Pathophysiology: Crohn’s disease is autoimmune where the body will attack it’s own GI mucosa. It causes inflammation deep in the layers of the GI tract throughout.
- Autoimmune inflammatory disease of GI mucosa anywhere from mouth to anus
- Most often affects the terminal ileum
- Thickening and scarring of intestinal walls
- Ulcerations and abscesses
- Remissions and exacerbations
- Abdominal cramping
- Abdominal pain after meals (relieved by defecation)
- Diarrhea containing mucus or pus, possibly blood (5-6 stools/day)
- Electrolyte imbalances
- Diet Therapy
- Low residue
- High protein
- High calorie
- Vitamins and iron
- Medications – similar to Ulcerative Colitis
- Surgical Options
- Bowel Resection – NOT curative
- Fluid & Electrolytes
- Weigh daily
- Maintain accurate I&O
- Monitor & replace electrolytes
- Encourage diet adherence
- Nutrient/Calorie dense foods
- Keep NPO in acute exacerbations
- Monitor stools for blood
- Administer Antidiarrheals
- Perform perineal care
- Appropriate dietary needs
- Medication instructions and side effects
- s/s to report to provider
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In this lesson we’re going to look specifically at Crohn’s Disease and how we care for these patients.
In the inflammatory bowel disease lesson, we talked in more detail about the patho, so let’s just review. Crohn’s disease is a chronic inflammatory condition that can affect the entire GI tract. Though it most often affects the terminal ileum, it can actually affect anywhere from the mouth to the anus. It causes thickening and scarring and lesions and abscesses in the intestinal walls. You can see in this image how the lesions are filled with purulent drainage and pus from the abscesses. Patients with Crohn’s disease will have multiple stools a day that usually contain pus or mucus and they’ll also experience periods of remission and exacerbation.
Assessment findings for Crohn’s disease include fevers and significant abdominal pain and cramping that is usually worse after meals. Interestingly, their pain tends to be relieved after having a bowel movement. Because of the malabsorption issues, we also see evidence of malnutrition and electrolyte imbalances, just like in Ulcerative Colitis. One thing that’s somewhat different, however, is that patients with Crohn’s disease tend to be anemic. With excessive bleeding in Ulcerative Colitis, you could see anemia, but in Crohn’s the anemia is due to a lack of absorption of iron in the stomach. So we see iron deficiency anemia, as opposed to anemia caused by bleeding. Review the anemia lesson in the hematology course to learn more about telling those apart.
As far as therapeutic management, we talked about these specific medications in the inflammatory bowel disease intro lesson, but we’ll give anti-inflammatories and immunomodulators as well as antidiarrheals to manage symptoms. We want to monitor and administer IV fluids and electrolytes because we expect significant dehydration and electrolyte abnormalities. The other major thing we can do for patients with Crohn’s is adjust their diet. We want to make sure that whatever food they are taking in is high protein, high calorie, and nutrient dense. We also encourage them to supplement vitamins and iron that they may be lacking. And then we want them eating a low residue diet and avoiding things that are irritating and high residue. So they should eat fully cooked fruits and vegetables instead of raw, and take the skin off things like apples or potatoes. And, they should opt for white bread instead of whole grains.
As we discussed in the inflammatory bowel disease intro lesson, our top nursing priorities are fluid & electrolytes, nutrition, and elimination. We want to get daily weights and maintain accurate intake and output measurements so that we can keep them properly hydrated. And we’ll monitor and replace electrolytes as needed. In terms of elimination, we’ll monitor their stools for blood and administer antidiarrheal medications. We also want to perform really good perineal care and use barrier wipes or barrier cream to prevent irritation and breakdown around the anus. We encourage them to eat those nutrient dense, low fiber foods. Sometimes you have to help them find what they like and can tolerate. And we do keep them NPO in acute exacerbations – sometimes they may even require TPN if it goes on for a while. Also, remember that Crohn’s disease can affect the whole GI tract, so if they are experiencing lesions in the mouth, make sure you provide good oral care. Check out the care plan and case study attached to this lesson to see more detailed nursing interventions and rationales.
So let’s recap. We know that Crohn’s is inflammation of the whole GI tract that leads to scarring and abscesses, and 5-6 mucousy stools a day. Patients experience abdominal pain, diarrhea, malnutrition, and fevers from the abscesses. We use anti-inflammatory meds and IV fluids plus bowel rest during acute exacerbations. We want to encourage high calorie, high protein, low residue diet choices and provide vitamin supplements as needed. And remember we prioritize fluid & electrolyte status, nutrition, and elimination needs for these patients.
That’s it for Crohn’s disease. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!