Tuesday, March 4, 2008

Crohn's Disease

Crohn’s Disease is a life-long, debilitating form of Inflammatory Bowel Disease (IBD) that can cause many complications. Like most autoimmune diseases, these complications and unpleasant symptoms may be unpredictable and difficult to control, which can cause a sense of powerlessness and lead to depression. A. Lei Correa



Because Crohn’s Disease affects mental as well as physical health, the nurse promotes wellness by thoroughly educating the patient on the disease process of Crohn’s Disease, nutrition and pharmacological management, and uses specialty skills to provide care and emotional support using a holistic approach.
The most common and initial indicators of Crohn’s Disease are fatigue, diarrhea, abdominal pain, gastrointestinal bleeding, and weight loss. These symptoms may also be present in patients with other forms of IBD, therefore thorough assessments and specific diagnostic testing is extremely important to avoid misdiagnosis. Since Crohn’s Disease is most often autoimmune (the body tissues attacking itself), patients may experience a multitude of other complications and exacerbations including arthritis, osteoporosis, anemia, malnourishment, fistulas, renal and hepatic disorders, vision problems and sensitive skin, just to name a few. Rayhorn and Rayhorn (2002) explain that this disease does not always effect just the bowel, “Internal organs, the eyes, blood, skin, and the musculoskeletal system are all potential targets for the devastating effects of this disease, known collectively as extraintestinal manifestations, or EMs”.
Gaining knowledge of Crohn’s Disease is the first step to remission. Patient education is one of the most important aspects of nursing; what is told to the patient about the disease and what to expect, and how well that information is understood will determine the patients’ self-perception, self-care, and choices in regards to disease management. The nurse educates the patient according to their learning ability, and (with permission of the patient to protect health information) educates family members who may be taking on the role of care-giver. An individual experiencing the unpleasant signs and symptoms of Crohn’s Disease is not necessarily eager to learn, and the nurse prepares for this by providing resources, pamphlets, and other reading material so it is convenient for the patient when they are ready to soak in more information. The age of the patient is also a factor. The patient should be informed of support groups in their area and can also be referred to the Crohn’s and Colitis Foundation of America (http://www.ccfa.org) (Rayhorn, 2003). Providing information with pictures will of course make it easier to visualize that which cannot be seen. The severity of the patient’s condition should be clearly understood, as well as warnings of potential problems.
Nutrient deficiency is a complication that should constantly be monitored because it can occur during flare-ups or while the patient is in remission. A significant amount of calories and carbohydrates for energy, and adequate hydration every day is absolutely vital in maintaining optimal health. Nutrient absorption is decreased in patients with Crohn’s Disease because the intestines do not function as well as in a healthy individual. Patients will become aware of the type of foods that will irritate their bowels and which foods are well tolerated. According to a webpage created by the New York Methodist Hospital, foods that have irritation potential include raw vegetables, alcohol, simple sugars, and caffeine because they are associated with inflammation. Other inflammatory foods are fruits with a lot of sugar such as grapes, watermelon or pineapple (2002). Sometimes medications can be the culprit for malnutrition. For example, Prednisone is a common drug for Crohn’s Disease patients, but it can cause osteoporosis, and therefore is treated with calcium and Vitamin D supplementation. Iron deficiency is also common, but oral iron supplementation is often not tolerated in patients with Crohn’s Disease and would then iron delivered intravenously or by injection. In extreme cases of the disease, enteral feeding can induce remission, as well as TPN in which bowel rest may be required (Jeejeebhoy, 2002).
Such a debilitating disease can cause the patient to feel powerless and depressed. Being a counselor and an active listener can make a drastic difference in the patient’s self-perception and quality of life. Specialty nurses who have become active participants in gastroenterology have made a huge difference in patients with Crohn’s Disease. Specialty nurses can improve disease management on a whole different level than just a practitioner. There is a motivation for change in the healthcare system as we advance and make new discoveries. Kamm & Norton (2002) agree that, “Changes may also come from a real desire to move the focus of healthcare away from an insensitive technological approach to one based on holistic care” (p. 331). Patients can be taught how to self-medicate when they are having a flare-up; this means utilizing home remedies and adhering to pharmacological measures as instructed. This will increase autonomy and decrease clinic visits. Kamm and Norton (2002) also provide evidence showing, “in a controlled study this reduced clinic visits by 30%, decreased the delay between symptom onset and treatment from 4 days to under 24 hours, increased the quality of life scores, and decreased costs” (p. 334). Patients with Crohn’s disease need a high level of nursing care; one that combines holistic as well as technical approaches.
Crohn’s Disease does not follow a predicted cycle of flare-ups and remissions; rather it can be rollercoaster of unexpected events. Patients are experiencing a total loss of control over their bodies and overall health. Uncontrollable bowels and discomfort can be extremely embarrassing and disheartening. The exacerbation of other problems caused by this disease, adds to this disparity. The pain and discomfort the patient experiences can be managed more effectively through proper education, pharmacological/nutritional management, and emotional support. This is an opportunity for nurses to take advantage of their specialty skills while providing a holistic type of care.






































References

Jeejeebhoy, N. K. (2002). Clinical nutrition: 6. Management of nutritional problems of patients with crohn's disease. Canadian Medical Association Journal, 166(7),
913–918. Retrieved January 29, 2007, from PubMed Central Database.
Norton, C, & Kamm, M.A. (2002). Specialist Nurse in Gastroenterology. Journal of the royal society of Medicine. 95(7): 331-335. Retrieved April 22, 2007, from PubMed Central Database.
Rayhorn, N. (2003). Inflammatory Bowel Disease. Nursing, 33(11), 54. Retrieved November 07, 2007, from Proquest Database.
Rayhorn, N., & Rayhorn, D.J. (2002). An in-depth look at inflammatory bowel disease. Nursing, 32(7), 26-36. Retrieved November 07, 2007, from Proquest Database.
What is the Role of Diet in Crohn’s Disease? (2001). New York Methodist Hospital. Retrieved February 05, 2007, from http://www.nym.org/healthinfo/docs/103/doc103diet.html




Intervention 1: Nutrition therapy along with pharmacological Management
Disadvantage 1: Debilitating side effects from necessary drugs.
The immunosuppressive drugs that are necessary for disease remission are life-long, and produce very unpleasant side effects that although the patient is in a state of “remission”, day-to-day life is still difficult. Remicaid (infliximab) is a drug used for the treatment of rheumatoid arthritis, and is used in Crohn’s patients to keep symptoms at bay, maintain remission, and treat rheumatoid arthritis that gets exacerbated by the disease. However, this drug can cause abdominal pain, nausea, vomiting, fatigue, headache, infusion reactions, and drug-induced lupus (Deglin & Vallerand, 2007, p.642). Azathioprine (Imuran) is another immunosuppressant that can cause the same kind of G.I. upset, along with thrombocytopenia, anemia, and hair loss (Deglin & Vallerand, 2007, p. 180). Methotrexate (Rheumatrex) is a heavy duty immunosuppressant that is actually used on cancer patients, as well as severe Crohn’s Disease. This drug can cause anorexia, G.I. upset, nephropathy, anemia, rashes, malaise, hair loss, and hepatotoxicity (Deglin & Vallerand, 2007, p. 772). In addition to any of the mentioned drugs, prednisone is usually used in addition to a chosen drug therapy. This drug can cause depression, muscle wasting, G.I. upset, peptic ulceration, abnormal fat deposits, and cushingoid appearance (moon face, buffalo hump) (Deglin & Vallerand, 2007, p. 323-327). Unfortunately, the Crohn’s patient will likely go through different therapies such as these before finding one that is effective and somewhat tolerable. Physicians use an algorithm of which drugs to try first, and depending on the reactions, what the next step would be (Knutson, Greenberg, & Cronau, 2003).

Deglin, J, & Vallerand, A. (2007). Davis’s drug guide for nurses. (10th ed.). Philadelphia: F.A. Davis Company.

Knutson, D, Greenberg, G, Cronau, H. (2003). Management of crohn’s disease – a practical approach. American Family Physician. 68(4), 707-14, 717-8, 595-7. (CINAHL Accession No. 2004070944)

Disadvantage 2: Unknown underlying G.I. problems preventing remission.
Some patients with Crohn’s Disease may also have other things going on with their digestive tract even before the onset of their disease. They could have just IBS, and therefore diet will be more selective. There is also a strong possibility of the patient having Celiac Disease (glutten-sensitive enteropathy), which would mean even more diet restrictions to take into consideration. Once Crohn’s Disease has been diagnosed, it seems imperative to also screen for Celiac Disease. It is quite common, affecting 1 in 100 to 1 in 300 (Edwards, 2006). Celiac, like Crohn’s, can cause similar symptoms of G.I. upset, so misdiagnoses can be more common than preceived. If a Crohn’s patient adheres to their drug regimen, and still not feeling well, it is difficult to assess if it is just the wrong drug regimen for them or if they actually have Celiac Disease as well and the glutten ingestion is inhibiting remission.

Edwards, M. (2006). Coeliac Disease – an update. Practice Nurse. 31(7), 42-4. (CINAHL Accession No. 2009176315)


Intervention 2: Specialty nursing
Disadvantage 1: Shortage of specialty nurses.
The field of gastroenterology indeed needs more specialty nurses. However, there is a shortage of nurses in general all around the world, as well as in specialties. It is a huge intervention to attempt to recruit individuals into the nursing field, let alone encouraging nurses to further specialize. The ICN conducted a survery and found some reasons why the number of nurses are declining. Nurses are already dealing with high nurse to patient ratios, long working hours, inadequate compensation, and reduced time with patients due to overburdened administration (“Where”, 2007). The ICN has called on the WHO, but the nursing shortage continues to rise.

(2007). Where are all the nurses. Australian Nursing Journal. 15(1), 19. (CINAHL Accession No. 2009645084).

Disadvantage 2: Not enough. Need communication - team medicine.
Crohn’s Disease can cause extra-intestinal manifestations (rheumatoid arthritis, anemia, osteoporosis, ulcers, malnourishment, renal and hepatic disease, etc.). These other diseases, mean other specializing physicians. One patient with Crohn’s Disease, may be seeing a rheumatologist, gastroenterologist, nephrologist, pharmacist, and dietician, as well as their general physician. If these physicians are not actively and accurately communicating, the patient’s health may be in jeopardy. It is suggested that stress can exacerbate Crohn’s symptoms, and Crohn’s symptoms can exacerbate stress. The need to see so many different doctors can be quite stressful, and may even be detrimental if it is not an efficient team. The patient’s stress level, and means of seeing the necessary specialties are not taken into account as much as it should.

Smith G,D, Watson, R, Roger, D, McRorie, E, Hurst, N, Luman, W, & Palmer K,R. (2002). Impact of a nurse-led counselling service on quality of life in patients with inflammatory bowel disease. Journal of Advanced Nursing. 38(2): 152-60. (CINAHL Accession No. 2002073703).span>

2 comments:

John Miller said...

Although you may have implied it, can you can add a more clearer statement about socioeconomic issues as disadvantages?

Unknown said...

Sometimes drugs are proved more harmful than the disease itself. Methotrexate drug can be cause of serious body ailments such as nephropathy, anemia, rashes, malaise and hair loss diseases etc if not taken carefully as per the advice of physicians. Thanks for publishing such great article. Wish you best luck and successful blogging carrier.