IBD concept map - 10th ed - Medical-Surgical Nursing PDF

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Summary

10th ed...

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Disease: Inflammatory Bowel Disease Chronic inflammation of the GI tract characterized by periods of remission interspersed with periods of exacerbation. Classified as either ulcerative colitis or crohns disease Ulcerative colitis: usually limited to colon Crohns disease: involve any segment of the GI tract. Etiology: Autoimmune disease involving an immune reaction to a person owns intestinal tract -

Environmental factors Genetic predisposition (occurs more frequently in family members of people with IBD) Alterations in immune function Diet Exposure to air pollution Stress Smoking High intake of total fats, polyunsaturated fatty acid, omega 6 fatty acids, meats is associated with an increased risk of IDB. Oral contraceptives and NSAIDS exacerbate crohns disease

Crohn`s disease: -

Occur anywhere in GI tract Most commonly involves distal ileum and proximal colon Skip lesion Involves all layers of bowel wall Ulceraction can be deep and logitudinal and penetrate between islands of inflamed edematous mucosa, causing cobbleston appearance Stricures can lead to obstruction Microscoping leaks in bowel wall can lead to peritonitis and abcsess formation Fistulas are common

Ulcerative colitis: -

Usually starts in rectum and moves in a continual fashion toward the cecum Mild inflammation may occur in the terminal ileum Disease of colon and rectum Fistulas and abscesses are rare Diarrhea w/ large fluid and electrolyte loss

S/S: -

Mild -acute exacerbations

Cronhs: -

Diarrhea with cramping and abd pain If s.intestines involved, weight loss occurs due to inflammation causing malabsorption Rectal bleeding but not as often as ulcerative colitis

Ulcerative colitis: -

Bloody diarrhea Abd pain Lower abd pain due to diarrhea Sever constant pain associated with acute perforations

Mild: -

Semi-formed stools with small amounts of blood

Moderate: -

Increased stool output (up to 10 stools/day) Increased bleeding Systemic symptoms such a fever, malaise, mild anemia, anorexia

Sever disease: -

Bloody diarrhea with mucous(10-20 times a day) Fever Rapid weight loss greater than 10% of total body wieght Anemia Tachycardia Dehydration

Complication: table 42-15 -

Local and systemic Hemorrhage, which can lead to anemia Strictures Perforation(which can lead to peritonitis) Abscesses Fistulas CDI Colonic dilation (toxic megacolon)( common with u.colitis) Nutritional problems (esp w/ crohns) when the terminal ileum is involved

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Fat malabsorption and pernicious anemia due to taking place in terminal ileum and it absorbing bile salts and colbamine Increased risk of colorectal cancer Liver problems Kidney problems

Dx studies: -

Ruling out other diseases CBC for anemia Elevated WBC Decreased serum sodium, potassium, chloride, bicarbonate, magnesium due to electrolle losses from diarrhea and vomiting Hypoalbuminemia with severe disease due to poor nutrition and protein loss Elevated rbc sedimentation rate C-reactive protein with wbc count indicate inflammation Stool examined for blood, pus, mucus, and cultured for bacteria Barium enema Small bowel series(small bowel follow through) Transabdominal ultrasound CT scan MRI colonoscopy capsule endoscopy for chrons of s.intestine

interprofessional care: -

meds preferred treatment due to high recurrence rate of crohns after surgery 5 main meds: aminosalicylates, antimicrobials,corticosteroids, immunosuppressants, biologic and targeted therapy Step up approach: less toxic to toxic Step down approach: started on more toxic meds Table 42-17(come back and make drug book entries for the specific drugs used)

Surgery: 42-18 U. colitis: - total proctolectomy with permanent ileostomy: permanent ileostomy with the removal of the colon, rectum, and anus with closure of the anal opening - end of terminal ileum isbrought out through abd wall forming a stoma(ostomy) - continence not possible with permanent ileostomy

Total proctolectomy with ileal pouch/anal anastamosis: -

Common procedure for u. colitis 2 procedures performed 8-12 weeks apart First part: colectomy, rectal mucosectomy,Ileal pouch(reservoir) construction, ileoanal astamosis, and temporary ileostomy 2nd surgery: closure of the ileostomy to direct stool toward the new pouch Pt ma have 4-6+ stools daily and then over 3-6 mos it decreases Complication: acute or chronic pouchitis; permanent ileostomy done if pouchitis not resolved

Surgery for crohns:

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Usually done for complications such as strictures, obstructions, bleeding, and fistula Resection of diseased segments Disease often recurs at site of anastamosis Short bowel syndrome(SBS): occurs when either surgery or disease leaves too little small intestine surface area to maintain normal nutrition or hydration; life time fluid boluses and parenteral nutrition may be needed Strictureplasty: opening of narrow areas obstructing bowels Recurrences at site of strictureplasty are uncommon

Post op care: Ileostomy: if formed, monitor stoma viability, the mucocutaneous juncture, and peristomal skin integrity After surgery, ileostomy pouch should be clear and in place. Replace pouches if feces leak onto skin Monitor ileostomy output: initially can be as high 1500-1800mL/24hr Monitor fluid and electrolyte balance as well as signs of dehydration Monitor for signs of hemorrhage Monitor for signs of abd abscess Monitor for small bowel obstruction If NG tube is used, do proper hygiene and remove as soon as normal bowel function returns Pts, especially with crohn`s, are at risk for developing a bowel obstruction during first 30 days post-op Kegel exercises about 4 weeks after surgery to strengthen pelvic floor and sphicter muscles Perianal skin care

Nutritional therapy: 1. 2. 3. 4.

Adequate nutrition without exacerbating symptoms Prevent or correct malnutrition Replace fluid and electrolyte losses Prevent weight loss

Nutritional deficiency causes: Decreased oral intake Blood loss Location of inflammation (such as small intestine) Malabsorption of nutrients Reduced appetite Bloody diarrhea leading to iron anemia Disease of terminal ileum leading to reduced absorption of colbamine and bile salts (needed for fat absorption and contribute to osmotic diarrhea)

Meds and nutritional intake: Sulfasalazine: should receive folate (folic acid) daily Corticosteroids: potassium supplements Vitamin D: may need to be supplemented due to malabsorption due to inflammation, surgical resection of intestine, reduced sun-light exposure, decreased dietary intake

Pts may not be able to tolerate a regular diet during an acute exacerbation: Liquid enteral feedings: preferred over parenteral nutrition because atrophy of the gut and bacterial overgrowth occur when the GI tract is not used Enteral nutrition: high in calories and nutrients, lactose free, easily absorbed Restarting regular diet gradually will help identify food triggers

Common intolerances: Lactose High fat, cold foods, high fiber may trigger diarrhea

Nursing Assessment: Table: 42-19

Nursing implementation: Monitor during acute phase -

Hemodynamic stability Pain control Fluid and electrolyte balance Nutritional support

Also monitor: -

I&O Number and characteristics of stool Blood in stools and emesis Serum electrolytes CBC Vitals Changed r/t diarrhea Dehydration Orthostatic hypotension

Give: Iv fluids Electrolytes Analgesics Anti-inflammatory meds

Diarrhea episodes: -

Give necessary pericare Use plain water and no harsh soaps Use moisturizing skin barrier to help prevent breakdown Use dibucaine(nupercainal), witch hazel, sitz baths, soothing compresses or ointments to reduce irritation

Other: -

Daily calorie intake Daily weight Assess abd including bowel sounds

Teaching: 1. 2. 3. 4. 5. 6. 7. 8.

Rest and diet Pericare Drugs and side effects Symptoms of recurrence When to seek medical care How smoking contributes to exacerbation Teach them to schedule and rest around frequent diarrhea episodes and pain Emotional aspect and support

Older pts: -

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2nd peak in occurrence happens in 6th decade Proctitis and left-sided ulcerative colitis are more common IBD can be confused with CDI and colitis associated with diverticulosis or NSAIDS ingestion Usual treatments may increase the risk of of adverse events, hospitalization, or mortality Pts with diminished renal and cardiovascular function are more vulnerable to the consequences and volume depletion from diarrhea Vulnerable to colitis from drug use and systemic vascular disease; NSAIDS, digitalis, sumatripan(Imitrex), vasopressin, estrogen, and allopurinol(zyloprim) have been associated with development of colitis in older adults Colitis may be 2ndary to ischemic bowel disease r/t atherosclerosis and Heart failure...