5-Aminosalicylates (5-ASA)

  • 6-mercaptopurines

  • Antimicrobials

  • Glucocorticoids

  • Immunosuppressants

  • Biologic response modifiers (BRM’s)

      - aka immunomodulators & different strengths

• 6-mercaptopurines & Antimicrobials are specific to Crohn’s and not UC 

Crohn’s: Biologic response modifiers (BRM) (immunomodulators)

• Biologic response modifiers (BRM) (immunomodulators)

  • infliximab (Remicade) (IV)

  • adalimumab (Humira)

  • natalizumab (Tysabri)

  • certolizumab pegol (Cimzia)

• Alters immune response

• To induce and maintain remission

• Watch for s/s of infections

• These are very heavy hitters and only used when other therapies don’t work 

• got to watch CBC with all of these

• usually we don’t start with these