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Volume 44 • Issue 2 May, June, July 2019

Reporter The Official Publication of the Delaware Nurses Association

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Importance of Follow-up after Bariatric Surgery

Page 6

Chronic Abdominal Pain in Children

Page 9Valerie Rebmann, MSN, FNP-BC

Maureen Egan, MSN, APRN

InsideDNA

REPORTER

Executive Director’s ColumnGuest Editor

Sharon Dudley-Brown, PhD, FNP-BC, FAAN, FAANP

Dr. Sharon Dudley-Brown has held several academic appointments, both nationally and internationally, and currently is the Director of the Doctor of Nursing Practice Program at the University of Delaware, School of Nursing. She has worked as a Nurse Practitioner at several institutions over the past 25+ years, and currently sees patients and conducts research on patients with inflammatory bowel disease at Johns Hopkins University. Dr. Dudley-Brown has published many peer-reviewed papers and abstracts in the fields of nursing and inflammatory bowel disease, and is currently a member of several editorial boards. She is a co-editor of a textbook on translation in evidence-based practice, entitled “Translation of evidence into nursing and health care,” published by Springer. Dr. Dudley-Brown is a nationally recognized leader in gastroenterology nursing and serves in leadership capacities with several gastroenterology and nursing organizations such as the Crohn’s and Colitis Foundation (CCF) and the Society of Gastrointestinal Nurses and Associates. Specific to the CCF, nationally, she is a contributing member of the Nurse & Advanced Practice Committee that reports to the National Scientific Advisory Board. Locally, Dr. Dudley-Brown is Chair of the Mission Committee for the Maryland/Southern DE Chapter of the CCF, providing oversight to educational programs to patients and providers within the chapter. Dr. Dudley-Brown can be reached at sdudley@udel.edu

Sharon Dudley-Brown

Problems of the gastrointestinal (GI) system are common. Whether acute or chronic (recurrent or constant), whether in children or adults, everyone at some point in time has suffered with at least one or more GI symptoms. In addition to GI symptoms, many GI disorders are associated with other health problems, such as sleep disorders and behavioral health disorders. In addition, GI disorders are among the most common system disorders seen in both pediatric

Guest Editor continued on page 2

Sarah J. Carmody, MBA

As a member-driven organization, DNA relies on its members to do the work of the association. Without members being generous with their time, expertise, and energy, DNA could not promote excellence in nursing through professional development programs. One DNA member, Alberta Regan, has been continuous in her participation on the DNA Continuing Education Committee since 1984. That is not a typo! That is 34 years of supporting excellence in continuing education for nurses in our state.

Through her work on the committee, there have been many a CE applicant who learned how to write a gap analysis, determine an outcome measurement, or how much content detail to show in support of the learning outcomes from Alberta. If she was firm, it’s because she wanted you to learn how to do it correctly. She was also a great mentor to new members of the committee and to me as we learned to navigate the development of continuing nursing education.

Alberta is also the oldest licensed nurse in the state of Delaware at 91 years old. Though she recently let her license lapse in February, Alberta continues to offer support in the DNA office was needed. When she and I talk about how long she has been active in nursing, she replies that she hopes others will be inspired to support organizations and their communities through volunteering. Our sincere thanks and gratitude to our friend, Alberta Regan.

While Alberta may be the oldest and longest active volunteer, there are many a DNA volunteer who have been continuously engaged, too many to name but you know who you are. Much appreciation and many thanks to you!

Please consider supporting DNA by joining a DNA committee, serving in a leadership role, or authoring an article for the DNA Reporter. Sharing your time and expertise will make a difference!

Sarah Carmody

Using the DNA Members Only Directory . . . . . . 2

President's Message . . . . . . . . . . . . . . . . . . . . . 3

Inflammatory Bowel Disease . . . . . . . . . . . . . . 4

Ostomy as a Surgical Option . . . . . . . . . . . . . . 5

Importance of Follow-Up after

Bariatric Surgery . . . . . . . . . . . . . . . . . . . . .6-7

Alberta Regan – The oldest living licensed

registered nurses in Delaware! . . . . . . . . . . . . 7

Celiac Disease and the Gluten-Free Diet . . . . . 8

Chronic Abdominal Pain in Children . . . . 9-10

LPN Membership Activation Form . . . . . . . . 10

DNA Membership Activation Form . . . . . . . 11

Welcome New and Returning Members . . . . 11

Page 2 • DNA Reporter May, June, July 2019RN, CWON, CCCN and her colleague Lois Dixon, MSN, APRN, AGNP-C, RN-BC, CWOCN provides information on ostomies, and in caring for the person with a stoma. The third article written by Valerie Rebmann, MSN, FNP-BC provides an overview of issues pertaining to people who undergo bariatric surgery, whose numbers are increasing in this country. The fourth article written by Jane Kurz, PhD, RN provides an overview of celiac disease, and is a reminder that it can not be diagnosed until adulthood.

The final article written by Maureen Egan, MSN, APRN addresses pediatric abdominal pain, and some common differential diagnoses, as well as management.

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The DNA Reporter, (ISSN-0418-5412) is published quarterly every February, May, August and November by the Arthur L. Davis Publishing Agency, Inc., for the Delaware Nurses Association, a constituent member association of the American Nurses Association.

EXECUTIVE COMMITTEE

President Past PresidentGary W. Alderson, Leslie Verucci, RN, MSN, RN, Esq. CNS, CRNP-A, APRN-BC

Treasurer SecretaryJon M. Leeking, Christopher E. Otto, MSN, RN BSN, RN, CHFN, PCCN, CCRN

COMMITTEE CHAIRS

Continuing Education CommitteeKathleen Neal, PhD, RN on Nomination Felisha A. Alderson, Professional Development MSN, RN, CRRN

Sandra Nolan, MSN, RN Terry Towne, MSN, RN-BC, NE-BC

ORGANIZATIONAL AFFILIATE

Oncology Nursing Society-Delaware Diamond Chaptercommunities.ons.org/delawarediamond/chapterleadership

LegislativeMembers of the Board of Directors

CommunicationsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

Executive DirectorSarah J. Carmody, MBA

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Acceptance of advertising does not imply endorsement or approval by the Delaware Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. DNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of DNA or those of the national or local associations.

Managing EditorsWilliam T. Campbell, Ed.D, RN

Karen Panunto, Ed.D, MSN, APRN

The DNA Reporter welcomes unsolicited manuscripts by DNA members. Articles are submitted for the exclusive use of The DNA Reporter. All submitted articles must be original, not having been published before, and not under consideration for publication elsewhere. Submissions will be acknowledged by e-mail or a self-addressed stamped envelope provided by the author. All articles require a cover letter requesting consideration for publication. Articles can be submitted electronically by e-mail to Sarah J. Carmody, MBA @ sarah@denurses.org.

Each article should be prefaced with the title, author(s) names, educational degrees, certification or other licenses, current position, and how the position or personal experiences relate to the topic of the article. Include affiliations. Manuscripts should not exceed five (5) typewritten pages and include APA format. Also include the author’s mailing address, telephone number where messages may be left, and fax number. Authors are responsible for obtaining permission to use any copyrighted material; in the case of an institution, permission must be obtained from the administrator in writing before publication. All articles will be peer-reviewed and edited as necessary for content, style, clarity, grammar and spelling. While student submissions are greatly sought and appreciated, no articles will be accepted for the sole purpose of fulfilling any course requirements. It is the policy of DNA Reporter not to provide monetary compensation for articles.

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Guest Editor continued from page 1

Did you know the DNA Reporter goes to all registered nurses in

Delaware for free?

Arthur L. Davis Publishing does a great job of contacting advertisers, who support the publication of our newsletter. Without Arthur L. Davis Publishing and advertising support, DNA would not be able to provide the newsletter to all the nurses in Delaware.

Now that you know that, did you know receiving the DNA Reporter does not automatically provide membership to

the Delaware Nurses Association?

DNA needs you! The Delaware Nurses Association works for the nursing profession as a whole in Delaware. Without the financial and volunteer support of our members, our work would not be possible. Even if you cannot give your time, your membership dollars work for you and your profession both at the state and national levels. The DNA works hard to bring the voice of nursing to Legislative Hall, advocate for the profession on regulatory committees, protect the nurse practice act, and provide educational programs that support your required continuing nursing education.

At the national level, the American Nurses Association lobbies, advocates and educates about the nursing profession to national legislators/regulators, supports continuing education and provides a unified nationwide network for the voice of nurses.

Now is the time! Now is the time to join your state nurses

association! Visit www.denurses.org to join or

call (302) 733-5880.

Did You

Know

and adult primary care, and GI specialists are among the busiest of specialists.

This month’s edition of the DNA Reporter addresses important issues and problems related to the GI system. Whether a registered nurse or advanced practice provider, all will interface with GI symptoms and GI problems, and so this month’s edition provides an overview and review for all nurses.

In the first article, I provide a review and update on inflammatory bowel disease, specifically Crohn’s disease and ulcerative colitis. The second article, written by Erica Harrell-Thompkins, MSN,

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May, June, July 2019 DNA Reporter • Page 3

President’s Message

Gary W. Alderson

Gary W. Alderson, RN, Esq.

Congratulations to our Executive Director, Sarah Carmody, for her recent certification as a Certified Professional in Learning and Performance (CPLP). In addition, thank you to Sarah for all of the work she has put into updating the policies and procedures of the Association. Sarah is a tremendous asset to DNA!

We are moving ahead with our advocacy initiative. As I write this, we are about to hold an online meeting for members interested in learning more and / or working on what we can do to increase our influence with the Delaware General Assembly for the greater good of nurses as well as the public at large, who, after all, are our patients and clients.

We have already been very active in this area, most especially regarding the proposed “Share the Care” bill. This bill would allow home care agencies to employ unlicensed personnel to go into homes to assist with medication administration. DNA is on record as opposing this bill out of a concern about potential liability for nurses who are employed by these home care agencies. In theory, the bill fills a need for persons who simply need help at home with medications. Our concerns arise over how the process will play out in practice. We have vigorously and consistently voiced our concerns about the bill and now it looks as though that even if the bill passes, no agency intends to participate. As we see it, all of the stakeholders should work together to craft a more workable solution for what is a very real problem; a solution that does not inadvertently create more problems than it fixes.

DNA is also very excited to participate in the planning of the first Delaware Nursing Summit, which will take place on May 15, 2019 at the STAR campus of the University of Delaware in Newark. Nurses from several different organizations, disciplines, and practice areas came together to plan this event.

It is hoped that this event will draw nurses from all practice areas and all geographical areas of the state together to discuss issues and build collaboration amongst nurses throughout the state to address tough issues facing nurses and the public at large as healthcare continues to evolve. Some of those issues include what we can do to promote better access to care, promoting nurse leadership in the community, transforming nursing education to meet the needs of a changing healthcare environment, and working with others to build healthier communities in Delaware.

As events on the national level continue to swirl around us in a disturbing political miasma, it is easy to become accustomed to politics as a “dirty word.” Consider this, however. In Delaware, nurses have a very real opportunity to have our voices heard on the statewide level. Nurses are respected and listened to. Moreover, it has been my experience that our Delaware legislators are decent and honorable individuals who may disagree over specific issues, but who agree that we should all strive to do what is best for Delaware and its citizens. They welcome input from all of us, especially when that input is positive, constructive, and realistic.

Thank you.

DNA WelcomesNew Organizational Affiliate

Delaware Diamond Chapter

President: Lori PepperPresident-Elect: Dionne Jones-DendyTreasurer: Courtney CrannellSecretary: Lauren Barone

For information on DNA organizational affiliation, visit www.denurses.org

Page 4 • DNA Reporter May, June, July 2019

See Guest Editor for complete bio on page 1

Sharon Dudley-Brown, PhD, FNP-BC, FAAN, FAANP

Inf lammatory Bowel Disease (IBD) includes both Crohn’s Disease (CD) and Ulcerative colitis (UC), and are chronic, idiopathic inf lammatory disorders of the gastrointestinal system. These patients suffer from debilitating and stigmatizing symptoms and need information about disease management, including that of medications, nutrition, and psychosocial issues, all of which are under the nurse’s purview. Characterized by exacerbations and remissions, symptoms typically include diarrhea (with or without bleeding), abdominal pain, and fatigue, as well as a variety of extraintestinal symptoms. Despite newer treatment options, there is no cure, and as such, persons with IBD are burdened with an uncertain disease state. This article will review the pathogenesis, typical signs and symptoms, diagnosis, & the management of IBD.

Pathogenesis While the exact pathogenesis is still

emerging, three key factors seem to play a role: genetics, luminal antigens and environmental exposures. Currently, IBD is felt to be a result of a dysregulated mucosal immune response to intestinal microf lora in a genetically predisposed individual (Hemperly, Sandborn, & Vande Casteele, 2018). Autoimmune in etiology, it shares many characteristics of other autoimmune diseases, such as having a familial component, and managed by the use of medications that work by suppressing the immune system. Both UC and CD begins at a young age, peak age 15-30 years, but lasts a lifetime.

Signs & SymptomsSymptoms of IBD include both intestinal and

extra-intestinal. The intestinal symptoms depend on the location of the inf lammation. Typically, in UC, the primary symptom is bloody diarrhea, commonly associated with urgency and tenesmus (the feeling of having to have a bowel movement, even when the rectum is empty: rectal retching), indicative of rectal inf lammation (Beery & Kane, 2014). This is because in UC, the disease always affects the rectum, and then may move proximally. In CD, symptoms depend on location. In CD, the disease can occur anywhere from the mouth to the anus, with most of the disease aff licting the end of the small intestine (the terminal ileum, or TI) and the right side of the colon. Disease present in the right lower quadrant (RLQ) typically produces pain in that region,

Inflammatory Bowel Disease

frequently accompanied by diarrhea. Other symptoms in IBD include systemic symptoms including fatigue, fever and weight loss can occur. Extraintestinal manifestations include eye (iritis, uveitis), skin (pyoderma gangrenosum, erythema nodosum), liver (primary biliary cirrhosis, primary sclerosing cholangitis), the kidney (nephrolithiasis), and the bones (osteoporosis) and joints (sacroilitis).

DiagnosisThe hallmark test is the colonoscopy and

biopsy. However, this may not reveal a diagnosis in CD, depending on disease location. In CD, imaging of the small intestine is important, whether it is in the form of a small bowel capsule video endoscopy test (PillCam®), a CT or MR Enterography, or a small bowel series. Other tests include a CBC to assess for degree of anemia, a CMP to assess for f luid and nutritional status, and CRP and sedimentation rate to assess general inf lammation. Also helpful are stool tests to look for inf lammation, such as the stool lactoferrin or calprotectin, which is a test for white blood cells, normally not present in the stool. However, “The diagnoses of Crohn’s disease and ulcerative colitis are based on a combination of inclusionary and exclusionary tests rather than on a single criterion” (Tremaine, 2014, p.1039).

ManagementManagement of IBD includes the use of

medications, monitoring, education, and the provision of psychosocial support.

MedicationsManagement is accomplished through a variety

of medications including the use of mesalamine products (oral and topical) in UC only, glucocorticoids, immunomodulators, and biologic agents. Management goals include achieving remission, suppressing inf lammation, controlling or minimizing complications, and maintaining remission. Choice of medication therapy is based on the severity of the disease (Blonski, Buchner & Lichtenstein, 2014).

First-line medications used to induce and maintain remission in patients with mild-to-moderately active UC are oral formulations of 5- aminosalicylic acid, such as mesalamine (Ko et al., 2019). Conventional corticosteroids (prednisone) should be introduced to patients who do not have an adequate response within 10-14 days to oral and topical 5-ASA formulations, and are effective in inducing remission within an average of 7-14 days, when given at a dosage of 40-60 g per day. Steroids are not, and were never indicated, as a maintenance medication for IBD.

Immunosuppressants and biologics (anti-TNF, alpha-4 integrins, IL-12/23 inhibitors), and JAK inhibitors are indicated for patients with moderate to severe UC & CD, and to date, are the mainstay of treatment (American Gastroenterological Association [AGA] Institute, 2015; Hemperly et al., 2018; Ko et al., 2019). While specific medical management of IBD is beyond the focus of this article, there are recent clinical practice guidelines for the medical management of IBD (AGA Institute, 2015; Hemperly et al., 2018; Ko et al., 2019). In primary care, however, the main take home point for Nurse Practitioners is to not prescribe steroids, and to be sure, patients have an IBD specialist provider.

The 2015 IBD care pathway and guidelines for the identification, assessment, and initial medical treatment by the American Gastroenterological Association (AGA) starts with providers determining whether the IBD patient is low or high risk. Then based on this categorization, initial treatment is recommended. The next step is to determine whether the patient is in remission or not, and as such, further recommendations for management are suggested. There are separate pathways for both CD and UC. More recently, the AGA completed their clinical practice guideline (using GRADE methodology) on the management of mild-to-moderate ulcerative colitis (Ko et al 2019).

MonitoringMonitoring partially depends on the type

and class of medications that are required. For example, patients on mesalamines need to have BUN and creatinine checked every six months.

Patients in thiopurines need to have a CBC and a hepatic panel done every three months. This can easily be delegated to a primary care provider, sending results to the IBD specialist.

Monitoring also includes that of the disease activity itself. For example, blood markers of inf lammation, such as CRP and sedimentation rate, and stool markers (fecal calprotectin or lactoferrin) can be used to guide the degree of inf lammation, and thus, be useful, in some cases, to see improvement after beginning or increasing a medication. In addition, colonoscopies can be used for monitoring of disease activity, as well as for surveillance for colorectal cancer.

EducationEducational needs for patients with IBD are

vast and include that of the disease, medications and treatment, nutrition, risk of colon cancer, as well as fertility and issues around pregnancy. Educational needs of the IBD patient also varies according to whether they are newly diagnosed or have had their disease for a number of years. However, even in the patient with a long history of IBD, assumptions must not be made on the patient’s individual educational needs. Partly because of rapidly changing advances in immunology and treatment, but also partly because of the life stage of the patient (independence, child-rearing, etc.). A recent study suggested that greater disease-specific knowledge maybe associated with decreased psychological distress and improved coping, further supporting the importance of education (Mordakhani, Kerwin, Dudley-Brown, &Tabibian, 2011).

Provision of psychosocial supportBecause these patients suffer from debilitating

and stigmatizing symptoms, they need education on psychosocial issues such as coping, and they need support and referrals. Using patient-centered education, goal setting and the provision of psychological support, it is clear that nurses can improve care and outcomes in the patient with IBD (Dudley-Brown & Fraser, 2009). Nurses can assist patients to navigate the health care system and better manage their IBD. From communication, advocacy, providing and navigating information, and assisting in referrals, nurses can treat or help manage the disease and the person with the disease. In conclusion, IBD is a chronic inf lammatory disease that can lead to significant morbidity, much of which can be modulated and mitigated by astute nurses and providers.

ReferencesAmerican Gastroenterological Association (AGA)

Institute (2015). AGA Institute care pathway on the identification, assessment and initial medical treatment in Crohn’s disease and ulcerative colitis. Available at https://www.gastro.org/guidelines/ibd-and-bowel-disorders

Beery, R.M. & Kane, S. (2014). Current approaches to the management of new-onset ulcerative colitis. Clinical and Experimental Gastroenterology, 7, 111-132.

Blonski, W., Buchner, A.M. & Lichtenstein, G.R. (2014). Treatment of ulcerative colitis. Current Opinion-Gastroenterology, 30 (1), 84-96.

Dudley-Brown, S. & Fraser, A. (2009). A transatlantic comparison of nurse-led, patient-centred care for ulcerative colitis. Gastrointestinal Nursing, 7(6), 38-43.

Hemperly, A., Sandborn, W.J., & Vande Casteele, N. (2018). Clinical pharmacology in adult and pediatric inf lammatory bowel disease. Inf lammatory Bowel Disease, 24 (12), 2527-42.

Ko, C.W., Singh, S., Feuerstein, J.D., Falck-Ytter, C., Falck-Ytter, Y., & Cross, R.K. on behalf of the American Gastroenterological Association (AGA) Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis. Gastroenterology, 156, 748-64.

Mordakhani, A., Kerwin, L., Dudley-Brown, S. & Tabibian, J. H. (2011). Disease-specific knowledge, coping, and adherence in patients with inf lammatory bowel disease. Digestive Diseases and Sciences, 56(10), 2972-7.

Tremaine, W.J. (2014). Nine medico-legal pitfalls in inf lammatory bowel disease in the United States. Current Drug Targets, 15, 1039-41.

May, June, July 2019 DNA Reporter • Page 5

Erica Harrell-Tompkins, MSN, RN, CWON, CCCNLois Dixon, MSN, APRN, AGNP-C, RN-BC, CWOCN

Erica Harrell-Tompkins is a board tri-certified wound, ostomy, and continence nurse at Christiana Care Health System. She is a 1992 graduate from the University of Delaware BSN program and a 2018 graduate from the Wilmington University MSN Leadership program with a concentration in education. Erica cares for inpatients with wound, ostomy, and continence issues at Wilmington Hospital. She has a passion for educating others to the specific needs of ostomy patients and families. Erica can be reached at her office at 302-320-2686 or eharrell-tompkins@christianacare.org

Erica Harrell-Tompkins

Ostomy as a Surgical Option

Lois Dixon is a board tri-certified wound, ostomy, and continence nurse at Christiana Care Health System. She graduated from Immaculata University with a BSN and from University of Delaware with Masters in Adult Geriatric Nursing. Lois graduated from the La Salle University WOC Nurse Education Program in 2006. Lois is a nurse practitioner and clinical leader for the Wound Ostomy Continence Nurses at Christiana Care. Her passion is providing education to patients and families related to ostomy care. Lois can be reached at her office at 302-733-3739 or lodixon@christianacare.org

Lois Dixon

In the United States, up to one million people live with an ostomy; annually, there are approximately 130,000 new ostomy surgeries performed (Maydick-Youngberg, 2017). As reported by Jayarajah, Samarasekara, and Samarasekara (2016), ostomy surgeries are on the rise secondary to an increase in the number of colorectal tumors and inflammatory bowel diseases, two of the leading causes of stoma creation. In addition to colorectal disease and inflammatory bowel disease, other indications for ostomy creation include “bladder cancer, …trauma, congenital disorders such as Hirschprung’s disease or imperforate anus, familial adenomatous polyposis, diverticular disease, and severe neurogenic bladder dysfunction not manageable by more conservative means” (Wound Ostomy and Continence Nurses Society [WOCN], 2018b, para. 3).

DefinitionAn ostomy is a “surgically created opening for the elimination of stool or urine that

can be temporary or permanent” (Wound Ostomy and Continence Nurses Society [WOCN], 2017, p. 1). Ostomies are identified by location, or more specifically, the section of bowel/intestine used during ostomy creation. The three most common types of ostomies include ileostomies, colostomies, and ileal conduit/urostomies (WOCN, 2018b). People with these types of ostomies must wear a pouching system as part of the care maintenance. A pouching system is defined as the products used to collect the stoma output; in addition, these pouching systems provide a predictable seal as well protect the peristomal skin (Colwell, 2016). Patients and caregivers are educated to provide ostomy care – which includes the application of a pouching system and use of accessories.

Ostomy Care EducationOstomates and caregivers are provided education to learn how to properly care

for and manage the ostomy. Optimally this education should occur preoperatively, but many times it may not occur until the postoperative period. Wound Ostomy Continence (WOC) nurses play an integral role in providing this education to patients and caregivers. Studies show that education provided by WOC nurses holds high value with patients and “improves postoperative psychosocial adjustment to the stoma” (Steinhagen, Colwell, & Cannon, 2017, Resources, para. 1). Key components to the ostomy self-care education include the following: stoma and peristomal characteristics and skin care, pouch changing and emptying, diet, medications, supplies – what to order, how to order, where to order, and complications management (WOCN, 2018b). Additionally, information regarding support resources, such as access to home healthcare services, access to a WOC nurse, location of a local ostomy support group are discussed. Local WOC nurse resource phone numbers should be given to the patient to call for questions or problems. If no local WOC nurse resource is available, the WOCN Society has a website with a link to the Patient Information section. This section has a multitude of valuable resources including a link to “Find a WOC Nurse” (WOCN, 2018a). Additionally, ostomy support group information should be discussed. The United Ostomy Associations of America (UOAA) is a national support group – with local affiliates – that “support, empowers, and advocates for people who have had or will have ostomy…surgery” (UOAA, 2019, para. 1). The UOAA website offers a link, Support Group Finder, that helps ostomates and caregivers find local ostomy support groups (UOAA, 2019).

ComplicationsEvidence suggests that stomal and peristomal complications are a common

occurrence. Maydick-Youngberg (2017) reported complication rates for peristomal skin conditions to be as high as 70%. More specifically, complication rates for colostomies and ileostomies have been reported to be as high as 58% and 76%, respectively (Jayarajah, Samarasekara, & Samarasekara, 2016). Complications include stomal

prolapse, stenosis, necrosis (Steinhagen, Colwell, & Cannon, 2017), as well as peristomal skin complications – irritant dermatitis, maceration, fungal infection, allergic contact dermatitis, mechanical damage, peristomal pyoderma gangrenosum (Salvadalena, 2016). Other complications specific to persons with ileostomies include dehydration and food blockage. Steinhagen, Colwell, & Cannon (2017) report that readmission rates of ostomates with ileostomies with a diagnosis of dehydration can be as high as 17%. Once the complication has been diagnosed, the main treatment goals are to promote healing through topical treatment and to adjust and maintain proper pouch seal to the skin (Steinhagen, Colwell, & Cannon, 2017).

With increasing rates for ostomy creation and associated high complication rates, it is imperative that ostomy patients and their caregivers are provided the necessary self-care education and management techniques. As healthcare providers, we have an amazing opportunity to provide this education as well as continued support to the ostomate.

ReferencesColwell, J. C. (2016). Selection of pouching system. In J. E. Carmel, J. C. Colwell,

& M. T. Goldberg (Eds.), Wound Ostomy and Continence Nurses Society Core curriculum: Ostomy management (pp. 120-130). Philadelphia, PA: Wolters Kluwer.

Jayarajah, U., Samarasekara, A., & Samarasekara, D. (2016). A study of long-term complications associated with enteral ostomy and their contributory factors. BMC Research Notes, 9(5). Retrieved from https://doi.org/10.1186/s13104-016-2304-z

Maydick-Youngberg, D. (2017). A descriptive study to explore the effect of peristomal skin complications on quality of life of adults with a permanent ostomy. Ostomy Wound Management, 63(5), 10-23. Retrieved from https://www.o-wm.com/article/descriptive-study-explore-effect-peristomal-skin-complications-quality-life-adults

Salvadalena, G. (2016). Peristomal skin conditions. In J. E. Carmel, J. C. Colwell, & M. T. Goldberg (Eds.), Wound Ostomy and Continence Nurses Society Core curriculum: Ostomy management (pp. 176-190). Philadelphia, PA: Wolters Kluwer.

Steinhagen, E., Colwell, J., & Cannon, L. M. (2017). Intestinal stomas- Postoperative stoma care and peristomal complications. Clinics in Colon and Rectal Surgery 2017; 30(03): 184-192. doi: 10.1055/s-0037-1598159

United Ostomy Associations of America. (2019). Who we are. Retrieved from https://www.ostomy.org/Wound Ostomy and Continence Nurses Society. (2017). Clinical guideline:

Management of the adult with a fecal or urinary. Mt Laurel, NJ: Author. Wound Ostomy and Continence Nurses Society, (2018a). Patient resources:

Resources for the WOC patient. Retrieved from https://www.wocn.org/page/PatientResources

Wound Ostomy and Continence Nurses Society. (2018b). WOCN Society clinical guideline management of the adult patient with a fecal or urinary ostomy —An executive summary. Journal of Wound Ostomy & Continence Nursing, 45(1), 50-58.

Page 6 • DNA Reporter May, June, July 2019

Importance of Follow-up after Bariatric SurgeryValerie Rebmann, MSN, FNP-BC

Valerie Rebmann earned her BSN at Catholic University of America in Washington, D.C. and her MSN at LaSalle University. She is currently working as the Bariatric NP Coordinator for Christiana Care Health System, pursuing her Bariatric Nurse Certification. Valerie has practiced for over fifteen years in the nursing field, with varied specialties including acute care neurology/neurosurgery, pediatrics, and primary care with a focus on diabetes management and education for population health. With a love for education, Valerie has taught in both the university and patient-specific environments. Valerie can be reached by email at Valerie.rebmann@christianacare.org or directly at 302-320-9206.

Valerie Rebmann

Bariatric surgery is a lifelong lifestyle change. There are several options available for weight loss surgery; most commonly sleeve gastrectomy, roux-en-y gastric bypass, and biliopancreatic diversion with duodenal switch (BPD/DS). These are managed by two mechanisms, decreasing the volume of tolerable intake (restrictive) and/or decreasing the amount of vitamins and minerals absorbed by bypassing absorptive intestine (malabsorptive). Sleeve gastrectomy is primarily restrictive in nature, roux-en-y gastric bypass is both restrictive and malabsorptive, and BPD/DS is malabsorptive.

Although each institution may vary in the specific program guidelines, all bariatric surgery programs are required by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to provide pre-operative education including diet, exercise, vitamin supplementation, and lifestyle changes. This pre-operative review should also include peri-operative expectations as well as post-operative complications. The investment patients make in their health makes it even more important for providers to help them in this life long lifestyle change. It is important to recognize this concept when talking about the required follow-up and monitoring after bariatric surgery. The monitoring for someone after bariatric surgery is different – and more in-depth – than any other healthy individual.

Based on (MBSAQIP) guidelines, each bariatric patient should be seen multiple times within the first year post-operatively and then yearly for five years by a bariatric provider and a registered dietitian (see Table 1). Studies have shown that improved follow-up after bariatric surgery will improve outcomes after surgery as well as decrease complications (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), 2016).

At these follow-up visits, there are particular macronutrients and micronutrients that are evaluated to determine a patient’s medical stability. Particularly, protein or prealbumin, B vitamins, folate, iron, and Vitamin D are all important to monitor pre- and post-operatively. Vitamins A, E, K, Magnesium and Zinc should be considered as many post-bariatric surgery patients may become deficient, specifically based on their surgery type.

Protein. Each patient prior to surgery is given a goal for protein in grams for intake. Pre-operatively and post-operatively, prealbumin levels help to monitor that these goals are being met. Due to malabsorption and restriction with bariatric procedures, meeting goals can be challenging. A goal for prealbumin for most bariatric patients will be approximately 1.1-1.5 g/kg ideal body weight per day of protein. The risk of protein malnutrition varies based on surgical procedure, and is much greater in malabsorptive procedures than restrictive procedures at approximately 18-25% and 2% respectively (Handzlik-Orlik, Holecki, Orlik, Wylezol, & Dulawa, 2016).

B Vitamins and Folate. B12 deficiency is common after bariatric surgery in large as a result of malabsorption and reduced intrinsic factor (IF) secretion. Studies have found that high dose Vitamin B12 supplementation may be necessary, however in some cases, due to poor absorption in the small bowel, subcutaneous administration may be required to achieve effective therapeutic levels (Handzlik-Orlik et al., 2016; Still, Sarwer, & Blankenship, 2014). Thiamin (B1) is absorbed in the proximal small intestine. Although there is a Thiamin serum test available, it is unlikely to provide an accurate indicator of total thiamin stores. Current recommendations for post-bariatric surgery patients are 10-64 ng/mL, which can commonly be found in bariatric multivitamins (Still, Sarwer, & Blankenship, 2014). Folate, absorbed in the first third of the small intestine, is usually found as a deficiency for those patients having undergone roux-en-y gastric bypass procedure. This deficiency can commonly be asymptomatic but can lead to anemia and may occur in up to 38% of patients. Oral supplementation for folate generally prevents deficiency (Concors et al., 2016).

Iron. Anemia is common post-operatively – more so in roux-en-y gastric bypass then sleeve gastrectomy, and a greater likelihood in biliopancreatic diversion with duodenal switch (BPD/DS) than roux-en-y gastric bypass. Many patients after weight loss surgery do not tolerate red meat as well as they did prior to surgery (Handzlik-Orlik et al., 2016). Up to 36% of patients after weight loss surgery may suffer from iron deficiency anemia. This can be related to poor iron absorption in the duodenum, decreased food intake, or decreased gastric content (Concors et al., 2016). Although there is iron supplementation in the multivitamins required post-operatively, some patients may require additional ferrous sulfate to prevent anemia due to poor absorption in the small bowel.

Vitamin D. Vitamin D has been found to be commonly deficient in the general population. According to Van Rutte, Aarts, Smulders, and Nienhuijs, (2014), in patients after weight loss surgery, vitamin D deficiency occurs in up to 81% of patients with more severe cases in 43.5% of patients on initial assessment and 36% and 10% respectively when treated and reassessed in one year (van Rutte et al., 2014). This is likely due to well-known findings that patients who are obese have a higher risk at baseline of Vitamin D deficiency due to impaired absorption in fat cell and hepatocytes (Handzlik-Orlik et al., 2016). Based on the guidelines of low vitamin D, ASMBS also recommends dual-

Medical Provider (with Metabolic and bariatric

surgical training)

Nutrition Follow-Up (by Registered Dietitian)

Year 1:• within 30 days of

postop follow-up• Full 30 day

postop follow-up (30-90 days from surgical date)

• 6 month follow-up• 1 year follow-up

Year 1:• within 30 days

post-op • 6 month

(optional-prn)• 9 month

(optional-prn)• 1 year

Year 2 to 5: • 2 year follow-up• 3 year follow-up• 4 year follow-up• 5 year follow-up • and annual

thereafter

Year 2 to 5: • 2 year• 3 year• 4 year• 5 year

May, June, July 2019 DNA Reporter • Page 7energy x-ray absorptiometry (DXA) to monitor for osteoporosis at baseline and at about two years post-operatively (Mechanick, et al., 2013).

Vitamins A, E, K, Magnesium, and Zinc. In particular, with BPD/DS, there is decreased mixing of gastric and pancreatic enzymes until the final portion of the ilium, which can significantly increase the risk of fat soluble vitamins such as A, E, and K (Still, Sarwer, & Blankenship, 2014). Magnesium, absorbed in the duodenum, has a higher likelihood to be deficient in the roux-en-y gastric bypass. Zinc deficiency has been shown, although not commonly, in weight loss surgery. A patient with zinc deficiency can exhibit symptoms such nail dystrophy, alopecia, or poor wound healing. The recommendation is to treat with oral zinc, which is commonly present in the bariatric multivitamins (Concors et. al., 2016).

Additional Considerations. As an advanced practice nurse, recognizing the effects of gastrointestinal changes and best ways to help care for a patient pre-operatively as well as after surgery will be pertinent to best care. Medications that were once well tolerated may need to be changed based on the alterations to the patient’s stomach post-operatively. In the sleeve gastrectomy, as well as in some cases of adjustable gastric banding, the smaller partitioning of the stomach can increase the gastric pH and create a shift in medication absorption. This change can create weaker absorption of acidic medications and increase absorption of more basic medications. Furthermore, extended release or long acting medications may have a diminished bioavailability. This is also a factor with medications that are absorbed and broken down in the small intestine, or in areas that may be bypassed in certain weight loss surgeries (Bland etal., 2016).

Providers can help manage care of the bariatric patient with multiple co-morbidities. As a patient

continues to lose weight successfully; the goal is to watch for the impact on chronic disease. Diabetes, hypertension, obstructive sleep apnea, gastrointestinal reflux disease, and hyperlipidemia are all specifically monitored by MBSAQIP for improvement and resolution with each follow-up visit. According to a meta-analysis by Ricci, Gaeta, Rausa, Macchitella, and Bonavina (2014), there is a clinically significant correlation between BMI reduction and Type 2 Diabetes, hypertension and hyperlipidemia risk reduction.

The importance of follow-up for vitamin and protein deficiency as well as chronic disease management is evident. The required guidelines for follow-up based on MBSAQIP recommendations will help to support this monitoring and improve care of this patient population. The nurse can encourage patients to keep follow-up with their surgeon and weight management practice to enhance each patient’s success. The nurse can also promote support group attendance and reputable online sites for guidance in this life long journey.

ReferencesBland, C.M., Quidley, A.M, Love, B.L., Yeager, C.,

McMichael, B., Bookstavery, P.B. (2016). Long-term pharmacotherapy considerations in the bariatric surgery patient. American Society of Health-System Pharmacists, 73(16), 1230-1242.

Concors, S.J., Ecker, B.L., Maduka, R., Furukawa, A., Raper, S.E., Dempsey, D.D., Williams, N.N., & Dumon, K.R. (2016). Complications and surveillance after bariatric surgery. Current Treatment Options in Neurology, 18, 1-10, DOI: 10.1007/s11940-015-0383-0

Handzlik-Orlik, G., Holecki, M., Orlik, B., Wylezol, M., & Dulawa, J. (2016). Nutrition Management of the Post-Bariatric Surgery Patient. Nutrition in Clinical Practice, 30, 383-390. DOI: 10.1177/0884533614564995

Mechanick, J.I., Youdim, A, Jones, D.B., Garvey, W.T., Hurley, D.L., McMahon, M.M., Heinberg, L.J., Kushner, R., Adams, T.D., Shikora, S., Dixon, J.B., & Brethauer, S. (2013). Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for Obesity and Related Diseases, 9, 159-191.DOI: 10.1016/j.soard.2012.12.010

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). (2nd ed) (2016). Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2016. Chicago, IL.

Parrott, J., Frank, L. Rabena, R., Craggs-Dino, L., Isom, K. A., & Greiman, L. (2017). American society for metabolic and bariatric surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: Micronutrients. Surgery for Obesity and Related Diseases, 13(5), 727-741. DOI: 10.1016/j.soard.2016.12.018

Ricci, C., Gaeta, M., Rausa, E., Macchitella, Y., & Bonavina, L. (2014). Early impact of bariatric surgery on type II diabetes, hypertension, and hyperlipidemia: A systematic review, meta-analysis and meta-regression on 6,587 patients. Obesity Surgery, 24, 522-528. DOI: 10.1007/s11695-013-1121-x

Still, C., Sarwer, D.B., Blankenship, J. (2014). The ASMBS Textbook of Bariatric Surgery: Volume 2: Integrated health. New York, NY: Springer.

Van Rutte, P.W.J., Aarts, E.O., Smulders, J.F, & Nienhuijs, S.W. (2014). Nutrient deficiencies before and after sleeve gastrectomy. Obesity Surgery, 24, 1639-1646. DOI: 10.1007/s11695-014-1225-y

Originally Alberta intended to be a physician and was accepted to the University of Delaware to start her undergraduate studies. Unfortunately, her family could not afford her tuition, so she accepted a job at DuPont Chemical Company. Shortly after starting work there, Alberta realized this was not the job for her and wanted to pursue a career in healthcare. Luckily, in 1946 she was offered a grant to the Wilmington Hospital diploma program where 100% of her tuition was paid if she agreed to work at the hospital for two years post-graduation.

Immediately after graduating from nursing school and receiving her license in August 1949, Alberta started work in the Operating Room and after two years, was promoted to OR supervisor. She continued in this role until her son was born in 1957. She then began part-time work in the Emergency Department. During the next 25 years she alternated between part-time and full-time employment working in the OR and the Emergency Department. While working and raising her son, Alberta earned a BSN in 1964 from the University of Pennsylvania.

Thereafter, Alberta began teaching in the Practical Nursing Program at Brown Technical High School in Wilmington. Eventually the high school closed, and the nursing program was transferred

to Delaware Technical Community College (DTCC)-Stanton Campus. When it was still part of the high school, the nursing program was accredited by the National League for Nursing. Because of her experience, Alberta was invited to become a visiting NLN reviewer. Along with other practical nursing educators from across the country, Alberta helped write exam questions to be used for the National Licensing Examination.

In 1977 she completed her MA in Psychology from Washington College in Chestertown, Maryland. Though she earned a master’s degree, a MSN degree was required to continue as a nurse educator. So, she returned to school while continuing to teach at DTCC. She completed her MSN in 1983 at the University of Delaware with a specialty in Mental Health Nursing. In 1984, Alberta began volunteering on the DNA Continuing Education Committee approving CE programs. Eventually, the DTCC practical nursing program closed and Alberta transferred to the Associate Degree program where she continued teaching until early 1991.

When asked to reflect on her career, Alberta said the highlights were times working in the OR and the many years teaching.

Consider that when Alberta entered the RN nursing program in 1946, there were still those who considered nurses to be ‘handmaidens of the physicians’ and treated them as such. Nurse had many limitations on what they could do while caring for patients. Alberta marveled how far nursing education has progressed, allowing nurses can have appropriate autonomy and be considered a valued member of the medical team.

When asked if she would recommend nursing to anyone considering the profession, Alberta said absolutely and encourage them to volunteer to help with patients to make sure it is the right career choice.

Alberta has not slowed down since she retired. She served as her parish’s Community Faith Nurse,

Alberta Regan – The oldest living licensed registered nurses in Delaware!

as an ANCC reviewer for many years and, until recently, an active member of the DNA Continuing Education Committee. As the oldest licensed nurse in Delaware (the next oldest is 87!), she recently let her license lapse because of the practice hour requirement.

Alberta does not intend to withdraw from nursing. She will continue as an honorary member of DNA to work on quality improvement projects in the office.

To access electronic copies of the DNA Reporter, please visit

http://www.nursingald.com/publications

Page 8 • DNA Reporter May, June, July 2019

Celiac Disease & the Gluten-Free Diet

Jane Kurz, PhD, RN

Dr. Jane Kurz is a professor at LaSalle University and currently serves as the interim Chair of the Undergraduate Program. She earned her BSN from Holy Family University in Philadelphia, her MSN in Burns Emergency and Trauma Nursing at Widener University, and her PhD in Family Studies at the University of Delaware. For more than 40 years, Dr. Kurz has taught medical-surgical nursing, theory, research, and leadership courses for undergraduate and graduate students in nursing and interdisciplinary programs. Her publications and presentations have addressed many topics, such as end-of life education programs, student learning, medical-surgical nursing, international nursing, but her research has focused on organ donation, and families’ involvement with heart-lung transplantation. She was a founding leader for the Celiac Sprue Association of NJ in 1985. Dr. Kurz can be reached at kurz@lasalle.edu

Jane Kurz

Celiac disease (CD), an auto-immune disease caused by sensitivity to gluten, was identified more than one hundred years ago. Gluten is a component of wheat, rye, barley, triticale, and their derivatives. Wheat sub-groups include: wheat berries, durum, emmer, semolina, spelt, farina, farro, graham, khorasan wheat and einkorn. CD is also known as gluten-sensitive enteropathy or non-tropical sprue. This T cell-mediated immune disease affects approximately 1% of the world’s population but especially those with a European background. Some epidemiologists have reported that it is now a common disease in North Africa, Middle East, and India, secondary to predisposing genotypes and increased consumption of gluten-containing cereals (Lionetti, Gatti, Pulvirenti, & Catassi, 2015). Heavey and Stoltman (2016) stated that more than 2 million people in the US are affected but 95% are undiagnosed. Patients with CD will demonstrate a variety of mild to moderate symptoms and are often not diagnosed in childhood. Often it is an astute clinician who assesses the adult client holistically before reaching an accurate diagnosis. CD can develop any time after clients start eating gluten-containing foods. Gluten can cause serious complications to the CD client who is exposed to the gluten though food and medications. Nurses will encounter adults and children with CD in a variety of settings and need to understand this disease.

PathophysiologyIn CD the immune reaction is triggered by

exposure to dietary glutens. There is both a genetic predisposition and an environmental trigger. Garner et al. (2015) have reported an association between genes that encode inherited human leukocyte antigen (HLA), the alleles known as HLA-DQ2 and FRMD4B, and gluten ingestion. The toxic component of gluten is gliadin which will travel to the small intestines. The immune system will produce immunoglobulin A (IgA) which attacks the mucosal lining of the small intestines, resulting in epithelial cell injury and destroying the intestinal villi which play a role in absorption. The villi atrophy and f latten. This inf lammatory response results in malabsorption of nutrients, fat-soluble vitamins, and minerals.

For some clients who eat gluten the IgA antibodies will be directed against epidermal transglutaminase. The antibodies then travel to the skin where they bind with the epidermal transglutaminase protein and produce a dermatitis herpetiformis (DH). This often appears with clients between 30 to 40 years old who often

have no gastrointestinal symptoms. DH affects 10 to 15% of clients diagnosed with CD (Dermatitis Herpetiformis, n.d).

Signs and SymptomsIn the past CD was considered a

gastrointestinal disorder characterized by diarrhea, weight loss, and abdominal pain, especially noted in children younger than two years. The current understanding is that CD is a multisystem disorder. Clients may present with faltering growth in childhood, delayed puberty, anemia, prolonged fatigue, osteoporosis, unexplained fractures, unexplained liver disease, and persistent but unexplained gastrointestinal symptoms. Some clients present with a raised blistery rash on the elbows, knees, or hairline, known as dermatitis herpetiformis (DH). Some “asymptomatic” children are candidates for testing after a first-degree relative is identified.

DiagnosisThe symptoms of CD are very similar to

Crohn’s disease, Irritable Bowel Syndrome, cow’s milk allergy, lactose intolerance, and other gastrointestinal problems. An accurate positive CD diagnosis is achieved via serologic or small bowel biopsy testing. The client must be ingesting gluten at the time of testing or a false negative could be reported. To diagnosis DH, a skin sample (via a punch biopsy) is taken from the area immediately next to a lesion and a f luorescent dye is used to look for the presence of Immunoglobulin A (IgA) deposits that appear in a granular pattern. Skin biopsies of people with DH are almost always positive for this granular IgA pattern. Once a client is diagnosed with CD or DH, the client must follow a strict lifelong gluten-free diet. Clients often find that the symptoms might be reduced when they start the diet initially but it will require several months before the intestinal villi completely recover. CD is never “outgrown” or cured.

Treatment: DietAdherence to the gluten-free diet can be a

challenge because of hidden additives in food. The client must avoid wheat, rye, barley, and their derivatives. Some experts suggest that CD clients avoid oats secondary to the potential of cross-contamination in factories that process other grains. Nurse practitioners and registered nurses in collaboration with dieticians will need to instruct clients and their families after the CD diagnosis during the first few months. If malnutrition was a problem, nutritional deficiencies (iron, calcium, folic acid, vitamins, or proteins) need to be addressed. Blood glucose and thyroid-function tests should be ordered since diabetes and thyroid disease are known to be associated with CD (Fok, Holland, Gil-Zaragozano, & Paul, 2016). Until the intestinal villi heal, clients will have transient lactose intolerance and should follow a lactose-free diet for the first year.

Nurses can highlight common foods which are gluten-free, e.g., rice, corn, potatoes, quinoa, fresh vegetables and fruits, eggs, seafood, and meats. Grocery stores offer many packaged gluten-free foods. However, consumers must read labels to verify it does not contain any gluten. Salad dressings, seasonings, soups, deli meats, candy, and other packaged foods can contain wheat starch or hidden glutens (emulsifiers) In 2013 the FDA began regulating how the label “gluten-free” is applied. However, the FDA still allows a food to be labeled gluten-free if gluten is present but less than 20 parts per million. Clients with CD can sustain intestinal damage if they ingest as little as 50 mg of gluten. This is the amount contained in a few crumbs of bread (Heavey & Stoltman, 2016). If a client with CD sustains injury after eating a product labeled gluten-free, they can contact the FDA’s Center for Food Safety and Applied Nutrition’s Adverse Event Reporting System (CAERS) by phone, 240-402-2405 or email, CAERS@cfsan.fda.gov.

Clients also need to check the ingredients of candy, chips, salsa, and fast food products to verify that they are gluten-free. One can contact the manufacturers directly or check their web sites for the latest available information. CD

organizations (check under resources) post lists of “safe” products. Communion wafers used in several Christian religions are usually made of wheat (unleavened bread) but there are groups that will produce one made from rice f lour. One source is https://www.christianbook.com. Nurse should advise clients to discuss this option with their pastor.

Nurses must warn clients to be cautious about gluten exposure with medications, vitamins, herbal teas, toothpastes, and lip balm. Client should partner with a knowledgeable pharmacist (local and in the hospital) to ensure that all medications are safe. If a brand-name medication is gluten-free, the generic version might not be gluten-free. Although all medications should be checked, capsules and tablets often contain binders, coloring agents, lubricants or bulking agents which could contain glutens. The client, nurse, or pharmacist will need to contact the company to verify the gluten-free formulation. Nurses can also use DailyMed (https://dailymed.nlm.nih.gov/dailymed/index.cfm) to find quickly the ingredients of specific drugs.

Resources Newly diagnosed clients and their families

need accurate information and guidance. Researchers report that women tend to have more psychological distress than men (Almargo, Almagro, Ruiz, Gonzalez & Martinez, 2018). The consensus is that CD affects clients and their families on a personal, emotional, social, and financial dimension. Several researchers report that clients with CD typically go to nurses for support (Almagroet al., 2018; Peterson & Grossman, 2016). Nurses can improve coping strategies by sharing the web sites of various CD organizations. Sources for more information and current research reports include the National Celiac Association (http://nationalceliac.org) and the Celiac Disease Foundation (http://celiac.org). Grzeskowiak (2015) also provided personal insight into the CD experience and client advocacy in her book, Dough Nation, which is available at www.Amazon.com.

ConclusionNurses can play a key role in encouraging

symptomatic clients to be tested without delay for an accurate diagnosis and to teach individuals and families strategies for following a gluten-free diet both at home and in social situations. Although the diet can be challenging, nurses can provide clients accurate food labeling and medication information so clients feel secure in their choices. Providing web sites and local organizational contacts can help clients feel less isolated. In conclusion clients with CD can live a normal and long life following the gluten-free diet.

ReferencesAlmagro, J., Almagro, D., Ruiz, C., González, J., &

Martínez, A. (2018). The experience of living with a gluten-free diet: An integrative review. Gastroenterology Nursing, 41(3), 189-200. doi:10.1097/SGA.0000000000000328.

Fok, C., Holland, K., Gil-Zaragozano, E., & Paul, S. (2016). The role of nurses and dietitians in managing paediatric coeliac disease. British Journal of Nursing, 25(8), 449-455. doi:10.12968/bjon.2016.25.8.449

Garner, C., Ahn, R., Ding, Y. C., Steele, L., Stoven, S., Green, P. H.,… Neuhausen, S. L. (2014). Genome-wide association study of celiac disease in North America confirms F R M D 4 B as new celiac locus. PloS One, 9(7), e101428. doi:10.1371/journal.pone.0101428

Heavey, E., & Stoltman, J. (2016). Caring for hospitalized patients with celiac disease. Nursing, 46(11), 50-55. doi:10.1097/01.NURSE.0000494646.62433.91

Lionetti, E., PhD, Gatti, S., Pulvirenti, A., & Catassi, C. (2015). Celiac disease from a global perspective. Best Practice & Research: Clinical Gastroenterology, 29(3), 365-379. doi:10.1016/j.bpg.2015.05.004

Peterson, M., & Grossman, S. (2016). Managing celiac disease for women: Implications for the primary care provider. Gastroenterology Nursing, 39(3), 186-194. d o i : 1 0 . 1 0 9 7 /SGA.0000000000000197

May, June, July 2019 DNA Reporter • Page 9

Chronic Abdominal Pain in ChildrenMaureen Egan, MSN, APRN

Maureen has been a pediatric nurse for 35 years, with 26 of those years as an APRN. She received her BSN from Widener University and MSN from the University of Pennsylvania. She spent the last 11 years in Pediatric Gastroenterology at Nemours DuPont Pediatrics. Maureen is actively involved in The Association of Pediatric Gastroenterology and Nutrition Nurse, National Association of Pediatric Nurse Practitioner and Crohn’s and Colitis Foundation. Maureen can be reached by e-mail at maureen.egan@nemours.org

Maureen Egan

Abdominal pain is a frequent complaint in pediatric patients accounting for approximately 3-4% of primary care visits and 25% of visits to a pediatric gastroenterologist (Gomez-Suarez, 2016). Yet only a small number of children with abdominal pain have an underlying organic disease (Subcommittee on Chronic abdominal pain, 2005). 25 years ago, The Rome Foundations was established to legitimize and update knowledge of functional gastrointestinal disorders by bringing together experts in the field to create recommendations for diagnosis and treatment (Drossman, 2016). The most recent criteria, published in 2016, differentiated abdominal pain as Functional Dyspepsia, Irritable Bowel Syndrome (IRB), Abdominal Migraines and Functional Abdominal Pain (FAP) (Hyams et al., 2016) see Table I.

The pathophysiology of functional abdominal pain involves a distortion of the perception of visceral sensation that alters the brain-gut communication (Gomez-Suarez, 2016). Functional abdominal disorders may be associated with visceral hyperalgesia, a decreased threshold for pain in response to changes in intraluminal pressure (Subcommittee on Chronic abdominal pain, 2005). The evaluation of abdominal pain begins with a detailed history and physical exam focusing specifically on each symptoms assessing for Alarm symptoms (Zeiter, 2017) see Table II.

The tests most commonly performed for evaluation of functional abdominal pain include a CBC, CMP, ESR, CRP, UA, fecal occult blood, celiac serology and in some select cases fecal calprotectin (Gomez-Suarez, 2016; Edwards, 2018). Specialty studies usually ordered by a pediatric gastroenterology provider include an upper endoscopy, colonoscopy, HIDA scan and breath tests (Gomez-Suarez, 2016).

A successful treatment plan starts with a strong patient-parent-provider relationship in which the child’s pain is validated (Leiby et al., 2016). The development of a treatment plan for patients with functional gastrointestinal disorders (FGID) is an individualized process. The arms of therapy include dietary therapy, pharmacologic therapy, psychosocial support and complementary/alternative interventions (Zieter, 2017). The Low-FODMAP diet shows some improvement in symptoms with Irritable Bowel Syndrome based on the results of the first double-blind randomized trial (Leiby et al., 2016). FODMAPs (fermentable, oligosaccharides, disaccharides, monosaccharides and polyols) are short-chain poorly absorbed carbohydrates. They have been grouped together under this umbrella term because they are all rapidly fermented and are osmotically active in the gut. This mechanism is thought to induce symptoms of IBS (Gibson et al., 2013; Barrett, 2013). Probiotic use is based on the concept that the pathophysiology of IBS involves an altered microflora although current data is limited. Despite these limitations, probiotic use for IBS is considered safe and well tolerated treatment option (Leiby et al., 2016). Pharmacologic therapy may include the use of antispasmodics (hyoscyamine and dicyclomine) and antidepressants (Zeiter, 2017). Although psychological and emotional factor are rarely the only concerns for FGID, the effect that chronic pain can have on a person means that both stressors and coping mechanisms need to be addressed (Edwards, 2018). A Randomized control trial of cognitive behavior therapy for Pediatric

Table II: Evaluation of Abdominal Pain

Potential Alarm Features in Children with Chronic Abdominal Pain

1. Family history of inflammatory bowel disease, celiac disease or peptic ulcer disease

2. Persistent right upper or right lower quadrant pain

3. Dysphagia4. Odynophagia5. Persistent vomiting6. Gastrointestinal blood loss7. Nocturnal diarrhea8. Arthritis9. Perirectal disease10. Involuntary weight loss11. Deceleration of linear growth12. Delayed puberty13. Unexplained fever

Hyams, J, Di Lorenzo, C, Spas, M, Shulman, R, Staiano, A & van Tilburg, M (2016). Childhood functional gastrointestinal disorders: Child/Adolescents. Gastroenterology, 150, 1456-1468.

Gary W. aldersonattorney at laW, reGistered nurse

Table I: Differentiated Abdominal Pain

Functional Dyspepsia(Fd)

Irritable Bowel Syndrome (IBS) Abdominal MigraineFunctional Abdominal Pain

– not otherwise specified

Diagnostic Criteria Diagnostic Criteria Diagnostic Criteria Diagnostic Criteria

• One or more of the following: a. Bothersome postprandial fullness. b. Bothersome early satiation. c. Bothersome epigastric pain. d. Bothersome epigastric burning.

• No evidence of Structural Disease that is likely to explain the symptoms.

Recurrent abdominal pain on average at least one day/week in the last three months associated with two or more of the following criteria:

• Related to defecation.• Associated with change

in frequency of stool.• Associated with change

in form (appearance of stool).

Must include all of the following at least twice:• Paroxysmal episodes of intense, acute

periumbilical, midline or diffuse abdominal pain lasting one hour or more (should be most severe and distressing symptom).

• Episodes are separated by weeks to months.• The pain is incapacitation and interferes with

normal activities.• Stereotypical pattern and symptoms in the

individual patient.• The pain is associated with two or more of the

following:a. Anorexiab. Nauseac. Vomitingd. Headachee. Photophobiaf. Pallor

• After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.

Must be fulfilled at least 4x/ month and include all the following:

1. Episodic or continuous abdominal pain that does not occur solely during a physiologic event (eating, menses).

2. Insufficient criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine.

3. After appropriate evaluation, the abdominal pain cannot be fully explained by another medical condition. Criteria fulfilled for at least two months prior to diagnosis.

Drossman, Douglas, Chang, Lin, Chey, William, Kellow, Johg, Tack, Jan, Whitehead, William & the Rome IV Committee (Eds), 2016, Rome IV Functional Gastrointestional Disorders, Disorders or Gut-Brain Interaction, Raleigh, NC, Rome Foundation.

Hyams, J, Di Lorenzo, C, Spas, M, Shulman, R, Staiano, A & van Tilburg, M (2016). Childhood functional gastrointestinal disorders: Child/Adolescents. Gastroenterology, 150, 1456-1468.

We're looking for RNs, LPNs and CNAs to join our team of dedicated professionals.

The contact person is Chad Golden (Director of Nursing)

email: don@brandywinenh.com phone number: 302-998-0101

OUR STAFF’S GOAL IS TO PROVIDE A WARM, FRIENDLY, AND CARING ATMOSPHERE, WHERE WE MEET THE MEDICAL AND PERSONAL NEEDS OF EACH RESIDENT.

Page 10 • DNA Reporter May, June, July 2019

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Functional abdominal pain showed a greater than 60% reduction of abdominal pain up to one year after treatment (van der Veek, Derkx, Benninga, Boer, & de Hann, 2013). Complementary/alternative therapy including herbs, turmeric, peppermint, and artichoke leaf have some suggestion of benefit (Leiby et al., 2016).

In summary, chronic abdominal pain is a significant complaint in pediatrics. Most patients will have a FGID which can be established with a good history and physical exam. The majority of patients will only require screening laboratory test. Effective treatment requires a holistic approach with a strong patient-parent-provider relationship. Nurses play a key role in the education and support of patients with FGID and their parents. Educational materials are available on reliable websites such KidsHealth.org and GI kids.org

ReferencesAmerican Academy of Pediatrics & North American Society of Pediatric

Gastroenterology, Hematology and Nutrition, 2005, Chronic abdominal pain in children. Pediatric, 11, 3, 812-815.

Barrett, Jacqueline (2013) Extending our knowledge of fermentable, short-chain carbohydrates for managing gastrointestinal symptoms. Nutrition in Clinical Practice, 28, 300-306.

Drossman, Douglas, Chang, Lin, Chey, William, Kellow, Johg, Tack, Jan, Whitehead, William & the Rome IV Committee (Eds), 2016, Rome IV Functional Gastrointestional Disorders, Disorders or Gut-Brain Interaction, Raleigh, NC, Rome Foundation.

Edwards, S (2018) Recurrent abdominal pain in children. Pediatrics and Child Health, 28, 1, 34-36.

Gibson, P.R, Barrett, J.S and Muir, J.G (2013) Functional bowel symptoms and diet. Internal Medicine Journal, 43, 1067-1074.

GI Kids https://www.gikids.org/Gomez-Suarez, R (2016) Difficulties in the diagnosis and management of

functional or Recurrent Abdominal Pain in Children. Pediatric Annals, 45, 11, e388-e393.

Hyams, J, Di Lorenzo, C, Spas, M, Shulman, R, Staiano, A & van Tilburg, M (2016) Childhood Functional Gastrointestinal Disorders: Child/Adolescents. Gastroenterology, 150, 1456-1468.

KidsHealth https://kidshealth.org/Leiby, A & Vazirani, M (2016) Complementary, integrative and holistic medicine:

integrative approaches to pediatric Irritable Bowel Syndrome. Pediatrics, 37, e10-e15.

Van der Veek, S, Derkx, B, Benninga, M, Boer & de Hann (2013) Cognitive behavior therapy for Pediatric Functional Abdominal Pain: a randomized controlled trial. Pediatric, 132, e1163-e1172.

Zeiter, D (2017) Abdominal pain in children. Pediatric Clinics of North America, 64, 3, 525-541.

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May, June, July 2019 DNA Reporter • Page 11

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