Inflammatory Bowel Disease ppt

INFLAMMATORY BOWEL DISEASE CROHN’S DISEASE A. Case Scenario Janine, a 22-year-old woman, comes to your office with a 6-week history of 5 loose, nonbloody stools daily, right lower quadrant abdominal pain (especially after eating), 20-lb weight loss. Findings from the physical examination show a definite and moderately tender 5-cm mass in the right lower quadrant of her abdomen. Results from the stool studies are negative for enteric pathogens, and the results from her blood work show mild anemia (hemoglobin, 11.2 g/dL), with a normal metabolic panel and normal thyroidstimulating hormone levels. Radiographic findings demonstrate a 10-cm narrowing in the terminal ileum (string sign) with a separation of bowel loops around the terminal ileum.

B. Overview  Defined as chronic inflammatory condition of the bowel in which there are patchy areas of inflammation anywhere in the entire GI tract; most common in the ileum or colon; referred to as inflammatory bowel disease (IBD) and grouped with ulcerative colitis because symptoms are similar  Incidence is higher among young adults and teenagers; occurs equally in both genders; more often seen in clients of Jewish and Caucasian race  Develops slowly, with remissions and exacerbations; emotional factors related to family matters or work aggravate the illness  Cause is unknown but thought to be multifactorial, probably involving an infectious process (bacteria, viruses, mycobacteria), allergy or immune disorder, psychosomatic, dietary, hormonal, and environmental factors

C. Clinical Manifestations  Inflammatory lesions may occur anywhere from the mouth to the anus; more often lesions occur in the ascending colon, distal ileum, and anorectal areas  Primarily submucosal -All layers of the bowel are involved, with the submucosal layer affected to the greatest extent  Cobblestone appearance -Resulting from the fissures and crevices that develop surrounded by areas of submucosal edema  Skip lesions -Characteristic feature of CD is the sharply demarcated, granulomatous lesions that are surrounded by normal appearing mucosal tissue -They are interspersed between what appear to be normal segments of the bowel  Scar tissue may interfere with movement of chime and perforation or obstruction may occur

D. Complications  Fistula formation -Fistulas are tubelike passages that form connections between diff sites, including the bladder, vagina, urethra, and skin. -Perianal fistulas- that originate in the ileum are relatively common and may lead to malabsorption, syndromes of bacterial overgrowth, and diarrhea  Abdominal Abscess formation - Fistulas can also become infected and cause abscess formation -The bowel becomes congested, thickened and may develop abscesses  Intestinal obstruction -Scar tissue may interefere with movement of chime and perforation/obstruction may occur  Fluid and electrolyte imbalance  Deficiency in absorption of folic acid, calcium and vitamin D

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Signs/Symptoms Intermittent diarrhea Weight loss Intermittent localized pain in the right lower quadrant (worsening as the disease progresses) F/E imbalance Dehydration Elevated WBC Iron deficiency anemia Fever Physical development and Growth retardation

F. Nursing Assessment  Nutritional and fluid status  Bowel pattern assessment  Daily weight  Activity tolerance  Visual examination of stool  History of risk factors/ stress level and emotional factors  Vital signs  Skin/nail color changes secondary to anemia

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Diagnostic Findings CBC (elevated WBC, low RBC, Hgb, and Hct) FE imbalance Barium enema (reveals characteristic “string sign” or skip lesions) Albumin level (low) High erythrocyte sedimentation rate (ESR)

H. Diagnostic Tests  Proctosigmoidoscopy  Visualizes ulcerations, edema, hyperemia, and inflammation (result of secondary infection of the mucosa and submucosa). Friability and hemorrhagic areas caused by necrosis and ulceration occur in 85% of these patients.  Endoscopic examinations, e.g., sigmoidoscopy, esophagogastroduodenoscopy, or colonoscopy  Identifies adhesions, changes in luminal wall (narrowing/irregularity); rules out bowel obstruction and allowed biopsy for features of Crohn’s disease or ulcerative colitis.  Stool specimens  (examinations are used in initial diagnosis and in following disease progression)  Mainly composed of mucus, blood, pus, and intestinal organisms, especially Entamoeba histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract. Stool positive for bacterial pathogens, ova and parasites or clostridium indicates infections. Stool positive for fat indicates malabsorption  Abdominal magnetic resonance imaging (MRI)/computed tomography (CT) scan, ultrasound  Detects abscesses, masses, strictures, or fistulas.  Barium enema  May be performed after visual examination has been done, although rarely done during acute, relapsing stage, because it can exacerbate condition.  CBC  May show hyperchromic anemia (active disease generally present because of blood loss and iron deficiency); leukocytosis may occur, especially in fulminating or complicated cases and in patients on steroid therapy.

I. PHARMACOLOGIC THERAPY 1. Aminosalicylates  The first aminosalicylate was sulfasalazine (Azuldifine), a combination drug that was developed in the 1940s to treat rheumatoid arthritis  Sulfasalazine contains sulfapyridine and 5-aminosalicylic acid 5-ASA. The 5ASA accounts for its therapeutic benefits for IBD. Its exact mechanism of action is unknown, but topical application to the intestinal mucosa suppresses proinflammatory cytokines and other inflammatory mediators.

 When given orally, 5-ASA alone is absorbed before it reaches the lower GI tract where it is needed. When combined with sulfapyridine, 5-ASA reaches the colon. However, many people are unable to tolerate sulfapyridine. Newer preparations have been developed to deliver 5-ASA to the terminal ileum and colon olsalazine(Dipentum), mesalamine (Pentasa) and balsalazide (Colazal) These drugs are as effective as sulfasalazine and are better tolerated when administered orally  May cause yellowish orange discoloration of skin and urine  Avoid exposure to sunlight and UV light until photosensitivity is determined 2. Antimicrobials  Antimicrobials are used to treat CD, although no specific infectious agent has been discovered. Metronidazole (Flagyl), ciprofloxacin (Cipro) and clarithromycin(Biaxin) have been used successfully with CD, but have not been shown to be as effective for UC. 3. Corticosteroids  Corticosteroids such as prednisone are used to achieve remission in IBD, they are helpful for acute flare ups, but are given for the shortest possible time because of side effects associated with long term use 4. Immunosuppressants  Two immunosuppressants, azathioprine(Imuran) and 6-mercaptopurine (Purinethol), are given orally and take 3-6 months to exhibit full effectiveness. They are most useful for patients with CD who do not respond to aminosalicylates, corticosteroids, or antimicrobials. Methotrexate has also been found effective for CD, but patients may suffer flu-like symptoms. 5. Biologic therapy  Infliximab (Remicade) is the first major biologic drug therapy (immunomodulator) to be approved for the treatment of IBD. Infliximab is a monoclonal antibody to the cytokine tumor necrosis factor. It is given IV to induce and maintain remission in patients with active CD and in patients with draining fistulas who do not respond to conventional drug therapy  J. SURGICAL MANAGEMENT  Total Proctocolectomy -The colon and rectum are removed and the anus closed. The terminal ileum is brought out through the abdominal wall and a permanent ileostomy formed.  Ileorectal Anastomosis -The colon is resected, leaving a rectal stump. The terminal ileum is then anastomosed to this stump. This is an early alternative to total proctocolectomy, however, it has several problems. The remaining

rectum is often still affected by the disease, and further treatment, even eventual resection, is often required. There is also a significant incidence of rectal cancer among clients who had this surgery.  Ileal Pouch-Anal Anastomosis -Also known as the J pouch; prevents the need for an ostomy and preserves the rectal sphincter muscle. The rectal mucosa is excised and the colon is removed. An ileoanal reservoir is then created in the anal canal, and a temporary loop ileostomy is formed. After healing has taken place, the ileostomy is reversed and stool drains into the reservoir, which is created by suturing two loops of bowel together.  Continental ileostomy or Kock Pouch -A procedure in which a reservoir or pouch is constructed from a loop of ileum. This allows stool to be stored intra-abdominally until it is drained through a nipple valve made from an intussucepted portion of ileum. This has advantages because the client does not need to wear an external pouch, has minimal skin problems, and usually has no leakage of stool or flatus. The client drains the pouch several times a day using a catheter, usually when a feeling of fullness occurs. K. Nursing Dx 1. Altered Nutrition: Less than Body Requirements r/t diarrhea and malabsorption  Weigh daily.  Encourage bedrest and limited activity during acute phase of illness.  Avoid or limit foods that might cause or exacerbate abdominal cramping, flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, orange juice).  Promote patient participation in dietary planning as possible.  Resume or advance diet as indicated (clear liquids progressing to bland, low residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as indicated). 2. Acute Pain r/t inflamed mucosa  Encourage patient to report pain.  Assess reports of abdominal cramping or pain, noting location, duration, intensity (0–10 scale). Investigate and report changes in pain characteristics  Note nonverbal cues (restlessness, reluctance to move, abdominal guarding, withdrawal, and depression). Investigate discrepancies between verbal and nonverbal cues.  Review factors that aggravate or alleviate pain.  Provide comfort measures (back rub, reposition) and diversional activities. 3. Risk for Ineffective Individual Coping r/t stress and exacerbations of the disease  Assess patient’s and SO’s understanding and previous methods of dealing with disease process.  Determine outside stressors (family, relationships, social or work environment).

 Provide emotional support:Active-Listen in a nonjudgmental manner;Maintain nonjudgmental body language when caring for patient;Assign same staff as much as possible.  Encourage use of stress management skills, (relaxation techniques, visualization, guided imagery, deep-breathing exercises).  Refer to resources as indicated (local support group, social worker, psychiatric clinical nurse specialist, spiritual advisor). L. Nursing Management

1. 2. 3. 4. 5.

Control diarrhea/promote optimal bowel function. Minimize/prevent complications. Promote optimal nutrition. Minimize mental/emotional stress. Provide information about disease process, treatment aspects/potential complications of recurrent disease.

needs,

and

long-term

6. Fluid replacement may be given to correct dehydration; monitor symptoms for dehydration; TPN may be added if necessary to provide for nutritional needs while allowing GI tract to rest M. Diet  Give low-residue, low-fat, high-protein, high-calorie diet

References Book Sources: Hogan, M. A., et.al. (2008). Pathophysiology: reviews & rationales. (2nd. ed.). New Jersey: Pearson Education McCance, K. L. & Huether, S. E. (2006). Pathophysiology: the biologic basis for disease in adults and children. (5thed.). St. Louis, Missouri: Elsevier Mosby. Porth, C.M. & Matfin, G. (2009). Pathophysiology: concepts of altered heath states. (8 thed.). Lippincott Williams & Wilkins. Internet Sources: Inflammatory Bowel Disease (IBD). Retrieved from: http://nurseslabs.com/7-inflammatory-bowel-disease-nursing-care-plans