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

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

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

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

5. 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

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

7. 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.

8. 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.

9. Peritonitis

10. Crohn’s Disease
Note cobblestone appearance of intestine.

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

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

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

14. Anal Fistula
Common sites of anal fistulas.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. Audience Response System Questions
Chapter 60
Audience Response System Questions 21

22. 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.

23. 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.

24. 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.