Unit 3: Inflammatory Bowel Disease (IBD)

Question 1

Inflammatory Bowel Disease (IBD)

Answer 1

umbrella term for Crohn’s Disease and Ulcerative Colitis

• chronic in nature
• cannot be cured w/ medications; but there are medications that help control the disease and treat or prevent exacerbations

Question 2

Pathophysiology of Inflammatory Bowel Disease (IBD)

Answer 2

-exact cause of IBD unknown
-linked to genetics, environmental conditions, and defects in immune regulation
>genetic predisposition may manifests as an overactive immune response to bacteria located in the GI tract
>may be then triggered by an environmental response such as infection, medication, or smoking
>the immune system usually attacks foreign invaders, but in IBD, the immune response has an inappropriate response in the GI tract causing inflammation; affects the ability to absorb nutrients resulting in diarrhea and weight loss

Question 3

Clinical Manifestations of IBD

Answer 3

• mild to severe

- periods of remission and exacerbations

Question 4

Similarities between Crohn’s Disease and Ulcerative Colitis

Answer 4

• persistent diarrhea
• abdominal pain or cramps
• fever
• weight loss
• fluid imbalances
• malnutrition
• mouth ulcers
• anemia
• blood from rectum
• joint, skin, or eye irritations
• delayed growth

Question 5

Extraintestinal Manifestations in IBD

Answer 5

• uveitis (intraocular inflammatory disorder)
• sclerosing cholangitis (inflammation of hepatic ducts)
• nephrolithiasis (renal stones)
• cholelithiasis (gallstones)
• joint disorders
• skin disorders
• oral ulcerations

Question 6

Crohn’s Disease

Answer 6

can affect any portion of the GI tract from mouth to anus

• transmural, affecting all layers of the bowel
• not uniform in appearance
• noted for having skip lesions w/ normal-appearing bowel between lesions
• lesions cause deep ulcerations between layers of edematous tissue, creating cobblestone appearance
• w/ exacerbation, the intestines become more scarred = less ability to absorb nutrients; nutritional deficits
• complications: fistulas, abscesses, and peritonitis
• diarrhea
• stool typically soft or semiliquid; do not usually contain blood unless there has been a perforation
• abdominal pain in RLQ

Question 7

Fistula

Answer 7

abnormal tracts between two or more body areas

Question 8

Ulcerative Colitis

Answer 8

affects the large intestine and involves only the mucosa and submucosa

• dpreads uniformly beginning at the rectum and spreading upward toward the cecum
• diarrhea; often w/ more than 20 stools; losses of several liters of fluid per day
• blood, mucus, and pus in stool
• abdominal pain and tenderness in LLQ
• tenesmus (spasms of anal sphincter and persistent desire to empty bowel)
• crypt abscess
• abscesses may form in ulcerated areas
• scar tissue; interfering w/ absorption of nutrients

Question 9

Tenesmus

Answer 9

spasms of the anal sphincter and persistent desire to empty the bowel
-seen in ulcerative colitis

Question 10

Crypt Abscess

Answer 10

• seen in ulcerative colitis

- releases secretions that result in purulent discharge from the bowel mucosa

Question 11

Primary Goal of IBD

Answer 11

• rest the bowel

- control the inflammation

Question 12

Goals of IBD

Answer 12

• rest the bowel
• control the inflammation
• combat infection
• correct malnutrition
• alleviate stress
• provide symptomatic relief
• improve quality of life

Question 13

Treatments for IBD

Answer 13

• medications
• surgery
• correction of nutritional deficits
• involve psychosocial needs
• IBD cannot be cured w/ medications, but there are medications that can help with controlling the disease and treat or prevent exacerbations

Question 14

Diagnostics for IBD

Answer 14

-Colonoscopy
-Sigmoidoscopy
-Barium Enemas
>Others: Complete blood count (CBC), serum electrolytes, serum albumin, and stool samples for pathogens

Question 15

Colonoscopy

Answer 15

• may assist in differentiating Crohn’s disease and ulcerative colitis
• In Crohn’s Disease: detects early mucosal changes including inflammation, stricture, and fistulae
• In Ulcerative colitis: swollen, friable bowel mucosa w/ multiple ulcerations

Question 16

Barium Enema

Answer 16

provide data regarding the depth of the disease involvement

Question 17

Medical Management For IBD: Fluid and Electrolyte management

Answer 17

fluid and electrolyte management is crucial for the patient with ulcerative colitis

• when bowel is inflamed, and the patient is exhibiting severe diarrhea, absorption of fluids and nutrients is compromised
• patient encouraged to rest frequently to decrease bowel motility

Question 18

IBD: Malnutrition

Answer 18

malnutriton is common w/ IBD

• leads to poor wound healing, decreased muscle mass, and dcreased immune system
• may need to be hospitalized for bowel rest and receive total parenteral nutrition (TPN)
• In Crohn’s disease: monthly vitamin B12 injections may be necessary b/c of the inability of the ileum to absorb this nutrient
• liquid vitamin preparations b/c tablets or capsules may be excreted intact b/c of frequency of diarrhea
• albumin levels to determine nutritional status
• foods to avoid: milk, gluten, caffeine, coca, chocolate, citrus juices, cold or carbonated drinks, nuts, seeds, popcorn, and alcohol

Question 19

Foods to avoid w/ Inflammatory Bowel Disease

Answer 19

• milk
• gluten
• caffeine
• cocoa
• chocolate
• citrus juices
• cold or carbonated drinks
• nuts
• seeds
• popcorn
• alcohol

Question 20

Complementary and Alternative Medicines (CAM)

Answer 20

• marijuana, turmeric and curcumin, fish oil, probiotics, aloe vera, Androphigus paniculata, Boswellia, Tripterygium wilfordii Hook F, wheat grass, and wormwood
• acupuncture and moxibustion, mind-body therapies, and exercise

Question 21

Why is Psychosocial Management included?

Answer 21

exacerbations may occur during times of emotional or physical stress
-inability to control manifestations can disrupt lives
-fear of being away from home b/c of frequency of diarrhea
-eating is associated w/ onset of abdominal pain; causing mealtimes to be unpleasant
-depression and anxiety are common in IBD
-patients may be concerned w/ how others view them; impacts self-esteem
-may be a perceived, or actual, loss of independence, sense of control, privacy, body image, healthy self, peer relationships, self-confidence, productivity, and ways pf expressing sexuality; causes depression
-embarrassment of public bathrooms
-shame with the individuals with ostomies
>thorough assessment of support systems, stress-producing factors, and coping mechanisms

Question 22

Surgical Management for Crohn’s Disease

Answer 22

reserved for patients for whom medical management has failed, an/or who experience complications from the disease

• when a diseased portion of the bowel is removed, it frequently recurs in another section of the bowel
• surgery does not cure Crohn’s disease

Question 23

Surgical Management for Ulcerative Colitis

Answer 23

for whom medical management has failed or who have experienced complications may undergo colectomy and be cured of the disease

• standard procedure: Ileal pouch anal anastomosis (IPAA)
• may undergo proctocolectomy w/ permanent ileostomy

Question 24

Ileal pouch anal anastomosis (IPAA)

Answer 24

• surgical procedure (ulcerative colitis)

- entire colon and rectum are removed, a pouch is created to collect waste, and the patient is able to defecate normally

Question 25

Proctocolectomy

Answer 25

• surgical procedure (ulcerative colitis)
• the removal of the colon and rectum and permanent closure of the anus
• ileostomy is permanent
• another option: continent ileostomy (kock or Koch pouch) after proctocolectomy

Question 26

Continent Ileostomy (Kock or Koch Pouch)

Answer 26

can be placed after a proctocolectomy

-a portion of the ileum is used to create a reservoir that can be catheterized to remove stool

Question 27

Complications that come from IBD

Answer 27

• perineal abscesses, fistulas, and structures found in Crohn’s disease
• joint swelling and pain, ankylosing spondylitis, osteoporosis, kidney stones, eye inflammation, mouth sores, and skin lesions
• during inflammation; fever, anorexia, and malaise
• anal fissures; d/t severe bouts of diarrhea
• intestinal obstruction secondary to inflammation and edema
• fibrosis and scarring over time may also cause narrowing of the bowel, leading to obstruction
• malnutrition b/c of malabsorption of nutrients, severe diarrhea, and anorexia d/t fear that eating may cause exacerbation of symptoms
• anemia from hemorrhage and malnutrition may lead to patients needing blood transfusions and iron supplements
• narcotic bowel syndrome from chronic narcotic use

Question 28

Surgical Complications

Answer 28

• anal canal strictures
• pelvic sepsis
• pouch failure
• fecal incontinence
• female infertility
• chronic pouchitis associated with IPAA procedure

Question 29

Complications from Fistula Formation

Answer 29

• common w/ Crohn’s disease
• sepsis
• skin irritations
• malnutrition
• dehydration
• fluid and electrolyte imbalance

Question 30

Nursing Management: Assessment and Analysis

Answer 30

• assessment of intake and output and daily weights helps determine nutritional status
• frequent diarrhea leads to extreme losses of fluids and potassium (hypokalemia)
• often victims of social isolation b/c of the fear of incontinence in public or having the need to be close to a bathroom at all times
• report exacerbations r/t a stressful event
• clinical manifestations: persistent diarrhea, abdominal pain or cramps, fever, weight loss, fluid imbalances, mouth ulcers, anemia, melena
• extraintestinal manifestations: uveitis, sclerosing cholangitis, nephrolithiasis, cholelithiasis, joint disorders, and skin disorders

Question 31

Nursing Diagnoses

Answer 31

• deficient fluid volume associated w/ diarrhea
• diarrhea associated w/ intestinal inflammation and malabsorption of nutrients
• imbalanced nutrition less than body requirements r/t inability to absorb nutrients secondary to inflammation
• ineffective coping associated w/ chronic disease

Question 32

Nursing Assessments

Answer 32

• Vital signs
• Nutritional Intake
• Frequency and characteristics of stools; note blood
• Intake and Output
• Daily weight
• Fluid and Electrolyte status
• Psychosocial Assessment and support systems

Question 33

Nursing Actions

Answer 33

> Encourage smaller frequent meals
-decreases gastric motility
Engage in mealtimes w/ family
Encourage periods of rest
Establish therapeutic relationship
Make appropriate referral to interprofessional team
Pain management
-positioning and maintaining a quiet environment may promote comfort; pain medications ordered; monitor for side effects
Provide meticulous skin care (especially rectal area)

Question 34

Patient Teaching

Answer 34

• Adequate nutrition: reducing fiber and fat intake during exacerbation, drink plenty of fluids, avoid milk and milk products
• Indications, actions, and side effects of prescribed medications
• Regular follow-ups and annual colonoscopy

Question 35

Evaluating Care Outcomes

Answer 35

• should have a good understanding of the importance of maintaining a healthy weight b/c malnutrition is a common problem
• important outcomes: stable vital signs, fluid and electrolyte imbalances, and stable weight
• patient who has failed medical management may undergo surgery to control clinical manifestations