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NUR 201 Week 10 > Inflammatory Intestinal Disorders > Flashcards

Inflammatory Intestinal Disorders Flashcards

- Crohn's disease - Ulcerative colitis

1
Q

IBD

Characterized by chronic, recurrent inflammation of intestinal tract

  • Periods of remission are interspersed w/periods of exacerbation
A
  • Exact cause is unknown
  • There is no cure
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2
Q

On the basis of clinical manifestations, IBD is classified as either ulcerative colitis (UC) or Crohn’s disease

A
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3
Q

?

Is inflammation of any segment of GI tract from mouth to anus

A

Crohn’s disease

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4
Q

?

Is inflammation & ulceration of colon & rectum

A

Ulcerative colititis

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5
Q

IBD

  • May occur @ any age
    > Common during teenage yrs & early adulthood
    > 2nd peak in 6th decade
A
  • Occurs more commonly in people of white & Ashkenazic Jewish origin
  • Many have a family member w/the disorder
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6
Q

An autoimmune disease

> Involves an immune reaction to a person’s own intestinal tract

> Some agent or combo of agents triggers an overactive, inappropriate, sustained immune response

> Results in widespread inflammation & tissue destruction

A

Involves a combo of factors

> Environmental factors

> Genetic predisposition

> Alterations in immune function

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7
Q

Environmental factors

  • Diet
    > High intake of total fats, PUFAs, omega-6 fatty acids, & meat is assoc w/inc risk of IBD
  • Exposure to air pollution
  • Stress
  • Smoking
A
  • More prevalent in industrialized countries
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8
Q

High vegetable intake is associated w/a decreased risk of which condition?

A

Ulcerative colitis

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9
Q

High fiber & fruit intake are assoc w/dec risk of Crohn’s disease

A

Oral contraceptives & NSAIDs exacerbate Crohn’s disease

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10
Q
  • Numerous genome-wide association studies have confirmed a genetic predisposition
  • Certain genetic mutations are assoc w/Crohn’s disease, others assoc w/UC, & many assoc w/both
  • IBD more likely to occur in those w/other genetic syndromes inc CF
A
  • An inc prevalence occurs in the presence of other inflammatory disorders w/genetic susceptibility like psoriasis & MS
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11
Q

?

This was the 1st gene assoc w/Crohn’s disease

  • Gene changes are assoc w/a form of Crohn’s disease that affects the ileum in persons of northern European descent
  • Gene changes trigger an abnormal immune response that allows bacteria to grow unchecked & invade intestinal cells, causing chronic inflammation & digestive problems
A

NOD2

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12
Q

A genetically susceptible person who is not exposed to a triggering agent will not become ill, & a person who is not genetically susceptible will not develop IBD even if exposed to a triggering agent

A

The pathway from genetic mutation to abnormal immune responses varies depending on which gene or genes are affected
> This variation may explain differences in pt responses to various rx therapies for IBD

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13
Q

?

This condition usually starts in the rectum & moves in a continual fashion toward the cecum
> Although mild inflammation may occur in the terminal ileum, it’s a dz of the colon & rectum

A

Ulcerative colitis

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14
Q

?

This condition can occur anywhere in the GI tract from the mouth to the anus, but most commonly involves the distal ileum & proximal colon

Segments of normal bowel can occur between diseased portions, so-called “skip” lesions

A

Crohn’s disease

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15
Q

Inflammation patterns differ between Crohn’s disease & ulcerative colitis

A
  • Chronic disorders
    > Pts suffer mild to severe acute exacerbations that occur @ unpredictable intervals over many yrs
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16
Q

The inflammation in Crohn’s disease involves all layers of the bowel wall

A
  • Ulcerations are deep & longitudinal & penetrate between islands of inflamed, edematous mucosa, causing the classic cobblestone appearance
  • Strictures @ areas of inflammation can cause bowel obstruction
  • Since inflammation goes through entire wall, microscopic leaks can allow bowel contents to enter peritoneal cavity & form abscesses or produce peritonitis
  • In active Crohn’s disease, fistulas are common
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17
Q
  • For UC, inflammation & ulcerations occur in the mucosal layer, the innermost layer of the bowel wall; fistulas & abscesses are rare since inflammation doesn’t extend through all bowel wall layers
  • B/c water & electrolytes aren’t absorbed through inflamed mucosa, diarrhea w/large fluid & electrolyte losses is common
A
  • Breakdown of cells results in protein loss through the stool
  • Areas of inflamed mucosa form pseudopolyps, tongue-like projections into the bowel lumen
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18
Q

Clinical Manifestations

  • Diarrhea
  • Weight loss
  • Abd pain
  • Fever
  • Fatigue
A
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19
Q

Diarrhea & cramping abdominal pain are 2 common symptoms in which condition?

A

Crohn’s disease

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20
Q

Crohn’s disease

If the SI is involved, wt loss occurs from inflammation of the SI causing malabsorption

A

Rectal bleeding sometimes occurs w/Crohn’s disease, although not as often as w/ulcerative colitis

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21
Q

The primary manifestations of ulcerative colitis are __ __ & __ __

A

bloody diarrhea; abdominal pain

> Pain may vary from the mild lower abd cramping assoc w/diarrhea to severe, constant pain assoc w/acute perforations

  • Mild, moderate, severe
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22
Q

?

In __ dz, the pt has inc stool output (up to 10 stools/day), inc bleeding, & systemic sx’s (fever, malaise, mild anemia, anorexia)

A

moderate

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23
Q

?

In __ dz, diarrhea is bloody, contains mucus, & occurs 10-20x/day

A

severe

  • In add’n, fever, rapid wt loss >10% of total body weight, anemia, tachycardia, & dehydration are present
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24
Q

?

In __ dz, diarrhea may consist of no more than 4 semi-formed stools daily that contain small amts of blood
> Pt may have no other manifestations

A

mild

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25
Q

GI tract (local) complications

  • Hemorrhage
  • Strictures
  • Perforation (w/possible peritonitis)
A
  • Abscesses
  • Fistulas
  • CDI
  • Colonic dilation (toxic megacolon)
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26
Q

Pts w/toxic megacolon are @ risk of perforation & may need an emergency colectomy

Toxic megacolon is more common with which condition?

A

ulcerative colitis

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27
Q

Perineal abscesses & fistulas occur in up to a 3rd of pts w/which condition?

A

Crohn’s disease

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28
Q

CDI (Clostridium difficile infection) inc in frequency & severity in pts w/IBD

A

Hemorrhage may lead to anemia & needs to be corrected w/blood transfusions & iron supplements

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29
Q

Nutritional problems are esp common in Crohn’s disease when the terminal ileum is involved

Bile salts & cobalamin are exclusively absorbed in the terminal ileum

A

Thus, dz in the terminal ileum can result in fat malabsorption & anemia

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30
Q
  • High risk for colorectal cancer
    > Those w/Crohn’s dz are @ inc risk for small intestinal cancer
A
  • Systemic complications
    > Joint, eye, mouth, kidney, bone, vascular, & skin problems
    > Circulating cytokines trigger inflammation
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31
Q
  • Liver failure
    > Routine LFT’s important b/c primary sclerosing cholangitis is a complication of IBD & can lead to liver failure
A
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32
Q
  • In early Crohn’s dz, the sx’s are similar to those of IBS
  • A CBC typically shows iron-deficiency anemia from blood loss
A
  • An elevated WBC count may be an indication of toxic megacolon or perforation and possible peritonitis
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33
Q
  • Decreases in serum sodium, potassium, chloride, bicarbonate, & magnesium levels occur d/t fluid & electrolyte losses from diarrhea & vomiting
A
34
Q

___ is present w/severe dz b/c of poor nutrition or protein loss

A

Hypoalbuminemia

35
Q
  • Elevated ESR, CRP level, & WBC count reflect inflammation
A
  • Stool examination
    > Pus
    > Blood
    > Mucus
  • Stool cultures (can determine if infection is present)
36
Q

Diagnostic Studies

Imaging studies
* Double-contrast barium enema study
* Small bowel series/small bowel follow through
* Transabdominal ultrasonography
* CT
* MRI

A
  • Colonoscopy
    > Allows for examination of the entire large intestine lumen & sometimes most distal ileum
  • Since a colonoscope can enter only the distal ileum, capsule endoscopy may be used to diagnose Crohn’s disease in the SI
37
Q

Goals of IBD treatment

  • Rest the bowel
  • Control inflammation & combat infection
  • Correct malnutrition
  • Alleviate stress
  • Relieve symptoms
  • Improve quality of life
A
  • Goals of drug treatment are to induce & maintain remission
    > Aminosalicylates
    > Antimicrobials
    > Corticosteroids
    > Immunosuppressants
    > Biologic & targeted therapy
38
Q
  • Drug selection depends on severity & location of inflammation
A

> Step-up approach

> Step-down approach

39
Q

?

Uses biologic & targeted therapy first

A

Step-down approach

40
Q

?

  • Uses less toxic therapies 1st (aminosalicylates, antimicrobials)
  • More toxic medications are started when initial therapies do not work
A

Step-up approach

41
Q

Aminosalicylates are more effective for which condition?

A

ulcerative colitis

However, they are first-line therapies for mild-to-moderate Crohn’s disease, esp when the colon is involved

42
Q
  • Exact mechanism of action of 5-ASA is unknown, but topical application to the intestinal mucosa suppresses proinflammatory cytokines & other inflammatory mediators
A
  • Benefits of these drugs usually depend on the dose: the larger the dose, the more likely pts will improve during the acute phase & remain in remission
  • H/e, may ppl cannot tolerate the side effects of sulfasalazine
    > HA’s, nausea, & fatigue occur @ the higher doses
43
Q
  • In men, long-term sulfasalazine treatment may cause abn sperm production, leading to infertility; these effects are reversible if sulfasalazine is discontinued
A
  • Sulfa-free rx’s are as effective as sulfasalazine & better tolerated when given orally
    > Olsalazine (Dipentum)
    > Mesalamine (Pentasal)
  • Topical 5-ASA preps include rectal suppositories & enemas
    > Topical treatment delivers the 5-ASA directly to the affected tissue & minimizes systemic effects
  • The combo of oral & rectal therapy is better than oral or rectal alone
44
Q

! Drug Alert ! - Sulfasalazine (Azulfidine)

  • May cause yellowish orange discoloration of skin & urine
A
  • Avoid exposure to sunlight & UV light until photosensitivity is determined
45
Q

Corticosteroids

  • Used to achieve remission in IBD
  • Given for the shortest possible time b/c of side effects assoc w/long-term use
A
  • Pts w/dz in the left colon, sigmoid, & rectum benefit from suppositories, enemas, & foams b/c they deliver the corticosteroid directly to the inflamed tissue w/minimal side effects
46
Q
  • Oral prednisone is given to pts w/mild to moderate dz who did not respond to either 5-ASA or topical corticosteroids
A
  • Those w/severe inflammation may require a short course of IV corticosteroids
  • Corticosteroids must be tapered to very low lvls when surgery is planned to prevent postop complications (e.g., infection, delayed wound healing, fistula formation)
47
Q

Immunosuppressants (i.e., 6-mercaptopurine, azathioprine [Imuran])

  • Suppress immune response
  • Maintain remission >corticosteroid induction therapy
  • Require regular CBC [depress bone marrow] & chemistry [lead to inflammation of pancreas or liver] monitoring
A
  • Have a delayed onset of action & are not useful for acute flare-ups
48
Q

___ is most useful in Crohn’s disease pts who can’t stop corticosteroid use w/o a flare-up or in whom other rx’s have been ineffective

Many pts have flu-like sx’s w/use, & some develop bone marrow depression & liver dysfunction
> Careful monitoring of CBC & liver enzymes is essential

Women of childbearing age should avoid pregnancy b/c of birth defects & fetal death

A

Methotrexate

49
Q

Biologic & targeted therapies

TNF (antitumor necrosis factor) agents
* Infliximab (Remicade)
* Adalimumab (Humira)
* Certolizumab (Cimzia)
* Golimumab (Simponi)

A

Integrin receptor antagonists [both given by IV infusion]
* Natalizumab (Tysabri)
* Vedolizumab (Entyvio)

> Inhibit leukocyte adhesion by blocking α4-integrin, an adhesion molecule
The use of these rx’s is limited to those who have not had an adequate response w/other therapies (corticosteroids, immunosuppressants, or TNF agents)

50
Q

Infliximab is a monoclonal antibody to TNF (proinflammatory cytokine)
> Is given IV to induce & maintain remission in pts w/Crohn’s disease & in pts w/draining fistulas who do not respond to conventional rx therapy

A

Side effects - most common adverse effects are
> upper respiratory & urinary tract infections
> HA’s
> nausea, joint pain, abd pain

more serious effects
> reactivation of hepatitis & tuberculosis (TB) [pts are tested <treatment begins & no live virus immunizations]
> opportunistic infections & malignancies, esp lymphoma

51
Q

! Use is assoc w/inc risk of infection, hepatotoxicity, & hypersensitivity reactions

A
  • B/c of risk of progressive multifocal leukoencephalopathy, natalizumab (Tysabri) is avail only through a restricted program
52
Q
  • Biologic & targeted agents don’t work for everyone
    > Are costly & may produce allergic reactions
    > Are immunogenic, meaning that pts receiving them freq produce antibodies against them
    > Immunogenicity leads to acute infusion reactions & delayed hypersensitivity-type reactions
A
  • These rx’s are most effective when given @ regular intervals
  • Infusion reactions are more likely if an rx is stopped & then restarted
53
Q

Nutritional Therapy

  • Dietary consultant
A

Goals of diet management
1. Provide adequate nutrition w/o exacerbating symptoms
2. Correct and prevent malnutrition
3. Replace fluid & electrolyte losses
4. Prevent weight loss

54
Q
  • Nutritional deficiencies are due to
    > Decreased oral intake
    > Blood loss
    > Malabsorption of nutrients
A
  • Pts w/diarrhea often dec their oral intake to reduce diarrhea
  • Inflammatory mediators reduce appetite
  • Bloody diarrhea leads to iron-deficiency anemia, which may need treatment w/supplemental iron (ferrous sulfate or ferrous gluconate)
    > Parenteral or IV iron may be needed for pts who cannot tolerate oral iron or if anemia is severe
55
Q
  • Dz of the terminal ileum reduces absorption of __ and __
A

cobalamin; bile acids

56
Q
  • Reduced cobalamin contributes to anemia, & bile salts are important for fat absorption & contribute to osmotic diarrhea
    > Those who develop anemia should receive cobalamin injections
A
57
Q

___, an ion-exchange resin that binds unabsorbed bile salts, helps control diarrhea

Zinc deficiency can result from severe or chronic diarrhea, & supplementation may be necessary

A

Cholestyramine

58
Q
  • Medications can contribute to nutritional problems

Pts receiving sulfasalazine should reduce what daily?

A

folate (folic acid)

59
Q

Those receiving corticosteroids are prone to __ and need which 2 supplements?

A

osteoporosis

calcium; potassium

60
Q

Vitamin __ deficiency requiring supplementation is common
> May be d/t malabsorption d/t inflammation, surgical resection of intestine, reduced sunlight exposure, & dec dietary intake

A

D

61
Q
  • During acute exacerbations
    > Regular diet may not be tolerated

> Liquid enteral feedings are preferred
* High in calories & nutrients
* Lactose free
* Easily absorbed

A
  • Regular foods introduced gradually
62
Q
  • Foods that trigger exacerbations vary
A
  • Food diary helps identify problems for individuals
    > Lactose intolerance [Greek yogurt as a substitute]
    > High-fat foods, cold foods, high-fiber foods [cereal w/bran, nuts, raw fruits w/peels] may trigger diarrhea
63
Q
  • Exacerbations are debilitating & frequent
    > Massive bleeding
    > Perforation
    > Strictures &/or obstruction
    > Tissue changes indicating dysplasia or carcinoma
A
  • Surgery is indicated if treatment fails
64
Q

Surgical Therapy - procedures for chronic UC

  • Total proctocolectomy w/ileal pouch/anal anastomosis (IPAA)
  • Total proctocolectomy w/permanent ileostomy (can be done laparoscopically)
A
  • B/c UC affects only the colon, a total proctocolectomy is curative
  • UC can be cured w/a total colectomy, in as much as the colon & rectum aren’t necessary for survival
65
Q

Total proctocolectomy w/ileal pouch/anal anastomosis (IPAA)

  • Most common surgical procedure for UC
  • A diverting ileostomy is performed
  • An ileal pouch is created & anastomosed directly to anus
A
  • Combination of 2 procedures done approx 8-12 wks apart
  • Initially may have 4-6 stools or more daily but adaptation over the next 3-6 mos will result in a dec # of BMs
  • Pt is able to control defecation @ anal sphincter

! major complication is acute or chronic pouchitis (permanent ileostomy may be done if pouchitis doesn’t resolve)

66
Q

Total proctocolectomy w/permanent ileostomy

  • 1-stage surgery
  • Removal of colon, rectum, & anus w/closure
    ! Continence is not possible
A
  • End of terminal ileum is brought out through abd wall to form a stoma (ostomy)
  • Stoma is usually placed in RLQ below belt line
67
Q

Surgical Therapy - Crohn’s disease

  • Commonly performed for complications
    > Strictures
    > Obstructions
    > Bleeding
    > Fistula
  • Most pts eventually require a surgery
  • Dz often recurs @ anastomosis site
A
  • Most common surgery is a resection of the diseased segments & then the remaining intestine is re-anastomosed
68
Q

?

Occurs when there is too little SI surface area to maintain normal nutrition & hydration from dz or surgery

> Lifetime fluid boluses & parenteral nutrition may be needed

A

Short bowel syndrome

69
Q

?
> Opens up narrowed areas obstructing bowel

  • Reduces risk of developing short-bowel syndrome & assoc complications b/c intestine remains intact
A

Strictureplasty (recurrences @ the site are uncommon)

70
Q

Postoperative Care

Ileostomy
* Monitoring of
> Stoma viability
> Mucocutaneous juncture (area where the mucous membrane of the bowel interfaces w/the skin)
> Peristomal skin integrity

A
  • Pt should return from surgery w/a clear ileostomy pouch in place
  • Replace pouches if feces leak onto the skin
  • If an NG tube is used, remove it when bowel function returns
71
Q
  • Output may be as high as 1500-1800 mL per 24 hrs
A

Observe for
> Fluid & electrolyte imbalance
> Hemorrhage
> Abd abscess
> Small bowel obstruction
> Dehydration

72
Q
  • Over a period of days to wks, the proximal small bowel adapts & inc fluid absorption. Then, feces will thicken to a paste-like consistency & the volume dec
  • Pts, esp those w/Crohn’s disease, are @ risk for developing small bowel obstruction during the 1st 30 days postop
A
  • Transient incontinence of mucus is a result of intraoperative manipulation of the anal canal
  • Initial drainage through the ileoanal anastomosis will be liquid
73
Q
  • Start Kegel’s exercises 4 wks >surgery to strengthen pelvic floor & sphincter muscles
  • Perianal skin care to protect epidermis from mucous drainage & maceration
A
74
Q

Nursing Assessment

  • Autoimmune disorders, infection
  • Use of prescribed & OTC medicines
  • Family history
  • Diarrhea (presence of blood)
  • Wt loss
  • Anxiety, depression
A

Nursing Diagnoses

  • Diarrhea
  • Imbalanced nutrition: less than body requirements
  • Ineffective coping
75
Q

Planning: Overall Goals

  1. Decreased # & severity of acute exacerbations
  2. Normal fluid/electrolyte balance
  3. Freedom from pain or discomfort
A
  1. Compliance w/medical regimen
  2. Nutritional balance
  3. Improved quality of life
76
Q

During acute phases, implement strategies that focus on

  • Hemodynamic stability
  • Pain control
  • Fluid & electrolyte balance
  • Nutritional support
A
  • Manage hygiene until diarrhea is controlled
    > Tend to odor control
    > Prevent skin breakdown
  • Monitor I&O
  • Weigh daily
  • Assess bowel sounds
  • Consult w/dietitian
77
Q
  • Dibucaine (Nupercainal), witch hazel, sitz baths, & other soothing compresses or ointments may reduce irritation & discomfort of the anus
A
78
Q

Teaching includes

  • How to manage this chronic illness [recurrent, unpredictable nature]
  • Importance of rest & diet management
  • Perianal care
  • Rx action & side effects
  • Symptoms of recurrence of dz
  • When to seek medical care
  • Ways to reduce stress
A
  • Establish rapport
  • Encourage discussion of self-care strategies
  • Fully explain all procedures & treatments
    > Helps build trust
    > Decreases apprehension
    > Increases self-control
  • Quitting smoking as smoking is assoc w/more severe dz
79
Q

Assist in setting realistic goals [long & short term]
> Consider need for increased rest [fatigue can be severe, limiting energy]
> Schedule activities around rest periods [may lose sleep d/t freq eps of diarrhea & abd pain]

> Nutritional deficiencies & anemia leave pt feeling weak, listless

A

Emotional support
> Intermittent exacerbations & remissions of sx’s can be common
- Frustration, depression, anxiety need management
* Therapy
* Stress management
* Support groups

80
Q

Expected Outcomes

> Decreased # of diarrhea stools

> Body wt maintained within normal range

A

> Freedom from pain & discomfort

> Use of effective coping strategies

81
Q

Gerontologic Considerations

  • 2nd peak in occurrence of IBD is in 6th decade
    > Proctitis & left-sided UC are more common
  • Diagnosis can be difficult & confused w/
    > CDI
    > Colitis is assoc w/diverticulosis or NSAID ingestion
A
  • Greater risk of complications in frail older pts w/IBD
    > Adverse events from corticosteroids
    > Inc’d infection & malignancy risk assoc w/rx therapy [immunosuppressants & biologic therapy]
    > Volume depletion & electrolyte imbalance from diarrhea
    > Physical limitations that impact self care
    > Colitis [from rx use & systemic vascular dz]
82
Q
  • NSAIDs, digitalis, sumatriptan (Imitrex), vasopressin, estrogen, & allopurinol (Zyloprim) have been assoc w/development of colitis in older pt
A
  • Colitis may also be 2° ischemic bowel dz r/t atherosclerosis & HF

NUR 201 Week 10 (4 decks)

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