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GI-3: Crohn’s Disease Instructor Guide Page 1 of 11 Detail Clinical Significance/Impact It is Monday morning and you are working on the medical unit. History of present illness: You are caring for John Bennett, a 40-year-old African American male who arrived from the ED department an hour ago to your medical unit. He came into the ED complaining of diarrhea, RLQ abdominal pain (7/10), fatigue, and weight loss. He noticed having frequent, loose stools with and without blood for the past week, but reports having diarrhea for several weeks and “stomach problems” for years. He finally came to the ED due to the blood in stool. His joints ache and has a low-grade fever (37.94°C/ 100.3°F). He is alert and oriented, ambulatory, and noticeably malnourished. Bloody stools are concerning, and the causes should be determined immediately to reduce the risk of further complications. Abdominal cramps and pain indicate an underlying process going on most likely in the gastrointestinal system. Prolonged diarrhea is a concern for dehydration and electrolyte abnormalities. Bloody diarrhea is a concern for anemia or hemorrhage. Low-grade fever may indicate an inflammatory response. Social History (from John) John lives an active lifestyle and performs moderate exercise 5 times a week. He eats a vegan diet and reports good sleep habits. He denies illicit drug use, tobacco, and alcohol use. He takes prescription medications for HTN and DM and takes OTC medications for abdominal pain (NSAIDs). He admits to always having “stomach issues” but it has progressively gotten worse over the last year. John seems to be healthy on paper (exercises, eats healthy does not drink or smoke), but something is wrong if he is reporting blood in the stool. Some OTC medications can cause gastrointestinal issues. A chronic history of gastrointestinal issues
GI-3: Crohn’s Disease Instructor Guide Page 2 of 11 He lives alone. warrants further investigation. Detail Clinical Significance/Impact Medical History: His past medical history includes HTN and DM type 2. Subjective History (from John) John is a 40-year-old African American male who is a full-time businessman. John notices diarrhea with blood about 1 week ago but reports having issues with his stomach for several years. He states he does not “feel well”. He does not know anything that makes the diarrhea better or worse. He denies drug, tobacco, or alcohol use. He takes amlodipine 10 mg daily for HTN and NovoLog (insulin aspart) for DM type 2. The takes OTC NSAIDs for abdominal pain. He reports maternal history of IBD, and his grandmother had colorectal cancer. He became concerned when he noticed blood in his stools. A reported change in overall wellbeing is something to look into. Often times, patients will know when something is “wrong” within their own body. Being familiar with RX medications is good to gather with social history. The last time taken, dose, reason, and name of medications should be discussed for RX medications. OTC NSAIDs can damage gastrointestinal mucosal membranes. Excessive use should be discussed. It should be noted that this has been a chronic problem, but now is an acute problem due to blood in the stool. Concern that his condition will affect his livelihood is understandable and should be addressed. Nursing Assessment: What assessment data is important and why? Vital signs Baseline vital signs should be taken so that you can compare future vital sign measurements. Vital sign changes are often clues to patient deteriorations. Gastrointestinal assessment: Bloody stool is significant and profoundly serious if confirmed. The abdomen should be palpated for tenderness, upon which quadrant is tender as well as the appearance of the abdomen (rounded, distended, flat, firm, obese, etc.). Stool characteristics: stool amount, color, size, and frequency are also important assessment tools. Last BM date and time should be documented. Auscultation of bowel sounds in all four quadrants. Are they hypoactive, hyperactive, normoactive? Is the patient belching, passing flatus, nauseous, or vomiting? Has the patient vomited? If so, what was the color, frequency, amount, and characteristics of the emesis? Pain: John’s pain is located in his RLQ abdomen and is moderate (7/10). The pain correlated with a low-grade fever is concerning. The pain is secondary to an underlying gastrointestinal disease process.
GI-3: Crohn’s Disease Instructor Guide Page 4 of 11 Detail Clinical Significance/Impact Objective Data General Appearance: Lying in bed with frequent repositioning, complaints of abdominal pain and tenderness in RLQ. Temp: 37.94°C (100.3°F) BP: 165/ HR: 130 RR: 21 SP02: 99% on RA RESP: Lungs CTA in all lobes, respirations even but slightly labored and dyspnea on exertion. No retractions noted. CARDIAC: Mucous membranes pale. Capillary refill < 3 seconds. Apical HR tachycardic. Peripheral pulses palpable X4 at +2. No edema. NEURO: Alert & oriented to person/place/time/situation. ℅ Pain (abdominal) rates a 7/10. Calm. PERRLA GI: Abd distended, tender in all quadrants but more so in RLQ. Hyperactive bowel sounds in RLQ and LLQ quadrants. Last BM 20 minutes ago. Liquid, light brown with blood streaks. GU: Voids painlessly and without hesitation. Urine clear yellow. UA negative. DSU + amphetamines Musculoskeletal: Able to move all extremities, equal grips bilaterally, ℅ generalized weakness and joint aching. Integumentary: Skin warm and dry to touch. Dry mucous membranes, cracked lips, dry skin on lower extremities. Scattered bruises noted on legs. No pressure injuries or wounds. What data from John’s assessment and recent clinical history provided is significant? What diagnosis do you suspect? The following symptoms are consistent with Crohns:
- Diarrhea- severe with or without blood
- Low grade fever
- Weight loss
- Severe malabsorption
- Tenderness in RLQ
- Abdominal pain and distention
- Familial tendencies
- Peaks at age 15 - 40 years old
- Nausea/vomiting Systemic symptoms include:
- Fever
- Anemia
- Dehydration
- Electrolyte imbalances
GI-3: Crohn’s Disease Instructor Guide Page 5 of 11 What tests do you expect the physician to order and why? Complete blood count (CBC) Elevated WBC may indicate infection. Low Hemoglobin/Hematocrit may indicate anemia or blood loss. Blood chemistry To evaluate fluid and electrolyte balances due to diarrhea and dehydration and also check blood glucose levels. Serum iron To evaluate iron absorption and determine malnutrition, iron deficiency and fatigue. C-Reactive Protein (CRP) Serum CRP is an acute phase reactant that rises with inflammatory activity Small bowel follow-through with barium solution Small bowel imaging is performed as part of the diagnostic evaluation for patients suspected with CD. Endoscopy Active inflammation can be visualized on endoscopy and chronic changes will be shown on biopsies taken from endoscopy. CT scan abdomen Can highlight bowel wall thickening and mesenteric edema, as well as obstructions, abscesses, and fistulas. Rectal examination Rectal examination may reveal evidence of blood and inflammation. Fecal occult blood sample FOB will confirm the presence of blood Fecal calprotectin or lactoferrin Stool inflammatory markers used to obtain objective testing prior to initiating immunosuppressive therapy C diff stool sample (Clostridioides [formerly Clostridium] difficile toxin) To exclude Cdiff infection given diarrhea symptom. Testing for enteric pathogens Stool cultures To exclude infection due to Salmonella, Shigella, Campylobacter, Yersinia, and Escherichia coli. Testing for enteric pathogens Stool ova and parasites sample To exclude infection due to parasites and Giardia. What orders do you expect and why? Vital signs Q4 hours Hemodynamic stability should be frequently assessed (BP and HR). Nursing physical assessment Q6 hours Performing physical examination such as abdominal distention/tenderness), tracking stool output (frequency, consistency, and presence of visible blood). NPO Patients should be made NPO in order to prep for surgical procedures or endoscopic procedures. Estimate fluid intake and output Provides indication for fluid balance. Daily weights A gain/loss of 1L of fluid is reflected in a body weight change of 1 kg (2.2 lbs.). Intravenous fluid therapy Fluid and electrolyte replacement are necessary to correct and prevent dehydration or electrolyte
GI-3: Crohn’s Disease Instructor Guide Page 7 of 11 immunosuppressive therapy Detail: Diagnostic Test Results Clinical Significance C diff stool sample (Clostridioides [formerly Clostridium] difficile toxin) Negative Excludes enteric pathogen cause for diarrhea. Stool cultures Negative Excludes infection due to Salmonella, Shigella, Campylobacter, Yersinia, and Escherichia coli. Stool ova and parasites sample Negative Excludes infection due to parasites and Giardia. Urine Drug Screen Positive amphetamines Indicates illicit drug use. Places John at greater risk for high blood pressure, stroke and death. Family Education What education is essential to communicate to John right now about his condition? What is important to tell John about illicit drug use? •John lives alone, but you can update family as per his request. The provider can phone a family member to update care. •Begin a food log to keep track of food items that may increase GI symptoms. John reports being a vegan. Vegans usually eat a lot of fruits and vegetables which can perpetuate symptoms of CD. •John’s urine drug screen came back + for amphetamines. The nurse should encourage John to stop using illicit drugs. Amphetamines can cause high blood pressure, stroke, and death. Detail: Case Study Continued Clinical Significance/Detail John is being transferred to the Progressive Care Unit with telemetry monitoring. You prepare to call report to the PCU nurse, Miriam RN. You review John’s most recent labs and presenting symptoms. John reports feeling lightheaded with palpitations. The cardiac monitor shows Sinus tachycardia with occasional PVCs. Normal Saline 0.9% infusing into a peripheral IV at 150 mL/hr. He is alert and oriented but complains of abdominal pain 7/10. Hemodynamic stability needs to be assessed and maintained. The nurse should give Miriam an updated set of vital signs. Feelings of lightheadedness could signal poor cerebral perfusion or low blood pressure. LOC changes should be followed with a BSG fingerstick for diabetic patients Palpitations with PVCs on the cardiac monitor should warrant further investigation.
GI-3: Crohn’s Disease Instructor Guide Page 8 of 11 Considering John’s history, what information is important to include in handover? Practice using the SBAR format. Situation: John is a 40-year old male being admitted for chronic diarrhea with recent bloody stools and worsening symptoms over the past week. He is a full code, does not have any drug allergies, and is being followed by an Internal Medicine team and GI specialty team. Background: John has a PMH of DM type 2 and HTN. He denies tobacco, alcohol, and drug use, but his DSU was + for amphetamines. He arrived at the emergency department and is being admitted to PCU for cardiac and hemodynamic monitoring. His condition is worsening, and a higher level of care is needed at this time to monitor for cardiac arrhythmias, fluid replacement, electrolyte replacement, and further GI testing. Assessment: John is alert and oriented x4, GCS 15. He reports feeling “lightheaded” and has RLQ abdominal pain. His PERRLA is intact. He is on room air with RR between 20-25 bpm/ is dyspneic with activity and on continuous Sp02 reading 99% currently on RA. Current CXR shows no cardiopulmonary diseases or infiltrates. He is on telemetry with sinus tachycardia reading 130 BPM, occasional PVCs and denies chest pain. Troponin lab is negative. Current BP is 165/75 mmHg. Peripheral pulses are palpable and normal x4 +2. He is NPO with last intake 8 hours ago. He complains of moderate abdominal pain 7/10 mostly in the RLQ. No opiates have been given. Abdomen is distended, tender to touch in RLQ quadrant. STAT CT abdomen/pelvis is completed. Last BM was 45 minutes ago. It was large, liquid blood tinged stool. Estimated blood loss 50 mL. Stool samples were collected and sent to lab. Recent blood glucose check is 55 mg/dL. Strict intake and output. Voids in a urinal- clear, yellow. Output 400 mL so far this shift. Intake is 400 mL of IV fluid. Urine samples collected and sent to lab. Moves all extremities with no overt deficits, joint pain in knees and elbows. Stand by assistance with ambulation. Fall risk precautions placed. Speaks English. Lives alone in a house without stairs. Is on SCDs for DVT prevention. Has a 20-gauge peripheral IV catheter in the left AC with NS at 150 mL/hr infusing. Tmax is 100.3 °F, Potassium Chloride 40 mEq is ordered but first dose not given. CBC, CRP, and Chemistry labs have been collected and resulted. SBFT completed. Endoscopy with biopsies completed and sent to pathology. Recommendation: Biopsy results are pending. GI consultation are pending. KCL infusion is due now and can be Y-sited in with the NS 0.9% infusion. Stool samples collected and pending cultures. Fall precautions. Frequent BP monitoring. Continuous cardiac monitoring for ectopic changes. Possible PRBC transfusion if Hgb continues to decline. Continue IV fluid for hemodynamics and electrolyte imbalance. Replete blood glucose and recheck fingersticks Q15 minutes until above 100 mg/dL. Recheck chemistry lab after KCL infusion.
GI-3: Crohn’s Disease Instructor Guide Page 10 of 11 Test your knowledge!
- How is Crohn’s disease different than ulcerative colitis?
- What are the acute complications of Crohns disease? 1. Crohn’s disease may develop inflammation anywhere in the GI tract from the mouth to the anus. Crohn’s Disease commonly affects the small intestine, may affect the entire thickness of the bowel wall, and can appear in patches. Ulcerative colitis affects the large intestine (colon) and the rectum. It can affect either a part of the entire colon, appears in a continuous pattern and the inflammation affects the innermost lining of the intestine. 2. Intrabdominal abscesses, intestinal fistulas, peritonitis, and development of fistulas are the acute complications of Crohn’s disease. Discharge Instructions You are preparing John for discharge. He was in PCU for 3 days and underwent electrolyte replacement therapy, GI workup and cardiac workup. He continuous to have mild abdominal pain and rates his pain 2/10. He is able to ambulate with minimal assistance and will be going home with a home health nurse visiting 3 times a week. He can tolerate his meals with no vomiting or nausea. He is on a regular, low carbohydrate diet. He has a decreased appetite and reports feeling overwhelmed. What instructions will be included in his discharge home? ● Follow up with PCP in 2 weeks ● Follow up with GI specialty clinic in 1 week. ● Take medications as prescribed. Almost all CD medications work by reducing inflammation and the body’s immune response. ● Discuss side effects of medications especially steroids which can increase blood glucose levels. ● Discuss how to monitor blood sugar levels and administer basal and prandial insulin. ● When to call 911 or go to the Emergency department (bloody stool with or without fever, severe abdominal pain, difficulty breathing). ● Crohn’s disease can lead to colon cancer. Get colonoscopy regularly. ● Cut down on foods that make your symptoms worse. Some people have problems with lots of fiber, fruits, and vegetables (John is vegan). ● Quit illicit drug use- amphetamine abuse increases risk of heart attack, stroke, seizures, and high blood pressure. ● Avoid medicines such as ibuprofen (Motrin, Advil) and naproxen (Aleve). Control pain with acetaminophen and do not take ibuprofen or naproxen. ● Increase activity as tolerated. ● Follow low fat, soft textured diet. Drink plenty of fluids. ● Discuss reasons for feelings of overwhelmingness and anxiety.
GI-3: Crohn’s Disease Instructor Guide Page 11 of 11 References Hinkle, J.L., & Cheever, K.H. (2018). Management of patients with intestinal and rectal disorders. Brunner & Suddarth's textbook of medical-surgical nursing (1331). Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins. (2012). The acute abdomen. The Washington Manual of Critical Care. (566). Philadelphia: Wolters Kluwer. Peppercorn, M., Kane, S., Lamont, JT., & Robson, K. (2020). Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults. Uptodate. Philadelphia: Wolters Kluwer
