In: Nursing
Explain the admission data in terms of the pathophysiology of her condition.
The client remains home for three weeks. She is readmitted again after a severe GI bleed secondary to her ulcerative colitis. Since her trip to Jamaica, she has lost over 30 lbs. due to loss of appetite, nausea, vomiting, and diarrhea. Due to her ulcerative colitis, she has uncontrollable bowel movements, both with and without rectal bleeding. She often chooses not to eat because she states, “it just runs right through me so why bother?”
Second Admission Data:
T 98.7 F (98.6) normal
BP 70/50 (120/80) extremely low
P 133 (60-99) extremely high
RR 18 (12-16) high
O2 sat (by pulse oximetry) 93% on room air (RA) (95-100) low
BUN 10 ( 6-20 mg/dl) normal range
Serum creatinine 0.5 (0.6-1.3 mg/dl) low
Hgb 7.8 (13.5-18 g/dl) low
Hct 25 (42%-52%) extremely low
WBC 10 (4K-10.5K/mcl) normal range
INR 7 (1.1 or below) extremely high
Sodium 128 (135-145 mEq/L) low
Potassium 2.9 (3.7-5.2 mEq/L) extremely low
Calcium 7.4 (8.6-10.3) low
Magnesium 1.5 (1.7-2.2) low,
Glucose 124 (< 100) low
Total protein 5.4 (6.0-8.3) low
Albumin 1.6 (3.4 to 5.4) extremely low
Introduction:
Ulcerative colitis is chronic inflammatory disorder of the large intestine in which there is chronic inflammation and ulceration of the mucosa of the large intestine. It is characterized by diarrhoea, most often bloody diarrhoea ,abdominal cramps and pain. The disorder is caused by probably an immune malfunction; dietary and stress factors may also cause ulcerative colitis.
Pathophysiology of ulcerative colitis
In ulcerative colitis, there is inflammation of the mucosal lining of the colon with ulcerations which initially starts in the rectum and then gradually extends to involve the entire colon. This inflammation is characterized by episodes of diarrhoea and bloody stools with abdominal cramps and pain. The inflammatory diarrhoea and bleeding that is associated with ulcerative colitis causes a lot of metabolic derangements for the patient with chronic malabsorptive status and anaemia.
Discussion of the patient's pathophysiological state
The patient here has had episodes of acute diarrhoea with uncontrollable bowel movement and there is a pathophysiological state of acute dehydration with a chronic malabsorptive state.
The patient has presented with shock and anaemia due to chronic diarrhoea and bleeding, hypoproteinemia hypomagnesemia hypocalcemia and elevated INR which are due to chronic malabsorption that is associated with ulcerative colitis.
There is a higher risk of Travelers diarrhoea in patients of inflammatory bowel disease. Since the patient has traveled to Jamaica and has exacerbation of the symptoms following return from Jamaica there is a possibility that she has a developed Travelers diarrhoea .The organism that are commonly responsible for travelers diarrhoea include clostridium difficile,Giardia and cytomegalovirus. Immunosuppression exists in patients of ulcerative colitis due to long term use of Steroids and they are at a higher risk of developing Travelers diarrhoea which exacerbates the inflammatory bowel disease. The possibility of this occurrence in our patient has to be ruled out by performing a stool examination and culture
The explanation of the admission data with respect to the disease of the patient and its pathophysiology has been detailed In The table below.
parameters | explanation with the pathophysiology of ulcerative colitis |
temperature 98.7 (normal) | low grade chronic inflammation without infection with normal body temperature.no pyrexia. |
bp 70/50 | hypotension (due to ongoing fluid loss and blood loss)hypovolemia due to diarrhoea ,nausea and vomiting bleeding.hypovolemic shock. |
p133/min | tachycardia secondary to hypotension and shock |
rr 18(12-16) | tachypnea secondary to hypotension |
O2 saturation 93% low |
1.anaemia with low hemoglobin concentration leading to low pO2. (less hemoglobin to bind with oxygen) 2.shock state,less perfusion of the lungs |
bun 10mg|dl | normal renal function |
Serum creatinine 0.5mg/dl low | low protein diet with microalbuminuria and microproteinuria causes low serum creatinine levels. |
Hgb low 7.8 |
The three causes of anaemia in ulcerative colitis are 1.poor iron absorption due to intestinal inflammation 2.decreased intake of iron rich foods and food in general by the patient due to the fear of diarrhoea 3.chronic blood loss because of ulcerative colitis with rectal bleeding. |
wbc normal haematocrit low(25) |
normal wbc levels. low haematocrit due to chronic blood loss and anaemia. rectal and colonic bleeds in ulcerative colitis with poor dietary intake of food and iron. |
INR 7 extremely high |
1.Vitamin K is required for the synthesis of four out of the 13 clotting factors. it is the most important vitamin that helps in the clotting of blood .vitamin K is derived from the green leafy vegetables which is part of the diet of the patient and also synthesized by the bacteria in the large intestine 2.In case of inflammatory bowel disease the dietary intake of the patient has reduced drastically and the synthesis of vitamin K is also affected because of the inflammation in the large intestine in ulcerative colitis. 3.Hence the synthesis of clotting factors here is affected and the PT INR is highly elevated .Factors dependent on vitamin K are Prothrombin protein C proteinS and factor IX and factor 7. 4.Hypoproteinemia has also affected the synthesis of clotting factors leading to their deficiency and increase in the clotting timeThe deficiency of Vitamin K and clotting factors has caused the increase in the PT INR levels in this patient. |
sodium 128 low |
1.loss of sodium in the body fluids through vomitus and bowel fluids leading to hyponatremia. 2.poor absorption of sodium and chloride in case of Bowel inflammation seen in ulcerative colitis 3.sodium loss in vomiting. |
potassium 2.9 extremely low |
1.loss of potassium in the large intestinal fluid diarrhoea leading to hypokalemia 2.increased secretion of potassium and diarrhoea 3.potassium loss in vomiting. |
calcium 7.4 low |
the reasons of hypocalcemia are as follows
2.avoidance of Dairy Foods and other specific dietary items because of food intolerance leading to calcium deficiency. 3.Lower Transit Time due to diarrhoea and inflammatory cytokines leading to poor absorption of calcium. 4.poor dietary intake. The patient often chooses not to eat because in her words it just runs right through me so why bother? Long term use of Steroids causes bone loss and osteoporosis by interfering with the calcium absorption |
magnesium1.5 low |
1.magnesium is absorbed in the colon,since there is inflammation of the colon and chronic diarrhoea, magnesium absorption is affected.and hence hypomagnesemia. 2.poor dietary intake. The patient often chooses not to eat because in her words it just runs right through me so why bother? |
glucose 124(<100) low |
patient levels of glucose is <100 mg/dl. blood glucose indicative of hypoglycemia 1.poor glucose absorption due to diarrhoea and vomiting and chronic malabsorption. 2.decreased intake of food due to fear of diarrhoea. The patient often chooses not to eat because in her words, it just runs right through me so why bother? rationale if elevated blood glucose levels found. Long term use of corticosteroids can elevate the fasting blood sugar to greater than hundred in patients of ulcerative colitis and point towards steroid induced Diabetes mellitus .in our patient if the fasting blood sugar found is greater than normal, investigation must be made to rule out steroid induced Diabetes mellitus normal fasting blood glucose <100mg/dl (random<200mg/dl) prediabetic 100-125mg/dl diabetic>126mg/dl |
total protein5.4 low |
1.ulcers in the mucosa of the large intestine cause leakage of protein rich fluids causing hypoproteinemia 2.Micro proteinuria and microalbuminuria are found in ulcerative colitis due to leaky renal capillaries which is caused by the inflammatory cytokines that are associated with the ulcerative colitis 3.poor dietary intake of protein. The patient often chooses not to eat because in her words it just runs right through me so why bother? |
albumin 1.6 extremely low |
1.ulcers in the mucosa of the large intestine cause leakage of protein rich fluids causing hypoproteinemia 2.Micro proteinuria and microalbuminuria are are found in ulcerative colitis due to leaky renal capillaries which is caused by the inflammatory cytokines that are associated with the ulcerative colitis 3 poor dietary intake of albumin The patient often chooses not to eat because in her words it just runs right through me so why bother? |