Crohn’s disease (CD), also known as granulomatous colitis or regional enteritis, is a chronic, nonspecific inflammatory disease of the bowel that occurs most commonly in the terminal ileum, jejunum, and the colon, although it may affect any part of the gastrointestinal (GI) system from the mouth to the anus. In the United States, the prevalence of crohn’s disease is approximately 7 cases per 100,000 population, and the prevalence has steadily increased in recent decades. Like ulcerative colitis, crohn’s disease is marked by remissions and exacerbations, but, unlike ulcerative colitis, it can affect any portion of the tubular GI tract. The disease creates deep, longitudinal mucosal ulcerations and nodular submucosal thickenings called granulomas, which give the intestinal wall a cobblestone appearance and may alter its absorptive abilities. The inflamed and ulcerated areas occur only in segments of the bowel, and normal bowel tissue segments occur between the diseased segments. Eventually, thickening of the bowel wall, narrowing of the bowel lumen, and strictures of the bowel are common. Also, fistulae that connect to other tissue—such as the skin, bladder, rectum, and vagina—often occur.
Research has not established a specific cause for crohn’s disease. Infectious agents such as a virus or bacterium, an autoimmune reaction, environmental factors such as geographic location, individual factors such as smoking and dietary exposure, and genetic factors are all being investigated. Researchers now believe that emotional stress and psychological changes are a result of the chronic and severe symptoms of crohn’s disease rather than a cause. Some experts suggest that patients have an inherited susceptibility for an abnormal immunologic response to one or more of the factors listed above.
Nursing care plan assessment and physical examination
Patients initially report insidious symptoms such as mild, nonbloody diarrhea (three to five semi-soft stools per day), fatigue, anorexia, and vague, intermittent abdominal pain. As the disease progresses, they complain of more severe, constant abdominal pain that typically localizes in the right lower quadrant, weight loss, more severe fatigue, and moderate fever. Some patients may also report skin breakdown in the perineal and rectal areas.
Because crohn’s disease is a chronic disease that affects the GI system and causes anorexia and multiple episodes of diarrhea, common problems are malnutrition and dehydration. Inspect for hair loss, dry skin, dry and sticky mucous membranes, poor skin turgor, muscle weakness, and lethargy. Also, inspect the patient’s perianal area for signs of fistula formation. Palpate the patient’s abdomen for pain, tenderness, or distension. Generally, pain localizes in the right lower quadrant, but note the location, intensity, type, and duration of discomfort. Auscultate the patient’s abdomen for bowel sounds. Often, hyperactive sounds will be noted during an acute inflammatory episode.
The effects of chronic illness and debilitating symptoms, along with frequent hospitalizations, often result in psychological problems and social isolation. Assess the coping mechanisms, as well as the patient’s support system.
Nursing care plan primary nursing diagnosis: Alteration in nutrition: Less than body requirements related to anorexia, diarrhea, and decreased absorption of the intestines.
Nursing care plan intervention and treatment
Much of the medical management centers on medications. During acute exacerbations, bowel “rest” is important to promote healing; bowel rest can be achieved by placing the patient NPO with the administration of total parenteral nutrition to supply the required fluids, nutrients, and electrolytes. Once the acute episode has subsided and symptoms are relieved, a diet high in protein, vitamins, and calories is prescribed. The patient’s diet should be balanced, and supplements of fiber may be beneficial for colonic disease; low-roughage diet is usually indicated for patients with obstructive symptoms. In addition, a low-residue, milk-free diet is generally well tolerated.
Surgery, though not a primary intervention, may be necessary for patients who develop complications such as bowel perforation, abscess, intestinal obstruction, fistulae, or hemorrhage and for those who do not respond to conservative management such as nutritional and drug therapy. Unfortunately, there is a 60% recurrence of the disease process after surgical intervention. Multiple resections also may lead to short bowel syndrome, defined as malabsorption of fluids, electrolytes, and nutrients, which leads to nutritional deficiencies. The syndrome occurs when less than 150 cm of functional small bowel remains.
Nursing care focuses on supporting the patient through acute episodes of inflammation and teaching measures to prevent future inflammatory attacks. Maintaining patient fluid and electrolyte balance is particularly important. Encourage the patient to drink 3000 mL of fluid per day, unless it is contraindicated. Implement measures to prevent skin breakdown in the perianal area. Provide frequent rest periods. Maintain adequate nutritional status using calorie counts. Other measures include assisting the patient with frequent oral hygiene; providing small, frequent meals with rest periods interspersed throughout the day; monitoring intravenous fluids and total parenteral nutrition as prescribed; and noting the patient’s serum albumin levels. Encourage patients to express their feelings and refer them for more extensive counseling as needed. Also, discuss measures to diminish stressful life situations with the patient and family.
Nursing care plan discharge and home health care guidelines
Emphasize measures that will help prevent future inflammatory episodes, such as getting plenty of rest and relaxation, reducing stress, and maintaining proper diet (high protein, low residue). Teach the patient to recognize the signs of incipient inflammatory attacks. Explain all the prescribed medications, including the actions, side effects, dosages, and routes. Be certain the patient understands signs of possible complications, such as an abscess, fistula, hemorrhage, or infection, and the need to seek medical attention if any of them occurs. Caution the patient to be vigilant with skin care, especially in the perianal area. Instruct the patient to assess frequently for breakdown in this area and seek medical attention if it should occur.