Mrs. Z is a 34-year-old female who come in with a complaint of diarrhea accompanied by abdominal pain. Onset of the symptom was about 4 days ago. She reports thinking she is running a fever but has not taken her temperature. She concerned that she is starting to feel weak.
She denies recent travel and reportedly has not been on any antibiotics in the past few weeks.
In reviewing her record, you notice that her health history is positive for history of ulcerative colitis. She has not been on any medications for this over the last few years as she had not been symptomatic.
Mrs. Z is on an oral contraceptive. She takes slippery elm capsules and has for the last several years. She reports that she has been taking 2 to 3 doses of Benefiber prebiotic fiber for the last couple days.
Objective data:
BP 116/70 sitting, 100/66 standing; P 92; Temp 100.1
Abdomen – active bowel sounds all 4 quadrants, mild tenderness with palpation
Otherwise her exam is unremarkable for pertinent positives or negatives.
Labs – WBC 14,000; Hgb 11.9; Hct 35.7; Sodium 133; Potassium 3.3
Instructions:
Please prepare and submit a paper 3-4 pages [total] in length (not including APA formatted title and references pages) answering the questions below. Please support your position with examples.
· What pharmacologic therapy would you prescribe for Mrs. Z?
· How will you evaluate the effectiveness of this therapy?
· What patient education would you provide for Mrs. Z relative to the pharmacologic agent you prescribed?
· Are there any pharmacogenetic considerations related to what you prescribed for the patient?
· Are there any alternative therapies or over-the-counter agents that might be of value to Mrs. Z?
· What, if any, lifestyle changes would you recommend?
Inflammatory bowel disease (IBD) can
affect structures or segments along the
gastrointestinal tract. The term includes both
acute and chronic disorders.
Acute and chronic IBD can result in nutritional
deficits, altered bowel elimination, infection,
pain, and fluid or electrolyte imbalances. The
nurse needs to be knowledgeable about acute
and chronic IBD in order to collaborate with the
client and the interprofessional team in treating
and managing these disorders.
ACUTE IN FLAMMATOR Y BOWEL DISEASE
Appendicitis
Inflammation of the appendix
●● Caused by an obstruction of the lumen or opening of
the appendix.
●● Fecaliths, or hard pieces of stool, can be the initial cause
of the obstruction.
●● Adolescents and young adults are at increased risk.
●● Refer to the NURSING CARE OF CHILDREN REVIEW MODULE,
CHAPTER 23: GASTROINTESTINAL STRUCTURAL AND
INFLAMMATORY DISORDERS.
Peritonitis
Inflammation of the peritoneum results from infection
of the peritoneum due to puncture (surgery or trauma),
rupture of part of the gastrointestinal tract (diverticulitis,
peptic ulcer disease, appendicitis, bowel obstruction), or
infection from continuous ambulatory peritoneal dialysis.
Gastroenteritis
Inflammation of the stomach and small intestine
●● Triggered by infection (either bacterial or viral).
●● Vomiting and frequent, watery stools place the client at
increased risk for fluid and electrolyte imbalance and
impaired nutrition.
CHRONIC IN FLAMMATOR Y
BOWEL DISEASE
Ulcerative colitis and Crohn’s disease are characterized by
frequent stools, cramping abdominal pain, exacerbations,
and remissions.
Ulcerative colitis
Edema and inflammation primarily in the rectum and
rectosigmoid colon
●● In severe cases, it can involve the entire length of the
colon. Mucosa and submucosa become hyperemic
(increase in blood flow), and the colon will become
edematous and reddened. It can lead to abscess formation.
●● Edema and thickened bowel mucosa can cause partial
bowel obstruction. Intestinal mucosal cell changes
can lead to colon cancer or insufficient production of
intrinsic factor, resulting in insufficient absorption of
vitamin B12 (pernicious anemia).
●● Classified as either mild, moderate, severe, and fulminant.
Crohn’s disease
Inflammation and ulceration of the gastrointestinal tract,
often at the distal ileum
●● All bowel layers can become involved; lesions are
sporadic. Fistulas are common.
●● Can involve the entire GI tract from the mouth to the anus.
●● Malabsorption and malnutrition can develop when
the jejunum and ileum become involved. Requires
supplemental vitamins and minerals, possibly including
vitamin B12 injections.
Diverticulitis
Diverticulitis is inflammation and infection of the bowel
mucosa caused by bacteria, food, or fecal matter trapped
in one or more diverticula (pouch‑like herniations in
the intestinal wall). Diverticulitis is not to be confused
with diverticulosis, which is the presence of many small
diverticula in the colon without inflammation.
●● Not all clients who have diverticulosis
develop diverticulitis.
●● Diverticula can perforate and cause peritonitis, and/or
severe bleeding.
ASSESSMENT
Etiology of ulcerative colitis and Crohn’s disease is
unknown but possibly due to a combination of genetic,
environmental, and immunological causes.
RIS K FACTORS
Genetics: Ulcerative colitis and Crohn’s disease
Culture: Caucasians (ulcerative colitis), Jewish heritage
(ulcerative colitis and Crohn’s disease), and African
Americans (diverticular disease)
Sex and age: The incidence of ulcerative colitis peaks at
adolescence to young adulthood (more often in females)
and older adulthood (more often in males). Crohn’s disease
usually develops in adolescents and young adults, but can
occur at any age. Diverticulitis occurs more often in older
adults and affects males more frequently than females.
Tobacco use: Crohn’s disease
EXPECTE D FINDINGS
Ulcerative colitis
●● Abdominal pain/cramping: often left‑lower quadrant pain
●● Anorexia and weight loss
PHYSICAL ASSESSMENT FINDINGS
●● Fever
●● Diarrhea: up to 15 to 20 liquid stools/day
●● Stools containing mucus, blood, or pus
●● Abdominal distention, tenderness, and/or firmness
upon palpation
●● High‑pitched bowel sounds
●● Rectal bleeding
Crohn’s disease
●● Abdominal pain/cramping: often right‑lower quadrant pain
●● Anorexia and weight loss
PHYSICAL ASSESSMENT FINDINGS
●● Fever
●● Diarrhea: five loose stools/day with mucus or pus
●● Abdominal distention, tenderness and/or firmness
upon palpation
●● High‑pitched bowel sounds
●● Steatorrhea
Diverticulitis
●● Acute onset of abdominal pain often in left‑lower quadrant
●● Nausea and vomiting
PHYSICAL ASSESSMENT FINDINGS
●● Fever
●● Chills
●● Tachycardia
●● Abdominal distention
LA BORATOR Y TESTS
Ulcerative colitis
Hematocrit and hemoglobin: Decreased
Erythrocyte sedimentation rate (ESR): Increased
WBC: Increased
C‑reactive protein: Increased
Albumin: Decreased
Stool for occult blood: Can be positive
K+, Na, Mg, Ca, and Cl: Decreased
Crohn’s disease
Hematocrit and hemoglobin: Decreased
ESR: Increased
WBC: Increased
C‑reactive protein: Increased
Albumin: Decreased
Folic acid and B12: Decreased
Anti‑glycan antibodies: Increased
Stool for occult blood: Can be positive
Urinalysis: WBC
K+, Mg, and Ca: Decreased
Diverticulitis
Hematocrit and hemoglobin: Decreased
ESR: Increased
WBC: Increased
Stool for occult blood: Can be positive
DIAGNOSTIC PROCE DURES
Magnetic resonance enterography: Used with all IBD
CLIENT EDUCATION: Maintain NPO for 4 to 6 hr prior to
the exam. You might be asked to drink a contrast medium
prior to the test.
Ulcerative colitis
Sigmoidoscopy or colonoscopy: Can diagnose
ulcerative colitis
Barium enema: Helpful to distinguish ulcerative colitis
from other disease processes
CT scan or MRI: Can identify the presence of abscesses
Stool examination: For the presence of parasites
or microbes
Crohn’s disease
Endoscopy
●● Newer diagnostic tools used, such as video
capsule endoscopy
●● Proctosigmoidoscopy: Performed to identify
inflamed tissue
●● Colonoscopy and sigmoidoscopy: A lighted, flexible
scope inserted into the rectum to visualize the rectum
and large intestine
Abdominal ultrasound, x‑ray, and CT scan: CT scans can
show bowel thickening.
Barium enema: Barium is inserted into the rectum as a
contrast medium for x‑rays. This allows for the rectum
and large intestine to be visualized, and is used to
diagnose ulcerative colitis. A barium enema can show the
presence of diverticulosis and is contraindicated in the
presence of diverticulitis due to the risk of perforation.
NURSING ACTIONS: Monitor postprocedure for
manifestations of bowel perforations (rectal bleeding, firm
abdomen, tachycardia, hypotension).
FINDINGS
●● Small intestine ulcerations and narrowing is consistent
with Crohn’s disease.
●● Ulcerations and inflammation of the sigmoid colon and
rectum is significant for ulcerative colitis.
CLIENT EDUCATION
●● Remain NPO as required, and perform bowel preparation.
●● There can be possible abdominal discomfort and
cramping during the barium enema.
PATIENT‑CENTERED CARE
NURSING CARE
Ulcerative colitis and Crohn’s disease
●● The client should receive instructions regarding the
usual course of the disease process.
●● The client should receive instructions regarding
medication therapy and vitamin supplements.
●● Monitor by colonoscopy due to the increased risk of
colon cancer.
●● Assist the client in identifying foods that
trigger manifestations.
●● Monitor for electrolyte imbalance, especially potassium.
Diarrhea can cause a loss of fluids and electrolytes.
●● Monitor I&O, and assess for dehydration.
●● Educate the client to eat high-protein, high-calorie,
low-fiber foods.