Professional Documents
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College of Nursing
Crohn’s Disease
Submitted to:
II. Assessment
A. Anatomy and Physiology of the Digestive tract
B. Pathophysiology
C. Signs and Symptoms
D. Diagnostic Tests
Mouth
The mouth is the oral cavity where foods are received and prepared for digestion.
The mouth is responsible for the secretion of salivary amylase, which begins the
digestion process by converting starches into sugars.
Pharynx
The pharynx ,or throat, is a muscular tube that serves as a vehicle for both
respiration and digestion. When we swallow, reflex movements of muscles in the
pharynx propel food into the esophagus.
Esophagus
The esophagus is a tube that carries swallowed foods to the stomach.
Stomach
The stomach is a muscular organ that is located in the central/upper left hand
region of the abdominal cavity. The function of the stomach is to break down food items.
The stomach secretes digestive juices, such as hydrochloric acid and pepsin, to aid in
this process. It's muscular walls churn the food until it is in a semi-liquid form.
Small Intestines
The small intestines digest and absorb many of the foods we eat. In addition to
secreting a strong mucus membrane to protect it's walls from the strong acid food
mixture that passes into it from the stomach, the small intestines (along with the liver
and pancreas) secrete enzymes that help to digest proteins and carbohydrates and
break them down into their simplest form. Once digested, nutrients are extracted and
are absorbed by the body.
Large Intestines
The large intestine is responsible for the elimination of food materials that cannot
be digested and assimilated by the body. It is also responsible for the re-absorption of
water used during the digestive process. As food materials pass through the large
intestine, friendly bacteria that live in the colon act upon this waste, producing vitamin K
and some of the B-vitamins.
Liver
The liver is the largest gland in our bodies. It is located in the upper right portion
of the abdominal cavity, with the lower edge of the liver extending just below the rib
cage. The liver is responsible for a multitude of different functions, including:
• The synthesis of lipoproteins such as cholesterol.
• Synthesis of bile, which is necessary for fat digestion and absorption.
• Manufactures carnitine for use in cell mediated fat transport.
• Regulation of the amount of cholesterol circulating in the blood.
• The storage and releasing of glucose.
• Converts lactic acid into glycogen.
• Converts B vitamins into their active co-enzyme form.
• Coverts ammonia into urea, which is excreted by the kidneys.
• The production or synthesis of specific proteins such as albumin and blood
clotting factors.
• The storage of substances such as glucose, fat soluble vitamins, including A,
B12, D, E & K, folate, and minerals such as copper and iron.
• Modification and inactivation of hormones; i.e., the breakdown of hormones that
have served their function.
• Detoxification of chemical elements whether ingested or inhaled.
• Removal of harmful substances from the blood and converts them into less
harmful substances that can be eliminated.
Pancreas
The pancreas is a gland that is located in the upper left hand quadrant of the
abdominal cavity. The pancreas houses the Isles of Landerhorn, which are responsible
for regulating blood sugar levels. It also produces enzymes that digest fats, proteins and
carbohydrates. In addition, the pancreas also produces an alkaline fluid, which
neutralizes the acidity of foods as they exit the stomach and proceed into the small
intestines.
B. Pathophysiology
(these lesions are not in continous contact with one another and are separated by
normal tissue. These cluster of ulcers tend to take on a classic “ cobble stone”
appearance.)
Fistula, fissures, and abscesses forms as the inflammation extend into the peritoneum
Clinical Manifestation:
-prominent lower right quadrant abdominal pain
-diarrhea unrelieved by medication
-scar tissue and formation of granuloma which interferes with the ability of the
intestine to transport products of the upper intestinal digestion
through the constricted lumen, results in
-crampy abdominal pain occurs after meals because eating stimulates
intestinal peristalsis
-abdominal tenderness and spasm
* to avoid this bouts of crampy pain the patient tends to limit food
intake, reducing the amount and types of food to such a degree that
normal nutritional requirement are often not met, results in
- weight loss
-malnutrition
-secondary anemia
*ulcers in the membranous lining of the intestine and other
inflammatory changes, results in
-weeping
-edematous intestine which continually empties an irritating discharge into the
colon . Inflamed intestine may perforate leading to
-intraabdominal and anal abscesses
-fever and leukocytosis
Chronic Symptoms:
-diarrhea
-abdominal pain
-steatorrhea ( excessive fat in the feces )
-anorexia
-nutritional deficiency
-weight loss
-Barium enema may show ulceration ( the cobble stone appearance), fissure,
and fistula
-CT scan which may show bowel wall thickening and fistula formation
-Complete Blood Count (CBC) is performed to assess hematocrit and
hemoglobin levels ( usually decreased ) as well as the
white Blood Cell Count ( may be elevated )
- Erythrocyte Sedimentation Rate (ESR) is usually elevated
-laboratory test that measures the rate of settling of
RBCs:elevation is indicative of inflammation also called
the “SED rate”
-Albumin and Protein level may be decreased, indicating malnutrition
-Relieving Pain
-Describe character of pain (dull, burning or cramp-like) and its onset,
pattern and medication relief
-Administer anticholinergic medications 30 minutes before a meal to
decrease intestinal motility.
-Give analgesic agents as prescribe; reduce pain by position changes,
local application of heat (as prescribed) diversional acivities, and
prevention of fatigue.
Promoting Rest
-Recommend intermittent rest periods during the day; schedule or
restrict activities to conserve energy and reduce metabolic rate.
-Encourage activity within limits; advise bed rest with active or passive
exercises for a patient who is febrile, has frequent stools, or is bleeding.
Reducing Anxiety
-Establish rapport by being attentive and displaying a calm, confident
manner.
-Provide time for patient to ask questions and express feelings.
-Note nonverbal indicators of anxiety (restlessness, tense facial
expressions).
-Tailor information about impending surgery to patient’s level of
understanding and desire for detail.
Continuing care
- Refer for homecare nurse if nutritional status is compromise and
patient is receiving PN.
- Explain that disease can be controlled and patient can lead a healthy
life between exacerbations.
- Encouraged patient to rest as needed and modified activities
according to energy levels during a flare-up. Advice patient to limit
task that impose strain on the lower abdominal muscles and to sleep
close to bathroom because of frequent diarrhea. Suggest room
deodorizers for odor control.
- Instruct about medications and the need to take them on schedule
while at home. Recommend used of medication reminders
(containers that separate pills according to day and time).
- Recommend low-residue, high-protein, and high- calorie diet during
an acute phase. Encourage patient to keep a record of foods that
irritate bowel and to eliminate them from diet. Recommend intake of
8 glasses of water per day.
- Provide support for prolonged nature of disease because it is a strain
on family life and financial resources. Arranged for individual and
family counseling as indicated.
- Provide time for patient to express fears and frustrations.
(Pharmacologic Management)
Drug Therapy
Anti-Inflammation Drugs. Most people are first treated with drugs containing
mesalamine, a substance that helps control inflammation. Sulfasalazine is the most
commonly used of these drugs. Patients who do not benefit from it or who cannot
tolerate it may be put on other mesalamine-containing drugs, generally known as 5-
ASA (5-aminosalycylic acid) agents, such as Asacol, Dipentum, or Pentasa. Possible
side effects of mesalamine-containing drugs include nausea, vomiting, heartburn,
diarrhea, and headache. Olsalazine (Dipentum).
Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine
caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may
prescribe one or more of the following antibiotics: ampicillin, sulfonamide,
cephalosporin, tetracycline, or metronidazole, ciprofloxacin Anti-infectives.
Metrinidazole, Ciprofloxacin treats local suppurative infections, or maybe part of a
long term treatment regimen.
Anti-Diarrheal and Fluid Replacements. Diarrhea and crampy abdominal pain are
often relieved when the inflammation subsides, but additional medication may also be
necessary. Several antidiarrheal agents could be used, including diphenoxylate,
loperamide, and codeine. Patients who are dehydrated because of diarrhea will be
treated with fluids and electrolytes.
Bile Acid Sequestrant. Cholestyramine binds bile salts, reducing diarrhea that results
from excess bile acid.
Cortisone or Steroids. AdrenoCorticoTropic Hormone (ACTH), Hydrocortisone
Cortisone drugs and steroids—called corticosteriods—provide very effective results.
Prednisone is a common generic name of one of the drugs in this group of
medications. In the beginning, when the disease it at its worst, prednisone is usually
prescribed in a large dose. The dosage is then lowered once symptoms have been
controlled. These drugs can cause serious side effects, including greater susceptibility
to infection.
Surgery
Two-thirds to three-quarters of patients with Crohn’s disease will require surgery
at some point in their lives. Surgery becomes necessary when medications can no
longer control symptoms. Surgery is used either to relieve symptoms that do not
respond to medical therapy or to correct complications such as blockage, perforation,
abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help
people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the
disease, and it is not uncommon for people with Crohn’s Disease to have more than
one operation, as inflammation tends to return to the area next to where the diseased
intestine was removed.
Some people who have Crohn’s disease in the large intestine need to have their
entire colon removed in an operation called a colectomy. A small opening is made in
the front of the abdominal wall, and the tip of the ileum, which is located at the end of
the small intestine, is brought to the skin’s surface. This opening, called a stoma, is
where waste exits the body. The stoma is about the size of a quarter and is usually
located in the right lower part of the abdomen near the beltline. A pouch is worn over
the opening to collect waste, and the patient empties the pouch as needed. The majority
of colectomy patients go on to live normal, active lives.
Sometimes only the diseased section of intestine is removed and no stoma is
needed. In this operation, the intestine is cut above and below the diseased area and
reconnected.
Because Crohn’s disease often recurs after surgery, people considering it should
carefully weigh its benefits and risks compared with other treatments. Surgery may not
be appropriate for everyone. People faced with this decision should get as much
information as possible from doctors, nurses who work with colon surgery patients
(enterostomal therapists), and other patients. Patient advocacy organizations can
suggest support groups and other information resources. (See For More Information for
the names of such organizations.)
People with Crohn’s disease may feel well and be free of symptoms for
substantial spans of time when their disease is not active. Despite the need to take
medication for long periods of time and occasional hospitalizations, most people with
Crohn’s disease are able to hold jobs, raise families, and function successfully at home
and in society.
(Surgical Management)
When nonsurgical measures fail to relieve the sever symptoms of inflammatory
bowel disease, surgery may be recommended (Segmental, Subtotal, or Total
Colectomy).A fecal diversion maybe needed, such as ileostomy, Continent Ileal
Reservoir (Koch Pouch), or Ileoanal anastomosis. Strictureplasty or fecal
diversions may be needed (e.g., Ileal reservoir, Ileoanal Anastomosis).
Proctocolectomy with Ileostomy (Excision of colon, rectum, and anus) may be
performed if rectum is severely involved.
IV.Expected Outcome
A.Prognosis