By Morrison, Dee
Karen C., a 35 year-old wife and mother of twin boys, was diagnosed with Crohn’s disease (CD) after an endoscopy, colonscopy, and tissue biopsy revealed discontinuous aphthous ulcerations, inflammation, and narrowing in the terminal ileum and left colon. After years of conservative therapy with medications and diet, and several episodes of relapses and remissions, she underwent a resection of the terminal ileum and hemicolecotmy, removing the cecum and appendix. Prior to surgery, Karen had been severely debilitated and malnourished, having lost 20 pounds over a 6- month period. She needed extensive nutritional support, and also admitted feeling anxious, fatigued, and depressed. Research has shown that anxiety and depression are sequelae of CD (Kurina, Goldacre, Yeates, & Gill, 2001). CD is a chronic inflammatory condition of unknown etiology, which may involve the whole digestive tract from the oral cavity to the anus. It most commonly involves either the lower part of the ileum, ileocecal region, or the colon (Metcalf, 2002). Because it has an immune-mediated pathology, treatment is geared toward attenuating the immune response. The incidence of CD is around 5 to 10 per 100,000 per year, affecting young people, with a peak incidence between the ages of 10 and 40 years (Carter, Lobo, Travis, & the IBD Section of the British Society of Gastroenterology, 2004).
The disease is familial and affects certain groups, such as Ashkenazi Jews, suggesting that genetic factors are significant. These ethnic groups are susceptible to environmental triggers, such as infection, drugs, or other agents. Crohn’s disease is 2 to 4 times more common in smokers, and the effect of stress in causing relapses remains controversial (Metcalf, 2002).
Surgery for CD is a last resort because it does not cure the disease. However, about 50% of patients will require surgery within 10 years, and 80% will require surgery by 20 years usually to stop bleeding, close fistulas, bypass obstructions, or remove the affected areas of the intestine (Kurina et al., Tandon, Penner, & Fedorak, 2008).
Post-Operative Care
Pain Control
The immediate post-op goal for Karen is to keep her comfortable. Effective pain control helps maintain hemodynamic stability and prevent pulmonary complications. The typical patient will receive opioids via a patient-controlled analgesia pump during the first two post-operative days and be switched to oral forms by the third post- operative day.
Positioning, distraction, and relaxation techniques also can be used to control pain. Early ambulation is encouraged to facilitate return of bowel function and prevent the formation of venous thromboemboli.
Wound Care/NG Tube
Karen’s surgery did not necessitate an ostomy, but it is still important to provide general post-operative wound care. Explain to her to support the operative site during deep breathing and coughing after pain medication is given. Teach her to report wound redness, swelling, bleeding, drainage, and fever to her physician. Expect the nasogastric tube to remain in place, attached to low intermittent suction, until bowel activity resumes. Irrigate the tube with normal saline solution as needed to keep the tube patent.
Diet Therapy
Post-operative weight loss follows almost all bowel resections. Restoring and maintaining good nutrition is a key principle in the management of Crohn’s disease. Karen will need an individualized, carefully planned, and nutritionally wellbalanced diet in consultation with the dietician. She should be instructed to keep a food journal and to eliminate foods that may trigger her disease. A food journal can pinpoint which foods are troublesome for her and also can reveal whether or not her diet is providing an adequate supply of nutrients. Small, frequent meals should be encouraged, and acidic, fried, and pickled foods should be avoided. She also needs to increase fluid intake to prevent dehydration.
Discharge Medications
Karen was continued on immunosuppressants, immunomodulators (6- mercatpo-purine and azathioprine), and antibody therapy (infliximab) for prevention of recurrence after surgery. These drugs are used when a person has had very severe or complicated disease prior to surgery. Infliximab had been shown to be effective for the treatment of acute flares of CD as well as maintenance therapy after surgery. Karen continued to have diarrhea as a result of bile salt overflow and was treated with cholestyramine. She also needed vitamin B12 every three months for life to avoid megablastic anemia.
Psychological Factors
Karen’s anxiety and depression should be addressed by employing good listening skills, which will validate her feelings. Providing her with the Crohns’s and Colitis Foundation of America’s Web site address (http://www.ccfa.org/) as a forum to share her thoughts about the disease is also beneficial. Other proven therapies that may lesson anxiety include acupuncture, aromatherapy, and meditation.
General Lifestyle
The following recommendations also may be suggested to Karen to assist her with maintaining general good health.
* Get sufficient rest and sleep. A daily nap is helpful.
* Chew food very well and avoid overeating.
* Ingest foods only when there is emotional calm and real hunger is present.
* Participate in moderate exercise, avoiding exhaustion.
* Obtain adequate sunshine and fresh air.
* Maintain cordial relationships with friends and family.
* Pursue work that is rewarding.
* Avoid toxins, such as coffee, tea, soft drinks, and alcohol.
References
Carter, M.J., Lobo, A.J., Travis, S.P.L., & the IBD Section of the British Society of Gastroenterology. (2004). Guidelines for the management of inflammatory bowel disease in adults. Gut, 53(Suppl. V), V1-V16.
Kurina, L.M., Goldacre, M.J., Yeates, D., Gill, L.E. (2001). Depression and anxiety in people with inflammatory bowel disease. Journal of Epidemiology and Community Health, 55(10), 716-720.
Metcalf, C. (2002). Crohn’s disease: An overview. Nursing Standard, 16(31), 45-52.
Tandon, P., Penner, R., & Fedorak, R. (2008). Medical prophylaxis of postoperative Crohn’s disease. UpToDate? for Patients. Retrieved March 31, 2008, from http://www.uptodate.com/ patients/content/ topic.do?topicKey=inf lambd/9847
Dee Morrison, MSN, APRN-BC, CNS, is a Clinical Nurse Specialist, Albert Einstein Medical Center, Bryn Mawr, PA.
Note: A related article on this topic, “Postoperative Pain Management: The Challenges of the Crohn’s Disease Patient,” can be found in the April 2008 issue of MEDSURG Nursing: The Journal of Adult Health , the official journal of the Academy of Medical- Surgical Nurses.
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