Care Needs for Crohn’s Disease Patient

The aim of this assignment is to critically analyse and evaluate the biological, psychological and sociological perspectives, holistic care needs and its influences on the health and well-being of a patient from placement. The patient suffers from Crohn’s disease and was admitted to the hospital for Ileocaecal resection. This surgical procedure will result in the patient having her terminal ileum and the caecum removed. To maintain the professional requirements of the Nursing and Midwifery Council (NMC) on confidentiality (NMC, 2015), the name has been changed and the patient will be referred to as Anne.

Health
can be defined as the ability to adapt and self-manage in the face of physical,
social and emotional challenges, to satisfy lives demand that comes with persons
age and cultural responsibility (Bircher, 2005., Campbell, Pleic and Connolly,
2012). This definition gives a clear understanding of what health should be
identified as and provides a holistic approach to health, as it takes into
consideration the changes in an individual’s lifestyle and it allows a better
understanding of the determinants of the disease (Lane, 2014). Diseases and
sicknesses are some of the factors identified to impact the health and
well-being of individuals in society today (Kwam, 2013). This research,
therefore, emphasises on the fact that diseases and sicknesses are able to
influence an individual’s behavior and emotion which could further lead to the
advancement of health problems (Lane, 2014).

Over
the last century, there have been controversies about the use of nursing models
such as Orem’s self-care model as some research have deemed it to be complex in
its understanding and information is likely to be misinterpreted (Kharis,
2016). Nevertheless, other research has disagreed as they have identified that
nurse’s experience is not enough to guide them and nurses are also able to
develop nursing practice by being able to think in depth and enhance insight on
the needs of the patient (Williams, 2015). Therefore, for this assessment, the
biopsychosocial model will be used to explore the present holistic and
individualized nursing care available for a patient suffering from Chron’s
disease. This is because this model relates to the study of the human being as
a whole rather than its individual parts (Williams, 2015).

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Whilst on a clinical placement on a surgical ward, a 36-year-old white British lady named Anne was admitted to the hospital with abdominal pain, vomiting and diarrhoea and has been scheduled for an Ileocaecal resection surgery. Anne was diagnosed with Crohn’s disease about six years ago and has had numerous hospital admissions due to the nature of the disease which presents with periods of remission. She was prescribed with anti-inflammatory drugs, antidepressant drugs and immunosuppressant drugs and occasionally takes antibiotics to reduce the symptoms and maintain remission of the disease. Anne is a divorced mother of two children, and currently living alone with her children who are 8 and 6 respectively. She lives in a two-bedroom social housing apartment situated miles away from the urban area, where she has less access to transportation and other social amenities such as GP surgery and supermarkets. Her mother and sibling all live abroad, and her mother also has a history of inflammatory bowel disease (IBD).

Anne
left school at the age of 18 and has worked as a classroom teaching assistant
since she was 21 however, because of her divorce which was less than a year ago
and her constant admissions, Anne decided to work part time instead to manage
her illness and family. Her lifestyle includes smoking approximately ten
cigarettes a day since the age of eighteen.  Due to the loss of her father at that age, the
stress of the divorce and her constant concerns for her health, she consumes a
bottle of wine every night. Her body mass index is currently 16.5 which is
identified as being underweight. This assignment will focus on the
biopsychosocial model to explain and understand its influence in Anne’s health
and wellbeing. According to Lane (2014), the term biopsychosocial refers to
factors which can be categorised as biological, psychological and social and
when combining these three determinants, they all identify aspects of an
individual’s life.

Crohn’s disease (CD) is a chronic, relapsing and an incurable inflammatory bowel disease (IBD) that causes inflammation in the bowel and currently affects over 3 million individuals in the Western World (Boyapati, Satsangi and Tzer Ho, 2015). CD is an immune-mediated disorder that causes inflammation, ulcer and tissue destruction anywhere along the gastrointestinal (GI) tract, from the mouth to the anus, however it most commonly affects the distal small intestine, which is between the terminal of ileum and start of the colon (De Mattos et al., 2015). This condition is also known as a transmural disease because it extends and affects the entire thickness of the intestinal wall (Fernandes et al., 2017).   

The
cause of Crohn’s disease is unknown; however, some scientists claim that there
is an interaction between the genes, the immune system and the environment
(Parkes, 2012., Marks et al., 2009., Wilson et al., 2015). Crohn’s disease is
believed to be related to abnormalities in the body’s immune system which is
usually aimed at protecting the body from infections or other foreign invaders
like bacteria and viruses (Boyapati, Satsangi and Tzer Ho, 2015). In
individuals with CD, the immune system reacts to the bacteria in the
gastrointestinal tract, which causes inflammation, bowel injury and ulceration
(Anaya et al., 2012). 

Furthermore,
as the lining of the GI tract becomes inflamed, it affects its ability to
effectively function, therefore it becomes difficult for water to be absorbed
and for certain nutrients from the digested food to be processed (Kaser and
Blumberg, 2014). This results in abdominal pain and diarrhoea which explains
Anne’s presentation at the hospital. In addition to this, the vitamin deficiency
is also likely to have caused Anne’s weight loss. However, the symptoms of CD
vary within individuals depending on the location and severity of the disease
(Parkes, 2012).

Considering
CD is incurable, the treatments available are aimed at alleviating symptoms and
minimizing complications (Cheifetz, 2014). For the management of the disease,
restoring and maintaining good nutrition is essential (Fernandes et al., 2017).
In addition, there are several medications that can be prescribed to patients
with CD such as antibiotics, corticosteroids, immunomodulators, biological
therapies and amino-salicylates however, as each person’s CD symptom is
different depending on the severity, so does the pharmacological therapies and
treatments (De Mattos et al., 2015). Further analysis on how the biological
consequences and symptoms of Crohn’s disease affects Anne will be identified
below.

Research
has identified a link between CD and genetics as epidemiological studies
suggest that at least one mutation of the NOD2/CARD15 intracellular protein
gene and the IBD1 gene on 16q deletions is present in nearly 30-40% of
individuals with CD (Klocker., 2016). This research, therefore, shows that
there is a high probability of Anne having the gene, which therefore increased
her chance of being diagnosed with CD. Additionally, this condition is believed
to be genetically inherited because having an affected relative is an important
risk factor for the onset of CD (Parkes., 2012). Furthermore, Parkes (2012),
insisted that an individual with the NOD2 gene has an increased risk of
developing this condition however, there is no definite evidence that Anne
inherited the gene from her mother. This is because her mother’s history of IBD
could be Ulcerative colitis or any other IBD which according to the research
does not show a link of heredity. On the other hand, considering Anne and her
mother both suffer from IBD, there is a possibility that the trait was
inherited however, there has been no convincing evidence to show that the trait
alone can lead to the development and progression of the condition.

Anne’s
gender could also have influenced the cause of the disease as women are three
times more likely to develop CD compared to men and this is possibly as a
result of hormonal factors (Mills et al., 2011). This is because specific
complications in women’s genitourinary tract, such as genital swelling can
result in the manifestation of this condition (Hauser, Plavsic and Stimac,
2013). To support this study, De Lima et al (2015) explained in their research
that over 40% of women will develop perianal manifestations before the other GI
symptoms develop. This research applies to Anne as she explained that she would
usually experience rectal pain and incontinence whilst she was pregnant, however
she assumed it was associated with her pregnancy. This, therefore, means that
this could have been a symptom of the Crohn’s disease but because the symptoms
of CD slowly develop, Anne might have thought it was not a cause for concern. 

There
are several factors that can cause Anne’s psychological distress and this could
clearly lead to the progression and the detriment of the condition. Stress has
a detrimental effect on an individual and this could also increase an
individual’s chance of developing CD (Goodhand and Rampton, 2008).  Anne could not cope with the loss of her
father, more recently the loss of her relationship with her ex-husband and her
chronic long-term condition that she drank to forget the pain and used
cigarette and the drinking as a coping mechanism to relax and cope better with
the stress she was feeling. Anne also showed signs of worry and concern for her
children living with her ex-husband while she recovers from her surgery.

Brunner
et al (2014) puts out that bereavement or a relationship loss can trigger
excessive smoking and drinking and possibly lead to the dependence of both
substances. This research is relevant to Anne as the loss of her father
initially lead to her drinking and since then, she has become dependent on both
alcohol and smoking, and it has then become used as a coping mechanism for Anne
to avoid her emotions. In the long run, this strategy is therefore likely to
lead to more medical complications. However, in this situation, if Anne spoke
to a psychologist, an approach coping style could have been used and this could
have led to less or no alcohol dependence, less depression and a long-term goal
of dealing with the psychological distress (Tamara., 2015).

According
to Amato and Anthony (2014), a marital divorce is equivalent to the death of a
human depending on the attachment. Anne’s divorce could possibly have led to an
increased level of depression as she is not only grieving the loss of the
relationship and partnership, but also her own mortality as she explained that
she is still getting used to the idea of having a chronic condition and her
continuous remission. As a result of this, it can be argued that Anne may be in
denial of her health issues and this could possibly be because she does not want
to be labelled and categorised in the sick role which was identified by Talcott
Parsons (Varul, 2010).

To
better understand Anne’s grief, bereavement of relationship and denial of the
condition is the Elizabeth Kubler-Ross’s research on five stages of grief. This
is because grief can refer to emotional reactions to other losses such as loss
of an individual’s social status, loss of health due to disease as grief is
known to be individualized (Tamara., 2015). This theory explains that an
individual is able to go through stages while grieving and these stages includes
denial, anger, bargaining, depression and acceptance (Mahmood, 2016). This
theory is very effective in identifying the stages an individual is likely to
undergo whilst grieving, however it does not give a timeline as to how long an
individual can be in that specific grieving stage. It is important for nurses
to understand the process of grief because without the understanding and
support of the nurses and the multidisciplinary team (MDT) during the grieving
process, the patient is likely to feel more alone, angry and isolated (Ghosh,
2013). Research has also shown that when separation occurs, individuals may
feel strong overpowering feelings of sadness and anxiety, rather than expressing
their emotions, the emotion is usually concealed (Tamara, 2015). This research
is applicable to Anne because not expressing her feelings could have
contributed to her depression and possibly worsen it.

In
addition to this, it is understandable that Anne is not willing to be
categorized in the sick role and she expressed feelings of not wanting to lose
her independence, considering she has no family support due to her siblings and
mother living abroad. Therefore, in this situation, it is important for nurses
to educate Anne about her mindset and reassure her that she would not be losing
her independence or adopt feelings of helplessness, but rather by adopting the
sick role, she could be more involved with her condition by working alongside
the health care professionals and making significant changes in her lifestyle choices(Baumgart
and Sandborn,  2012). It is also
important for the professionals to communicate effectively with Anne in a non-judgmental
manner and make her feel comfortable (Mahmood, 2016). Furthermore, adopting the
sick role could also lead to more health promotions, for instance, helping Anne
limit or quit smoking and drinking, eating healthier foods and being involved
in exercise programmes which she can be referred to by the nurses (Flinkfeldt,
2017). However, this intervention will require her working alongside the MDT to
help Anne become healthier in terms of her diet and provide her with more
information regarding the effect that her unhealthy lifestyle choices has on
her condition.

To
provide adequate individualised nursing care to Anne, Neuman’s system model is
considered to be relevant to the psychological issues relating to her
condition. This model focuses on the issues of stress and its relationship with
patients in care (Barrett et al, 2009).
Additionally, the model insisted that most of the
patient’s human factors are surrounded by some dense mechanism, which are the
several lines of resistance, normal lines of defence and the flexible lines of
defence (Gonzalo, 2011). This model can be applied by
the nurses informing Anne of the importance of taking her antidepressant
medications and other drugs to maintain remission of CD. Also, educate her about
the effects of stress and depression, whilst preparing for her surgery. Archer
et al (2012) study explained that during surgery, stress and depression can detrimentally
affect patients’ quality of life resulting in a poor patient’s outcome.
This research definitely applies to Anne as she believes that her unhealthy
lifestyle does not have anything to do with the prognosis of her condition,
rather it is the appropriate method of managing the stress associated with CD.
This is because individuals who live unhealthy lifestyles most times believe
that it reduces their level of stress (Flitz, Kaufman and Moore, 2013).  Therefore, as a result of this, it is
important for nurses to identify Anne as an individual and analyse the health
beliefs and health behaviour specific to her.

There
are several social factors including income, socialisation, lifestyle choices
and housing that affects Anne and the management of her disease. Smoking cigarette is regarded as a
lifestyle choice which have detrimental
effects on the human body as it contains over 300 harmful chemicals
including carbon monoxide, nitrosamines and nicotine (Flitz, Kaufman and Moore,
2013). Anne smoked ten cigarettes a day and was aware of the complication that
smoking could have on her health. These substances and Anne’s reluctance to
quit smoking will have a harmful effect on her condition and her recovery
following the surgery (Hanauer, 2008., Panes et al., 2014). This is because
there is a direct correlation between smoking and CD as smoking has been known
to aggravate CD and this could, in the long run,
worsen her health and cause further cardiovascular complications such as
chronic obstructive pulmonary disease (COPD) (Parkes, 2012). However, Anne’s
reluctance to give up smoking may be a result of the fact that she has used
smoking as a coping mechanism with the loss of her father at a younger age and
after finalising her divorce (Kaser and Blumberg, 2014). On the other hand, her
reluctance of quitting smoking could also be a result of her socialisation. Individual’s
social group and support system have the ability to influence one’s health
awareness and health belief (Flitz, Kaufman and Moore, 2013). However,
considering the fact that her family lives abroad and she does not have a lot
of friends to socialise with, due to her hectic schedule of managing the
children alone, therefore her smoking lifestyle may be her personal choice.

Mills
et al (2011) study showed that CD could cause significant disability as 75% of
the patients are capable of working within the year of diagnosis and 15% of the
patients are not able to work after 5 to 10 years of the diagnosis. Anne’s
experience is contrary to this research as she has been able to continue
working full time for at least four years after her diagnosis.  However,
changing her working pattern from full time to part time will affect her
finances tremendously as she would not be able to conveniently fend for herself
and her children’s financial and material needs without the help of her
ex-husband.  Individuals from low socioeconomic status groups have fewer
opportunities to undergo regular preventive medical checkups and screening
(Pampel, Krueger and Denney, 2010). In addition to this, the research also
identifies an inability for individuals from a low socioeconomic group such as
Anne to buy fresh fruits and vegetables or lean meats, joining gyms for
exercise and pay for counselling. This research is relevant to Anne because her
low-income rate does not provide her with enough to live a healthy life as Anne
explained that she is only able to afford food items high in carbohydrate and
fat which is not identified as an appropriate diet for her condition. As a
result of Anne’s situation, it is important that the MDT provide her with
relevant information regarding the care of her children or rather refer her to
the social worker who would be better equipped to provide support for her
circumstance. 

In
conclusion, the term health and well-being is described as the absence of
diseases, mental distress and physical illness. The idea of health and well-being differ between people’s life stages,
various cultures and changes over time. The biopsychosocial model of health and
well-being was used to explore Anne’s perception of her overall physical,
social and psychological well-being. CD affects any part of the
gastrointestinal tract ranging from the mouth to the anus with symptoms ranging
from abdominal pain, diarrhoea and weight
loss. It was vital to emphasis on how an
individual’s gender, age, genetics, emotion and economic status could have
contributed to the development and progression of her condition. The
biopsychosocial model of health and well-being has proven to be effective in
identifying Anne’s holistic care needs and providing individualized and person centred care to the individual. Various
theories and emphasis on the nursing role was
applied to relate the holistic nursing approach to
the patient.

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