hello this is going to be a discussion about a gastrointestinal system and in relationship specifically to inflammatory bowel disease before you dive into this content be sure you are free from distractions and can debit your full attention be sure that you have read the textbook pages that are associated with this content be prepared to actively learn I will be sharing my knowledge and understanding with you but you must do the learning participate in your learning you will be the nurse next to that patient not me you need to acquire the knowledge skills and attitudes to take care of that patient safely competently and compassionately think beyond your next classroom exam rather think about being that nurse taking care of that patient that is what you are preparing for not classroom examinations listen with curiosity asking questions seeking answers imagine being the nurse responsible for the care of this patient imagine being the patient needing this nursing care think about your prior experiences that are related to this content from both the health care provider's point of view and or the patient's point of view think about building knowledge on the foundation of what you already know be prepared to change your understanding of this content if new information is presented take advantage of this recorded source pause as needed to think about the content or write down notes or questions be curious about learning more review the content and your notes as needed to gain understanding that you seek test yourself on the content to determine if you really learned it or not the first thing I want you to do is pause and reflect I want you to start by stopping the recording and thinking and writing down in these three areas I want you to think about what you already know about this topic and write down at least three to five items I want you to stop and think about any of your prior experiences related to the content I want you to write down your thoughts and feelings related to your experiences lastly I want you to think about what you don't know about this content think about you know acts of knowledge and understanding and things that you're curious about learning write down at least three to five items then you'll be ready to dive into the content here are the learning objectives for this discussion make sure that you understand what the purpose of this is and that you'll be able to meet these objectives upon the completion the first of the inflammatory bowel disease is that we will discuss is Crohn's disease Crohn's disease is not completely understood as far as the causes of it there are some suspected factors including genetic predisposition and altered immune response I.E and autoimmune disease and also perhaps an altered response to gut microorganisms as with most autoimmune disorders the patient experiences periods of exacerbation and remission with some potential triggers being perhaps foods that that patient is sensitive to setting off an exacerbation sometimes an excess of stress in one's life poor quality or the amount of sleep and maybe even environmental toxins or chemicals the usual age of onset for Crohn's disease is 15 to 40 years old it is also known as Regional enteritis that's another term for Crohn's disease and that kind of refers to the fact that the lesions that are formed can happen anywhere in the GI system from the mouth to the anus but most commonly they occur in the distal ilium and the ascending colon there's no real Rhyme or Reason to where they develop and they can skip around so you can have a lesion in one part of the small intestines and several feet of good healthy functioning organ and then end up with two or three lesions in the large intestines it it's really random um the lesions are what's considered transmural that means they go all the way through the layers of the Lumen of the GI tract it is uh Progressive in a lot of cases where inflammation can lead to abscesses abscesses lead to ulcers fissures and fistulas can develop scarring occurs from the repeated bouts of in exacerbation and then it clearing up and then going back to another exacerbation so there can be a lot of scarring going on and fibrosis in this tissues and even stenosis as the scars build up and decrease the the diameter of the lumen repeated flare-ups and exacerbations lead to scarring and then increasing dysfunction of the affected part of the bowel so the signs and symptoms are going to vary a little bit depending upon the location of the lesions if most of the patient's lesions are in the small bowel then you're going to see a lot of trouble with absorption of nutrients if most of the lesions are in the large bowel then you're going to see a lot of trouble with absorption of water and electrolytes um most of the time folks with crohn's have little to no bleeding and that's in the stools they sometimes will have diarrhea but it's not very frequent and not very severe because the prominent location for lesions to develop is the distal ilium and the ascending colon most of the time if they have abdominal pain that they can point to an area they're going to say it hurts in the right lower quadrant which makes sense because that's where that part of the anatomy is they will complain about crampy abdominal pain they'll talk about having to limit their food intake maybe having no appetite because of the symptoms perhaps malnutrition and weight loss and likely even anemia or dehydration because of these same all of the signs the other aspects of it usually if a patient with crohn's has anemia it's not because of blood loss because I said the mild the Blazing is usually mild in Crohn's it's usually due to chronically poor food intake going into anemia as you can imagine we'd want to do a head to toe assessment with an additional attention paid to the GI system because anemia is a potential problem we also would want to look at the cardiovascular system and see if it's being impacted by this um anemia and then a general assessment of the patient's nutritional status would also be very important additionally a focused assessment on the psychosocial care concerns would need to be completed because we want to look at this is a very difficult disease to live with it impacts a lot of aspects of a patient's life and it can have because stress can cause exacerbations it can kind of lead to this vicious cycle where they have an exacerbation and then that makes them even more stressed out which leads to additional exacerbations so one of the big things we can do for a patient with crohn's is just help deal with those psychosocial care needs and see what we can do to help manage that stress and all those concerns your medical management is going to begin with diagnostic testing and Labs so you can see a patient ordered perhaps x-rays MRIs or CT scans or a combination they may have a colonoscopy to have a look at what's going on in the large bowel CBC and BMP um they're probably going to do an ESR blood test the urethrocyte sedimentation rate which is a marker of inflammation and also a C-reactive protein which is another marker of inflammation in the body it kind of gives us a picture of how bad the GI system might be inflamed um we're probably also going to be looking at albumin and protein levels in the blood so we can assess more about the nutritional status and we want to look at the stools for bleeding perhaps even occult blood that you can't just outright see but is in there um some of the additional medical management is going to include some medications to help often we give corticosteroids because they're anti-inflammatory and um Amino salicylates immunomodulators which kind of help boost up the patient's immune system to help them fight back against this autoimmune disorder which is another reason um the same reason that we give sometimes monoclonal antibodies and then antibiotics are given if there's an infection or we're trying to prevent one with a big flare-up we also want to give good nutritional support and supplementation this is a patient that may need to have parental feeding the GI system is flared up in an acute exacerbation we don't really want to be giving this patient food to process we want the GI system to rest and everything to calm down so this patient might be receiving parenteral feedings so we would be looking at perhaps a PICC line and bags of tpn being given to this patient which would require our care and monitoring we're also very concerned that they stay properly hydrated if they have um anemia we we have some different ways to handle that if um we we could give iron either oral or IV probably IV if they're in the middle of an acute exacerbation we wouldn't want to tax their system with an ion tablet if for some reason they have had any significant blood loss and we could be looking at administering a blood transfusion sometimes these patients might have surgery an ileostomy but that really doesn't cure the disease because the patient can have exacerbations later and as I said earlier this can happen anywhere along the GI tract so just because we're doing an ileostomy doesn't necessarily mean they can't develop lesions in their large bowel and then they still have problems some of the most common complications of Crohn's Disease or Regional enteritis is anorexia so loss of appetite weight loss malnutrition abdominal pain and these patients are at an increased risk of osteoporosis and therefore fractures some of the most life-threatening complications that can happen would be strictures or obstructions fluid and electrolyte imbalances fistulas and abscess formations these patients are at an increased risk of colon cancer they can have a perforation of the bowel and they can Hemorrhage especially if say they have a perforation and of course peritonitis if they have a perforation um some of our nursing care considerations we want to address the anemia monitor if a patient is anemic regardless of what the treatment is that the provider orders we need to have that on our radar we need to be monitoring Vital Signs especially blood pressure and heart rate as well as monitoring for dizziness lightheadedness and other signs and symptoms of anemia if they have an acute Hemorrhage this can lead to shock so we would need to be monitoring for our signs and symptoms of shock the patient may be NPO and require IV fluids so we should be ready to help provide Oral Care maintain their IV access and administer order of ID fluids and record the fluids on the patient's chart as intake anytime the patient is receiving IV fluids the nurse should monitor intake and output to assess the patient's fluid balance if an instruction is present the patient may need to have an NG tube to low intermittent suction to decompress the bowel we should assess the proper placement and function of the tube record the output on the patient's chart other nursing considerations include administering ordered pain medications antibiotics antiemetics corticosteroids and other meds assessing the patient before and after Administration and monitoring for side effects and life-threatening adverse effects as well a nurse is also responsible for teaching the patient about their condition the treatments the medications Etc and also responsible for being supportive and caring as is one of our nursing responsibilities listening to and empathizing with the patient's concerns is an important aspect of caring for the patient we need to be practicing our therapeutic communication in providing the patient with education we first need to assess what they need to know what they're willing to learn how they like to learn provide information at a level the patient can understand and then amounts that they can absorb remember not to overload the patient the point of education is to help them understand and be a better participant in their own health care help them in a way that empowers them to take part in their own condition this leads naturally into the psychosocial and holistic aspects of patient care listening with empathy and supporting the patient through the hospitalization has been shown to improve patient outcomes and improve the patient's opinions of their caregivers and the care they received provide a non-judgmental listening ear and try to help the patient come to terms with their condition now is another opportunity for you to pause the recording and think of I would like you to think about what a patient's colon with crohn's disease would look like how does the change in the structure of the lining of the small and large intestines impact the processing of the nutrients and what do you think a patient with an acute exacerbation of Crohn's Disease would be complaining of the other inflammatory bowel disease we're going to discuss is ulcerative colitis ulcerative colitis is a chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum that is characterized by unpredictable periods of remission and exacerbation with bouts of abdominal cramps and bloody or purulent diarrhea um the inflammatory changes typically begin at the rectum and progress approximately through the colon once again for this disease process the causes are not completely understood they have similar risk suspected risk factors as Crohn's disease which include predisposition genetically altered immune response altered response to the gut microorganisms and perhaps the periods of exacerbation might be triggered by specific Foods by stress by lack of quality or quantity of sleep or environmental factors like chemicals or toxins once again the Aged onset typically is 15 to 40 years old this looks different than Crohn's disease in that the lesions begin at the rectum at the very end of the GI tract and they progress stepwise up the colon so you won't find all sorts of colitis lesions in the small belt or anywhere else in the GI trend it can overtake the entire colon but that's as far as it goes um inflammation affects only the inner lining of the bowel so we don't have that transmural um lesion that goes all the way through the layers therefore Crohn's Crohn's can have the fistulas and the seizures ulcerative colitis will not because it doesn't track outside the inner lining of the large bowel but because it's only in that inner layer it often causes a lot of bleeding can cause narrowing and thickening and shortening of the bowel so you have less and less of the large vowel that's really effective to do its function the on-again off-again nature of this can lead to extensive scarring and have flare-ups and remissions and then flare up over again your clinical manifestations this patient will have potentially severe bleeding it is common with ulcerative colitis to have a lot of bleeding so they'll have also a lot of diarrhea frequent severe diarrhea perhaps up to six or more episodes a day and the diarrhea can be quite bloody because you know all of this lesions are at the lower end of the GI tract this patient if they complain about abdominal pain will have pain in the lower left quadrant as opposite of the Crohn's disease they'll have more likely to have electrolyte imbalances and dehydration because those large bowels are not being able to absorb the fluid and electrolytes as usual they'll have anemia and fatigue and the anemia of ulcerative colitis is usually due to acute blood loss some of our nursing assessments are similar very similar to what we talked about just a little bit ago with the Crohn's disease a head to toe assessment is always appropriate and necessary additional attention paid to the GI system we want to look specifically at the cardiovascular system because of the possibility of anemia for this patient General assessment of nutritional status and focused assessment on the psychosocial and Care concerns just like we were talking about with the Crohn's patient our medical management we're going to have similar diagnostic testing and labs done so could be x-ray MRI or CT or any combination colonoscopy CBC and BMP the ESR and the C-reactive protein also as markers of inflammation we're going to be giving this patient nutritional support probably parenteral feedings because we don't want to tax the GI system during an acute exacerbation of this disease process we'll be giving hydration through IV fluids probably electrolyte Replacements will be monitoring those labs and watching for those shifts in the electrolytes and giving electrolyte replacement through the IV it's probably um if the patient has severe anemia from the blood loss we'll be giving a blood transfusion and this patient because the ulcerative colitis is confined just to the colon often they can have a colectomy a surgical procedure and this could actually cure the disease process and end its recurrence so some patients opt for to have a colectomy we'll use similar medications for this patient the steroids Amino salicylates as anti-inflammatories immunomodulators monoclonal antibodies to help their immune system build back up and maybe help fight this disease process antibiotics if we're looking at an infection or prophylactically to prevent one so remember that this is very inflammatory and so your medications like corticosteroids are going to help to decrease the inflammation this disease process has very similar common complications as um Crohn's disease anorexia loss of appetite include and then weight loss malnutrition which is mostly due to a lack of the desire to eat because the large bowel is the part that's effective the small bowel can still do its job of absorbing but because there's so much um problems with the large bowel sometimes people don't even want to eat at all so they can experience malnutrition they're going to have some abdominal pain and this patient is also at increased risk of osteoporosis and fracture the life-threatening complications for ulcerative colitis are a little bit different we have some similar like strictures and obstructions fluid and electrolyte imbalances an increased risk for colon cancer possibility of perforation and Hemorrhage but in addition to that this patient has a high risk of a life-threatening complication called toxic megacolod now the toxic megacolon is the inflammatory process extends into the muscular areas of the bowel inhibiting its ability to contract and resulting in the colon being very distended since so it the the bowel just kind of gets real distended and then there's absolutely no way for it to kind of do the peristalsis it kind of halts peristalsis um the patient will present with a fever abdominal pain and distension vomiting and fatigue um if toxic megacolon does develop it needs to be managed within seven to two hours or it can be fatal um this patient will have an NG tube desection IV fluids with electrolyte Replacements corticosteroids antibiotics and probably surgery because they can't stay that way it doesn't resolve and it can be a potentially deadly a subtotal colectomy may be performed if the bowel has not already perforated otherwise a full colectomy is indicated and it is ultimately needed in up to one-third of patients that have ulcerative colitis will have to have that because of toxic megacolod so one of the things we need to realize is that we may have a patient in the hospital for any other reason and they have all sorts of colitis okay they're not there because of all sorts of colitis they're there because of pneumonia or a fractured hem or something else but when we see that they have ulcerative colitis on their medical records that needs to put all these possible complications on our radar so that we are monitoring for this toxic megacolon which can develop at any time with a patient who has ulcerative colitis and of course being in the hospital for any reason increases the level of stress for a person and so that increased stress could lead to an acute exacerbation of all sorts of colitis even though that's not even why they're in the hospital to begin with um so once again our nursing considerations we want to be looking because this patient is likely to be anemic and malnourished so we're watching for those um battle sign changes that show um with anemia or with acute blood loss for that matter especially with ulcerative colitis because bleeding is very common so remember those signs and symptoms where we're going to see changes in the bottle signs like the blood pressure and the heart rate maybe even the respiratory rate dizziness lightheadedness and other signs of anemia which can include a patient complaining of chest pain um acute Hemorrhage can lead to a shock for the patient so we need to be monitoring four signs and symptoms of shock and the patient's likely to be NPO and require IV fluids so we'll be required to provide Oral Care provide IV access and maintain that monitoring it for any signs and symptoms of complications for the IV and recording the amount of fluids that are are given as part of the patient's chart remember that anytime the patient is receiving fluids we should be monitoring as a nose to assess the patient's fluid balance if the patient has an obstruction from the ulcerative colitis then we're going to be looking at an ng2 probably to low intermittent suction to decompress the bowels so we have to assess the proper placement and function of the tube we have to monitor the output and record that as well we're going to be giving medications as I mentioned before we're going to be giving pain meds antibiotics antiemetics corticosteroids other medications and we have to monitor our patient we need to do an assessment of the patient before we give them meds and then we need to come back and reassess them after they've received the meds we were looking for both the therapeutic and non-therapeutic reactions to the medications we also need to do a lot of teaching we're teaching the patient about their disease process we're teaching them about the medications we're teaching them about the treatments and we're offering our therapeutic communication to help this patient deal with this problem listening to them empathizing with them listening to their concerns that's an important aspect of care for every patient when we're doing us uh patient education we always want to do a good assessment of what the patient already knows we want to know if they have any misinformation so that we can correct that we also want to know are they willing to listen because we're wasting our time and our breath if they're not willing to listen okay don't approach a patient with a whole packet of information and they don't they're too busy watching the TV to pay attention to what you're saying or they're just tired or now is not a good time okay there's a lot of reasons why they just might not be ready to receive that information so time it wisely warn them I'm going to come back in a few minutes and I'm going to bring some information I'd like to share with you would that be a good time for us to talk um ask them how they like to learn you know sometimes patients want a piece of paper they can hold in their hand that they can read about it they'll listen to you talk but they want to keep that piece of paper and go back over it later maybe they prefer to go to a website and you could give them a link to a good website or maybe they want to watch a video about it so you could find them a video that they could watch at their convenience and learn about this and then go back later and assess what they got from that um don't overload them okay remember that you can only handle so much information at once and depending upon our stress level we may not be able to really absorb what's what's coming at us so remember that our education is the purpose of it it's not just so we can check a box that says yes I educated my patient it's so that that patient has more empowerment to be a participant in their own health care so that they know the things that will help them to be more successful in doing with and managing their condition and that's in every situation um psychosocially that kind of ties in with this right we want to listen to what their concerns are and help them find answers to their specific concerns don't assume that just because they have X disease they have this concern maybe their concern is something completely different whatever it is if we can do something to help them with that then um that would be taking care of those psychosocial and holistic care concerns and that is a really important part of good nursing care all right another chance for pause and think so take a minute and describe what a patient's call-in with ulcerative colitis would look like if they were to have a colonoscopy how does the change and structure of the lining of the large intestines impact the processing of nutrients for this patient and what do you think a patient with an acute exacerbation of ulcerative colitis might be complaining of foreign thing for you these two disease processes of Crohn's and ulcerative colitis have many similarities but also some specific differences and so it can be a little confusing sometimes to try to organize your thoughts around these two diseases because they have so many similarities but there's some very specific things about them that are different I urge you to stop and create your own list of the ways these diseases are the same and the ways they are different because some of our nursing care is going to be the same and some of our nursing care is going to be different because the diseases have different presentations and processes so take a little time make your own list to help you differentiate these two conditions and this I have more Paws and think for you I want you to think about the fact that inflammatory bowel disease generally manifests in the late teens to early adulthood and continues to manifest in acute exacerbations throughout the rest of the patient's life imagine you have developed one of these conditions and think about how it would impact your day-to-day life well would that look and feel like in your own life what worries and concerns would you have if tomorrow you were diagnosed with crohn's disease or ulcerative colitis and had these signs and symptoms think about yourself in that patient's position and then how can you apply those thoughts and cares and concerns to the care of the patient that you will take care of that has this medical condition this is the end of the content be sure to review these learning objectives test yourself on this information if you still have gaps in your knowledge review this presentation dig into your textbook watch videos and or seek tutoring until you are sure of your knowledge and understanding of this content thank you