- Email: [email protected]
Care of Patients with Inflammatory Bowel Disease
SPECIAL NEEDS P O P U L AT I O N S
Care of Patients with Inflammatory Bowel Disease 1.3 KRISTINA AMPLO, MSN, RN, CPN; DIANE NELSON, MSN, RN, CPN
Complete this CE activity online at aorn.org/CE
ccording to the Crohn’s & Colitis Foundation of America, approximately 1.4 million Americans are living with inflammatory bowel disease (IBD), and about 30,000 new cases are diagnosed each year.1 Inflammatory bowel disease consists of two chronic diseases: Crohn’s disease and ulcerative colitis.1 Of patients diagnosed with IBD, about half are diagnosed with Crohn’s disease and half with ulcerative colitis, and men and women are equally affected.2 Inflammatory bowel disease often is diagnosed in adolescents and young adults between the ages of 15 and 35. The cause of IBD is unknown, and there is no medical cure at this time. Patients with IBD experience flare-ups without warning, which can be emotionally and financially draining. The annual cost to care for the patient with IBD in the United States—including surgery, medications, hospitalizations, and loss of labor— is between $1.8 and $2.6 billion per year.1 Perioperative nurses care for diverse patients, some of whom may have a primary or secondary diagnosis of IBD.
A
CLINICAL SIGNS
AND
SYMPTOMS
There is a difference between Crohn’s disease and ulcerative colitis, although some individuals have a combination of indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 915-916 and then completing the answer sheet and learner evaluation on pages 917-918. The contact hours for this article expire December 31, 2012.
© AORN, Inc, 2009
both. Crohn’s disease can involve any part of the digestive tract from the mouth to the anus. A skin tag on the anus is a cardinal sign of Crohn’s disease. The disease process affects all layers of the intestine and involves both the small and large intestines. Causes of Crohn’s disease are unknown, but research indicates that IBD may be inherited, caused by problems with the immune system, or triggered by the environment.2 Crohn’s disease is classified as incurable but can be managed through diet, medications, and surgery as needed.1 Comparatively, a surgical procedure called a Inflammatory bowel colectomy, which is the removal of the colon, can disease consists greatly reduce the symptoms of ulcerative colitis. of two chronic Ulcerative colitis involves only the inner lining of the diseases: Crohn’s large intestines or colon. Symptoms of IBD are disease and similar in each disease, but often much more ulcerative colitis. severe in Crohn’s disease. Symptoms range from mild to severe and some are even life-threatening, so it is very important to listen to and observe the patient with IBD for any of these symptoms: • persistent diarrhea; • abdominal pain or cramps; • blood passing through the rectum; • fever; • weight loss; • joint, skin, or eye irritations; or • delayed growth and retarded sexual growth in children.1 The extent of the disease drastically
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The patient with inflammatory bowel disease needs to be counseled preoperatively on the risks and benefits of surgery as well as what he or she should expect postoperatively; the health care team should especially note possible complications, pain management, and long-term outcomes.
effects the clinical signs and symptoms that a patient experiences. Because Crohn’s disease and ulcerative colitis affect the lining of the bowel, nutritional status is almost always affected by malabsorption during active disease. For this reason, the patient may experience weight loss, anemia, hypoalbuminemia, and deficiencies of vitamin A, vitamin B12, vitamin D, iron, selenium, folic acid, and zinc.3,4 During patient assessment, the perioperative nurse should record data that includes • the number of bowel movements the patient has each day and their consistency, • low hemoglobin count, • increased erythrocyte sedimentation rate, • the presence of leukocytosis or tachycardia and alterations in temperature, • low albumin level, and • weight loss greater than 10% within the previous six months.5-7 The patient may experience mental status changes, hypotension, dehydration, and electrolyte abnormalities if he or she is experiencing systemic toxicity.6 Therefore, using a blood metabolic profile is helpful when assessing dehydration status and fluid replacement.4 Patients who are diagnosed with Crohn’s disease may also develop fistulas, which are passages or tunnels from one cavity to another that can lead to abscesses. Symptoms that a
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patient may present with are dependent on the location of the fistula. Enteroenteric fistulas are the most common internal fistulas; they are relatively asymptomatic but may present as palpable masses.3,6 Enterovaginal; enterovesicular (ie, into the urinary bladder); and entercutaneous fistulas also may be present.3,6
PERIOPERATIVE CARE Approximately 70% to 90% of patients with Crohn’s disease will require at least one surgery in their lifetime,3,5 and approximately 25% of patients with ulcerative colitis will require a colectomy in their lifetime.7 Failure to initiate high-dose corticosteroid therapy for severe colitis positively correlates with an increased risk of requiring a colectomy to control the disease.7 TREATMENT TEAM. A collaborative treatment team should be established to ensure efficient and quality care for the patient with IBD. Members of the team might include • an RN; • a gastroenterologist; • a nutritionist; • a colorectal surgeon; • an interventional radiologist (ie, if the patient experiences intra-abdominal abscesses);6 • pain management personnel to help with both chronic and acute pain issues; • a physical therapist to encourage movement, prevent sedentary complications, and assist with physical limitations; • a wound/ostomy nurse; and • a psychologist because depression is reported in 33% to 100% of patients with Crohn’s disease.3 PREOPERATIVE CARE. As with all preoperative care, the patient needs to be counseled on the risks and benefits of the procedure and what he or she should expect postoperatively. The health care team should take special note to share possible complications, pain management, and the long-term outcomes of the procedure. The health care team needs to research and document the extent of the disease, paying special consideration to laboratory test values, imaging results, and the medication course.3 Because of the nature of IBD, the nutritional needs of the patient must be addressed. If surgery is not emergent, enteral or parenteral
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Perioperative Nursing Implications for Patients Undergoing Surgery for Inflammatory Bowel Disease Preoperative care • Ensure that the consent has been signed. • Review the risks and benefits of the procedure with the patient and answer questions as needed. • Arrange pain management for preoperative and postoperative care. • Ensure that a bowel prep has been administered the night before surgery to ensure the patient’s bowels are completely cleansed. • Review the patient’s laboratory test results, including complete blood count; complete metabolic screen; albumin level; and levels of vitamins A, B12, and D and iron, selenium, folic acid, and zinc. • Review radiological test results including upper gastrointestinal and small bowel series, colonoscopy, computed tomography scans, and magnetic resonance imaging, as needed. • Ensure that antibiotics are administered within one hour before the surgical incision is made and are discontinued within 24 hours after surgery end time unless further antibiotic therapy is indicated. • Ensure that a wound/ostomy nurse consultation for site verification has been arranged. • Ensure that enteral or parenteral nutrition is administered before surgery to maintain nutritional status and correct any nutritional deficiency. • Ensure that psychological counseling has been arranged.1 Intraoperative care • Ensure appropriate instrumentation and positioning equipment is available for the scheduled procedure. • Consider the use of compression devices for thrombus prophylaxis. • Ensure IV antibiotics are administered in a timely fashion as needed. • Implement appropriate interventions to maintain body temperature. • Observe vital signs closely. • Insert an indwelling urinary catheter as needed. • Observe for any adverse effect of anesthesia. • Ensure that pain and antiemetic medications are administered before the patient leaves the OR. Postoperative care • Monitor vital signs to watch for signs and symptoms of sepsis. • Monitor intake and output and laboratory test results for electrolyte imbalance. • Observe for signs and symptoms of bowel obstruction such as vomiting, pain, and fever. • Manage pain with patient-controlled analgesia and narcotics. • Administer parenteral nutrition to maintain nutritional status. • Administer aminosalicylates, antibiotics, corticosteroids, thiopurines, and probiotics to prevent recurrence.1 • Ensure that psychological counseling has been arranged to help the patient deal with depression as needed. 1. Gardiner KR, Dasari BV. Operative management of small bowel Crohn’s disease. Surg Clin North Am. 2007;87(3):587-610.
nutrition should be given to the patient to achieve optimal postoperative outcomes.3,5 The nurse should expect to prep the bowel for surgery and administer an antibiotic within one hour before the surgical incision is made; antibiotics should be discontinued within 24 hours after surgery end time unless further
antibiotic therapy is indicated. To prevent bleeding, low-molecular-weight heparin should be discontinued if it is being administered before surgery .3 A wound/ostomy nurse should be consulted to assist in locating a site for a stoma if it is possible that an ostomy will be needed. The nurse aornjournal.org
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Web Sites Related to Inflammatory Bowel Disease Organization Crohn’s & Colitis Foundation of America About.com: inflammatory bowel disease KidsHealth® from Nemours Medline Plus: Crohn’s disease Ulcerative colitis Mayo Clinic: Crohn’s Disease Ulcerative Colitis
Web site* http://www.ccfa.org http://ibdcrohns.about.com http://kidshealth.org/parent/medical/digestive/ibd.html http://www.nlm.nih.gov/medlineplus/crohnsdisease.html http://www.nlm.nih.gov/medlineplus/ulcerativecolitis.html http://www.mayoclinic.com/health/crohns-disease/DS00104 http://www.mayoclinic.com/health/ulcerative-colitis/DS00598
*Access verified September 14, 2009.
should consider several factors before recommending a site for the ostomy, including abdominal muscles and fat distribution, old scars, bony prominences, dominant hand usage and dexterity, and possible intraoperative incision location.3 INTRAOPERATIVE CARE. The colorectal surgeon must assess many factors when deciding what surgical technique to use for the patient with IBD. There are several surgical options for patients with ulcerative colitis that the surgeon may choose to achieve the best outcome. The goal of surgical intervention for ulcerative colitis is removal of the affected bowel to help the patient achieve a higher quality of life. The most common procedures that surgeons perform on this type of patient are proctocolection with an ileostomy and restorative proctocolectomy with an ileal pouch-anal anastomosis.7 The surgical team must confirm the intended procedure and ensure availability of all instruments and equipment. Usually, the patient will undergo the proctocolectomy laparoscopically, which results in a shorter hospital stay, less postoperative pain, and an improved cosmetic result. A temporary loop ileostomy is performed most often in patients who have a proctocolectomy to allow time for the colon to heal. The colorectal surgeon will perform a take-down (ie, remove the temporary loop ileostomy) and create a pouch, usually in the shape of a “J.”7 The surgical outcome for a patient with Crohn’s disease is quite different than for a patient with ulcerative colitis. The goal of sur-
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gically removing the affected bowel can be achieved for the short term, but Crohn’s disease can affect the digestive tract from the mouth to the anus. Removing the diseased section of the small or large intestine does not guarantee that a new section of the bowel will not become inflamed. Laparoscopic surgery is the technique of choice, but it cannot always be used because large amounts of bowel sometimes need to be resected. If an open laparotomy is needed, the patient can be placed in the modified lithotomy or supine position. The modified lithotomy position is favored because any portion of the bowel may need to be resected. A midline incision is often favored because it allows easy access to the small intestine and ileocecal area without compromising possible stoma locations. Also, this incision can be reopened easily if future surgeries are needed. Careful examination of the entire bowel is often necessary because frequently more bowel is affected by the disease than preoperative radiological imaging and colonoscopy have indicated.3 Patients with Crohn’s disease often develop many strictures within the bowel. Strictureplasty can be performed on patients who have symptomatic strictures and have undergone extensive bowel resections in the past or within the previous year. This procedure relieves the obstructive symptoms caused by the strictures while conserving bowel length.3 No matter which technique is used to remove the affected bowel, great care must be taken not to perforate the bowel by sharp or
Special Needs Populations
blunt dissection. Prophylactic treatment for a thrombus also should be considered with the use of compression devices in both the intraoperative and postoperative setting.3 POSTOPERATIVE CARE. There are critical considerations for postoperative care of the patient with IBD. The nurse should pay close attention to the patient’s vital signs to check for signs of infection or pain, including fever or increased heart rate or blood pressure. Strict intake and output should be maintained to ensure adequate electrolyte balance and hydration. Nutritional support also is maintained. With surgical intervention, there is a chance of bowel obstruction so the postoperative nurse needs to assess the patient for vomiting, abdominal pain, or fever, and if any of these symptoms are noted, they should be reported to the surgeon.3 Pain management is of the utmost importance in postoperative care of the patient with IBD. A patient-controlled analgesia device with a narcotic is used so that the patient can control his or her postoperative pain, which is usually significant in this group of patients. Other considerations for the postoperative care of a patient with IBD are nutrition and emotional status. Nutrition is maintained through parenteral access until the patient is able to tolerate food and liquids by mouth, which may be as soon as one day or as long as several weeks after surgery.3 Many patients with IBD are depressed and need support and counseling from a psychological standpoint.3,8 The nurse should order a postoperative psychiatric consultation. It has been reported that a relatively high incidence of postoperative morbidity and septic conditions occur in patients with Crohn’s disease. Many factors can lead to this, but some that might be present are malabsorption leading to poor nutrition, abdominal abscess before surgery, obstruction, systemic infection, and chronic corticosteroid therapy. To reduce postoperative intra-abdominal septic complications leading to morbidity, the creation of a temporary stoma is indicated.5 The PACU and unit RNs should monitor for sepsis by assessing for fever, hypotension, and poor capillary refill. A patient with ulcerative colitis may have
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The postanesthesia care unit nurse should monitor the patient with ulcerative colitis who has had an internal pouch created for signs of pouchitis, which include diarrhea, abdominal cramps, fever, malaise, and loss of anorectal function.
had an internal pouch created that needs to be monitored for infection. A patient may get pouchitis at any time after the pouch is created, and this is the most frequent complication of a colectomy for ulcerative colitis.6,7 Signs of pouchitis include diarrhea, abdominal cramps, fever, malaise, and loss of anorectal function.6 To treat pouchitis, ciprofloxacin or metronidazole can be used either alone or in combination. Approximately 60% of those who get pouchitis will experience recurrent episodes.7
CARING
FOR THE
PATIENT
WITH
IBD
Generally, the patient with IBD has numerous physical and emotional needs. Caring for the patient with IBD can be emotionally and physically draining to nursing personnel as well. Many patients feel restricted from participating in everyday life because of the urgency they feel when needing to have a bowel movement. It is important to have the patient meet with the treatment team as soon as a diagnosis has been made and with each hospitalization to create a plan of care that is acceptable and agreed upon by all. It is the nurse’s goal to encourage the patient to partake in activities of daily living when he or she is experiencing a flare-up, as well as resume regular activities while healthy and asymptomatic. The nurse also should encourage patients to decrease the chances of future aornjournal.org
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flare-ups by following a low-residue diet, decreasing stress, and not smoking.5 The main goal of treatment is to improve the patient’s quality of life. With the increasing incidence of IBD in the United States, it is imperative that the nurse be aware of the needs of these patients and understand the signs and symptoms of IBD.
REFERENCES 1. About Crohn’s and ulcerative colitis. Crohn’s & Colitis Foundation of America. http://www.ccfa.org /about/press/ibdfacts. Accessed September 11, 2009. 2. About Crohn’s disease. Crohn’s & Colitis Foundation of America. http://www.ccfa.org/info/about /crohns. Accessed September 11, 2009. 3. Gardiner KR, Dasari BV. Operative management of small bowel Crohn’s disease. Surg Clin North Am. 2007;87(3):587-610. 4. How IBD is diagnosed. Crohn’s & Colitis Foundation of America. http://www.ccfa.org/info/about /diagnose. Accessed September 11, 2009. 5. Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive
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patients. Dis Colon Rectum. 2007;50(3):331-336. 6. Marrero F, Qadeer MA, Lashner BA. Severe complications of inflammatory bowel disease. Med Clin North Am. 2008;92(3):671-686. 7. Metcalf AM. Elective and emergent operative management of ulcerative colitis. Surg Clin North Am. 2007;87(3):633-641. 8. Merchant A. Inflammatory bowel disease in children: an overview for pediatric healthcare providers. Gastroenterol Nurs. 2007;30(4):278-284.
Kristina Amplo, MSN, RN, CPN, is a clinical educator at Children’s Healthcare of Atlanta, Scottish Rite, Atlanta, GA. Ms Amplo has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Diane Nelson, MSN, RN, CPN, is a clinical educator at Children’s Healthcare of Atlanta, Scottish Rite, Atlanta, GA. Ms Nelson has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Examination
1.3
Care of Patients with Inflammatory Bowel Disease PURPOSE/GOAL To educate perioperative nurses about caring for patients with inflammatory bowel disease (IBD).
BEHAVIORAL OBJECTIVES After reading and studying the Special Needs Populations column on patients with IBD, nurses will be able to
1. describe the clinical signs and symptoms of IBD, 2. discuss the key steps to take during a preoperative assessment, 3. identify common surgical procedures performed on patients with IBD, and 4. discuss postoperative care of the patient with IBD. QUESTIONS 1. Crohn’s disease involves 1. all layers of the intestine. 2. both the small and large intestines. 3. only the inner lining of the large intestine or colon. 4. any part of the digestive tract from the mouth to the anus. a. 1 b. 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
3. joint, skin, or eye irritations. 4. abdominal pain or cramps. 5. blood passing through the rectum. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5
2. Ulcerative colitis involves 1. all layers of the intestine. 2. both the small and large intestines. 3. only the inner lining of the large intestine or colon. 4. any part of the digestive tract from the mouth to the anus. a. 1 b. 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
4. When assessing a patient with IBD, the perioperative nurse should record data that include 1. hemoglobin count and erythrocyte sedimentation rate. 2. the number and consistency of bowel movements the patient has each day. 3. presence of leukocytosis and tachycardia and alterations in temperature. 4. weight gain greater than 20% within the previous six months. a. 1 and 3 b. 1, 2, and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
3. Symptoms of IBD, which can be more severe in patients with Crohn’s disease, include 1. weight gain. 2. fever.
5. Preoperatively, the RN should 1. address the patient’s nutritional needs and administer enteral or parenteral nutrition if surgery is not emergent. 2. administer an antibiotic within one hour
© AORN, Inc, 2009
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before the surgical incision is made. 3. prep the bowel for surgery. 4. discontinue the patient’s low-molecular weight heparin. a. 1 and 2 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 6. Surgical options for patients with ulcerative colitis include 1. proctocolection with an ileostomy.
3. restorative proctocolectomy with an ileal pouch-anal anastomosis. 4. laparoscopic proctocolectomy. a. 1 and 2 b. 2, 3, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4 7. If an open laparotomy is needed in a patient with Crohn’s disease, the patient can be placed in the 1. reverse Trendelenburg position. 2. modified lithotomy position. 3. supine position. 4. high lithotomy position. a. 1 or 2 b. 2 or 3 c. 3 or 4 d. 1, 2, or 4 8. For an open laparotomy during surgical treatment of Crohn’s disease, a midline incision is often favored because it allows easy access to the small intestine and ileoThe behavioral objectives and examination for this program were prepared by Kimberly Retzlaff, editor, with consultation from Rebecca Holm, RN, MSN, CNOR, clinical editor, and Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
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cecal area without compromising possible stoma locations. a. true b. false 9. During postoperative care of the patient who undergoes surgery for IBD, the nurse should 1. pay close attention to the patient’s vital signs to check for signs of infection or pain. 2. maintain strict input and output to ensure adequate electrolyte balance and hydration, and maintain nutritional support. 3. monitor the patient for increased heart rate or blood pressure. 4. watch for signs of bowel obstruction such as vomiting, abdominal pain, or fever. a. 1 and 3 b. 2 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4 10. Factors that may lead to postoperative morbidity in patients with Crohn’s disease include 1. obstruction. 2. chronic corticosteroid therapy. 3. malabsorption leading to poor nutrition. 4. systemic infection. 5. abdominal abscess before surgery. a. 1, 2, and 3 b. 2, 3, and 4 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes this activity as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Answer Sheet Care of Patients with Inflammatory Bowel Disease
1.3 Event #09293 Session #1198
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
P
AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 1.3 continuing education contact hour (78-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #_________________________________________ Name_______________________________________________ Address _____________________________________________ City ___________________________________________________
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A score of 70% correct on the examination is required for credit. Participants receive feedback on Save time and money by completing this CE activity online. incorrect answers. Each applicant who No processing fees at aorn.org/CE. successfully completes this program will Program offered December 2009; The deadline for this program is December 31, 2012. receive a certificate of completion. © AORN, Inc, 2009
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Learner Evaluation Care of Patients with Inflammatory Bowel Disease
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
T
PURPOSE/GOAL To educate perioperative nurses about caring for patients with inflammatory bowel disease (IBD).
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe the clinical signs and symptoms of IBD. 2. Discuss the key steps to take during a preoperative assessment. 3. Identify common surgical procedures performed on patients with IBD. 4. Discuss postoperative care of the patient with IBD. To what extent 5. did this article increase your knowledge of the subject matter? 6. was the content clear and organized? 7. did this article facilitate learning? 8. were your individual objectives met? 9. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 10. were they reflective of the content? 11. were they easy to understand? 12. did they address important points?
LEARNER INPUT 13. Will you be able to use the information from this article in your work setting? a. yes b. no 14. I learned of this article via a. the AORN Journal I receive as an AORN member.
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b. an AORN Journal I obtained elsewhere. c. the AORN Journal web site. 15. What factor most affects whether you take an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ © AORN, Inc, 2009
Care of Patients with Inflammatory Bowel Disease 1.3 KRISTINA AMPLO, MSN, RN, CPN; DIANE NELSON, MSN, RN, CPN
Complete this CE activity online at aorn.org/CE
ccording to the Crohn’s & Colitis Foundation of America, approximately 1.4 million Americans are living with inflammatory bowel disease (IBD), and about 30,000 new cases are diagnosed each year.1 Inflammatory bowel disease consists of two chronic diseases: Crohn’s disease and ulcerative colitis.1 Of patients diagnosed with IBD, about half are diagnosed with Crohn’s disease and half with ulcerative colitis, and men and women are equally affected.2 Inflammatory bowel disease often is diagnosed in adolescents and young adults between the ages of 15 and 35. The cause of IBD is unknown, and there is no medical cure at this time. Patients with IBD experience flare-ups without warning, which can be emotionally and financially draining. The annual cost to care for the patient with IBD in the United States—including surgery, medications, hospitalizations, and loss of labor— is between $1.8 and $2.6 billion per year.1 Perioperative nurses care for diverse patients, some of whom may have a primary or secondary diagnosis of IBD.
A
CLINICAL SIGNS
AND
SYMPTOMS
There is a difference between Crohn’s disease and ulcerative colitis, although some individuals have a combination of indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 915-916 and then completing the answer sheet and learner evaluation on pages 917-918. The contact hours for this article expire December 31, 2012.
© AORN, Inc, 2009
both. Crohn’s disease can involve any part of the digestive tract from the mouth to the anus. A skin tag on the anus is a cardinal sign of Crohn’s disease. The disease process affects all layers of the intestine and involves both the small and large intestines. Causes of Crohn’s disease are unknown, but research indicates that IBD may be inherited, caused by problems with the immune system, or triggered by the environment.2 Crohn’s disease is classified as incurable but can be managed through diet, medications, and surgery as needed.1 Comparatively, a surgical procedure called a Inflammatory bowel colectomy, which is the removal of the colon, can disease consists greatly reduce the symptoms of ulcerative colitis. of two chronic Ulcerative colitis involves only the inner lining of the diseases: Crohn’s large intestines or colon. Symptoms of IBD are disease and similar in each disease, but often much more ulcerative colitis. severe in Crohn’s disease. Symptoms range from mild to severe and some are even life-threatening, so it is very important to listen to and observe the patient with IBD for any of these symptoms: • persistent diarrhea; • abdominal pain or cramps; • blood passing through the rectum; • fever; • weight loss; • joint, skin, or eye irritations; or • delayed growth and retarded sexual growth in children.1 The extent of the disease drastically
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The patient with inflammatory bowel disease needs to be counseled preoperatively on the risks and benefits of surgery as well as what he or she should expect postoperatively; the health care team should especially note possible complications, pain management, and long-term outcomes.
effects the clinical signs and symptoms that a patient experiences. Because Crohn’s disease and ulcerative colitis affect the lining of the bowel, nutritional status is almost always affected by malabsorption during active disease. For this reason, the patient may experience weight loss, anemia, hypoalbuminemia, and deficiencies of vitamin A, vitamin B12, vitamin D, iron, selenium, folic acid, and zinc.3,4 During patient assessment, the perioperative nurse should record data that includes • the number of bowel movements the patient has each day and their consistency, • low hemoglobin count, • increased erythrocyte sedimentation rate, • the presence of leukocytosis or tachycardia and alterations in temperature, • low albumin level, and • weight loss greater than 10% within the previous six months.5-7 The patient may experience mental status changes, hypotension, dehydration, and electrolyte abnormalities if he or she is experiencing systemic toxicity.6 Therefore, using a blood metabolic profile is helpful when assessing dehydration status and fluid replacement.4 Patients who are diagnosed with Crohn’s disease may also develop fistulas, which are passages or tunnels from one cavity to another that can lead to abscesses. Symptoms that a
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patient may present with are dependent on the location of the fistula. Enteroenteric fistulas are the most common internal fistulas; they are relatively asymptomatic but may present as palpable masses.3,6 Enterovaginal; enterovesicular (ie, into the urinary bladder); and entercutaneous fistulas also may be present.3,6
PERIOPERATIVE CARE Approximately 70% to 90% of patients with Crohn’s disease will require at least one surgery in their lifetime,3,5 and approximately 25% of patients with ulcerative colitis will require a colectomy in their lifetime.7 Failure to initiate high-dose corticosteroid therapy for severe colitis positively correlates with an increased risk of requiring a colectomy to control the disease.7 TREATMENT TEAM. A collaborative treatment team should be established to ensure efficient and quality care for the patient with IBD. Members of the team might include • an RN; • a gastroenterologist; • a nutritionist; • a colorectal surgeon; • an interventional radiologist (ie, if the patient experiences intra-abdominal abscesses);6 • pain management personnel to help with both chronic and acute pain issues; • a physical therapist to encourage movement, prevent sedentary complications, and assist with physical limitations; • a wound/ostomy nurse; and • a psychologist because depression is reported in 33% to 100% of patients with Crohn’s disease.3 PREOPERATIVE CARE. As with all preoperative care, the patient needs to be counseled on the risks and benefits of the procedure and what he or she should expect postoperatively. The health care team should take special note to share possible complications, pain management, and the long-term outcomes of the procedure. The health care team needs to research and document the extent of the disease, paying special consideration to laboratory test values, imaging results, and the medication course.3 Because of the nature of IBD, the nutritional needs of the patient must be addressed. If surgery is not emergent, enteral or parenteral
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Perioperative Nursing Implications for Patients Undergoing Surgery for Inflammatory Bowel Disease Preoperative care • Ensure that the consent has been signed. • Review the risks and benefits of the procedure with the patient and answer questions as needed. • Arrange pain management for preoperative and postoperative care. • Ensure that a bowel prep has been administered the night before surgery to ensure the patient’s bowels are completely cleansed. • Review the patient’s laboratory test results, including complete blood count; complete metabolic screen; albumin level; and levels of vitamins A, B12, and D and iron, selenium, folic acid, and zinc. • Review radiological test results including upper gastrointestinal and small bowel series, colonoscopy, computed tomography scans, and magnetic resonance imaging, as needed. • Ensure that antibiotics are administered within one hour before the surgical incision is made and are discontinued within 24 hours after surgery end time unless further antibiotic therapy is indicated. • Ensure that a wound/ostomy nurse consultation for site verification has been arranged. • Ensure that enteral or parenteral nutrition is administered before surgery to maintain nutritional status and correct any nutritional deficiency. • Ensure that psychological counseling has been arranged.1 Intraoperative care • Ensure appropriate instrumentation and positioning equipment is available for the scheduled procedure. • Consider the use of compression devices for thrombus prophylaxis. • Ensure IV antibiotics are administered in a timely fashion as needed. • Implement appropriate interventions to maintain body temperature. • Observe vital signs closely. • Insert an indwelling urinary catheter as needed. • Observe for any adverse effect of anesthesia. • Ensure that pain and antiemetic medications are administered before the patient leaves the OR. Postoperative care • Monitor vital signs to watch for signs and symptoms of sepsis. • Monitor intake and output and laboratory test results for electrolyte imbalance. • Observe for signs and symptoms of bowel obstruction such as vomiting, pain, and fever. • Manage pain with patient-controlled analgesia and narcotics. • Administer parenteral nutrition to maintain nutritional status. • Administer aminosalicylates, antibiotics, corticosteroids, thiopurines, and probiotics to prevent recurrence.1 • Ensure that psychological counseling has been arranged to help the patient deal with depression as needed. 1. Gardiner KR, Dasari BV. Operative management of small bowel Crohn’s disease. Surg Clin North Am. 2007;87(3):587-610.
nutrition should be given to the patient to achieve optimal postoperative outcomes.3,5 The nurse should expect to prep the bowel for surgery and administer an antibiotic within one hour before the surgical incision is made; antibiotics should be discontinued within 24 hours after surgery end time unless further
antibiotic therapy is indicated. To prevent bleeding, low-molecular-weight heparin should be discontinued if it is being administered before surgery .3 A wound/ostomy nurse should be consulted to assist in locating a site for a stoma if it is possible that an ostomy will be needed. The nurse aornjournal.org
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Web Sites Related to Inflammatory Bowel Disease Organization Crohn’s & Colitis Foundation of America About.com: inflammatory bowel disease KidsHealth® from Nemours Medline Plus: Crohn’s disease Ulcerative colitis Mayo Clinic: Crohn’s Disease Ulcerative Colitis
Web site* http://www.ccfa.org http://ibdcrohns.about.com http://kidshealth.org/parent/medical/digestive/ibd.html http://www.nlm.nih.gov/medlineplus/crohnsdisease.html http://www.nlm.nih.gov/medlineplus/ulcerativecolitis.html http://www.mayoclinic.com/health/crohns-disease/DS00104 http://www.mayoclinic.com/health/ulcerative-colitis/DS00598
*Access verified September 14, 2009.
should consider several factors before recommending a site for the ostomy, including abdominal muscles and fat distribution, old scars, bony prominences, dominant hand usage and dexterity, and possible intraoperative incision location.3 INTRAOPERATIVE CARE. The colorectal surgeon must assess many factors when deciding what surgical technique to use for the patient with IBD. There are several surgical options for patients with ulcerative colitis that the surgeon may choose to achieve the best outcome. The goal of surgical intervention for ulcerative colitis is removal of the affected bowel to help the patient achieve a higher quality of life. The most common procedures that surgeons perform on this type of patient are proctocolection with an ileostomy and restorative proctocolectomy with an ileal pouch-anal anastomosis.7 The surgical team must confirm the intended procedure and ensure availability of all instruments and equipment. Usually, the patient will undergo the proctocolectomy laparoscopically, which results in a shorter hospital stay, less postoperative pain, and an improved cosmetic result. A temporary loop ileostomy is performed most often in patients who have a proctocolectomy to allow time for the colon to heal. The colorectal surgeon will perform a take-down (ie, remove the temporary loop ileostomy) and create a pouch, usually in the shape of a “J.”7 The surgical outcome for a patient with Crohn’s disease is quite different than for a patient with ulcerative colitis. The goal of sur-
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gically removing the affected bowel can be achieved for the short term, but Crohn’s disease can affect the digestive tract from the mouth to the anus. Removing the diseased section of the small or large intestine does not guarantee that a new section of the bowel will not become inflamed. Laparoscopic surgery is the technique of choice, but it cannot always be used because large amounts of bowel sometimes need to be resected. If an open laparotomy is needed, the patient can be placed in the modified lithotomy or supine position. The modified lithotomy position is favored because any portion of the bowel may need to be resected. A midline incision is often favored because it allows easy access to the small intestine and ileocecal area without compromising possible stoma locations. Also, this incision can be reopened easily if future surgeries are needed. Careful examination of the entire bowel is often necessary because frequently more bowel is affected by the disease than preoperative radiological imaging and colonoscopy have indicated.3 Patients with Crohn’s disease often develop many strictures within the bowel. Strictureplasty can be performed on patients who have symptomatic strictures and have undergone extensive bowel resections in the past or within the previous year. This procedure relieves the obstructive symptoms caused by the strictures while conserving bowel length.3 No matter which technique is used to remove the affected bowel, great care must be taken not to perforate the bowel by sharp or
Special Needs Populations
blunt dissection. Prophylactic treatment for a thrombus also should be considered with the use of compression devices in both the intraoperative and postoperative setting.3 POSTOPERATIVE CARE. There are critical considerations for postoperative care of the patient with IBD. The nurse should pay close attention to the patient’s vital signs to check for signs of infection or pain, including fever or increased heart rate or blood pressure. Strict intake and output should be maintained to ensure adequate electrolyte balance and hydration. Nutritional support also is maintained. With surgical intervention, there is a chance of bowel obstruction so the postoperative nurse needs to assess the patient for vomiting, abdominal pain, or fever, and if any of these symptoms are noted, they should be reported to the surgeon.3 Pain management is of the utmost importance in postoperative care of the patient with IBD. A patient-controlled analgesia device with a narcotic is used so that the patient can control his or her postoperative pain, which is usually significant in this group of patients. Other considerations for the postoperative care of a patient with IBD are nutrition and emotional status. Nutrition is maintained through parenteral access until the patient is able to tolerate food and liquids by mouth, which may be as soon as one day or as long as several weeks after surgery.3 Many patients with IBD are depressed and need support and counseling from a psychological standpoint.3,8 The nurse should order a postoperative psychiatric consultation. It has been reported that a relatively high incidence of postoperative morbidity and septic conditions occur in patients with Crohn’s disease. Many factors can lead to this, but some that might be present are malabsorption leading to poor nutrition, abdominal abscess before surgery, obstruction, systemic infection, and chronic corticosteroid therapy. To reduce postoperative intra-abdominal septic complications leading to morbidity, the creation of a temporary stoma is indicated.5 The PACU and unit RNs should monitor for sepsis by assessing for fever, hypotension, and poor capillary refill. A patient with ulcerative colitis may have
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The postanesthesia care unit nurse should monitor the patient with ulcerative colitis who has had an internal pouch created for signs of pouchitis, which include diarrhea, abdominal cramps, fever, malaise, and loss of anorectal function.
had an internal pouch created that needs to be monitored for infection. A patient may get pouchitis at any time after the pouch is created, and this is the most frequent complication of a colectomy for ulcerative colitis.6,7 Signs of pouchitis include diarrhea, abdominal cramps, fever, malaise, and loss of anorectal function.6 To treat pouchitis, ciprofloxacin or metronidazole can be used either alone or in combination. Approximately 60% of those who get pouchitis will experience recurrent episodes.7
CARING
FOR THE
PATIENT
WITH
IBD
Generally, the patient with IBD has numerous physical and emotional needs. Caring for the patient with IBD can be emotionally and physically draining to nursing personnel as well. Many patients feel restricted from participating in everyday life because of the urgency they feel when needing to have a bowel movement. It is important to have the patient meet with the treatment team as soon as a diagnosis has been made and with each hospitalization to create a plan of care that is acceptable and agreed upon by all. It is the nurse’s goal to encourage the patient to partake in activities of daily living when he or she is experiencing a flare-up, as well as resume regular activities while healthy and asymptomatic. The nurse also should encourage patients to decrease the chances of future aornjournal.org
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flare-ups by following a low-residue diet, decreasing stress, and not smoking.5 The main goal of treatment is to improve the patient’s quality of life. With the increasing incidence of IBD in the United States, it is imperative that the nurse be aware of the needs of these patients and understand the signs and symptoms of IBD.
REFERENCES 1. About Crohn’s and ulcerative colitis. Crohn’s & Colitis Foundation of America. http://www.ccfa.org /about/press/ibdfacts. Accessed September 11, 2009. 2. About Crohn’s disease. Crohn’s & Colitis Foundation of America. http://www.ccfa.org/info/about /crohns. Accessed September 11, 2009. 3. Gardiner KR, Dasari BV. Operative management of small bowel Crohn’s disease. Surg Clin North Am. 2007;87(3):587-610. 4. How IBD is diagnosed. Crohn’s & Colitis Foundation of America. http://www.ccfa.org/info/about /diagnose. Accessed September 11, 2009. 5. Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive
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patients. Dis Colon Rectum. 2007;50(3):331-336. 6. Marrero F, Qadeer MA, Lashner BA. Severe complications of inflammatory bowel disease. Med Clin North Am. 2008;92(3):671-686. 7. Metcalf AM. Elective and emergent operative management of ulcerative colitis. Surg Clin North Am. 2007;87(3):633-641. 8. Merchant A. Inflammatory bowel disease in children: an overview for pediatric healthcare providers. Gastroenterol Nurs. 2007;30(4):278-284.
Kristina Amplo, MSN, RN, CPN, is a clinical educator at Children’s Healthcare of Atlanta, Scottish Rite, Atlanta, GA. Ms Amplo has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Diane Nelson, MSN, RN, CPN, is a clinical educator at Children’s Healthcare of Atlanta, Scottish Rite, Atlanta, GA. Ms Nelson has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Examination
1.3
Care of Patients with Inflammatory Bowel Disease PURPOSE/GOAL To educate perioperative nurses about caring for patients with inflammatory bowel disease (IBD).
BEHAVIORAL OBJECTIVES After reading and studying the Special Needs Populations column on patients with IBD, nurses will be able to
1. describe the clinical signs and symptoms of IBD, 2. discuss the key steps to take during a preoperative assessment, 3. identify common surgical procedures performed on patients with IBD, and 4. discuss postoperative care of the patient with IBD. QUESTIONS 1. Crohn’s disease involves 1. all layers of the intestine. 2. both the small and large intestines. 3. only the inner lining of the large intestine or colon. 4. any part of the digestive tract from the mouth to the anus. a. 1 b. 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
3. joint, skin, or eye irritations. 4. abdominal pain or cramps. 5. blood passing through the rectum. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5
2. Ulcerative colitis involves 1. all layers of the intestine. 2. both the small and large intestines. 3. only the inner lining of the large intestine or colon. 4. any part of the digestive tract from the mouth to the anus. a. 1 b. 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
4. When assessing a patient with IBD, the perioperative nurse should record data that include 1. hemoglobin count and erythrocyte sedimentation rate. 2. the number and consistency of bowel movements the patient has each day. 3. presence of leukocytosis and tachycardia and alterations in temperature. 4. weight gain greater than 20% within the previous six months. a. 1 and 3 b. 1, 2, and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
3. Symptoms of IBD, which can be more severe in patients with Crohn’s disease, include 1. weight gain. 2. fever.
5. Preoperatively, the RN should 1. address the patient’s nutritional needs and administer enteral or parenteral nutrition if surgery is not emergent. 2. administer an antibiotic within one hour
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before the surgical incision is made. 3. prep the bowel for surgery. 4. discontinue the patient’s low-molecular weight heparin. a. 1 and 2 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 6. Surgical options for patients with ulcerative colitis include 1. proctocolection with an ileostomy.
3. restorative proctocolectomy with an ileal pouch-anal anastomosis. 4. laparoscopic proctocolectomy. a. 1 and 2 b. 2, 3, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4 7. If an open laparotomy is needed in a patient with Crohn’s disease, the patient can be placed in the 1. reverse Trendelenburg position. 2. modified lithotomy position. 3. supine position. 4. high lithotomy position. a. 1 or 2 b. 2 or 3 c. 3 or 4 d. 1, 2, or 4 8. For an open laparotomy during surgical treatment of Crohn’s disease, a midline incision is often favored because it allows easy access to the small intestine and ileoThe behavioral objectives and examination for this program were prepared by Kimberly Retzlaff, editor, with consultation from Rebecca Holm, RN, MSN, CNOR, clinical editor, and Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
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cecal area without compromising possible stoma locations. a. true b. false 9. During postoperative care of the patient who undergoes surgery for IBD, the nurse should 1. pay close attention to the patient’s vital signs to check for signs of infection or pain. 2. maintain strict input and output to ensure adequate electrolyte balance and hydration, and maintain nutritional support. 3. monitor the patient for increased heart rate or blood pressure. 4. watch for signs of bowel obstruction such as vomiting, abdominal pain, or fever. a. 1 and 3 b. 2 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4 10. Factors that may lead to postoperative morbidity in patients with Crohn’s disease include 1. obstruction. 2. chronic corticosteroid therapy. 3. malabsorption leading to poor nutrition. 4. systemic infection. 5. abdominal abscess before surgery. a. 1, 2, and 3 b. 2, 3, and 4 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes this activity as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Answer Sheet Care of Patients with Inflammatory Bowel Disease
1.3 Event #09293 Session #1198
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
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AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 1.3 continuing education contact hour (78-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #_________________________________________ Name_______________________________________________ Address _____________________________________________ City ___________________________________________________
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A score of 70% correct on the examination is required for credit. Participants receive feedback on Save time and money by completing this CE activity online. incorrect answers. Each applicant who No processing fees at aorn.org/CE. successfully completes this program will Program offered December 2009; The deadline for this program is December 31, 2012. receive a certificate of completion. © AORN, Inc, 2009
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Learner Evaluation Care of Patients with Inflammatory Bowel Disease
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
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PURPOSE/GOAL To educate perioperative nurses about caring for patients with inflammatory bowel disease (IBD).
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe the clinical signs and symptoms of IBD. 2. Discuss the key steps to take during a preoperative assessment. 3. Identify common surgical procedures performed on patients with IBD. 4. Discuss postoperative care of the patient with IBD. To what extent 5. did this article increase your knowledge of the subject matter? 6. was the content clear and organized? 7. did this article facilitate learning? 8. were your individual objectives met? 9. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 10. were they reflective of the content? 11. were they easy to understand? 12. did they address important points?
LEARNER INPUT 13. Will you be able to use the information from this article in your work setting? a. yes b. no 14. I learned of this article via a. the AORN Journal I receive as an AORN member.
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b. an AORN Journal I obtained elsewhere. c. the AORN Journal web site. 15. What factor most affects whether you take an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ © AORN, Inc, 2009