1. Crohn’s Disease A Case Study
Isabella Bourke
Jaymie McAllister
Jessica Nemerovsky
NUR 4216

2. Objectives
Student will be able to identify causative factors of Crohn’s Disease
Student will be able to explain the pathophysiology of Crohn’s Disease
Student will learn about the incidence and prevalence of Crohn’s Disease
Student will be able to identify an appropriate nursing diagnosis for a patient with Crohn’s Disease and possible nursing interventions

3. What is Crohn’s Disease?
Genetically linked inflammatory disorder of GI tract classified as an inflammatory bowel disease (Alisa & Siew, 2011)
Involves all layers of intestinal wall
Characteristic skip lesions from intermittent patterns of inflammation
Affects any portion of the GI tract from mouth to anus
Causes are not definitively known
Combination of heredity, abnormal immune response, and imbalance of gastrointestinal flora

4. Clinical Manifestations
Systemic S/S
Fever, fatigue, joint pain, mouth sores, fatty liver, autoimmune hepatitis
Diarrhea (Osborn, Wraa & Watson, 2009)
As many as bowel movements per day
Weight loss
Abdominal pain
Right lower quadrant
Anemia
Malnutrition
Deficiency of fat-soluble vitamins

5. Diagnostic Procedures
Endoscopy (Osborn, Wraa & Watson, 2009)
Gold standard
Radiography
Not favored due to risk of colonic perforation
Blood tests
Detect CBC r/t anemia
Stool sample
Checks for blood or infectious microbes
Barium enema
Start video at 2:18

6. Pathophysiology
Chronic inflammation from T-cell activation leading to tissue injury
Activation by antigen presentation results in unrestrained release of helper lymphocytes type 1 (Th1)
Defective regulation of Th1 cytokines such as interleukin (IL) -12 and tumor necrosis factor (TNF)-alpha stimulate the inflammatory response
Nonspecific inflammatory substances, like platelet activating factor and free radicals are released, resulting in direct injury to intestine (Medscape)

7. Incidence & Prevalence
Men and women equally affected by IBD
Women, however, more likely to have Crohn’s Disease
Crohn’s disease affects every 133 people per 100,000
Genetic link to Crohn’s Disease
Chromosome 10
Chromosome 7

8. Patient Scenario
A 22 year old woman presents to the E.R. with a 6 week history of five loose, non-bloody stools daily, right lower quadrant abdomnial pain (especially after eating), a twenty pound weight loss, and bilateral knee and ankle pain. Findings from physical examination shows a definite and moderately tender 5 cm mass in the right lower quadrant of her abdomen. Stool culture are negative for enteric pathogens and blood work results show mild anemia (Hmg 11.2), with a normal metabolic panel and normal thyroid stimulating hormones. Radiographic findings show a 10cm narrowing of the terminal ileum and a separate of bowel loops around the terminal ileum.
This patient is then diagnosed with Crohn’s disease. The patient is started on 5-aminosalcylic acid (5ASA), antibiotics and nutritional therapy.

9. Research
A gap between research exists when looking at antibiotic treatment for Crohn's disease patients.
A study by Feller, Huwiler, Schoepfer, Shang, Furrer, and Egger (2010) determined the effectiveness of long-term antibiotic treatment in 865 patients with Crohn’s disease.
This study suggested that “long-term treatment with nitroimidazoles or clofazimine appears to be effective in patients with Crohn’s disease.”
The current antibiotic treatment is Cipro and Flagyl. This study is level one and found that clofazimine and nitroimidazoles have been researched and are recommended for long-term antibiotic treatment. This is important because diarrhea is a very common and painful symptom in these patients. Antibiotics are known to cause diarrhea so it is imperative that we use these researched antibiotics to prevent this as much as possible.

10. Treatment Modalities No current cure Diet therapy:
No specific diet is recommended other than a balanced regular diet and avoidance of triggers
High fiber can lessen diarrhea and improve rectal urgency
Antibiotics
Flagyl
Cipro
Anti-inflammatory drugs
Immune system suppressors
Azathioprine
6-mercaptopurine (6-MP)
Aminosalicylate
Azulfidine
Decreases fever, pain, diarrhea and rectal bleeding
Azulfidine: decreases fever, stomach pains, diarrhea and rectal bleeding. Also used to increase time between attacks
-6-MP: can be taken in place of corticosteroids
Laxatives: good for before diarrhea exacerbations because imflammation is bad enough to cause obstruction; In some cases, swelling may cause your intestines to narrow, leading to constipation. Talk to your doctor before taking any laxatives, because even those sold over-the-counter may be too harsh for your system.

11. Treatment Modalities Continued
Corticosteroids
used when traditional therapy does not work
Antidiarrheals
Laxatives
Pain relievers (tylenol)
Surgery
Can correct fistulas that may have formed
Anastomosis of affected portion of GI tract
Ostomy placement
("Crohn's disease: Treatment," 2011)

12. Elijah’s New Ostomy

13. Prognosis Varies depending on the severity
Possible to have one episode in a lifetime while others suffer from chronic episodes
Rarely the direct cause of death, and many people live a normal lifespan (Simon, 2008)
3 out of 4 people with Crohn’s disease will end up needing surgical intervention ("Crohn's disease: Treatment," 2011)

14. Nursing Diagnoses
Diarrhea related to inflammatory process (Ackley & Ladwig, 2011)
Acute pain related to increased peristalsis
Imbalanced nutrition related to diarrhea and altered ability to absorb and digest food
Risk for fluid volume deficit related to abnormal loss of fluid from diarrhea

15. Nursing Interventions
Assess defecation patterns. Assessment will help direct treatment
If the diarrhea is related to IBS, interventions may include the use of complementary or alternative treatment such as probiotics. Probiotics enhance the normal intestinal microflora and decrease symptom of diarrhea
Observe for signs and symptoms of sodium and electrolyte loss (weakness, abdominal or leg cramps, dysrthmias). Excessive diarrhea causes electrolyte abnormalities
Monitor intake and output. Dark, concentrated urine is an indication of deficient fluid volume
With chronic diarrhea, observe for signs and symptoms of malnutrition and consult with primary care provider for dietary consult and the possibility of supplemental feeding methods such as TPN.
Provide a readily available bathroom, commode or bedpan at all times
Ensure stringent perianal care for the patient daily and as needed using and a skin protectant (barrier cream)administral of antidiarrheal medications. At risk for perineal skin injury
(Ackley & Ladwig, 2011)

16. Conclusion
A definitive cure for Crohn’s disease does not currently exist
Treatment modalities depend upon the severity and the progression of the disease
Research is still being conducted to improve treatment modalities for Crohn’s disease
Inflammatory bowel diseases, including Crohn’s, contribute to a high incidence of colon cancers
These cancers are almost completely preventable with a proper diet that consists of bulk forming and low fat foods
With the exponential rise of obesity in America, it is important to promote awareness and teach preventative dietary methods.

17. NCLEX Question #1
The nurse is reviewing the record of a female client with Crohn’s disease. Which stool characteristics should the nurse expect to note documented in the client’s record?
A. Diarrhea
B. Chronic constipation
C. Constipation alternating with diarrhea
D. Stools constantly oozing from the rectum

18. NCLEX Answer #1 A!
Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options B, C, and D are not characteristics of Crohn’s disease.

19. NCLEX Question #2
The nurse is preparing a client with Crohn’s disease for discharge. Which of the following statements indicates that he needs further teaching?
A. “Stress can make it worse.”
B. “Since I have Crohn’s disease, I am not likely to get colon cancer.”
C. “I realize I will always have to monitor my diet.”
D. “I understand there is a high incidence of familial occurrence with this disease.”

20. NCLEX Answer #2 B!
Persons with Crohn’s disease are at high risk for the development of colon cancer. The other options are all correct and do not indicate a need for further instruction

21. References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier.
Ailsa L., H., & Siew C., N. (n.d). Inflammatory bowel disease: Crohn’s disease. Medicine, 39(Gastroenterology Part 3 of 4), doi: /j.mpmed
Crohn's disease: Treatment and drugs. (2011, August 09). Retrieved from
Feller, M., Huwiler, K., Schoepfer, A., Shang, A., Furrer, H., & Egger, M. (2010). Long-term antibiotic treatment for Crohn's disease: systematic review and meta-analysis of placebo-controlled trials. Clinical infectious diseases, 50(4),
Gastrointestinal diseases nclex review questions part 1. (n.d.). Retrieved from
Osborn, K. S., Wraa, C. E., & Watson, A. B. (2009).Medical-surgical nursing, preparation for practice. (Vol. 1). Prentice Hall.
Simon, H. (2008, December 01). Crohn's disease: Prognosis. Retrieved from
WebMD, LLC (2012). Medscape For Android (Version 2.2) [Mobile Application Software]. Retrieved from Google Play Store.