Question

C.W., a 36-year-old woman, was admitted several days ago with a diagnosis of recurrent inflammatory bowel disease (IBD) and possible small bowel obstruction (SBO). C.W. is married, and her husband and 11-year-old son are supportive, but she has no extended family in-state. She has had IBD for 15 years and has been taking mesalamine (Asacol) for 15years and prednisone 40 mg/day for the past 5 years. She is very thin; at 5 feet 2 inches she weighs 86 pounds and has lost 40 pounds over the past 10 years. She has an average of 5 to 10 loose stools per day. C.W.'s life has gradually become dominated by her disease (anorexia; lactase deficiency; profound fatigue; frequent nausea and diarrhea; frequent hospitalizations for dehydration; and recurring, crippling abdominal pain that often strikes unexpectedly). The pain is incapacitating and relieved only by a small dose of diazepam (Valium), oral electrolyte solution (Pedialyte), and total bed rest. She confides in you that sexual activity is difficult: “It always causes diarrhea, nausea, and lots of pain. It's difficult for both of us.” She is so weak she cannot stand without help. You indicate complete bed rest on the nursing care plan.

1. discuss the pathophysiology of this client

2. Create a plan of care

3. Provide 3 management goals

Answer 1

1. Pathophysiology of Inflammatory Bowel Disease:

Inflammatory Bowel Disease ( IBD) is a group of intestinal disorders that are characterised by chronic inflammation of digestive tract especially the intestines. The main inflammatory disorders coming under the term IBD are Ulcerative Colitis and Crohn's disease. The exact cause of IBD is unknown, but genetic factors and immune system disorders are playing a major role along with the Risk factors such as:

* Smoking

* Urban dwellers

* Family history and ethnicity ( common in Caucasians )

* sedentary lifestyle

* Increased consumption of fat and processed food.

Pathophysiology of Crohn's disease ( CD)

Due to unknown etiology/ or risk factors / immune system disorders

? ( leads to)

Full thickness Inflammation of the intestinal wall , especially ileum region( CD can affect any part of the digestive system).

?

Abdominal pain, chronic diarrhoea due to inflammation

?

Small bowel inflammation leads to swelling and intestinal obstruction of small intestine or ileus

   ?

Distention, nausea, Colicky pain in the abdomen

?

Gastro intestinal bleeding due to chronic and transmural inflammation and ulcers

?

Continous loose stools, muco purulent discharge and presence of fresh blood in stools ( hematochezia).

?

Weight loss, malnutrition, Vitamin deficiencies etc.

Ulcerative Colitis:

The inflammatory process is same but the location is different in Ulcerative Colitis. In CD inflammation occurs in any part of Digestive system, but specially in Ileum region. Inflammed areas may alternate with healthy areas. But in Ulcerative colitis the whole area of Colon segment of large intestine is getting affected.

Chronic inflammation of gastrointestinal tract may complicated to fistula, strictures and abscesses.

2. Plan of Care for IBD

Pharmacological management:

* Immunomodulators: to regulate the immune system. eg: Mercaptopurine , azathioprine

* Aminosalycilate: Antiinflammatory agents, to treat the symptoms of bowel inflammation . eg: Sulfasalazine

* Corticosteroids: to reduce inflammation. eg: Budesonide, prednisone

* Antibiotics to treat infection . eg: Metranidazole

* Probiotics: A dietary supplements, containing live bacteria for therapeutic reasons.

eg: Lacto bacillus GG

Nursing Management :

* Assess the severity of symptoms and monitor the vital signs 4 hourly.

* Administer medications as per Doctor's order.

* Provide Psychological support to the patient.

* Cessation of feeding, if it is ordered.

* Intravenous infusion as per order .

* Check the signs of any dehydration.

* Monitor lab values for  Fluid- electrolyte balance .

* Promote bed rest

* Provide bed side commode , remove stool promptly and use room deodorants .

* Observe for any fever , tachycardia and lethargy to detect the signs of complications.

* Asess the patient's level of anxiety.

* Encourage the patient to ventilate the feelings and distress.

* Encourage use of stress management skills ; deep breathing exercises, relaxation techniques, guided imagery.

* Provide reference of local support group, spiritual support and counselling services.

* Instruct the patient and the family regarding the dietary restrictions, such as intestinal irritants, high fiber food ( vegetables, fruits, whole grains etc).

3. Goals of Management of IBD

* Eliminate or reduce  the symptoms of Inflammatory Bowel Disease

* Promote Optimal nutrition  

* Improve the quality of life of the patient with IBD

* Prevent  the complications and avoid recurrent hospitalization and surgery.