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Nursing 172 > Week 12: Chp 58: Inflammatory Bowel Disease (IBD) > Flashcards

Week 12: Chp 58: Inflammatory Bowel Disease (IBD) Flashcards

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1
Q

IBD is an umbrella term for two very similar chronic diseases of the GI tract which are?

A
  • Crohn’s Disease

- Ulcerative Colitis

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2
Q

Causes of IBD

A

exact cause is unknown but has been linked to genetic predisposition, environmental conditions, and defects in immune regulation

  • the genetic predisposition may manifest as an overactive immune response to bacteria located in the GI Tract; it may then be triggered by an environmental response such as infection, medication, or smoking
  • whereas the immune system usually attacks foreign invaders, in people with IBD, the immune response has an inappropriate response in the intestinal tract causing inflammation; this inflammation affects the ability to absorb nutrients resulting in diarrhea and weight loss in some patients
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3
Q

What is the immune system like in a patient with IBS

A

whereas the immune system usually attacks foreign invaders, in people with IBD, the immune response has an inappropriate response in the intestinal tract causing inflammation
-this inflammation affects the ability to absorb nutrients resulting in diarrhea and weight loss in some patients

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4
Q

Clinical Manifestations

A

IBS is chronic in nature, and the severity ranges from mild to severe, with periods of remission and exacerbations
-exacerbations often are precipitated by physical or emotional stress

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5
Q

Similarities of Crohn’s disease and Ulcerative Colitis

A

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

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6
Q

Extraintestinal Manifestations seen in IBD

A
  • uveitis (intraocular inflammatory disorder)
  • sclerosing cholangitis (inflammation of the hepatic ducts)
  • nephrolithiasis (renal stones)
  • cholelithiasis (gallstones)
  • joint disorders
  • skin disorders
  • oral ulcerations
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7
Q

Patients with Crohn’s disease are at higher risk for what?

A

cancer of the small bowel

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8
Q

Patients with Ulcerative colitis have a higher risk for what?

A

colon cancer

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9
Q

What cures ulcerative colitis in the GI tract?

A

colectomy (removal of the large intestine)

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10
Q

Colectomy

A

removal of the large intestine

-cures ulcerative colitis

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11
Q

Patients with Crohn’s disease who undergo resection of diseased sections of the bowel are at increased risk of what?

A

reoccurrence at the sites of the anastomoses (the area where the two sections of the bowel were reattached after removal of the diseased bowel)

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12
Q

anastomoses

A

area where the two sections of the bowel were reattached after removal of the diseased bowel

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13
Q

Crohn’s Disease

A

can affect any portion of the GI tract from mouth to anus, but more common in terminal ileum and colon
-affects small bowel and malabsorption is most common in this disorder
-it is transmural, affecting all layers of the bowel
-not uniform in appearance, noted for having skip lesions with normal-appearing bowel between lesions
-the lesions cause deep ulcerations between layers of edematous tissue, creating a cobblestone appearance
-with each exacerbation, the intestine becomes more scarred, which then leads to less ability to absorb nutrients
-diarrhea is less severe than in ulcerative colitis
-stools are typically soft or semiliquid and do not usually contain blood unless there has been a perforation
-nutritional deficits arise from the inability to absorb nutrients, and electrolyte disturbances are common
-abdominal pain is usually worse in the RLQ
>no known cure for Crohn’s disease

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14
Q

Because Crohn’s Disease is transmural, what complications does this lead to?

A

it may actually penetrate the bowel wall, leading to complications such as fistulas, abscesses, and peritonitis
-strictures and adhesions are also common

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15
Q

Fistulas

A

abnormal tracts between two or more body areas

-patients with Crohn’s disease may develop anovaginal and rectovaginal fistulas

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16
Q

How does Crohn’s Disease Manifest?

A

patchy involvement throughout all layers of the bowel

-it may skip areas of the bowel and can occur anywhere in the GI tract from mouth to anus

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17
Q

How does Ulcerative Colitis Manifest?

A

begins in the rectum and proceeds in a continuous, diffuse pattern towards the cecum
-affects the large intestine

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18
Q

Ulcerative Colitis

A

affects the large intestine and involves only the mucosa and submucosa
-disease spreads uniformly beginning at the rectum and spreading upward toward the cecum
-diarrhea is common, often with more than 20 stools per day with losses of several liters of fluid per day
-blood, mucus, and pus are common with ulcerative colitis
-abdominal pain and tenderness that is worse in the LLQ
-patients may manifest tenesmus; which involves spasms of the anal sphincter and persistent desire to empty the bowel
-a lesion called a crypt abscess releases secretions that result in a purulent discharge from the bowel mucosa
-abscesses may form in ulcerated areas
-scar tissue is common, interfering with absorption of nutrients
>total colectomy is surgical cure for ulcerative colitis

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19
Q

Indeterminate Colitis

A

this is the diagnosis when healthcare providers are unable to determine if the patient has ulcerative colitis or Crohn’s disease

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20
Q

Tenesmus

A

happens in people with ulcerative colitis

-involves spasms of the anal sphincter and persistent desire to empty the bowel

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21
Q

Clinical Manifestations of Ulcerative Colitis

A
  • diarrhea
  • blood, mucus, and pus in stool
  • abdominal pan and tenderness in LLQ
  • tenesmus
  • crypt abscess releases secretions that result in purulent discharge from the bowel mucosa
  • abscesses may form in ulcerated areas
  • scar tissue is common, interfering with the absorption of nutrients
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22
Q

Crypt abscess

A

seen in ulcerative colitis

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

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23
Q

Primary Goals of Treatment

A

to rest the bowel and control the inflammation
-other goals are to combat infection, correct malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life

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24
Q

What does treatments include?

A

medications, surgery, and correction of nutritional deficits and involve many psychosocial needs

  • IBD cannot be cured with medication but, there are medications to help control the disease and treat or prevent exacerbations
  • additional tests: CBC, serum electrolytes, serum albumin, and stool samples for pathogens
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25
Q

What is used in the diagnosis of both Crohn’s disease and Ulcerative Colitis?

A

colonoscopy, sigmoidoscopy, and barium enema

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26
Q

Colonoscopy Findings

A

assist in differentiating Crohn’s disease and ulcerative colitis

  • Crohn’s disease: the colonoscopy detects early mucosal changes including inflammation, stricture, and fistulae
  • Ulcerative Colitis: swollen, friable bowel mucosa with multiple ulcerations
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27
Q

Barium Enema Findings

A

may provide data regarding the depth of the disease involvement

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28
Q

Besides a colonoscopy, sigmoidoscopy and barium enema, what other diagnostic tests can you include?

A

CBC, serum electrolytes, serum albumin, and stool samples for pathogens

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29
Q

What type of management is crucial for the patient with Ulcerative Colitis?

A

Fluid and electrolyte management
-when the bowel is inflamed, and the patient is exhibiting severe diarrhea, absorption of fluids and nutrients is compromised
>patient is encouraged to rest frequently to decrease bowel motility

30
Q

Nutrition: Malnutrition

A

malnutrition is common with IBD and can lead to many other complications such as poor wound healing, decreased muscle mass, and a decreased immune system
-more common in Crohn’s disease because it affects mostly the small bowel

31
Q

Nutritional abnormalities can be caused by?

A

malabsorption, decreased food intake, medications, and/ or intestinal losses
>patient may need to be hospitalized for bowel rest and receive total parenteral nutrition (TPN)

32
Q

What may be necessary in patients with Crohn’s disease who have the inability of the ileum to absorb this nutrient?

A

monthly B12 injections

33
Q

Nutritional Deficits

A

zinc, potassium, magnesium, and vitamins
>liquid vitamin preparations are usually necessary because tablets or capsules may be excreted intact because of the frequency of diarrhea
-vitamin b12 injections may be necessary for patients with Crohn’s disease

34
Q

Albumin Levels

A

frequently used to determine nutritional status, but other factors may alter albumin levels such as inflammation, infection, or cancer

35
Q

Foods to Avoid

A

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

36
Q

Complementary and Alternative Medicines

A

patients often reluctant to mention this to provider for fear of being judged

  • marijuana, turmeric and curcumin, fish oil, probiotics, aloe Vera, Androphigus paniculata (e.g. India echinacea), Boswellia (e.g. frankincense), Tripterygium wilfordii Hook F (thunder god vine), wheat grass, and wormwood
  • acupuncture, moxibustion, mind-body therapies, and exercise
37
Q

Exacerbations of IBD may occur when?

A

during times of emotional or physical stress
-patients with IBD are concerned with how others view them; there may be a perceived, or actual, loss of independence, sense of control, privacy, body image, healthy self, peer relationships, self-confidence, productivity, and ways of expressing sexuality, therefore increasing risk of depression

38
Q

Surgical Management: Crohn’s disease

A
  • Crohn’s disease: is reserved for patients when medical management has failed and/ or who experience complications from the disease like strictures, abscesses, intestinal obstruction, perforation, hemorrhage, or cancer.
  • 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
39
Q

Surgical Management: Ulcerative Colitis

A

for whom medical management has failed or who have experienced complications may undergo a colectomy and be cured of the disease but not of the extra-intestinal manifestations
>standard procedure: is an ileal pouch anal anastomosis (IPAA); the entire colon and rectum are removed, a pouch is created to collect waste, and the patient is able to defecate normally

40
Q

Standard Procedure In surgical Management of Ulcerative Colitis

A

Ileal Pouch anal anastomosis (IPAA)
-the entire colon and rectum are removed, a pouch is created to collect waste, and the patient is able to defacate normally

41
Q

Proctocolectomy with permanent ileostomy

A

patients with ulcerative colitis may undergo this procedure

  • includes the removal of the colon and rectum and permanent closure of the anus
  • the ileostomy is permanent
42
Q

Proctocolectomy with a Kock or Koch Pouch

A

a continent ileostomy

  • patients with ulcerative colitis
  • a portion of the ileum is used to create a reservoir that can be catheterized to remove stool
43
Q

Complications

A
  • perineal abscesses and fistulas occurs in patients with Crohn’s disease
  • strictures and fistulas more common in Crohn’s disease
  • intestinal obstruction occurs secondary to inflammation and edema
  • fibrosis and scarring over time may also cause narrowing of the bowel, leading to an obstruction
  • malnutrition frequently develops because of malabsorption of nutrients, severe diarrhea, and anorexia due to the fear that eating may cause an exacerbation of symptoms
  • anemia from hemorrhage and malnutrition may lead to patients needing blood transfusions and patients are often prescribed iron supplements to treat anemia
44
Q

Extraintestinal Complications

A
  • joint swelling and pain
  • ankylosing spondylitis
  • osteoporosis
  • kidney stones
  • eye inflammation
  • mouth sores
  • skin lesions
45
Q

During Inflammation, what may the patient experience?

A
  • fever
  • anorexia
  • and malaise
46
Q

Anal Fissures

A

tears in the anal wall

-develop secondary to severe bouts of diarrhea

47
Q

Surgical Complications

A

anal canal strictures, pelvic sepsis, pouch failure, fecal incontinence, pouch dysplasia/cancer, sexual dysfunction, and female infertility

48
Q

Chronic Pouchitis

A

complication associated with the IPAA procedure

-one probiotic preparation may be effective in the prevention of recurrent pouchitis (VSL #3)

49
Q

Fistulas

A

more common in Crohns Disease
-can often cause other complications such as sepsis, skin irritation, and malnutrition, dehydration, and fluid and electrolyte imbalances
>Enterocutaneous Fistula (between skin and intestine)
>Enteroenteral Fistula (between intestine and intestine)
>Enterovesicular Fistula (between bowel and bladder)
>Enterovaginal Fistula (between bowel and vagina)

50
Q

Skin Irritation and Excoriation often occur because of what?

A

intestinal secretions being rich in enzymes; protection of the skin is of utmost importance
-skin may become in contact with secretions through fistulas and ostomies (surgical openings in an organ), such as an ileostomy (opening in the ileum) and colostomy (opening in the colon)
> the anus can also become irritated from frequent diarrhea

51
Q

Toxic Megacolon

A

colonic dilation of greater than 5 cm

  • occurs more frequently in ulcerative colitis and requires emergency colectomy
  • bacterial overgrowth contributes to toxic megacolon
52
Q

Short Bowel Syndrome

A

can occur if more than 100 cm of small bowel is removed because absorption is greatly affected

  • the jejunum is where most carbohydrate and protein absorption takes place, and the ileum is where absorption of fats, fat-soluble vitamins, and b12 takes place; if the jejunum is removed, the ileum assumes the function of fat absorption; the removal of the ileum accounts for more complications because it is responsible for the absorption of fats, vitamins, bile salts, and B12
  • patients having 50% to 70% of the small intestine removed experience malabsorption but can usually be managed with dietary supplementation
53
Q

Narcotic Bowel Syndrome

A

characterized as chronic, intermittent, and cramping abdominal pain associated with the effects of the narcotic analgesic wearing off

54
Q

Nursing Management: Assessment and Analysis

A

assessment of intake and output and daily weight s will help determine nutritional status of patients with suspected IBD

  • frequent diarrhea leads to extreme losses of fluids and potassium, or hypokalemia
  • patients with IBD are often victims of social isolation because of the fear of incontinence in public or having the need to be close to a bathroom at all times
  • patients with IBD often report exacerbations as related to 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
55
Q

Nursing Diagnoses

A
  • Deficient fluid volume r/t diarrhea
  • Diarrhea r/t intestinal inflammation and malabsorption of nutrients
  • Imbalanced nutrition: less than body requirements r/t inability to absorb nutrients secondary to inflammation
  • Ineffective coping r/t chronic disease
56
Q

Nursing Interventions: Assessment

A
  • vital signs
  • nutritional intake
  • frequency and characteristics of stools and note any presence of blood
  • intake and output
  • daily weight
  • fluid and electrolyte status
  • psychosocial assessment and support systems
57
Q

Assessment: Vital Signs

A

with significant fluid loss, the patient may develop signs of decreased fluid volume including a low-grade fever, elevated heart rate, and decreased blood pressure

58
Q

Assessment: Nutritional intake

A

assisting the patient to maintain a intake diary will assist in monitoring nutritional status
-frequent diarrhea is associated with malabsorption of nutrients

59
Q

Assessment: Frequency and characteristics of stools and note any presence of blood

A

excessive losses result in complications such as fluid and electrolyte imbalances
-blood may be noted in the stool of the patient with ulcerative colitis but is unusual in Crohn’s disease

60
Q

Assessment: Intake and Output

A

patients often do not attempt to eat or drink in fear of exacerbating clinical manifestations
-urine output should be monitored for at least 30 mL/hr to provide information regarding renal perfusion

61
Q

Assessment: Daily Weight

A

weight is the best measurement for nutritional needs

62
Q

Assessment: Fluid and Electrolyte Status

A

patients tend to loose many electrolytes through diarrhea, particularly potassium and magnesium

63
Q

Assessment: Psychosocial Assessment and support systems

A

the patient frequently is a victim of social isolation because of fears of incontinence and/or frequent trips to the bathroom

64
Q

Nursing Actions

A
  • encourage smaller frequent meals
  • encourage the patient to engage in mealtimes with family
  • encourage periods of rest
  • establish a therapeutic relationship
  • make appropriate referral to interprofessional team
  • pain management
  • provide meticulous skin care
65
Q

Actions: Encourage smaller frequent meals

A

decreases gastric motility

66
Q

Actions: encourage periods of rest

A

help decrease gastric motility and conserve energy

67
Q

Actions: Establish a therapeutic relationship

A

helps develop trust between patient and healthcare provider

68
Q

Actions: Make appropriate referrals to interprofessional team

A

inflammatory bowel disease is a complex disease and requires a team approach including a case manager, dietician, and any local support group

69
Q

Actions: Pain Management

A

positioning and maintaining a quiet environment may promote comfort
-pain medications may be ordered; if administered monitor for side effects like constipation

70
Q

Actions: Provide meticulous skin care

A

having frequent diarrhea needs special attention to the rectal area because the feces contain enzymes that may cause excoriation to the skin surrounding the anus

71
Q

Teachings

A
  • importance of adequate nutrition
  • indications, actions and side effects of prescribed medications
  • importance of regular follow-ups and annual colonoscpy
72
Q

Teachings: Importance of adequate nutrition

A

malnutrition due to malabsorption is common with IBD

  • adequate nutrition is required for healing and maintaining a stable weight
  • a daily multivitamin may be prescribed, but vitamins with iron may be controversial due to poor tolerance and may worsen symptoms
  • reducing fiber and fat intake during exacerbation, drinking plenty of fluids, and avoiding milk and milk products during exacerbations are important

Nursing 172 (120 decks)

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