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TABLE OF CONTENTS

I. INTRODUCTION ....................................................................................................................... 2 OBJECTIVES ............................................................................................................................. 5

II. DEFINITIONS OF THE DISEASE ........................................................................................... 6

III. ANATOMY & PHYSIOLOGY ............................................................................................... 7

IV. SYMPTOMATOLOGY ......................................................................................................... 16

V. ETIOLOGY ............................................................................................................................. 19

VI. PATHOPHYSIOLOGY ......................................................................................................... 22

VII. DIAGNOSTIC TESTS .......................................................................................................... 26

VIII. MEDICAL MANAGEMENT.............................................................................................. 28

IX. SURGICAL MANAGEMENT .............................................................................................. 32

X. NURSING CARE PLANS....................................................................................................... 34 Nursing Care Plan No.1 ............................................................................................................ 34 Nursing Care Plan No.3 ............................................................................................................ 39 Nursing Care Plan No.4 ............................................................................................................ 43 Nursing Care Plan No.5 ............................................................................................................ 47

XI. BIBLIOGRAPHY................................................................................................................... 49

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I. INTRODUCTION

Regional enteritis or commonly known as Crohn's disease, is a chronic inflammatory disease of the intestine primarily in the small and large intestines but which can occur anywhere in the digestive system between the mouth and the anus. MediceneNet (2011, April 5). It was named after Burrill Crohn who described the disease in 1932. The disease usually affects persons in their teens or early twenties. It tends to be chronic, recurrent with periods of remission and exacerbation. In the early stages, it causes small scattered shallow crater-like areas (erosions) called aphthous ulcers in the inner surface of the bowel. With time, deeper and larger ulcers develop, causing scarring and stiffness of the bowel and the bowel becomes increasingly narrowed, leading to obstruction. Deep ulcers can puncture holes in the bowel wall, leading to infection in the abdominal cavity (peritonitis) and in adjacent organs. When only the large intestine (colon) is involved, the condition is called Crohn's colitis. When only the small intestine is involved, the condition is called Crohn's enteritis. When only the end of the small intestine (the terminal ileum) is involved, it is termed terminal ileitis. When both the small intestine and the large intestine are involved, the condition is called Crohn's enterocolitis (or ileocolitis). Pain, diarrhea, vomiting, fever, and weight loss can be symptoms. Crohn's disease can be associated with reddish tender skin nodules, and inflammation of the joints, spine, eyes, and liver. Diagnosis is by barium enema, barium x-ray of the small bowel, and colonoscopy. Treatment includes medications for inflammation, immune suppression, antibiotics, or surgery. The disease is also called granulomatous enteritis. MediceneNet (2011, April 5). Crohn's disease is a life-long illness. The severity of the disease can vary, and a patient can experience periods of time when the disease is not active and he or she is symptom free. However, the complications and risks of Crohn's disease tend to increase over time. Well over 60% of all patients with Crohn's disease will require surgery, and about half of these patients will require more than one operation over time. About 5-10% of all Crohn's patients will die of their disease, primarily due to massive infection. Farlex (2011). About 35% of Crohn's disease cases involve the ileum alone (ileitis); about 45% involve the ileum and colon (ileocolitis), with a predilection for the right side of the colon; and about 20% involve the colon alone (granulomatous colitis), most of which, unlike ulcerative colitis (UC), spare the rectum. Occasionally, the entire small bowel is involved (jejunoileitis). The

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stomach, duodenum, or esophagus is clinically involved only rarely, although microscopic evidence of disease is often detectable in the gastric antrum, especially in younger patients. In the absence of surgical intervention, the disease almost never extends into areas of small bowel that are not involved at first diagnosis. There is an increased risk of cancer in affected smallbowel segments. Patients with colonic involvement have a long-term risk of colorectal cancer equal to that of UC, given the same extent and duration of disease. The Merck Manual Professional (2010) According to the National Institute of Allergy and Infectious Diseases (NIAID), a division of the US Department of Health and Human Services that accumulates and publishes the statistics for Crohn’s disease and other health problems, one in 500 people suffer from Inflammatory Bowel Disease (IBD), the group of diseases that includes Crohn’s syndrome and ulcerative colitis. The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) reports similar numbers. Approximately 544,000 people suffer from IBD in the United States. Weissheiss (2011, April 11). Worldwide, there are typically three or four new cases per 100,000 people reported annually. There are also currently 90,000 people living with Crohn's disease in the U.K. There are more than 8,000 new cases every year and research has shown that the number of people with Crohn's disease has been rising, particularly among young people. Crohn's disease affects about one in 1,000 people and affects between 400,000 and 600,000 people in North America. It may run in families with 20% of people diagnosed with the disease having a blood relative with some form of inflammatory bowel disease. It is usually diagnosed between the ages of 20 to 30, although people of all ages can suffer from Crohn's. People of Jewish heritage have a greater risk of developing the disease while people of African American heritage have less of a risk. If a certain person has a Crohn's disease that affects his large bowel (colon), he will surely have the higher risk of developing bowel cancer. One in 20 people with Crohn's disease will develop bowel cancer in the 10 years after their condition is diagnosed. St. Marks Foundation (2011, January 27) In Asian countries, Crohn’s disease was also present. According to research conducted by the US Census Bureau of 2006, it is said that China rank as one of the country having the highest prevalence with 2,387,587cases out of an estimated population of 1,298,847,6242; while Macau rank as the lowest prevalence among Asian countries with 818 number of cases out of an

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estimated population of 445,2862. Philippines rank at number 7 with 158,532 numbers of cases out of an estimated population of 86, 241, 6972, following the Indonesia at number 6 with 438,332 cases out of an estimated population of 238, 452, 9522. Cure Research (2010, March 2)

Significance of the study: This case study will allow me and all the student nurses to understand more about Regional Enteritis or the so-called Crohn’s disease. In order for us to have an additional idea about the said disease, it’s process, signs & symptoms, medical & surgical treatments and it’s appropriate nursing managements; and in order for us also to apply it among our patients experiencing this kind of disease.

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OBJECTIVES

General Objectives:

This case study tends to enhance my capability and knowledge as student nurses about the Regional Enteritis or Crohn’s disease; in order for me to apply what I have learned during NCM 103 discussions and be prepared in times of encountering patients experiencing this disease.

Specific objectives:

This case study specifically aims:         To present the different definitions of the disease according to different sources; to review the anatomy and physiology of the involved organs and system; to identify the symptomatology and etiology of the chosen disease; to trace the pathophysiology of the disease; to identify and define the appropriate diagnostic tests; to identify the different medical and surgical managements; to present nursing care plans regarding about the different manifestations; and to list down all the trusted references used in this case study.

National Digestive Diseases Information Clearinghouse (NDDIC) (2006. The disease can affect any area from the mouth to the anus. August 9)  Causes inflammation of the digestive system. which can lead to abdominal pain. It involves all the layers of the bowel but most commonly involves the terminal ileum. called the ileum. It is a slowly progressive and recurrent disease with predominant involvement of multiple regions of the intestine with normal sections between. It often affects the lower part of the small intestine called the ileum. The swelling can cause pain and can make the intestines empty frequently. Mayo Clinic Staff (2011. or both. December 13)  An inflammatory condition that affects the digestive tract . Igantavicius & Workman (2006) . Crohn’s disease can affect any area of the GI tract. where it connects with the large intestine.. resulting in diarrhea. The swelling extends deep into the lining of the affected organ. Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people. stomach. the colon (20%). from the mouth to the anus. MD FRCS. but it most commonly affects the lower part of the small intestine. esophagus. (2011. It causes inflammation of the lining of your digestive tract. It is one of a group of diseases called inflammatory bowel disease. It can affect any portion of the digestive tract.the lowest portion of the small intestine.6 II.including the mouth. NIH: National Institute of Diabetes and Digestive and Kidney Diseases (2010. It is an ongoing disorder that causes inflammation of the digestive tract. also referred to as the gastrointestinal (GI) tract. severe diarrhea and even malnutrition. DEFINITIONS OF THE DISEASE Regional Enteritis (Crohn’s Disease)  Also known as Crohn’s disease. and anus. June 11)  An idiopathic disease of small intestine (60%). but is most common in the ileum . Slowik G. small and large intestine. February)  An inflammatory bowel disease (IBD).

Secondly. undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). . Thus the salivary glands. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. pancreas and gall bladder have important functions in thedigestive system. fats and carbohydrates are chemically broken down into their basic building blocks. Finally. First food must be ingested into the mouth to be mechanically processed and moistened. stomach and intestines to the rectum and anus.7 III. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. The primary purpose of the gastrointestinal tract is to break food down into nutrients. which can be absorbed into the body to provide energy. where food enters the mouth. digestion occurs mainly in the stomach and small intestine where proteins. oesophagus. ANATOMY & PHYSIOLOGY The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity. continuing through the pharynx. liver. where food is expelled. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water.

the epithelium may be simple (a single layer) or stratified (multiple layers). malabsorption. lymphoid tissue and glands that support the mucosa. vomiting. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. Depending on its function. Although each section of the tract has specialized functions. the entire tract has a similar basic structure with regional variations. these functions of the gastrointestinal tract are not achieved successfully. diarrhoea. The wall is divided into four layers as follows: Mucosa The innermost layer of the digestive tract has specialized epithelial cells supported by an underlying connective tissue layer called the lamina propria. Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells. The lamina propria contains blood vessels. Patients may develop symptoms of nausea. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus.8 In the case of gastrointestinal disease or disorders. called epithelium. The inner . Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives. constipation or obstruction. nerves. Areas such as the mouth and esophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food.

Muscularis externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibers separated by the myenteric plexus or Auerbach plexus. manipulates the food bolus to come in contact with the teeth. fibrous connective tissue and larger vessels and nerves.9 lining is constantly shed and replaced. starts the process of digestion of complex carbohydrates. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion. a component of saliva. The tongue. a strong muscular organ. Individual components of the gastrointestinal system Oral cavity The oral cavity or mouth is responsible for the intake of food. Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. This supplies the mucosa and submucosa. It is also the sensing organ of the mouth for touch. The mucin (a glycoprotein) in saliva acts as a lubricant. The final function of the oral cavity is absorption . making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. such as the tongue. Submucosa The submucosa surrounds the muscularis mucosa and consists of fat. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. This comprises layers of smooth muscle which can contract to change the shape of the lumen. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen. Serosa/mesentery The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium. hard palate and roof of the mouth. temperature and taste using its specialised sensors known as papillae. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus.

Each gland is divided into smaller segments called lobes. across the mucosa. . Each pair of salivary glands secretes saliva with slightly different compositions. The parotids produce a watery secretion which is also rich in proteins. From the mouth. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each is a complex gland with numerous acini lined by secretory epithelium.10 of small molecules such as glucose and water. smell or even appearance of food. Salivary glands Three pairs of salivary glands communicate with the oral cavity. They are situated below the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can be easier felt when one clenches their teeth. Parotids The parotid glands are large. They secrete 25% of saliva. Salivation occurs in response to the taste. irregular shaped glands located under the skin on the side of the face. food passes through the pharynx and oesophagus via the action of swallowing. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break down complex carbohydrates. The acini secrete their contents into specialised ducts.

Oesophagus The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. They produce approximately 5% of the saliva and their secretions are very sticky due to the large concentration of mucin. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. rich in mucin and with a smaller amount of protein. This nerve plexus surrounds the lower portion of the oesophagus. These glands produce a more viscid (thick) secretion. in a groove along the inner surface of the mandible. The fundus is the superior. covered by a thin layer of tissue at the floor of the mouth. The main functions are to provide buffers and lubrication. The first section is the cardia which surrounds the cardial orifice where the oesophagus enters the stomach. Stomach The stomach is a J shaped expanded bag. dilated portion of the stomach that has contact with the left dome of the diaphragm. They are found in the floor of the mouth.11 Submandibular The submandibular glands secrete 70% of the saliva in the mouth. The body is the largest section between the fundus and the curved portion of the J. Sublingual The sublinguals are the smallest salivary glands. Finally the pylorus is the curved base of the stomach. Mucin is a glycoprotein that acts as a lubricant. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. It is divided into four main regions and has two borders called the greater and lesser curvatures. This is where most gastric glands are located and where most mixing of the food occurs. These allow the stomach to stretch and expand when . located just left of the midline between the oesophagus and small intestine. The oesophagus functions primarily as a transport medium between compartments. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the oesophageal nerve plexus.

Some absorption of substances such as alcohol. Mechanical breakdown of food by churning and mixing motions. and ileum. 3. the ileum. jejunum. The start of the jejunum is marked by a sharp bend. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins.5 litres of material. 2. . The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. 4. Chemical digestion of proteins by acids and enzymes. The functions of the stomach include: 1. extending from the pyloric sphincter of the stomach to the ileocaecal valve separating the ileum from the caecum. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. 5. Small intestine The small intestine is composed of the duodenum. The stomach can hold up to 1. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The short-term storage of ingested food. Stomach acid kills bugs and germs.12 food enters. It averages approximately 6m in length. The final portion. the duodenojejunal flexure. is the longest segment and empties into the caecum at the ileocaecal junction. It is in the jejunum where the majority of digestion and absorption occurs.

control the passage of faeces. . known as sphincters. and the rectum. These secretions enter the duodenum at the Ampulla of Vater. The rectum is the final 15cm of the large intestine. After further digestion. It consists of the appendix. caecum. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border).5m and a width of 7. fats. food constituents such as proteins. descending and sigmoid colon.13 The small intestine performs the majority of digestion and absorption of nutrients. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon.5cm. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. Thick bands of muscle. and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. Some are responsible for absorption. ascending. Large intestine The large intestine is horse-shoe shaped and extends around the small intestine like a frame. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). The mucosa of the small intestine contains several specialised cells. This increases the surface area for absorption by a factor of several hundred. whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. It has a length of approximately 1. transverse.

It acts as a mechanical filter by filtering blood that travels from the intestinal system. Some digestion by bacteria. The bile produced by cells of the liver. producing albumin and blood clotting factors. However. its main roles in digestion are in the production of bile and metabolism of nutrients. caudate and quadrate lobes. Numerous goblet cells line the glands that secrete mucous to lubricate fecal matter as it solidifies. The functions of the large intestine can be summarized as: 1. In addition. left. The main functions of the gall bladder are storage and concentration of bile.14 The mucosa of the large intestine lacks villi seen in the small intestine. The bacteria are responsible for the formation of intestinal gas. Here. 2. 3. It consists of a fundus. Reabsorption of water. enters the intestines at the duodenum. sugar and vitamins. Liver The liver is a large. . Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Gall bladder The gallbladder is a hollow. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The mucosal surface is flat with several deep intestinal glands. body and neck. bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act. It empties via the cystic duct into the biliary duct system. pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It is surrounded by a strong capsule and divided into four lobes namely the right. The liver has several important functions. the liver has synthetic functions. reddish-brown organ situated in the right upper quadrant of the abdomen. It detoxifies several metabolites including the breakdown of bilirubin and oestrogen. Bile is produced by the liver but stored in the gallbladder until it is needed. salts. The accumulation of unabsorbed material to form feces. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food.

glucagon and other substances and these are the areas damaged in diabetes mellitus. The pancreas has both exocrine and endocrine functions. The enzymes become active once they reach the duodenum. The organ is approximately 15cm in length with a long. the pancreas is a lobular. nucleases and proteolytic enzymes that can break down different components of food. January 30) . It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. These are secreted in an inactive form to prevent digestion of the pancreas itself. slender body connecting the head and tail segments. The pancreas secretes fluid rich in carbohydrates and inactive enzymes. The Islets produce insulin. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. Pancreatic enzymes include carbohydrases. The exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to the gastrointestinal tract. lipases. Virtual medical centre (2006.15 Pancreas Finally. Secretion is triggered by the hormones released by the duodenum in the presence of food.

Knudson. (2011)  Loss of appetite  An inflamed intestine as in the case with Crohn's Disease is less able to fully absorb and digest the nutrients from food. and cramping. or gas. This is more typical for a stomach virus. Medline Plus Encyclopedia (2011)  Cramp-like pain is usually not serious. Crohn’s Disease & Living Probiotics (2011)  Pain with passing stool (tenesmus)  Pain with passing stool (tenesmus) Tenesmus is the feeling that you constantly need to pass stools. Depending on how severe the small intestine has been injured by inflammation. SYMPTOMATOLOGY SYMPTOM  JUSTIFICATION  Crampy abdominal (belly area) pain Abdominal pain is pain that you feel anywhere between your chest and groin. and is more likely to be due to gas and bloating. Pain may be generalized. If the pain becomes more severe. Medline Plus Encyclopedia (2011)  Fever & Fatigue  Individuals suffering with Crohn's disease may experience low-grade fevers and an overall feeling of fatigue. It is often followed by diarrhea. Medline Plus Encyclopedia (2011) . may travel into thelarge intestine to a varying degree. This is often referred to as the stomach region or belly.16 IV. High or persistent fevers may indicate an infection. meaning that it is present in more than half of your belly. vital nutrients as well as unabsorbed bile salts. even though your bowels are already empty. lasts longer (more than 24 hours). It may involve straining. More worrisome signs include pain that occurs more often. This is why many Crohn's patients don’t have much of an appetite and are normally malnourished. Chronic fatigue often accompanies severe diarrhea and may indicate dietary deficiencies. indigestion. J. or has a fever with it. pain. it may be caused by a blockage of the intestines.

 A fistula is an abnormal connection between an organ. when combined with scarring often associated with ulcers. causing it to swell. In other words. (2011)   Bowel Obstruction  Crohn's disease inflames the intestine.( 2011) watery diarrhea & bleeding  Unintentional weight loss  Unintentional weight loss is a decrease in body weight that is not voluntary. Knudson.17 SYMPTOM  JUSTIFICATION  Persistent. but also a result of the way in which the digestive system works--food may not be properly absorbed into the system as would be seen in someone without the condition George. It can also result from infection or inflammation. D. The diarrhea may be mild. (2011)  Fistulas (usually around the rectal area. The diarrhea may be accompanied by blood in the stool. but severe cases may require surgical intervention. Stomach pain. Inflammatory bowel . This is partly due to the fewer calories consumed when a person loses his appetite. rectal bleeding may not be associated with passing stool and may lead to anemia or other complications if not treated. you did not try to loss the weight by dieting or exercising. Fistulas are usually the result of injury or surgery. vessel. may cause draining of pus. Diarrhea is a common symptom of Crohn's disease. or intestine and another structure. Medline Plus Encyclopedia (2011) Some people who are suffering from Crohn's disease have also experienced weight loss. bloating and vomiting are common symptoms of a bowel obstruction. Some people with Crohn's disease may have symptoms diminish and reoccur without warning. Knudson. or frequent and chronic. it may cause an obstruction of the bowel.J. Anti-inflammatory medication often reduces swelling and relieves the obstruction. In severe cases. J.

(2000)  Eyes – episcleritis  Mouth . F. Surgery or a liver transplant may be needed to overcome this disease. Fatty liver disease is caused by the accumulation of fat in the liver. Medline Plus Encyclopedia (2011)  Liver inflammation  Fatty liver disease is the most common form of liver inflammation in Crohn's disease patients. (2011)  Complications involving the eyes. skin and joints:  These complications may be caused by immunologic response. PharmD. (2011) . PhD. microbiologic concomitants.18 SYMPTOM mucus.arthritis of the . According to studies cited in the Postgraduate Medical Journal.Primary Sclerosing Cholangitis  Primary sclerosing cholangitis is a disease that causes severe inflammation of the liver and bile ducts. mouth.Fatty Liver Disease . Gorman. Lac. F. or unknown reasons. pyoderma gangrenosum and pustular lesions  Joints .aphthous Stomatitis  Skin . Gorman. Injury can lead to fistulas between arteries and veins. Chen.erythema nodosum. according to the Crohn's & Colitis Foundation of America. often by the prescription of steroids. This is because of an abnormality in the liver's metabolism. genetic interrelationships. primary sclerosing cholangitis can occur in up to 4 percent of Crohn's disease patients. J. Fatty liver disease is easily treated. such as ulcerative colitis or Crohn's disease is an example of a disease that leads to fistulas between one loop of intestine and another. OMD. or stools) JUSTIFICATION disease.

& Cronau. M. ankles. G. and parents of persons with IBD. Chen. children. but it is more common in women than in men.D.. This gene helps the body decide how to react to certain JUSTIFICATION . Greenberg. August 15) Family History Brothers. (2000) Gender Regional Enteritis or Crohn’s disease affects the two genders. M. (2003. sisters.D. Knutson. Greenberg..D. D. H. M. PhD. M. D. J.D. American Family Physician (August 2003) Crohn's disease usually begins before age 35. Is this tendency toward IBD and Crohn's disease passed genetically? Scientists have identified a gene linked to Crohn's disease. H.. M. but it is more common in whites than in blacks & in Jewish than in non-Jewish persons. And the disease is more common in certain ethnic groups. & Cronau. About 10% to 20% of people with Crohn's disease have at least one other family member who also has the disease.19 SYMPTOM larger joints such as the knees. OMD. including Crohn's disease..D. G. ETIOLOGY PREDISPOSING FACTORS Age Regional Enteritis or Crohn’s disease affects all ages. hips and elbows JUSTIFICATION V.D. Lac.. are more likely to develop the disease themselves. M. with peak incidence between 14-24 years old. (2003.. August 15) Race Regional Enteritis or Crohn’s disease affects all races. such as people of Jewish descent and whites. Knutson. PharmD.

National Digestive Diseases Information Clearinghouse (NDDIC) (February 2006) Smoking . They may trigger an immune system response. decrease blood flow to the intestines. IBD or Crohn's disease may develop. Why smoking increases the risk of Crohn's disease is unknown. These environmental factors may include any of the following: substances from something you've eaten. People with Crohn's disease have this mutated gene twice as often as people who do not have the disease. Once started. They may directly damage the lining of the intestines.20 PREDISPOSING FACTORS JUSTIFICATION microbes. microbes such as bacteria or viruses. If the gene has changed or mutated in some way. cigarette smoke & other substances that are yet unknown Environmental factors may contribute to Crohn's disease in one of these two ways: 1. repeat surgery. smoking is linked with a higher rate of relapse. or cause immune system changes that result in inflammation. 2. WebMD (February 2010) PRECIPITATING FACTORS Environment JUSTIFICATION Environmental factors may help trigger Crohn's disease. This may cause Crohn's disease to begin or to speed up. WebMD (February 2010) Among people with Crohn’s disease. the response cannot stop. and the need for drug therapy. but some researchers believe that smoking might lower the intestines defenses. Women have a higher risk of relapsing and needing surgery and treatment than men whether they are current or former smokers. your body's reaction to microbes may also be different from the normal reaction. Over time.

such as strains of mycobacterium. Some scientists suspect that infection by certain bacteria. In individuals with IBD. however. MedicineNet. viruses. To date. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is an important mechanism of defense used by the immune system.21 PRECIPITATING FACTORS Abnormal activation of the immune system JUSTIFICATION Activation of the immune system in the intestines appears to be important in IBD. may be the cause of Crohn's disease.) Normally. The continued abnormal activation of the immune system results in chronic inflammation and ulceration. there has been no convincing evidence that the disease is caused by infection per se. Normally. however.com (2011) . the immune system is activated only when the body is exposed to harmful invaders. the immune system is abnormally and chronically activated in the absence of any known invader. The immune system is composed of immune cells and the proteins that these immune cells produce.com (2011) Infections The cause of Crohn's disease is unknown. these cells and proteins defend the body against harmful bacteria. fungi. and other foreign invaders. MedicineNet.

PATHOPHYSIOLOGY PREDISPOSING FACTORS  Age  Gender  Race  Family History PRECIPITATING FACTORS  Environment  Smoking  Abnormal activation of the immune system  Infections Inflammation Appearance of small. shallow. scattered. crater-like ulcerations (erosions) on the inner surface of the bowel (ileum & ascending colon) Tiny focal aphthous ulcers Develop into deep longitudinal & transverse ulcers with intervening mucosal edema Creates a characteristic of: Cobblestoned appearance bowel S/s: Persistent watery diarrhea & bleeding Transmural spread of inflammation Lymph edema Thickening of the wall & mesentery Mesenteric fat extends to the serosal surface of the bowel .22 VI.

23 Mesenteric lymph nodes enlarge Extensive inflammation Hypertrophy of the muscularis mucosae. fluid & gas from the stomach & small intestine cannot pass the colon S/s: Severe abdominal cramps. fibrosis & stricture formation Bowel obstruction Cessation of flow of the contents into the intestine Digesting food. nausea. vomiting & abdominal distention Fecal Stasis Deep ulcers developed Puncture holes in the bowel .

high fever & abdominal pain .24 Creating a tunnel between intestine & adjacent organs A channel (fistula) is formed Ulcer tunnel reaches an adjacent empty space inside the abdominal cavity Fistula between intestine & bladder (Entericventricular fistula Fistula between colon & vagina (colonic-vaginal fistula) Fistula from intestine to anus (anal fistula) Bacteria from within the bowel will spread Collection of infected pus is formed (abdominal abscess) Frequent UTI & passage of gas & feces during urination Gas & feces emerge through the vagina Discharge of mucous & pus from the fistulas opening around the anus S/s: tender abdominal.

 Maintaining fluid intake. (2010..  Relieving pain. Hinkle. D. K. H. R. P. (1988.25 IF TREATED IF NOT TREATED Nursing Management:  Maintaining normal elimination pattern. J.  Promoting rest  Reducing anxiety  Enhancing coping measures  Preventing skin breakdown on the perianal skin  Monitoring & managing potential complications Medical Management:  Anti-inflammatory Drugs  Cortisone or steroids  Immune System Suppressors  Antibiotics  Antidiarrheals & fluid replacement Surgical Management:  Total Colectomy with ileostomy  Continent Ileostomy  Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis  Electrolyte imbalance  Metabolic Disorders  Digestive Tract Cancer  Sepsis DEATH Prevention of complications God / Fair Prognosis Andrew.. Walfish. Bare.. S. 28).. Feb.. Allan..). Smeltzer. E. N.. Medicine Net (2011) Scachar. B. A. Lewis..(2010) . & Cheever. Nov. A.

and pictures (X-rays) can be taken of the stomach and the small intestines. and. When barium is ingested orally (upper GI series) it fills the intestine. Smeltzer. MedicineNet (2011) Stool Examination A stool sample is taken and examined for blood. S. sometimes.(2010) Colonoscopy Direct visualization of the rectum and the large intestine can be accomplished with flexible viewing tubes (colonoscopes). An elevated white blood cell counts and sedimentation rates result. or both.Colonoscopy is more accurate than barium X-rays in detecting small ulcers or small areas of inflammation of the colon and terminal ileum. pictures of the colon and the terminal ileum can be obtained. When barium is administered through the rectum (barium enema). Barium is a chalky material that is visible by X-ray and appears white on X-ray films. Bare. K. infectious organisms.. indicating the constriction of a segment of intestine. low blood proteins. Barium X-rays can show ulcerations. & Cheever. J. both of which suggest infection or inflammation. Other blood tests may show low red blood cell counts (anemia). Colonoscopy also allows for small tissue samples (biopsies) to be taken . nature. DIAGNOSTIC TESTS TEST Complete Blood Count (CBC) DESCRIPTION & RESULT A test done to determine the complete blood count of an individual. narrowing.. and severity of the disease. Hinkle. reflecting loss of these minerals due to chronic diarrhea. B. fistulae of the bowel.26 VII. Health Central (March 2007) Barium X-ray study A test used to define the distribution.. MedicineNet (2011) It shows a “STRING SIGN” on an x-ray film of the terminal ileum. and low body minerals.

As the capsule travels through the small intestine. MedicineNet (2011) A CT scan may show bowel wall thickening & fistula formation. Video capsule endoscopy should not be performed in patients who have . it sends video images of the lining of the small intestine to a receiver carried on a belt at the waist. B. video capsule endoscopy was demonstrated to be superior in its ability to detect small bowel pathology missed on small bowel radiographic studies and CT exams. MedicineNet (2011) Computerized axial tomography (CAT or CT) scanning A computerized X-ray technique that allows imaging of the entire abdomen and pelvis. It can be especially helpful in detecting abscesses. a capsule containing a miniature video camera is swallowed. Colonoscopy also is more accurate than barium X-rays in assessing the degree (activity) of inflammation. The images are downloaded and then reviewed on a computer..(2010) Magnetic Resonance Imaging (MRI) Magnetic resonance imaging is another advanced imaging technique that may be useful for detecting abscesses and other injuries related to Crohn's disease in the pelvis.27 TEST DESCRIPTION & RESULT and sent for examination under the microscope to confirm the diagnosis of Crohn's disease. mild abnormalities of Crohn's disease. Hinkle. Video capsule endoscopy may be particularly useful when there is a strong suspicion of Crohn's disease but the barium X-rays are normal. J. The value of video capsule endoscopy is that it can identify the early. K. Smeltzer.. In a prospective blinded evaluation. Health Central (2007) Video capsule endoscopy(VCE) For video capsule endoscopy. S. Bare.. A variant called magnetic resonance spectroscopy (MRS) may prove to be useful for differentiating between Crohn's disease and ulcerative colitis. & Cheever.

& Cheever. MEDICAL MANAGEMENT DRUG Aminosalicylates (Oral) Sulfasalazine (Azulfidine) Converted in colon to  Assess for allergy to sulfonamides or aspirin. K.Take in divided doses. aminosalicylic acid (5ASA). . . MedicineNet (2011) Sigmoidoscopy Sigmoidoscopy.Maintain liberal fluid intake (2. but it is not painful. nausea & vomiting. through . lasts about 10 minutes and is done without sedation. sulfapyridine & 5.5-3 L/day).. may  Teach patient to: antieffect. exert inflammatory possibly prostaglandin inhibition. . Sands.Report skin rash or other adverse effects. B.Take with full glass of fluid or with food. Smeltzer. Bare. Monitor for common side effects: anorexia. Hinkle. B. which is used to examine only the rectum and left (sigmoid) colon. Hinkle. . J.(2010) Results may be unremarkable unless accompanied by perianal fistulas. Marek & Gren (2007) Olsalazine (Dipentum) As above without  Monitor for common side effects as above and for mild to moderate diarrhea. Monahan.28 TEST DESCRIPTION & RESULT obstruction of the small intestine..Take in divided doses. Neighbors. J.. Health Central (2007) & Smeltzer. It may be mildly uncomfortable. S. Bare. & Cheever. K.  Teach patient to: . This is performed to determine whether the rectosigmoid area is inflamed.(2010) VIII. headache. INTERVENTIONS antibacterial action of sulfapyridine.. which ACTION NSG... S. The capsule may get stuck behind the obstruction and make the obstruction worse.

Marek & Gren (2007)  Teach patient to: . Mesalamine (Asacol.29 DRUG ACTION NSG. Monahan. Sands. Teach patient to: As above  Administer enema while patient is positioned on left side. fatigue. Sands. .5-3 L/day). do not chew or break outer coating. Monahan. or joint pain occurs. Neighbors. Neighbors.5-3 L/day).Stop drug & see physician if signs of allergy or worsening colitis occur. nausea & vomiting. Pentasa) Same as olsalazine . releasing active 5- ASA with action as above. Monahan. Marek & Gren (2007) Aminosalicylates (Rectal) Mesalamine in suspension for retention enema Mesalamine suppository Corticosteroids (Oral or IV) Prednisolone Potent systemic anti. Sands.Take in divided doses. INTERVENTIONS . Marek & Gren (2007) Balsalazide (Coloazal) Prodrug 5-ASA  Teach patient to: . Neighbors. .Swallow tablets whole.Take with full glass of fluid or with food. Monahan. & teach patient to retain as long as possible.Take with a full glass of water. stomach. Sands.Maintain liberal fluid intake (2. connected to carrier by an A20 bond Colon bacteria break bond. . . Neighbors.Maintain liberal fluid intake (2.Continue taking but consult physician if headache. Marek & Gren (2007) .

. side effects should be less.Maintain good personal hygiene. . . . Neighbors. Sands.Do not change dose or schedule or abruptly discontinue drug. Sands. Monahan. asses for edema.Be aware that mood swings occur commonly. . Purinethol) suppression immune . (6-MP. .Monitor weight gain. & teach patient to retain as long as possible.Take with food or fluid. Marek & Gren (2007) Immune Modifiers 6-Mercaptopurine Potent systemic  Teach patient to: of response.Have blood pressure checked regularly.30 DRUG Prednisone ACTION inflammatory action. presystemic metabolism minimizes absorption. Monahan. Monahan.Be alert to easy bruising. Marek & Gren (2007) Corticosteroids (Rectal) Hydrocortisone Intrarectal foam (Cortifoam) -Retention enema (Cortenema) Budesonide enema As above. keep perianal area clean & dry. NSG. Sands. Marek & Gren (2007) rapid  Administer enema while patient is positioned on left side.Be alert to signs of infection & report promptly. . Neighbors. Neighbors. INTERVENTIONS . .  Perform other interventions as above.Report any signs of infection. As above  As for oral or IV corticosteroids.

Marek & Gren (2007) Antibiotics Metronidazole (Flagyl)  Teach patient to: . Sands. Sands. fatigue. necrosis factor-alpha. Neighbors.31 DRUG ACTION may take 4-6 mo for full effect NSG. hypotension. Sands. Marek & Gren (2007)  As above Monahan.Return for laboratory work as scheduled.  Teach patient to promptly report any signs of infection. . peripheral neuropathies. Neighbors.Report side effects: diarrhea. Marek & Gren (2007) Azathiopine (Imuran) As above Cyclosporine (Sandimmune) As above. Monahan. dyspnea. strong metallic taste. effects seen after several days Monoclonal Antibodies Infliximab (Remicade) Binds to tumor  Monitor for infusion-related problems: pruritis. headache. . avoid refrigeration. blocking its activity & decreasing inflammation.  Teach patient to: .Monitor blood pressure . Neighbors. Marek & Gren (2007)  Oral solution may be mixed in glass & given with milk or orange juice at room temperature. INTERVENTIONS .Take with food or after meals. Monahan.Maintain liberal daily fluid intake (2.Report hematuria or any change in urinary function. Neighbors. Sands.5-3 L/day) . Monahan.

INTERVENTIONS .Avoid alcohol use.. Hinkle.. S. SURGICAL MANAGEMENT TYPE OF SURGERY Total Colectomy with Ileostomy DESCRIPTION An Ileostomy.32 DRUG ACTION NSG. Neighbors. Monahan.(2010) Continent Ileostomy Another procedure involves the creation of a continent ileal reservoir (ie. the surgical creation of an opening into the ileum or small intestine (usually by means of an ileal stoma on the abdominal wall). B. Smeltzer. or inability to . J. & Cheever. This procedure eliminates the need for an external fecal collection bag. K. Approximately 30cm of the distal ileum is reconstructed to form a reservoir with a nipple valve that is created by pulling a portion of the terminal ileal loop back into the ileum. The drainage is liquid to unformed and occurs at frequent intervals. It allows for drainage of fecal matter (ie. lack of retal sphincter tone. alcohol use with drug can cause disulfiram (Antabuse) reaction.. effluent) from the ileum to the outside of the body. is commonly performed after a total colectomy (ie. GI effluent can accumulate in the pouch for several hours and then be removed by means of a catheter inserted through the nipple valve. Bare. Kock pouch) by diverting a portion of the distal ileum to the abdominal wall and creating a stoma. Possible indications for a total colectomy with Kock pouch placement (rather than restorative proctocolectomy with IPAA) include a badly diseased rectum. Sands. Marek & Gren (2007) IX. excision of the entire colon).

33 TYPE OF SURGERY DESCRIPTION achieve fecal continence post-IPAA. Hinkle. A temporary diverting loop ileostomy that promotes healing of the surgical anastomoses is constructed at the time of surgery & closed about 3 months later.. B. Bare. Bare. Smeltzer. & the surgeon connects the pouch to the anus in conjunction with removing the colon & the rectal mucosa (ie. K. Hinkle.. K. It establishes an ileal reservoir that functions as a “new” rectum & anal sphincter control of elimination is retained.. & Cheever... The procedure involves connecting the ileum to the anal pouch (made from a small intestine segment). Smeltzer. total abdominal colectomy & mucosal proctectomy). B. S. & Cheever. J. S.(2010) Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis A restorative proctocolectomy with IPAA is the surgical procedure of choice in cases where the rectum can be preserved in that it eliminates the need for a permanent ileostomy..(2010) . J.

® To decrease stress/ anxiety. .nonabsorbed relation exercises & factors for visualizations).1 ASSESSMENT Objective cues: ..Reestablish & maintain normal dietary pattern of bowel functioning as evidenced by a formed. ® This could stimulate the bowel & may increase peristalsis.X. NURSING CARE PLANS Nursing Care Plan No. avoid milk & fruits.Demonstrate 34 EVALUATION Bowel sounds inflammatory process of care. progressive hypersecretion water& electrolytes by at the intestinal mucosa. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: . . with exerted 0 as no pain.State relief from cramping & less or no diarrhea. patient will: during auscultation . ® This is to avoid foods /substances that could in pattern of bowel functioning evidenced by as a stools per day . 1. in response to the pressure by food . .Pain scale of 8 osmotic out of 10.Verbalize understanding of causative factors & rationale for treatment regimen. precipitate diarrhea. . .Grimaced face .Promote the use of relaxation techniques (e.Urgency .Frequency of at least loose three liquid SCIENTIFIC BASIS: Large volume diarrhea is caused by a of secondary to regional enteritis.Guarding movement formed. particles in the chyme rationale . with pain scale of 4-1 as mild pain to 0 as no pain at all. soft stool. .Reestablish maintain decreases peristalsis.Verbalize understanding causative & of the abdominal This secretion occurs area.Restrict solid food intake as After 8 hours span of indicated.Hyperactive Diarrhea related to the Within 8 hours span NSG. .Limit caffeine & high fiber foods. with pain scale of 4 noted. . ® This is to provide care.State a relief from cramping & less diarrhea. patient was able to: & normal rest for the stomach & . soft stool. 4 as mild pain.Provide changes intake.g. .

ASSESSMENT 5-8 NSG. or commercial preparations. ® To decrease gastrointestinal motility & hypersecrete water in the presence of infectious Severe cramping. avoidance of irritating foods) . ® To replace fluid loss.g. as or to direct irritation of mucosa. abdominal Tenesmus (persistent spasm) of the anal area. . ® To prevent skin breakdown. irritation integrity. 35 . barrier as needed. severe felt. . . DEPENDENT: .Demonstrate appropriate behavior to assist with resolution of causative factors INTERVENTIONS . .Maintain a rectal area free of movement. abdominal distention. & borborygmus (loud minimize fluid losses. DIAGNOSIS OBJECTIVE treatment regimen. bouillon. avoidance of irritating foods) .g. transit time through the intestine is significantly decreased.Apply peristalsis may also result inflammation mucosal from as cells maintain -GOAL METlotion/ointment skin irritation. Increase (e.Encourage oral intake of fluids containing electrolytes such as juices.Administer IV fluids with doctor’s order. ® To promote treatment of fluid loss.Assist patient as needed with pericare after ® & each To bowel prevent skin EVALUATION appropriate behavior to assist with resolution of causative factors (e. organism..Administer antidiarrheals with doctor’s order. is & the moderate pain the and 9-10 as Peristalsis pain increased..Maintain a rectal area free of irritation.

DIAGNOSIS bowel sounds) may also occur. ® To prevent spread of infectious diarrhea.Use standard precautions when caring for clients with diarrhea. ® To either rule out or diagnose an infectious process. & Green OBJECTIVE INTERVENTIONS COLLABORATIVE: . Sands.Obtain stool specimens as EVALUATION ordered. .ASSESSMENT NSG. Marek (2007) Neighbors. Monahan. 36 . use of gloves and proper hand washing.

Teach patient a specific behavior on the is abdominal area.Diaphoresis . This secretion occurs in response to the osmotic pressure exerted by food nonabsorbed particles in the chyme or to direct irritation of the mucosa.V/ radio & socialization with others).Demonstrate use of relaxation skills & diversional activities.Guarding SCIENTIFIC BASIS: Large volume diarrhea caused by a of Acute pain related to Within 20 min. crying. . 2 ASSESSMENT Objective cues: .Verbalize methods that provide relief.Demonstrate use of relaxation skills & diversional activities. ® To divert attention from pain to other activities providing comfort & alleviate pain.. ® This is to provide comfort and alleviate the pain felt. patient will be GI inflammation. span increased peristalsis & of care. .Report pain is relieved as evidenced by having a pain scale of 0 out of 10.. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: .Facial mask of pain (eyes lack luster. span of (e. & the transit time through the relaxation strategy (e.Verbalize methods that provide relief. alleviating pain & promoting relief 37 -GOAL MET- . T.Distraction behavior (moaning..Follow prescribed pharmacologic regimen. .Provide comfort the patient some After 20 min.Encourage use of diversional activities (e. EVALUATION measures change of position & use of heating pad applied into the abdomen). fixed or scattered movement. . “beaten look”. .g. slow. . . . ® Breathing exercises relaxes the body.g. care.Increase BP & PR hypersecretion water& electrolytes by the intestinal mucosa. patient was able to: .g. able to: . grimace) . NSG.Follow prescribed pharmacologic regimen. .Report pain is relieved as evidenced by having a pain scale of 0 out of 10.Nursing Care Plan No. Peristalsis is increased. rhythmic breathing or deep breath). pacing & restlessness) .

peristalsis result inflammation mucosal Increase may also from as cells OBJECTIVE INTERVENTIONS . DIAGNOSIS intestine is significantly decreased. distention.Encourage adequate rest EVALUATION periods. ® To decrease intestinal motility. ® Anti-inflammatory drugs . 5-8 cramping. moderate (persistent spasm) of anal area. as such as propantheline bromide 30 minutes before meal as prescribed.Administer anti-inflammatory drugs with doctor’s order. relieving pain.A pain scale of hypersecrete water in 8 out of 10.Self-focusing NSG. Sands. & borborygmus (loud bowel sounds) may also occur. 1-4 as Severe organism.Administer anti-cholinergic or antispasmodic medications with 0 as no infectious pain. ® To prevent fatigue. DEPENDENT: .Increased or decreased respiratory rate . Marek & Green (2007) 38 . abdominal Tenesmus mild pain.ASSESSMENT . pain and 9-10 the as severe pain abdominal felt. Neighbors. the presence of reduce the inflammation of the bowel. Monahan.Papillary dilatation . .

.Decreased skin turgor .Maintain volume at fluid a NSG.Frequent defecation with 3 or more loose liquid stools per day.Verbalize understanding causative Distributing the intake over the entire 24-hour period & providing snacks & preferred beverages causative factors & purpose of individual of factors 39 .. gravity. Within 3-day shifts span of care. fresh fruits.Provide fresh water & oral fluids preferred by the client (distribute over 24 hours [e.Sudden weight loss .Thirst . offer snacks (e.Maintain volume at fluid a EVALUATION tastes in the mouth and allows the client to respond to the sensation of thirst. 800 ml on evenings. & 200 ml on nights])..Increased hematocrit: SCIENTIFIC BASIS: Inflammation of the mucosal cells is the major cause of triggering these symptoms to appear. .Nursing Care Plan No. nausea & diarrhea secondary to regional enteritis. moist mucous membranes & good skin turgor. . ® The oral route is preferred for maintaining fluid balance.Dry skin and mucous membranes .g. It causes deficient Deficient fluid volume related to anorexia. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: .Verbalize understanding of stable vital signs. . at After 3-day shifts least twice a day & explain its span of care. stable vital signs. moist mucous & membranes good skin turgor. patient purpose to the patient. functional level as evidenced by functional level as evidenced individually adequate urinary by individually adequate urinary (<30mL/hr) normal output with specific output (<30mL/hr) with specific normal gravity. Anorexia or loss of appetite is one of the systemic symptoms because of inflammation.g.Weakness .3 ASSESSMENT Objective cues: . 1200 ml on days.Provide frequent oral hygiene. frequent drinks. patient will be able to: . ® Oral was able to: hygiene decreases unpleasant . fruit juice). provide prescribed diet.Vomiting 3 times or more a day. .

The vomiting center. .Watch trend in output for 2-3 days.5⁰C 37. .39 .Demonstrate measures that can be taken to treat fluid volume loss. include all routes of intake & output & note color & specific gravity of urine.50 .Instruct patient to avoid solid foods & high in fiber. located in the medulla adjacent to the respiratory & salivary controls centers. can be stimulated directly by both the vagus nerve & sympathetic OBJECTIVE therapeutic interventions medications. .ASSESSMENT <0. ® Monitoring for trends for 2-3 days gives a more valid picture of the client’s EVALUATION & purpose of individual therapeutic interventions medications.010-1.030 .Demonstrate measures that can be taken to treat fluid volume loss. & -GOAL MET- hydration status than monitoring 40 . ® Postural hypotension can cause dizziness.Decreased NSG. . On the other hand.Increased body temperature: <36.Increased pulse rate: <60-100 bpm .Decreased urine output: >30 mL/hr (or 720mL/day) . . & to decrease intake of milk products. ® These measures allow the bowel to rest preventing vomiting & diarrhea. nausea is a subjective sensation of an impending urge to vomit. DIAGNOSIS fluid volume because of the inability to acquire nutrients & electrolytes needed by the body. which places the client at higher risk for injury. & INTERVENTIONS increases the likelihood that the client will maintain the prescribed oral intake.Increased urine concentration as evidenced by dark-colored urine.0.Elevated urine specific gravity: <1.Assist the client with ambulation if postural hypotension is present.5⁰C . .

Monitor vital signs every 15 minutes to 1 hour for the unstable clients (every 4 hours for the stable client). same also a diarrhea. frequent quantities of slightly chilled solutions. if it is progressing or not. . DIAGNOSIS nervous system. ® This is to monitor the health of the patient. ® Maintenance of oral intake stabilizes the ability of the intestines to digest & absorb nutrients. hydration. when triggered by spasm or inflammation. which excretes a watery loose stools frequently resulting OBJECTIVE INTERVENTIONS for a shorter period. Provide small. DEPENDENT: . glucose electrolyte 41 . It causes deficient fluid volume since more nutrients and electrolytes were excreted from the body via vomiting. Receptors can be found throughout the GI tract & the internal organs that. .Provide oral replacement therapy as ordered & tolerated with a hypotonic glucose-electrolyte (IV) ® solutions To as EVALUATION maintain solution.ASSESSMENT blood pressure: >110/70-120/80 mmHg NSG.Hydrate the client with ordered intravenous prescribed. can directly produce vomiting.

Marek & Green (2007) OBJECTIVE INTERVENTIONS solutions absorption increase while net fluid EVALUATION correcting deficient fluid volume. multiple organ failure. 42 . & stool volume.Consult physician if signs & symptoms of deficient fluid volume persist or worsen.Administer medications such as antiemetics & antidiarrheals with doctor’s order. COLLABORATIVE: . Sands. Monahan. & death. . Neighbors. DIAGNOSIS to fluid loss. A study demonstrated that decreasing the osmolality of standard glucoseelectrolyte oral replacement solutions improves the absorption of water. including shock. ® To prevent vomiting & diarrhea. ® Prolonged deficient fluid volume increases the risk for development of complications.ASSESSMENT NSG.

Verbalize understanding of causative factors and necessary interventions. This is partly due to the fewer calories consumed when a person loses . . . ® Determining the to: patient’s preference enhances the appetite to eat. & the like. ® This is to give flavor on the patient’s food.4 ASSESSMENT Objective cues: .Satiety immediately after food. 5. lemon & herbs) if salt are restricted.Abdominal cramping with a pain scale of 8 SCIENTIFIC out of 10. . .Use flavoring agents (e. & malabsorption. ® A clean & relaxing .Demonstrate NSG. Spicy.Nursing Care Plan No. . .g.Lack of interest High risk for in food. .Limit fiber/bulk. . hot/cold foods. ® These foods can cause intolerances and may also increase gastric motility. milk products.Promote pleasant. patient was able EVALUATION particular meal..Body weight 20% or more under ideal. ® This could lead to an early satiety. Within 3 days shifts span of care. . .Unintentional disease also imbalanced nutrition. 1-4 Some people who as mild pain. patient will be able to: . caffeinated beverages. relaxing environment. less than body requirements. .Demonstrate progressive weight gain toward goal. including socialization when possible. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: .Prevent & demonstrate progressive weight gain toward goal.Display free signs of malnutrition as reflected in defining characteristics. . experienced weight loss. with 0 BASIS: as no pain.Avoid gas-forming foods.Demonstrate behavior changes to regain & 43 ingesting related to dietary restrictions. nausea.Verbalize understanding of causative factors and necessary interventions.Display free signs of malnutrition as reflected in defining characteristics. .are suffering from 8 as moderate Crohn's pain and 9-10 as have severe pain felt.Determine whether patient prefers / Within ___ span of tolerates more calories in a care. preventing nausea & vomiting. .

but OBJECTIVE behavior changes to regain & maintain appropriate weight. DIAGNOSIS his appetite. . also a result of the way in which the digestive works--food not be system may properly negative effect on appetite. .Promote adequate fluid intake.Frequent defecation with 3 or more loose liquid stools per day. The oral mucosa must be moist. .Pale conjunctiva condition. ® Unpleasant odors & sights could stimulate the vomiting center -GOAL MET- absorbed into the system as would be seen in without someone the resulting to a feeling of nauseated then later vomit. NSG. the condition of the oral mucosa is critical to the ability to eat.ASSESSMENT weight loss. ® Good oral hygiene enhances appetite. . with adequate saliva production to facilitate & aid in the digestion of food.Prevent/minimize odors/sights that may unpleasant have a EVALUATION maintain appropriate weight. INTERVENTIONS environment together with a companion at mealtime encourages nutritional intake. & mucous membranes George.Provide oral care before/after meals.Poor muscle tone . ® May want to limit fluids 1 hour prior to meal to decrease possibility of 44 . .Hyperactive bowel sounds . (2011). D.

Weigh the patient everyday and prn. CHO. ® This is to have a proof of an effective nursing care rendered. wine) if indicated. calories.Small feedings with snacks (easily digested snacks) .Appetite stimulants (e. DIAGNOSIS OBJECTIVE INTERVENTIONS early satiety.Mechanical feedings . . . DEPENDENT: ..Provide diet modifications as EVALUATION indicated. liquefied tube .ASSESSMENT NSG. ® Modification in feedings provides the appropriate nutrients needed by the body depending on the condition of the patient.Increase CHON. 45 soft. .g. For example: .Dietary supplements. Some of the diets also facilitate a rapid absorption in the GI tract.

antidiarrheals) ® Drugs facilitate a direct target of healing.g. EVALUATION knowledge about the appropriate foods for the patient’s condition. antiemetics. 46 .ASSESSMENT NSG. DIAGNOSIS OBJECTIVE INTERVENTIONS . antacids.Vitamin . ® To have further (e.. COLLABORATIVE: .Administer pharmaceutical agents as indicated: .Digestive drugs/enzymes .Medications anticholinergics.Consult dietitian/nutritional team as indicated.

monitoring provides a baseline data for the planned activity. desired activities.Plan care with rest periods physiologic signs of intolerance as evidenced by the vital signs taken in within range. -GOAL MET- accompanies severe 47 . the patient was able EVALUATION pressure.Pallor skin color weakness . ® cyanosis.Nursing Care Plan No. DIAGNOSIS OBJECTIVE INTERVENTIONS INDEPENDENT: . . confusion.Frequent defecation with watery loose stools . ® This is to reduce & prevent chronic fatigue. . desired activities.Dry lips & skin . heart & respiratory rate. watching for After 8 hours span of dramatic changes in blood care.Cyanotic nail beds . ® This provides the patient a time to exercise & relax at the same time conserving energy in the right manner. with 1 – completely BASIS: Individuals suffering Crohn's may with disease experience secondary to regional enteritis.5 ASSESSMENT Objective cues: .Demonstrate decrease a in a .Report measurable increase in activity intolerance .Participate willingly necessary in or NSG.Monitor vital signs.Participate willingly in necessary or . VS & .Demonstrate a decrease in physiologic signs of intolerance as evidenced by the vital signs taken in within normal range. fatigue Chronic often between activities.Report a measurable increase in activity intolerance .Increase exercise/activity levels gradually. to: and/or pallor. teach energy conserving methods such as rest for 3 minutes during a 10-minute walk and so forth. normal low-grade fever and an overall feeling of fatigue.Abnormal heart rate or blood pressure response High risk for activity intolerance related to generalize Within 8 hours span of care patient will be able to: . .Has a musculoskeletal function status of 3 out of 5.Low grade fever SCIENTIFIC .

NSG. George. ® This allows the patient to be encouraged & be willing to participate since he/she already knew the activities to be done.ASSESSMENT independent 2 – requires help of equipment to assist self. ® This is to provide the client a proper oxygenation for dyspnic episodes. (2011).Involve patient in planning of activities. . dietary OBJECTIVE INTERVENTIONS . DIAGNOSIS diarrhea and may indicate deficiencies.Provide/monitor supplemental use oxygen of with doctor’s order.Assist the patient during the activities & provide with assistive devices such as walker or EVALUATION wheelchair. 48 . 5 – completely dependent. 3 – requires help or supervision of others 4 – requires help from other persons. ® This is to protect the patient from injury. DEPENDENT: . D.

Retrieved Sept. Crohn’s Disease. Seventh Edition. Andrew.com http://www.ehow. G. Fourth Edition. F. 2011 from Liver Inflammation in Crohn's Disease | eHow. M. Vol. Mortality in Crohn’s Disease – A Clinical Analysis. Retrieved Sept.com/mpacms/at/article. P. A Guide to Planning Care.html#ixzz1YA39lXHU.. Liver Inflammation in Crohn’s Disease. 2011 from http://qjmed.com http://www. George. Interventions. F. (1988.html. Philadelphia. Lewis. 25. 2011 from http://www. 2011 from http://acupuncturetoday.. Issue 2. Chen. QJM: An International Journal of Medicine. Davis Company.php?id=27652.F.com/Crohn's+disease. PhD. Nursing Diagnosis Handbook. Retrieved Sept..htm. Elsevier Pte Ltd. 16.com/c/crohns_disease/stats-country. March 2). (2000. Retrieved Sept.html#ixzz1YA5FKZty. 6. Crohn’s Disease. 25. OMD. A. Gorman. Retrieved Sept. H.. D. (2011). The Free Dictionary.). (1993). Lac. Cure Research (2010.abstract. Farlex. Crohn’s Disease & Living Probiotics (2011). (2006). (2011).oxfordjournals. A. 2011 from Symptoms of Crohn's Disease | eHow.crohnsdisease-probiotics.. PharmD. M. Ladwig.com/crohns-disease-diet. R. (2011). 16.ehow. Allan. N.49 XI. 16. B. . Retrieved Sept. 2011 from http://medical-dictionary. 71. 2011 from http://cureresearch. 22. Symptoms of Crohn’s Disease. Nov. 28).com/facts_4828904_symptoms-crohns- disease.com/facts_5934851_liverinflammation-crohn_s-disease. BIBLIOGRAPHY Ackley. Nurse’s Pocket Guide: Nursing Diagnoses with Doenges. Moorhouse. Statistics by Country for Crohn’s Disease.org/content/71/2/399.thefreedictionary. November. J. Singapore. Retrieved Sept.

Eight Edition. Greenberg. . Eleventh Edition. T. Mayo Clinic Staff (2011. Retrieved Sept. Treatment.ehow. Management of Crohn's Disease—A Practical Approach. D. Medline Plus Encyclopedia (2011).gov/medlineplus/ency/article/000249. M.D.50 Knudson. April 27). Neighbors. F...com (2011).html.org/afp/2003/0815/p707.com/script/main/art. (2011. 16. Phipps’ Medical Surgical Nursing. Lippincot Williams & Wilkins. Philadelphia. Crohn’s Disease Symptoms.. 22. 2. 2011 from http://www. J. (2003. 15. 2011 from http://www.medicinenet. & Cronau. 15. M. C. How Does Crohn’s Disease Affect the Body?.. August 9). F. Singapore. Moyet. (2006). Health & Illness Perspectives.D.aafp.htm.com/health/crohns-disease/DS00104.medterms.nih.com/crohns_disease/article. MedicineNet. Vol. ( 2011). J. Marek. Crohn’s Disease.htm. Retrieved Sept. Regional Enteritis. 2011 from http://www. MedicineNet. 25. 2011 from http://www. Elsevier Pte Ltd. 6. MedicineNet. Handbook of Nursing Diagnosis.asp?articlekey=5280. 2011 from http://www. 25. 2011 from http://www. J. G.html.mayoclinic.nlm.htm. Monahan. Retrieved Sept. M. Retrieved Sept.com/crohns_disease/article.com: We Bring Doctor’s Knowledge to you. D.. Green. L. (2007).com/how-does_4965355_crohns-disease-affect-body. Retrieved Sept.medicinenet. August 15).D. K... J. M. Causes. Retrieved Sept. 2011 from http://www.com: We Bring Doctor’s Knowledge to You (2011). H. Retrieved Sept.. Knutson.. Sands.

Hinkle. 2011 from http://ehealthmd. 15. MD FRCS. 2011 from http://digestive. St. Wolters Kluwer Health | Lippincott Williams &Wilkins.org/index. January 30). Retrieved Sept. 2011 from http://www. 2011 from http://www. February). Feb.com/content/what-crohns-disease-cd.. Scachar. June 11). . L.nlm. H.virtualmedicalcentre. Brunner & Suddarth’s Textbook of Medical – Surgical Nursing. NIH: National Institute of Diabetes and Digestive and Kidney Diseases (2010.. Retrieved Sept.html. G. The Merck Manual Professional: Crohn’s Disease: Inflammatory Bowel Disease (IBD). 15.nih. 1. Philadelphia. Bare.nih. What is Crohn’s Disease? Retrieved Sept. Retrieved Sept.. Useful Statistics about Bowel Disease. (2011. 2011 from http://www. B.. Jan.html Slowik G. K. 25. D. Retrieved Sept. Smeltzer. 2011 from http://www. Virtual medical centre (2006.gov/ddiseases/pubs/ crohns/.niddk. C.. Walfish..php?mact=News.stmarksfoundation. Cheever.. A. Twelfth Edition. (2010. Marks Foundation (2011. 15.gov/medlineplus/ crohnsdisease.51 National Digestive Diseases Information Clearinghouse (NDDIC) (2006. Introduction to the gastrointestinal system.nih. E.com/professional/gastrointestinal_disorders/inflammatory_bowel_dis ease_ibd/crohns_disease. December 13). Vol. What is Crohn’s Disease? (CD).merckmanuals. Crohn’s Disease. Retrieved Sept. 2011 from http://digestive.gov/ddiseases/pubs/smoking/.asp?sid=7 &title=Gastrointestinal-System.com/anatomy. (2010). S. Smoking & your Digestive System. Retrieved Sept. National Digestive Diseases Information Clearinghouse (NDDIC) (2006.cntnt01.print. 11. 15. 25. 7).0&cntnt01 articleid=114&cntnt01showtemplate=false&cntnt01returnid=77. February).). J.niddk.

Retrieved Sept. April 11). February 28). The Statistics for Crohn’s Disease Patients. D. WebMd Weissheiss (2011. Workman. L. Treatment Cost & Appropriateness..52 WebMD (2010.ashtanga-accommodation. Crohn’s disease.11. . 2011 from http://www. (2006). Fifth Edition.. Singapore. Elsevier. 25.com/ibd-crohns-disease/crohns-disease/crohns-disease-causes February 28 2010. M.webmd.info/thestatistics-for-crohns-disease-patients-treatment-costs-appropriateness. Medical Surgical Nursing – Critical Thinking for Collaborative Care. 2011 from http://www. & Ignatavicius. Retrieved Sept. D.