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Crohn's Disease Nursing Guide

Overview: Crohn’s Disease

This content is intended as a Quick Reference for Crohn’s disease and will cover an overview as well as nursing considerations utilizing the nursing process.

Crohn’s Disease Etiology and Epidemiology

Crohn’s disease (CD) is a chronic inflammatory condition of the intestinal tract. Crohn’s disease may also be referred to as:

  • Regional enteritis
  • Chronic granulomatous ileocolitis
  • Inflammatory bowel disease (IBS)

Key distinctions of Crohn’s disease include:

  • Occurs at any age, but most often in people between 15 and 35 years old
  • Affects males and females equally
  • Shows symptoms ranging from mild to severe
  • Involves inflammation of the GI transmural mucosa
  • Affects any part of the GI tract from mouth to anus
  • Extends from partial to full thickness of the bowel wall

A specific cause for Crohn’s disease remains elusive but is believed to involve many factors. Causative or exacerbating factors include:

  • Barrier defects to the epithelium
    • Increased luminal permeability
    • Sustained inflammation
  • Environmental factors
    • Diet
    • Smoking
    • Drugs
    • Infection
    • Geography
    • Stress
  • Immune system dysfunction
  • Gut microbial disruption
  • Genetic predispositions

Risk factors for Crohn’s disease include:

  • Familial history
  • Ethnicity
  • Tobacco use
  • Childhood antibiotic exposure
  • Risks related to specific medication use:
    • Oral contraceptives
    • Aspirin
    • NSAIDs

Developed countries and urban areas experience higher incidence of Crohn’s disease. Although previously prevailing in Western nations, many Eastern nations such as Japan, China, and India are experiencing increasing incidence (DynaMed, n.d.).

The regions with the highest incidence of Crohn’s disease per 100,000 individuals are:

  • Europe with 322 cases
  • Canada with 319 cases
  • U.S. with 214 cases

Nearly one million Americans may be affected by Crohn’s (Crohn’s and Colitis.com, 2020).

Crohn’s Disease Diagnosis

The diagnosis of Crohn’s disease is primarily clinical. Confirmation is achieved through endoscopic or imaging studies with associated histologic exam. 

Typical symptoms reported include:

  • Chronic or bloody diarrhea
  • Abdominal pain and distention
  • Right lower quadrant tenderness
  • Fatigue

Laboratory findings suggestive of inflammation and disease process include:

  • Serum blood urea nitrogen
  • Potassium
  • Serum red blood cells
  • Hemoglobin
  • Hematocrit
  • Platelets
  • Serum proteins and albumin
  • Serum C-reactive protein
  • Sedimentation rate
  • Stool analysis

Endoscopic study findings may reveal:

  • Asymmetric transmural inflammation
  • Longitudinal and serpiginous ulcerations
  • Terminal ilium and colon involvement
  • Cobblestone appearance
  • Deep ulcerations and fissures

Histology findings may reveal:

  • Granulomatous inflammation
  • Transmural inflammation
  • Fissures or aphthous ulcerations

Other diagnostic studies considered include:

During diagnostic consideration, infectious sources and other causes of colitis must be ruled out.

Crohn’s Disease Management

General management for individuals with Crohn’s disease includes:

  • Clinical correction of deficiencies of:
    • Nutrition
    • Electrolyte
    • Vitamins
  • Promotion of smoking cessation
  • Behavioral coaching and cognitive therapy to reduce or eliminate:
    • Stress
    • Depression
    • Anxiety
  • Promotion of medication compliance
  • Dietary modification
  • Up to date vaccinations
  • Risk screening for opportunistic conditions
  • Monitoring bone density
  • Routine monitoring for neoplasia’s

Severity and risk of disease typically correlates to symptomology, personal risk factors, Simple Endoscopic Score for Crohn’s Disease (SES-CD), and the Crohn Disease Activity Index (CDAI) score, which measures Crohn’s activity based on a seven-day symptom diary, clinical examination, and hematocrit value. CDAI scoring grades of severity are:

  • Mild to moderate disease (150 to 220)
  • Moderate to severe disease (220 to 450)
  • Severe to fulminant disease (> than 450)

In cases of severe disease or the presence of a perirectal abscess or fistula, a surgical consultation is suggested. Greater than 50% of patients with Crohn disease require surgery at some point (DynaMed, n.d.). Medically stubborn Crohn’s disease and enteric complications are indications for surgical intervention. The goal of surgery should include preserving bowel length and avoiding short bowel syndrome or intestinal failure. 

Medications indicated for remission or induction may include:

  • Mild to moderate disease:
    • Budesonide (Pulmicort®)
    • Prednisone (Deltasone®)
    • Sulfasalazine (Azulfidine®)
    • Antidiarrheals
  • Moderate to severe disease:
    • Corticosteroids
    • Azathioprine (Imuran®, Azasan®)
    • Mercaptopurine (Purinethol®, Purixan®)
    • Methotrexate (Otrexup™, Rasuvo®)
    • Infliximab (Remicade®)
    • Adalimumab (Humira®)
    • Certolizumab (Cimzia®)
    • Vedolizumab (Entyvio®)
    • Natalizumab (Tysabri®)
    • Ustekinumab (Stelara®)
  • Severe to fulminant disease:
    • IV corticosteroids
    • Infliximab (Remicade®)
    • Adalimumab (Humira®)
    • Certolizumab (Cimzia®)

Crohn’s Disease Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for Crohn’s disease are listed below.

Crohn’s Disease Nursing Care Plan

Assessment

During the nursing assessment, emphasis should be placed on the person’s:

  • Abdomen
  • Fluid and electrolyte status

Abdominal visual and palpation assessment should determine the current state of:

  • Contour
  • Distention
  • Firmness
  • Rigidity

Additional parameters that should be assessed include:

  • Auscultated bowel sounds for pitch and frequency
  • Stool frequency, characteristics, and amount
  • Unintentional weight loss
  • Symptoms of dehydration, bleeding, and infection including:
    • Frequent bloody diarrhea
    • Poor skin turgor
    • Dry mucous membranes
    • Sunken eyes

Crohn’s Disease Nursing Diagnosis/Risk For

  • Imbalanced nutrition, less than body requirements related to impaired absorption as evidenced by:
    • Alterations in mental state
    • Complaints of weakness
    • Tachycardia or weak pulse
    • Weight loss
    • Concentrated urine
    • Decreased urine output
    • Dry mucous membranes
    • Sunken eyeballs
    • Decreased skin turgor
    • Decreased blood pressure
    • Postural hypotension
  • Diarrhea related to bowel inflammation as evidenced by:
    • Increased bowel sounds/peristalsis
    • Hyperactive bowel sounds
    • Frequent watery stools
    • Changes in stool color
    • Abdominal pain
    • Urgency
    • Cramping
  • Acute pain related to GI tract inflammation as evidenced by:
    • Reports of pain
    • Distraction
    • Guarding
    • Autonomic responses
  • Deficit in knowledge of symptom prevention and condition management as evidenced by:
    • Request for information
    • Verbalization of problems
    • Presence of preventable complications
  • Anxiety related to stress as evidenced by:
    • Increased tension
    • Apprehension
    • Expression of concern regarding injury and loss of normal function

Crohn’s Disease Interventions

  • Manage pain control.
  • Administer IV fluids.
  • Observe for:
    • Fever
    • Tachycardia
    • Lethargy
    • Leukocytosis
    • Decreased serum protein
    • Anxiety and prostration
  • Improve bowel management through:
    • Enemas
    • Suppositories
    • Bowel decompression
    • Observing and recording stool frequency
  • Perform guaiac occult blood stool testing.
  • Assess for baseline lab values.
  • Assess for contraindications, action, and side effects of medications.
  • Promote rest, comfort, and safety.

Expected Outcomes

  • Demonstrates improved hydration and electrolyte balance
  • Regains stable bowel function
  • Maintains optimal nutritional status
  • Demonstrates positive coping skills
  • Reports decreased pain
  • Reports decreased anxiety

Individual/Caregiver Education

Education should encourage a return to previous levels of independence and mobility (Peppercorn & Kane, 2021).

  • General information about:
    • Diagnosis and treatments
    • Diarrhea management
    • Signs of potential complications
    • Proper diet and avoidance of foods that trigger symptoms
  • Smoking cessation
  • Medications they are prescribed and teach them to:
    • Take their medicine as directed
    • Avoid OTC medications such as salicylates and NSAIDs
  • Call the provider if:
    • Your pain or symptoms worsen
    • You have questions or concerns about your condition or care
  • Recommended follow-up with healthcare provider

Pharmacology of Inflammatory Bowel Disease CE Course

Inflammatory bowel disease (IBD) is a chronic disorder involving an abnormal immune reaction to specific components of the gastrointestinal (GI) tract. The two primary forms of IBD are Crohn’s disease (CD) and ulcerative colitis (UC).
0.5 Contact Hours

Gastroenterology Nursing: Standards of Care CE Course

The goal of this course is to provide nurses with knowledge related to the standards of care specific to gastroenterology nursing.
1.0 Contact Hours

Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2024

Writer

Edward Bartels, RN, BSN, MICN

Ed has over 30 years of clinical and teaching experience, and his areas of expertise are emergency and critical care, skilled nursing, behavioral health, occupational health, and safety, and home care. Ed served in several senior nursing leadership roles including: Emergency Services Director, Physician Practices Director, and Administrative Director of Nursing at the executive level. Ed is certified in LEAN efficiency fundamentals and tactics, which he has successfully deployed over the years in multiple settings resulting in cost savings, improved quality, and patient safety. Ed is a certified clinical nursing instructor in North Carolina. He earned his Diploma in Nursing from St. Vincent's School of Nursing in Staten Island, New York, in 1990 and Bachelor of Science in Nursing from the University of North Carolina, Greensboro in 2006. Ed is retired from the U.S. Coast Guard with 34 years.

Disclosure: Edward Bartels, RN, BSN, MICN has no relevant financial or non-financial relationship(s) with ineligible companies to disclose.

Resources

References

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