Inflammatory Bowel Disease Edapt Notes PDF

Inflammatory bowel disease, or IBD, is an umbrella term to describe diseases that involve chronic inflammation of the digestive tract. The two types of IBD include Crohn’s disease and ulcerative colitis (UC). Both of these processes are considered autoimmune diseases, where the body develops antibod...

Inflammatory bowel disease, or IBD, is an umbrella term to describe diseases that involve chronic inflammation of the digestive tract. The two types of IBD include Crohn’s disease and ulcerative colitis (UC). Both of these processes are considered autoimmune diseases, where the body develops antibodies that attack the intestine, causing chronic inflammation and other concerns. What portion of the intestinal tract can be affected by Crohn’s disease? Only the colon Anywhere along the gastrointestinal (GI) tract Only the rectum Only the stomach Autoimmune Disease Characteristics What is a clinical manifestation of autoimmune diseases? They have periods of exacerbation and remission. They only impact the gastrointestinal system. They are not genetically linked. They impact only the African American population. Desired Outcomes What are desired outcomes for a client with inflammatory bowel disease (IBD)? Select all that apply. Because of the symptoms' chronic nature, treat the symptoms only when they are severe. Improve nutritional status deficits. Educate the client on how to alleviate stress. Treat the client with the most cost-effective way to manage the disease. Help the client achieve and maintain remission of symptoms. Types of Inflammatory Bowel Disease Two types of inflammatory bowel disease (IBD) include Crohn’s disease and ulcerative colitis. Both Crohn’s disease and ulcerative colitis have an increased risk of clostridium difficile infections, colon cancer, and anemia. Although they have commonalities, Crohn’s disease and ulcerative colitis differ in patterns of inflammation, signs and symptoms, and management of care. Select each disease tab to learn further details. • Crohn’s Disease • Ulcerative Colitis Crohn’s Disease Crohn’s disease can impact any portion of the intestinal tract from the mouth to the anus, but most commonly involves the distal ileum and proximal colon. It also causes all layers of the bowel wall to become inflamed, which can lead to fistulas and microscopic tears in the bowel that leak intestinal contents into the abdominal cavity. A client with Crohn’s disease may also have skin lesions. Segments of healthy, normal bowel are next to segments of diseased bowel. Ulcerative Colitis As its name suggests, ulcerative colitis is an inflammatory bowel disease continuously affecting the colon and rectum. Only the innermost layers of the bowel wall become inflamed, so fistulas and abscesses are rare with this disease. Crohn’s Disease Complication A client with Crohn's disease is at risk of developing which complication? Toxic megacolon Peritonitis Cirrhosis Portal hypertension Crohn’s Disease: Recognizing Cues Crohn’s disease is an autoimmune disorder that has periods of symptom exacerbation and remission over the lifetime of the client. There is no cure for this disease, so symptom management and preventative actions are essential for overall health and wellness. Desired outcomes for clients with Crohn’s disease include bowel rest, reducing and controlling inflammation, pain management, infection prevention, and improving quality of life. Review the electronic medical record shown here and identify the cues of Crohn’s disease. Transcript Link Ulcerative Colitis: Recognizing Cues Ulcerative colitis is also an autoimmune disorder that has periods of symptom exacerbation and remission over the lifetime of the client. There is no cure for this disease, so symptom management and preventative actions are essential for overall health and wellness. Desired outcomes for clients with ulcerative colitis are bowel rest, reducing and controlling inflammation and bleeding, infection prevention, pain management, and improving quality of life. Review the electronic medical record shown here and identify the cues of ulcerative colitis. Analyzing Cues: Risk Factors Review the image to learn more about the risk factors for ulcerative colitis and Crohn’s disease. Transcript Link Ulcerative Colitis Amy (pronouns: she/her/hers) is a 28-year-old client with ulcerative colitis (UC). She reports that her father also has a history of ulcerative colitis. Which risk factors are associated with UC? Select all that apply. Stress Family history of ulcerative colitis Red hair Low-fat diet Client history of campylobacter infection Analyzing Cues The nurse recognizes that rectal bleeding is a common finding in ulcerative colitis. Which question is important for the nurse to ask during an assessment? “Do you have a headache?” “Do you have a sensitivity to bright lights?” “Do you feel weak or light-headed?” “Do you hear ringing in your ears?” Pharmacological Review Review this slideshow to explore a pharmacological review of inflammatory bowel disease (IBD). Desired outcomes of pharmacological treatment for IBD are to provide symptomatic relief (pain, gastrointestinal symptoms), prevent infection, improve quality of life, and prevent exacerbations of the disease process. Drugs of choice are dependent on the location and severity of the inflammation, presenting signs and symptoms, preventative action, and personal preferences after discussing the risk and benefits of medications with a healthcare provider. Is the client willing or able to give themselves injections at home? Is the client able to adhere to the prescribed regimen? Clients with IBD are treated with a ‘step-up’ and ‘step-down’ approach. With the step-up approach, clients begin on conservative medications (such as antimicrobials and aminosalicylates) and drug therapies may be increased to more potent medications (e.g., biologic therapies or targeted therapy) when a conservative approach does not work. The step-down process is the opposite. The client is initially started on potent medications without attempting the more conservative approach to therapy first. Each client, though, is individualized based upon their specific care needs. Review the medication classifications commonly used for IBD by selecting each tab for more information. Antimicrobials Antimicrobials, such as metronidazole or ciprofloxacin, are utilized to prevent or treat any secondary infection the client may be experiencing. Remembering that an infection can be a cause of autoimmune disease symptom exacerbation, these drugs can be very beneficial in preventing symptom worsening or complications of the disease. Action Prevent or treat secondary infection Examples ciprofloxacin, clarithromycin, metronidazole Aminosalicylates Aminosalicylates, like mesalamine, decrease inflammation at the source by decreasing inflammatory mediator action. These medications are the cornerstone for helping clients achieve and maintain remission of their symptoms, as well as prevention of flare-ups or exacerbations. Action Decrease inflammation by suppressing proinflammatory cytokines and other inflammatory mediators Examples Systemic: balsalazide, mesalamine, olsalazine, sulfasalazine Topical: 5-ASA enema, mesalamine suppositories Corticosteroids Corticosteroids, including systemic corticosteroids like prednisone or methylprednisolone, reduce the immune response and decrease inflammation. They can render the client immunocompromised. Corticosteroid therapy is only used on a short-term basis due to the risk of side effects associated with long-term steroid usage. Action Decrease inflammation Examples Systemic: corticosteroids (prednisone, budesonide), hydrocortisone or methylprednisolone (IV for severe IBD) Topical: hydrocortisone suppository or foam or enema Immunosuppressants Immunosuppressants, most commonly methotrexate for clients with IBD, are also helpful in assisting clients to achieve and maintain remission. Methotrexate requires frequent blood monitoring, including CBC, due to the risk of bone marrow suppression. Flu-like symptoms are common for clients starting this treatment, so correct dosing and client compliance is important. Action Suppress immune response Examples azathioprine, cyclosporine, methotrexate, 6-mercaptopurine Biologic The last classification of helpful medications for IBD is biologic and targeted therapies, which include examples such as infliximab (Remicade), vedolizumab (Entyvio), and adalimumab (Humira). These medications target proinflammatory pathways in the intestine. These medications are either administered subcutaneously (like adalimumab) or through IV infusion (infliximab or vedolizumab). These medications may not be an option for everyone; they are costly, have a high risk for side effects, and require more maintenance and education than just taking oral medications. Action Inhibit the cytokine tumor necrosis factor (TNF) Examples adalimumab, certolizumab pegol, golimumab, infliximab Action Prevent migration of leukocytes from the bloodstream to inflamed tissue Examples natalizumab, vedolizumab Postoperative Client Surgical management of inflammatory bowel disease (IBD) is an option for some clients. Surgery may be indicated if there is suspicion of cancer, an intestinal obstruction, fistulas (which is a common occurrence in Crohn’s disease), or the client fails to respond to other conservative methods of treatment. For clients with Crohn’s disease, surgical intervention involves removing the diseased portions of the intestine and reattaching (or reanastomosis) the remaining healthy portions of the bowel. This is due to the skip lesions that commonly occur with this disease process. Unfortunately, there is a high probability of disease reoccurrence at the anastomosis sites. Postoperative Client: Ileostomy Ulcerative colitis is usually restricted to the colon itself; removal of the colon (a colectomy) may be curative for many clients. Commonly, this procedure involves the creation of an intestinal stoma, such as an ileostomy, or a stoma created in the ileum. Stomas and ostomies are named for where they are located within the intestinal tract. The more distal the ostomy, the more functional bowel is present, thus allowing the contents of the ostomy pouch to resemble a formed stool just as if the client’s intestinal tract was intact. The ileum is very high/proximal in the intestinal tract. Therefore, output from an ileostomy resembles liquid to semiliquid stool. Taking Action: Psychosocial Integrity While caring for a post-surgical client with an ostomy, it is important to remember their psychosocial needs. Important concepts include: • Providing psychosocial support as the client copes with new changes to their body; function, image, and self-esteem concerns. • Self-care: Provide client education for both the client and any caregivers on ostomy care and management. • Relationships: Social roles may change and returning to the workplace. Taking Action: Ostomy Care The nurse will assess the client’s new stoma for its size, appearance, and document any output. A new stoma should be beefy red in appearance, signifying good, healthy, perfused tissue. Some mild edema is common in the immediate postoperative period, as well as some minimal bleeding (as a stoma is vascular). Any other assessment findings require further investigation and immediate intervention. Selecting an appropriate sized pouch or collection bag is important for both the client’s psychosocial and physical well-being. Most collection systems are adhesive-backed wafers that stick to the client’s skin around the stoma, and a drainage pouch or bag that clips onto or adheres to the wafer that collects the client’s output (stool). It is important to choose the correct size of wafer and drainage bag as a wafer too small can constrict blood flow to the stoma. A wound ostomy care (WOC) nurse is a great source of information for both clients and caregivers. WOC nurses are expert clinicians who treat complex wounds, ostomy issues, and incontinence. Visit the WOCN Society website for additional client resources. Wound, Ostomy, and Continence Nurses Society. (n.d.). Patient resources. https://www.wocn.org/learning-center/patient-resources/ A newly formed stoma with pouch wafer on the skin Collection bag or pouch with adhesive wafer Taking Action: Client Teaching Client teaching regarding ostomy care and management is important prior to discharge. The client and caregivers, if applicable, should have ample time to practice dressings and address any supply issues. The nurse or wound care nurse specialist will teach about: • removing the skin barrier or wafer of the stoma • cleansing around the stoma site • how to size appropriately and apply a new skin barrier or wafer correctly • how to attach, empty, and clean the collection bag or pouch. The client should be instructed to empty the collection bag when it is approximately one-third of the way full to avoid any accidental ruptures or leaks. • discussing immediate concerns and when to contact their healthcare provider, such as for signs and symptoms of dehydration, infection, and uncontrolled pain Dietary Modifications Clients with inflammatory bowel disease (IBD) may need to make dietary changes, especially when an exacerbation of the disease occurs. Certain foods may cause more symptoms when the disease is active. Some foods are more inclined to produce gas, odor, or cause diarrhea (such as highfat foods and green vegetables). Eating a low-fat diet is ideal overall, as a high-fat diet is a risk factor for ulcerative colitis. Avoiding FODMAPs is a common recommendation of healthcare providers. FODMAPs are hard to digest carbohydrates and sugars. If the client has a stoma, beverages and food items such as beer and alcohol, eggs, asparagus, broccoli, cabbage, and spicy foods will affect stoma output (diarrhea). The client with an ostomy should also increase their fluid intake (unless contraindicated) to 3,000 mL of fluids a day to prevent dehydration. Transcript Link Therapeutic Response James (pronouns: they/them/their) has a follow-up appointment with a healthcare provider about their recent cancer diagnosis. They have decided to proceed with a colectomy with the creation of a temporary ileostomy due to severe ulcerative colitis. James and their partner seem visibly anxious about their relationship and self-care concerns. What is the most therapeutic response by the nurse? “Lots of people have ileostomies and still lead normal lives.” “I will call the WOCN (wound ostomy care nurse) and she will talk to you about it.” “Your ileostomy is only temporary, so it’s nothing to worry about.” “Tell me what your concerns are regarding your surgery and ileostomy.” Case Study: J.T. Recognizing Cues Select findings that require immediate follow-up by the nurse. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. Case Study: J.T. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. Analyzing Cues J.T. is at highest risk for celiac disease Crohn's disease ulcerative colitis as evidenced by rectal bleeding, severe diarrhea, and a high-fat diet. Case Study: J.T. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. Prioritizing Hypotheses J.T. was diagnosed with ulcerative colitis and needed a temporary ileostomy. The new shift nurse enters his room 24 hours after the postsurgical ileostomy to perform a shift assessment. The nurse observes him tearful in bed and approaches to change the ostomy dressing per prescribed orders. J.T. becomes visibly upset, crying, and verbalizing, “Don’t touch that! It’s so awful to look at and it smells terrible. I’m never leaving my house again.” What is the priority nursing diagnosis for this client? Risk for impaired skin integrity Disturbed body image Deficient knowledge Risk for imbalanced nutrition Case Study: J.T. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. J.T. was diagnosed with ulcerative colitis and needed a temporary ileostomy. The new shift nurse enters his room 24 hours after the postsurgical ileostomy to perform a shift assessment. The nurse observes him tearful in bed and approaches to change the ostomy dressing per prescribed orders. J.T. becomes visibly upset, crying, and verbalizing, “Don’t touch that! It’s so awful to look at and it smells terrible. I’m never leaving my house again.” Generating Solutions Which interventions does the nurse anticipate the healthcare provider prescribing? Select all that apply. Put the client on NPO status. Initiate cardiac monitoring. Place a rectal tube. Obtain informed consent for a total colectomy. Place a nasogastric tube. Case Study: J.T. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. J.T. was diagnosed with ulcerative colitis and needed a temporary ileostomy. The new shift nurse enters his room 24 hours after the postsurgical ileostomy to perform a shift assessment. The nurse observes him tearful in bed and approaches to change the ostomy dressing per prescribed orders. J.T. becomes visibly upset, crying, and verbalizing, “Don’t touch that! It’s so awful to look at and it smells terrible. I’m never leaving my house again.” Taking Action J.T. is worried about the odor associated with his temporary ileostomy. The nurse should advise T.J. to avoid which foods known to cause gas with a strong odor? Select all that apply. Eggs Potatoes Carbonated beverages Beer Broccoli Bread Case Study: J.T. J.T. (pronouns: he/him/his), a 34-year-old, arrives at the emergency department with stabbing abdominal pain that is 9 out of 10 on the 0-10 pain scale, with episodic rectal bleeding and severe diarrhea for the last two days. The client was recently treated and released from the hospital for a salmonella infection. Vitals are T 98.7 °F (37 °C), BP 90/64, P 124, R 18, oxygen saturation 96% RA. J.T. states, “I try to eat healthy,” but a busy work schedule has him eating fast food most days during the work week. J.T. was diagnosed with ulcerative colitis and needed a temporary ileostomy. The new shift nurse enters his room 24 hours after the postsurgical ileostomy to perform a shift assessment. The nurse observes him tearful in bed and approaches to change the ostomy dressing per prescribed orders. J.T. becomes visibly upset, crying, and verbalizing, “Don’t touch that! It’s so awful to look at and it smells terrible. I’m never leaving my house again.” Evaluating Outcomes J.T. has a follow-up appointment with his healthcare team to discuss medication compliance. He is concerned about adhering to his medication regimen due to his busy schedule. Which statements by J.T. support medication adherence? Select all that apply. “My partner helps me when I need to take my injection.” “I have been taking my evening medications at the same time every day.” “I have been able to purchase a daily pill box with scheduled times listed.” “If I feel better, I can skip a day taking my medications.” “I set a reminder on my cell phone when it's time to give myself an injection.” “I place my morning pills by my toothbrush to remind me to take them first thing in the morning.” Routes of Administration The nurse is teaching clients with inflammatory bowel disease (IBD) about subcutaneous injections for prescribed biologic medication therapy. Which clients would be appropriate for subcutaneous injections? Select all that apply. A 26-year-old male who is in nursing school A 78-year-old female with severe rheumatoid arthritis (RA) of the hands who lives alone A 64-year-old male with diabetes mellitus type II A 34-year-old female with dermatitis Immediate Intervention Which client with an ostomy requires immediate intervention by the nurse? Stomal tissue is oozing a small amount of blood. Stomal tissue appears dusk/pale and is cool to the touch. Stomal tissue is moderately edematous. Stomal tissue appears beefy red in color.