Care of Patients with Inflammatory Intestinal Disorders Chapter 60 Care of Patients with Inflammatory Intestinal Disorders Crohn's disease (left) and ulcerative colitis (right).

Inflammatory Disorders Intestinal Appendicitis Peritonitis Bowel Gastroenteritis (acute) Crohn’s disease (chronic) Ulcerative colitis (chronic)

Inflammatory Disorders Anal Anorectal abscess Anal fissure Parasitic infections Food poisoning Salmonellosis Staph E. coli Botulism

Group Activity for Inflammatory Disorders Priority concern(s) Common manifestations Treatment options Include collaborative health care team Potential complications Implications for older adults

Group Activity for Inflammatory Disorders Individualized questions Appendicitis Signs/symptoms before and after rupture Peritonitis Teaching plan for surgical patient Gastroenteritis Medications used Ulcerative colitis Profile of “typical” patient; dietary teaching plan Crohn’s disease Teaching plan

Group Activity for Inflammatory Disorders Diverticulosis vs. diverticulitis Compare/contrast Anorectal abscess, anal fissure, anal fistula Key differentiations Food poisoning Teaching plan regarding organisms

Diverticula Several abnormal outpouchings, or herniations, in the wall of the intestine, which are diverticula. These can occur anywhere in the small or large intestine but are found most often in the sigmoid, as shown in this figure. Diverticulitis is the inflammation of a diverticulum that occurs when undigested food or bacteria become trapped in the diverticulum.

McBurney’s Point (Appendicitis) McBurney’s point is located midway between the anterior iliac crest and the umbilicus in the right lower quadrant. This is the classic area for localized tenderness during the later stages of appendicitis.

Peritonitis

Crohn’s Disease Note cobblestone appearance of intestine.

Ulcerative Colitis Photo shows severe mucosal edema and inflammation with ulcerations and bleeding.

Anorectal Fissure Common sites of anorectal abscesses and fistulas. Inflammation often begins in the anal crypts.

Fistulas The types of fistulas that are complications of Crohn’s disease.

Anal Fistula Common sites of anal fistulas.

Skin Barriers Skin barriers, such as wafers (A), are cut to fit 1/8 inch around the fistula. A drainable pouch (B) is applied over the wafer and clamped (C) until the pouch is to be emptied. Effluent should drain into the bag and not contact the skin.

Case Study The patient is a 21-year-old who has recently been diagnosed with ulcerative colitis. In the ED, she tells you that she has been having 7 to 8 bloody stools daily. Upon assessment, you find that her heart rate is 120/min, and she has abdominal pain upon palpation. Laboratory results show a hemoglobin level of 9 g/dL. How is the severity of the patient’s ulcerative colitis categorized? Mild Moderate Severe Fulminant ANS: C Severe UC presents with greater than 6 bloody stools daily and may include fever, tachycardia, anemia, abdominal pain, and an elevated C-reactive protein and/or ESR.

Case Study (cont’d) The patient is admitted to the acute medical unit. Which ordered medication would the nurse question? Mesalamine (Asacol) Prednisone (Deltasone) Ibuprofen (Motrin) Loperamide (Imodium) ANS: C Ibuprofen is an NSAID; NSAIDs increase the risk for bleeding.

Case Study (cont’d) Later in the afternoon, the patient states that the abdominal pain is getting worse. Which interventions would be implemented for her pain? (Select all that apply.) Administering analgesics as ordered Assisting with frequent positioning Providing sitz baths as needed Teaching music therapy or guided imagery Evaluating the diet for foods that cause pain Providing antidiarrheal medications as needed ANS: A, B, D, E Sitz baths will help prevent skin excoriation or irritation, as will antidiarrheal drugs. Complementary therapies used in conjunction with analgesics can be very helpful in controlling pain. The other interventions would not be helpful in managing the patient’s pain.

Case Study (cont’d) The patient states, “I am afraid I’ll never get to go out with my friends again because I can’t be away from the toilet.” Which is the appropriate nursing response? “What makes you say that?” “Your friends will understand.” “I wouldn’t worry about it if I were you.” “It sounds like you are concerned about managing this disorder when you are out.” ANS: D This response verbalizes the implied. Response A does not address the concern and requires the patient to give an answer that defends her feelings. Responses B and C minimize the patient’s feelings and do not address her concerns.

Case Study (cont’d) The patient is preparing for discharge. She asks what is the best way to keep her skin from breaking down. What is the nurse’s best response? “Wash with mild soap and warm water after each bowel movement.” “Apply a pectin-based skin barrier after each bowel movement.” “Add high-fiber or high-cellulose foods to your diet.” “Take a laxative daily at bedtime to facilitate morning bowel movements.” ANS: A Good skin care after each bowel movement is the best way to protect from excoriation or irritation due to frequent bowel movements. Pectin skin barriers should be used with ostomies. High-fiber or high-cellulose foods should be avoided, as should laxatives.

Audience Response System Questions Chapter 60 Audience Response System Questions 21

Question 1 An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? Dehydration Hypokalemia Hypernatremia Perineal skin breakdown Answer: A Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.

Question 2 A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient’s laboratory results for evidence of which condition? Hypernatremia Hypercalcemia Hyperglycemia Hyperkalemia Answer: C Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection.

Question 3 What priority laboratory analysis should the nurse review when caring for a patient with Crohn’s disease? C-reactive protein Serum albumin Hemoglobin Potassium Answer: C Rationale: Crohn’s disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulcerations that result in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. C-reactive protein may be monitored as a marker of inflammation, albumin to assess nutritional status, and potassium related to losses from diarrhea.