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Running head: CROHN’S DISEASE

Case Summary Paper about Christian Barnes

Jacqueline Butsavage

NUR 612

Advanced Physical Assessment, Pathophysiology, and Pharmacology I

Pennsylvania College of Health Sciences

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Living with Crohn’s Disease

The case summary is about Christian Barnes, a thirteen-year-old white male living with a

diagnosis of Crohn’s disease. Crohn’s disease is a chronic condition, there is unknown cause for

Crohn’s disease, and there is no cure. Having a child that has Crohn’s disease, not only affects

the child, that is the patient, but can also affect the family. When there is only the one parent, the

child is a big responsibility. Christian has a not uncommon but yet not typical family dynamics.

Family dynamics will be his health care recipient concept that will be discussed. Christian was

recently diagnosis with Crohn’s disease. Christian has experienced a few health related and

illness adjustments since his diagnosis of Crohn’s disease resulting in an alteration in bowel

elimination, fluid and electrolyte imbalances, and nutrition. These concepts will be discussed

and explained in detail.

Part I, Health Care Recipient Nursing Concepts

There is a uniqueness in every family dynamic. Christian’s family dynamic is that he

lives with his mother Lyndsey Barnes, in Allentown, Pennsylvania in Lehigh County. The role

of each member in the family takes on a significant part within their family dynamics. Directly

asking Christian or Lyndsey about their living arrangements would address their family dynamic

of the patient care setting. Lyndsey is the sole provider, for her and Christian. Christian has

never meet his father, he left before he was born. Lyndsey and Christian have a very devoted

relationship, they are very close knit, just the two of them. Christian is only thirteen years, but

he tries to help out his mother as much as he can around the house, he knows that his mother

cannot do everything by herself. Lyndsey likes to talk with Christian to know how he is doing

and feeling. Christian feels that he can openly discussion anything with his mother, like how he

is physically or emotionally doing especially since adolescence can be challenging. Christian

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knows that his mother really understands him and can notice when he is not feeling well.

Lyndsey is a Registered Nurse, she works at a doctor’s office, and she is making a middle-

income salary. Lyndsey at times relies on her extended family, her mother and father, to help her

when needed. They are a valuable resource to help her with Christian when she is at work.

Every family has their own unique dynamics, that is what makes up their family.

Part II, Health and Illness Concepts

Christian started having symptoms when he was 12 years old. There were some changes

at Christian’s school that increased his anxiety and stress. Christian thought that stress is why

and was the cause of his symptoms. Christian symptoms started with a low-grade temperature of

99.8, abdominal cramping, and intermittent abdominal pain. He lost his appetite, began feeling

tired, and fatigued. He started having loose stool associated with diarrhea, a couple of times a

day and he even had to wake up during the night with episodes of diarrhea. He was having an

alteration in bowel elimination. He repeatedly went to the Pediatrician for the symptoms and

every time the doctor did a complete history and physical examination to try to figure out what

was causing his symptoms.

Reviewing a complete medical history and physical examination: Christian has no known

allergies. He has a past medical history of Crohn’s disease, bull’s eye rash, otitis media with

effusion, and hypocalcemia. He has no history of surgery. He is currently not taking any

prescribed medication, just his multivitamin and Tums supplement. His vitals are: temperature-

97.9, heart rate-68, respiratory rate-14, oxygenation saturation- 100% on room air, blood

pressure 124/62. He’s height is: 5 foot 3 inches and weight is: 93 lbs. or 42.3 kg. Complete

system review: Christian is alert and oriented to person, place, time, and situation. His speech is

clear, spontaneous, logical and appropriate. His bilateral pupils are 3 mm round, brisk, and
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reactive to light PEARLA, smile symmetrical and tongue midline. He is able to follow

commands with bilateral equal and strong hands, arms, legs, and feet. He has good movement

and sensation of all extremities. He’s bilateral lungs and breath sounds are clear on auscultation.

His apical heart rate is normal and regular. He’s abdomen is soft, nontender with audible bowel

sounds in all 4 quadrants, no current bowel issues or concerns moving his bowels. He voids

clear yellow urine without any difficulties. His skin is clean, dry, and intact.

The Pediatrician assessed Christian’s complete abdomen for any abnormal findings.

Christian was asked to empty his bladder prior to positioning for the examination and he was

appropriately draped. He was instructed to lie on his back and try to relax to start assessing his

abdomen. The Pediatrician completed a visual inspection of his abdomen checking symmetry,

flat contour, assessing for any abdominal distension, no scars, no striae, no dilated veins, rashes,

or ecchymosis, the umbilicus, and the perianal area for redness, lesions or any abnormality and

observing for any complains of pain or discomfort (Giddens, 2013). Christian had a normal

abdominal inspection. The Pediatrician using a stethoscope auscultated Christian’s abdomen

listening to bowel sounds in all 4 quadrants, he had normal bowel sounds in all 4 quadrants.

Absence of bowel sounds is an abnormal finding, possible ileus, hypoactive or hyperactive

bowel sounds can be related to having GI inflammation or intestinal obstruction (Giddens, 2013).

Listening with a stethoscope in the epigastrium for the aorta pulsation, listen over the iliac

arteries, and the femoral arteries. The Pediatrician gently palpated Christian’s abdomen, normal

is soft nondistended assessing the over the entire abdomen observing for any masses and

identifying any abnormalities, abdominal pain or discomforts, rectal palpation is completed to

assess the rectal sphincter and also assess for any masses, lesions, or impacted stool (Giddens,

2013). Christian’s palpation was normal. The Pediatrician assessed his abdomen for any
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increased resistance, pain, or tenderness. Having the patient take slow deep breaths, the

abdominal muscles may tense up, reassure the patient to try to relax, and if needed flex or bend

the knees to relax. The Pediatrician did abdominal percussion to assessing the distribution of

tympany and dullness, assess for any masses, fluid accumulation, or excessive intestinal gas

(Giddens, 2013). Tympany is a high-pitched musical sound that indicates a hollow space filled

by air or gas in the stomach or intestines, dullness suggests fluid or underlying organs. During

the assessment examine the liver for its size, using percussion and dullness to identify the border

assessing for hepatomegaly. Also examine and assess the spleen, the tip of the spleen is palpable

in only 5% of normal adult’s abdominal assessment. Having the patient position on their right

side with legs flexed at the hips, gravity may position the spleen forward and to the right to be

able to assess the size of the spleen if enlarged. Percuss the left lower anterior chest wall roughly

from the boarder of cardiac dullness at the 6th rib to the anterior axillary line and down to the

costal margin this is the area called Traube’s space, continue to assess tympany and dullness to

check for splenomegaly. Christian’s abdominal assessment was normal.

Christian had stool samples sent to the lab, typical stool sample assess stool color, normal

color is brown. A patient that has red, black or tarry stools are an abnormal result representing

gastrointestinal (GI) bleeding. Hemoccult testing is completed to check of any presence of

melena is present, normal results are negative. Stool consistency is identified, formed stool is

normal, loose stools or diarrhea may be associated due to diet, inflammation, or infection

(Giddens, 2013). Christian’s stool results were normal. Typical diagnostic tests done included:

bloodwork drawn-complete blood count to check white blood count (3.5-10.5 billion cells/L),

hemoglobin (13.5-17.5 grams/dL), hematocrit (38.8-50.0 percent), and platelet count (150-450

billion/L), to detect infection, anemia, or can indicate inflammation (Mayo Clinic, 2018). All of
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Christian’s results were normal. A complete metabolic panel is done to check electrolytes,

assessing glucose (70-125 mg/dL), sodium (136-144 mEq/L), potassium (3.7-5.2 mEq/L),

chloride (96-106 mmol/L), BUN (7-20 mg/dL) and creatinine (0.8-1.4 mg/dL), calcium (8.5-10.9

mg/dL), magnesium (1.8-2.6 mEq/L), protein (6.3-7.9 g/dL), serum albumin level (3.9-5.0 g/dL),

and Glomerular filtration rate (90-120 mL/min/1.73 m2) (Mayo Clinic, 2018). All of Christian’s

results were normal. He had and erythrocyte sedimentary rate (ESR) to check for nonspecific

infection or inflammation (0-22 mm/hr) (Mayo Clinic, 2018). Christian’s results were elevated-

24 mm/hr. A C-reactive protein (CRP) was completed to rule out a nonspecific infection or any

inflammatory disorder (below 3.0 mg/L) (Mayo Clinic, 2018). Christian’s results were elevated-

(7.0 mg/L) (Mayo Clinic, 2018). The lab results for a patient with Crohn’s disease will resemble

Christian’s labs as he has inflammation, if there is an infection an elevated white blood cell count

would be reflected in the results. If this is chronic Crohn’s disease there can be electrolyte

deficiencies due to prolonged bouts of diarrhea which can result in hyponatremia, hypokalemia,

hypocalcemia and hypomagnesium that would require medical attention for electrolyte

replacement to prevent further complications.

Typical diagnostic tests are abdominal x-rays, abdominal ultrasound, and a barium

swallow study, these tests are assessing for bowel obstruction or intra-abdominal abscesses.

Christian’s results were normal. Other typical diagnostic tests are having computed tomography

and magnetic resonance images which can better identify if he has any abdominal inflammation,

fibrosis, or obstruction the results showed inflammation of the ileum and colon. Christian’s

results showed he had inflammation in the ileal and colonic areas. In some cases, a colonoscopy

or sigmoidoscopy are completed to directly visualize the colon or sigmoid colon, to assess for

any abnormal polyps, abnormal tissue, samples biopsy of polyps or tissue are obtained, or any
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inflammatory conditions are present. Due to Christian being inflamed currently scoping was not

completed at this time. After getting all the results back and with the symptoms still present, the

doctor diagnosed Christian with Crohn’s disease. Christian’s gastrointestinal system was

primarily disrupted by the diagnosis of having Crohn’s disease. There are many different disease

processes that can disrupt bowel elimination, alter fluid and electrolyte balances, and nutrition. It

is important and useful to identify risk factors in terms of what causes this disease rather than

focusing on the behavior caused by that disease (Giddens, 2013). Significant fundamental

insight was taken in to consideration into the molecular pathogenesis of Crohn’s disease or other

possible disorders that can cause malabsorption or malnutrition. Christian having loose stool and

diarrhea had a disruption in bowel elimination. The total amount and concentration of the fluid

in the body can influence the function of all the cells in the body; the body is continuously

making adjustments trying to maintain a balance and recognizing and managing imbalances for

optimal cellular function (Giddens, 2013). Christian can have an alteration in fluid and

electrolyte balances related to impaired GI mucosal lining that will also lead to and alteration in

nutrition less than body requirements from the body not having adequate absorption or not being

able to utilize the proper nutrition that has been consumed.

Lyndsey was shocked and devastated when they finally received Christian’s diagnosis of

Crohn’s disease. The exact cause of Crohn’s disease is unknown. Lyndsey is a nurse, therefore

she found it difficult to watch Christian get so sick so quickly. He struggled with having

frequent episodes of diarrhea that left him exhausted and so tired all the time and it was

interfering with his school and sports he plays. Christian has been through a lot since his

diagnosis of Crohn’s disease. He has had to learn so much, physically and socially while making

adjustments during his emotional development. He had to psychologically understand from his
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experiences and manage his emotions. Trying to practice and play sports can be difficult,

especially when having bouts of diarrhea and loose stools. A person with Crohn’s disease may

find it challenging knowing that there is no cure and having to live their life and adjust.

Christian is trying to develop and adjust his life and deal with a chronic disease, not exactly

knowing what is going to come of the future.

Crohn’s disease etiology is a progressive, systemic autoimmune disorder with debilitating

GI manifestations, abnormal acute or chronic inflammation of the GI tract which can include

areas from the mouth and extending to the anus (Mazal, 2014). Clinical manifestations of a

patient with Crohn’s disease and typical findings and GI symptoms of a patient’s history can be

having abdominal pain, abdominal cramping or colicky, dehydration, tired or fatigued, fever,

unexplained weight loss, nutritional deficiency, and diarrhea are common symptoms of this

disease either presenting as an acute, chronic or intermittent episode. Crohn’s disease

occurrence is most common in Northern hemispheres and Western countries; the United States

realizes 3 to 5 cases per 100,000; and Northern Europe 27 to 48 cases per 100,000 (Mazal,

2014). Crohn’s disease can affect anyone at any age and totaling more than 2.5 million people.

Crohn’s disease equally affects males and females (Mazal, 2014). Environmental risk and

socioeconomic status can play a factor in Crohn’s disease such as having access to quality

healthcare, sanitation standards, hygiene practices and dietary habits (Mazal, 2014). Risk factors

for Crohn's disease can include: occurrence at any age, but likely younger than 40 years old,

affects any ethnicity, familial tendency, as many as 1 out of 5 family members, cigarette

smoking, taking certain medications, and geographic location (Mazal, 2014).

The pathophysiology of Crohn’s disease is there is impairment of the function of the GI

mucosa. Crohn’s disease can affect any part of the GI tract causes inflammation and it can
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spread deeper to all the layers of GI tissue (Litin, 2015). Why this typical problem occurs is the

mucosal surface that lines the GI tract are the physical interfaces of the body’s immune system

with contact to the outside world. The GI tract consists of a large portion of the body’s mucosal

lymphoid tissue, maintaining mucosal integrity is crucial to prevent illnesses (Mazal, 2014). In

Crohn’s disease, the focused problem is the epithelial layer of the GI tract increases in

permeability, allowing pathogens to enter and leak through the mucosal layers beneath (Mazal,

2014). There is a familial genetic predisposition or risk of Crohn’s disease. After Christian’s

diagnosis, Lyndsey felt upset that there is a genetic predisposition for someone else in their

family that can have Crohn’s disease.

Patient’s that have chronic diarrhea need to be worked up and assessed for specific

deficiency such as hyponatremia, hypokalemia, hypocalcemia and hypomagnesium in

conjunction related to the cause and consequences of the reason for having diarrhea (Giddens,

2013). Adolescence like Christian also have a variation in their body composition and their

inherited genetic makeup that can have an effect on their diet. Nutrigenomics is the genetic

influences on nutritional interventions (Giddens, 2013). There is a correlation of Crohn’s disease

dietary necessities and need for adequate nutrition. Patient’s that have Crohn’s disease are at risk

for developing disease complications of malnutrition and malabsorption due to decreased food

intake (Mazal, 2014). Christian’s height is 5 foot 3 inches and weight is 93 lbs. or 42.3 kg.

Christian’s height and weight falls in the 25th percentile for weight, which falls below the

average, 75 out of 100 kids will weigh more and 25 will weigh less (Gill, 2018). Christian tries

to eat a balanced and healthy diet, proper nutrition-food and nutrients is required for adequate

growth and development, health promotion, and disease prevention (Giddens, 2013). Adequate

nutrition is interrelated to health and illness, prevention and management of diseases, and body
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functions (Giddens, 2013). Patients with Crohn’s disease can develop a nutritional deficiency

and dietary intolerance or avoid consuming meat protein, milk protein, and polyunsaturated fatty

acids or refined foods because they can be associated with abdominal cramping, pain with

digestion, and impairment through the lack of absorption of dietary nutrients. Alteration in

nutrition or malnutrition is when your body is not getting enough nutrients and malabsorption is

when your body cannot absorb the vitamins and minerals that the body needs from the food you

eat. Certain medications can cause hypocalcemia or decrease the calcium absorption, which

include corticosteroids, aminoglycosides, and antibiotics; medications that Christian was taking

over the past few months (Chisholm-Burns, et al., 2016). People with Crohn’s disease usually

limit or avoid dairy products because not eating dairy improves bouts of diarrhea, abdominal

bloating, gas, distension, and pain or discomforts are lessened (Litin, 2015). Eating a low-fat

diet, patients with Crohn’s disease may not be able to digest or absorb fat normally (Litin, 2015).

Possible worsening of symptoms can occur due to high fiber foods, spicy foods, alcohol, or

caffeine beverages (Litin, 2015). Patients with Crohn’s disease find that eating small frequent

meals such as five or six instead of two or three and drinking plenty of water or liquids overall

feel better (Litin, 2015). There is a lifestyle of change and dietary adjustments.

After Christian was diagnosed with Crohn’s disease, he received treatment for the GI

problem. Medications are prescribed based on the stage of Crohn’s disease process, the level of

disease activity, and evidence of extent of mucosal damage or penetration within the vessel walls

of the GI tract. Christian was prescribed to take a corticosteroid, Prednisone 40 mg by mouth

twice a day with tapering doses as prescribed to take until a follow up with the next Pediatrician

and Gastroenterologist doctor appointment. The typical treatment plan and goals is to alleviate

the signs and symptoms, maintain and improve the patient’s quality of life, suppression of
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inflammation during acute episodes. Other typical medications prescribed to relieve associated

symptoms are antidiarrheal, corticosteroids, antibiotics, and anti-inflammatory medication to

alleviate the symptoms and try to bring the disease into a state of remission and prevent future

flare-ups or disease relapse (Mazal, 2014). The pharmacologic action of Prednisone is potent

anti-inflammatory and immunosuppressant response properties and usually improve symptoms

and disease severity rapidly (Chisholm-Burns, et al., 2016). Prednisone modifies the body’s

immune response to Crohn’s disease (Apo-Prednisone, n.d.). Prednisone causes an

immunosuppressant action by stimulating the synthesis of enzymes needed to decrease the

inflammatory response (Apo-Prednisone, n.d.). Prednisone suppresses the immune system

response by reducing activity of the lymphatic system, decreasing immunoglobulin by

decreasing the passage of immune complexes through basement membranes, and possibly by

depressing reactivity of tissue to antigen-antibody interactions (Apo-Prednisone, n.d.).

Prednisone triggers an anti-inflammatory action, corticosteroid of choice for anti-inflammatory

or immunosuppressive effects (Apo-Prednisone, n.d.).

Christian had to deal with much stress and a change in lifestyle since the diagnosis of

Crohn’s disease. There is an immense amount of stress applied to the family dynamics when

your only child has a chronic condition. Crohn’s disease is a progressive and systemic, acute to

chronic GI disorder. Crohn’s disease is a debilitating chronic condition that effects bowel

elimination, that can affects fluid and electrolyte imbalance and can impair nutrition from

associated symptoms of abdominal pain, abdominal cramping, unexplained weight loss, dietary

deficiency, caused from bouts of diarrhea.

There currently is no cure for Crohn’s disease. There are some complementary or

alterative medical approaches; acupuncture, pre and probiotics, botanical extracts, herbal and
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nutritional supplements, lifestyle modifications, and dietary restrictions (Mazal, 2014). There

are Crohn’s Foundation of America support groups that has chapters all across the country to

offer support to people living with Crohn’s disease.

Conclusion

Being diagnosed with Crohn’s disease is challenging, not knowing the exact cause, or

cure to a chronic condition. Having a child that has Crohn’s disease, not only affects the child

but can also affect the family dynamics and can also affect the uniqueness of what makes up

their family. Crohn’s disease main connection and associated contributing factors is alterations

in bowel elimination by having diarrhea and having diarrhea can lead to fluid and electrolyte

imbalances that need to be medically managed. One treatment recommendation for Crohn’s

disease is taking the prescription, of temporary titrated doses, of corticosteroid Prednisone.

Prednisone has potent anti-inflammatory and immunosuppressant response properties to relieve

the symptoms of Crohn’s disease. Patients that have Crohn’s disease require nutritional support,

that can also have demanding nutritional obligations to avoid malabsorption or malnutrition to

prevent further health and illness issues or prevention and management of having a chronic

condition. Christian will continue with the help of his mother, Lyndsey and extended family to

try and develop to adjust his life dealing with a Crohn’s disease a chronic condition, not exactly

knowing what is in store for of the future.

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References

Apo-Prednisone. (n.d.). Retrieved from

https://www.glowm.com/resources/glowm/cd/pages/drugs/p056.html.

Centers for Disease Control and Prevention. (2016). Retrieved from

https://www.cdc.gov/lyme/diagnosistesting/index.html.

Chisholm-Burns, M. A., Schwinghammer, T., Wells, B., Malone, P., Kolesar, J. M., & DiPiro, J.

(2016). Pharmacotherapy principles and practice. (4th ed.). New York, NY: McGraw-

Hill.

Giddens, J. F. (2013). Concepts for nursing practice. (2nd ed.). St. Louis, MI: Elsevier.

Gill, K. (2018). Retrieved from https://www.healthline.com/health/average-weight-for-a-13-

year-old.

Litin, S.C. (2015). Mayo Clinic: A to Z health guide everything you need to know about signs,

symptoms, diagnosis, treatment, and prevention. New York, NY: Time INC. Books,

Time Home Entertainment Inc.

Mayo Clinic. (2018). Retrieved from https://www.mayoclinic.org/tests-procedures/complete-

blood-count/about/pac-20384919.

Mazal, J. (2014). Crohn’s disease: Pathophysiology, diagnosis, and treatment. Radiologic

Technology, 85(3), 297-316.