Care Needs for Crohn’s Disease Patient

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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).

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).

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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.

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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.

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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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