Crohn’s disease is a type of inflammatory bowel disease that can affect any portion of the gastrointestinal (GI) tract but most commonly affects the small bowel. It causes thickening and scarring, leading to obstruction, fistulas, ulcerations, and abscesses. Remissions and exacerbations characterize Crohn’s disease.
Crohn’s disease originates from an inappropriate autoimmune response in the colon to environmental factors brought on by substances, toxins, infections, or intestinal bacteria.
An intestinal crypt is the site of the first lesion’s infiltration. Ulceration then progresses, starting in the uppermost layer of mucosa and spreading to deeper layers. Granulomas develop in all layers of the intestinal lining as the inflammation worsens. The inflamed portions of the intestines are replaced by scarring when the Crohn’s flare subsides.
Symptoms of Crohn’s disease include the following:
- Fever
- Following meals, a cramp-like and colicky abdominal pain
- Diarrhea (semisolid), which may be bloody or include pus or mucus
- Abdominal distension
- Vomiting, nausea, and anorexia
- Significant weight loss
- Anemia
- Dehydration
- Imbalanced electrolyte levels
- Malnutrition (may be worse than that found in ulcerative colitis)
No specific test can diagnose Crohn’s disease. It is likely diagnosed after ruling out other conditions. The following tests and procedures help confirm the diagnosis:
- Stool tests:
- To rule out infections, culture and sensitivities, ovum and parasites, Clostridium difficile toxins, and leukocyte count.
- Calprotectin can detect active Crohn’s disease and is used for monitoring the disease.
- Blood tests:
- Complete blood count and a metabolic panel to check for anemia (B12 or iron deficiency) or liver disease.
- Special serology (anti-neutrophil cytoplasmic antibodies (ANCA) and anti-saccharomyces cerevisiae antibodies (ASCA)) distinguishes Crohn’s disease from ulcerative colitis.
- C-reactive protein (CRP) or erythrocyte sedimentary rate (ESR) monitors the severity of the inflammation.
- Imaging:
- Computed tomography (CT) scan/magnetic resonance enterography (MRE) of the abdomen and pelvis can detect abscesses and fistulization.
- Video capsule endoscopy (VCE) can visualize the small bowel when regular endoscopy or colonoscopy cannot reach some areas of the GI tract. VCE can only detect mucosal changes.
- Plain x-rays are used when bowel obstruction is suspected.
- Small bowel follow-through assesses the involvement of the terminal ileum and detects fistulas.
- Colonoscopy reveals sites of inflammation.
Currently, there is no known cure nor a single medication that is effective for patients with Crohn’s disease. Reduced inflammation is one of the objectives of medical treatment. Crohn’s disease may be mild to moderate or moderate to severe and treated with a combination of immunomodulators and biologics. By reducing complications, the long-term prognosis improves.
Nursing Process
Symptom management and early detection are key to managing and preventing complications. The nurse can advise of the following:
- Encourage patients to get screenings to check for cancers due to increased risks
- Monitor the patient’s mental health for anxiety and depression, common with Crohn’s disease
- Educate and develop a meal plan with the patient
- Instruct the patient on skincare and stool evacuation to prevent skin breakdown and infection
Although medications are useful, complications may require surgical procedures to manage the symptoms. Remissions and exacerbations are expected; therefore, patients may require lifelong monitoring and routine consultation from a gastroenterologist.
Nursing Care Plans Related to Crohn’s Disease
Imbalanced Nutrition: Less than body requirements
Imbalanced nutrition: less than body requirements associated with Crohn’s disease can be caused by malabsorption of nutrients, restricted intake, anxiety/fear that eating may result in diarrhea, and increased metabolism.
Nursing Diagnosis: Imbalanced Nutrition: Less than body requirements
Related to:
- Malabsorption of nutrients
- Restricted intake as prescribed or recommended
- Anxiety/fear that eating may result in diarrhea
- Increased metabolism
As evidenced by:
- Significant weight loss
- Diminished subcutaneous fat or muscle mass
- Muscle tone loss
- Hyperactive bowel sounds
- Pale oral mucosa
- Food aversion
Expected outcomes:
- Patient will maintain weight within the normal BMI range for height and weight.
- Patient will be able to list at least five preferred food choices.
- Patient will be able to create a meal plan following the recommended diet.
Assessment:
1. Evaluate the patient’s diet, eating habits, and choices.
Identify the patient’s daily dietary consumption, eating patterns (such as the frequency of meals and snacks), and food preferences as a baseline.
2. Weigh the patient.
Patients with Crohn’s disease typically have low body weight and struggle to maintain an ideal body mass index (BMI). The nurse should take the patient’s muscle tone into consideration.
3. Monitor the patient’s intake and output.
The monitoring of intake is used to ensure the patient is getting the right amount of fluid. Monitoring output determines whether stool and urine output balances the patient’s intake.
4. Assess for any signs and symptoms affecting nutrition.
Nausea, vomiting, abdominal pain, and diarrhea can cause an aversion to eating. Monitor for symptoms as well as the emotional effects that prevent proper nutrition.
Interventions:
1. Assist the patient in developing nutritional and weight goals.
Develop a daily food, fluid, and weight chart to track the patient’s dietary intake and progress toward weight-related goals. Talk with the patient about their short and long-term nutritional and weight goals.
2. Offer dietary selections applicable to the patient.
It’s crucial to continue eating a balanced and nutrient-rich diet even during remission. Introduce new foods gradually.
3. Advise the patient to keep a meal diary.
A meal diary can identify trigger foods by listing all food consumed by the patient each day. Once trigger foods are known, the patient can feel more in control by avoiding foods that cause symptoms.
4. Remind foods to avoid during flares.
When the patient experiences a flare-up, high-fiber fruits and vegetables, whole grains, nuts and seeds, fatty and spicy foods, caffeine, and alcohol can worsen symptoms.
5. Emphasize a high-calorie and high-protein diet.
Maintaining a high-calorie and high-protein diet is crucial, especially if loss of appetite and malabsorption are present due to Crohn’s disease. This will help the patient get the necessary nutrition to maintain their weight and energy.
6. Encourage snacks in between meals.
Emphasize eating three meals per day along with an additional two or three snacks. Snacks in between meals will help sustain enough protein, calories, and nutrients for the patient within the day.
7. Administer supplements as prescribed.
Supplements can help replenish the body’s essential vitamins and nutrients since the patient is at risk for malnutrition and malabsorption.
8. Consult with a nutritionist or dietitian.
A dietician can assist the patient in creating a customized diet by providing information on the foods that are recommended or should be avoided.
Diarrhea
Diarrhea associated with Crohn’s disease occurs during flares when the intestinal mucosa becomes inflamed.
Nursing Diagnosis: Diarrhea
Related to:
- Inflammation of the GI tract
- Irritation in the bowel
- Trigger foods that aggravate symptoms
As evidenced by:
- Increased bowel sounds
- Increased peristalsis
- Abdominal cramping
- Increased urgency to defecate
- Loose or watery stools
- Defecation more than three times a day
- Blood or pus in the stool
Expected outcomes:
- Patient will be able to manifest decreased urgency and frequency of stools less than 3 per day.
- Patient will report a more formed and solid stool consistency without the presence of blood.
- Patient will be able to express the alleviation of abdominal cramps.
Assessment:
1. Assess the patient’s bowel movements.
Bowel movement frequency and characteristics may be affected by inflammation. Irritated intestinal mucosa cannot absorb fluids and causes intestinal muscle spasms leading to diarrhea.
2. Inspect the stool color.
Malabsorption is a potential symptom of Crohn’s disease. Therefore, colorful foods like bright green leafy vegetables may only be partially digested and maintain the color in the stool.
3. Check if the stool is bloody or mucoid in appearance.
Blood or mucus in the stool is common during a flare-up due to inflammation or fissures in the colon. The stool may become red or black in color due to the presence of blood. Mucus can have a yellow or white color and a stringy or gel-like appearance.
4. Observe for bowel signs and symptoms.
After using the toilet, people with Crohn’s disease sometimes feel as though they still haven’t completed their bowel movements. Additionally, they could have abdominal cramps and pain during bowel movements. Changes in bowel habits may indicate a flare-up of Crohn’s disease.
Interventions:
1. Maintain hydration.
There is a risk of dehydration in Crohn’s disease due to diarrhea. It is essential to maintain proper hydration. Water, broth, soup, and rehydration solutions can be given orally. If severe, the patient may require inpatient admission with IV fluids.
2. Promote complete bed rest.
Complete bed rest promotes the relaxation of gastric muscles and lowers peristaltic movements.
3. Encourage a clear liquid diet.
To avoid dehydration during the acute phase of diarrhea, avoid oral intake that may trigger peristalsis and gradually increase clear fluid consumption.
4. Encourage a low-fiber and low-residue diet.
Low-fiber and low-residue diets decrease bowel movements, urgency, and frequency of defecation.
5. Control the inflammation.
Administer the following medications as prescribed to control inflammation:
- Aminosalicylates are used for mild inflammation in the gastrointestinal tract.
- Biologic therapies help the immune system to tame the inflammation of the intestines.
- Corticosteroids manage the swelling caused by moderate to severe Crohn’s disease.
- Immunomodulators stop inflammation by controlling the immune system. These may take effect weeks or months after the initial dose.
6. Manage the symptoms.
The following medications can be given as ordered to manage the symptoms:
- Acetaminophen relieves the pain in Crohn’s disease.
- Antibiotics target infections in the GI tract that could result in abscesses or fistulas.
- Loperamide is a short-term anti-diarrheal treatment.
7. Avoid the triggers.
Avoid triggering factors such as food (dairy products, fatty and greasy foods), smoking, and medications (ibuprofen, naproxen, and aspirin) that can aggravate the symptoms.
8. Prepare for possible surgery.
Most patients with Crohn’s disease eventually require surgery. Surgery can remove the scarred portion of the intestine and preserve the healthy sections.
Deficient Knowledge
Deficient knowledge associated with Crohn’s disease can result in a misconception of triggers, symptoms, prevention, and management.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Inadequate knowledge about Crohn’s disease
- Lack of understanding of signs and symptoms of Crohn’s disease
- Misinformation about remission and exacerbation of Crohn’s disease
- Misunderstanding of triggers causing exacerbation of Crohn’s disease
- Unfamiliarity with the treatment plan
As evidenced by:
- Expressed concerns about Crohn’s disease
- Questions about Crohn’s disease
- Ineffective meal plan
- Worsening symptoms leading to exacerbations
- Nonadherence with prevention and management recommendations
Expected outcomes:
- Patient will be able to verbalize knowledge about Crohn’s disease and its signs and symptoms.
- Patient will list three trigger factors that can exacerbate Crohn’s disease.
- Patient will not experience an exacerbation of Crohn’s disease symptoms.
Assessment:
1. Assess the patient’s knowledge of Crohn’s disease.
The nurse must first assess the patient’s understanding of Crohn’s disease and the expectations of treatment before creating a health teaching plan. This will help the nurse to determine what should be focused on during teaching.
2. Assess the factors affecting learning.
The nurse must assess the patient’s perspective of Crohn’s disease and barriers to learning. The nurse can assess the patient’s motivation, support system, socioeconomic status, culture, and other factors that may influence how they learn.
3. Distinguish between myths and facts.
The nurse must assess the patient’s knowledge to determine the patient’s beliefs and distinguish between facts and myths.
4. Review the patient’s meal plans, eating habits, and food preferences.
Review the patient’s current meal plans, eating habits, and food choices. The nurse can then intervene if misunderstandings are apparent.
Interventions:
1. Involve the patient in the development of the care plan.
Patient engagement in the care plan will promote independence, commitment, and adherence to the prevention of exacerbations and management of symptoms of Crohn’s disease.
2. Welcome clarifications and questions.
Patients with Crohn’s disease experience anxiety, embarrassment, fear, and powerlessness. Clarification and questions from patients should be encouraged and welcomed. An approachable manner will create a trusting environment between the nurse and patients.
3. Appreciate the patient’s efforts.
Express appreciation for the patient’s efforts and commitment to their care plan. Adhering to the management of Crohn’s disease requires a lifetime commitment. When patients achieve their health goals, exacerbations and complications can be prevented.
4. Ask the patient to list the preventive measures for Crohn’s disease.
Avoiding triggering factors is the best way to manage symptoms and prevent flare-ups. Evaluate the patient’s understanding by having them list factors that trigger their symptoms.
5. Refer to an IBD specialist.
Inflammatory bowel disease (IBD) specialists deliver professional advice and expertise. They can answer inquiries and guide the patient about Crohn’s disease care.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Mayo Clinic. (2020, October 13). Crohn’s disease – Diagnosis and treatment – Mayo Clinic. Retrieved January 2023, from https://www.mayoclinic.org/diseases-conditions/crohns-disease/diagnosis-treatment/drc-20353309
- National Center for Biotechnology Information. (2022, May 15). Crohn’s disease – StatPearls – NCBI bookshelf. Retrieved January 2023, from https://www.ncbi.nlm.nih.gov/books/NBK436021/
- Roybal, B. (2008, July 15). Diagnosing Crohn’s disease. WebMD. Retrieved January 2023, from https://www.webmd.com/ibd-crohns-disease/crohns-disease/crohns-disease-diagnosis
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
