Ulcerative colitis is a chronic, inflammatory disease of the colon, and 20% of the cases occur before the individual reaches the age of 20 years. Usually, the disease begins in the rectum and sigmoid colon and gradually spreads up the colon in a continuous distribution pattern. The inflammatory process involves the mucosa and submucosa of the colon.
Gradually, multiple ulcerations and abscesses form at the inflamed areas. As the disease progresses, the colon mucosa becomes edematous and thickened with scar tissue formation, which results in altered absorptive capabilities of the colon. The severity of the disease ranges from a mild form that is localized in specific areas of the bowel to a critical syndrome with life-threatening complications. The most common complications are nutritional deficiencies; others include sepsis, fistulae, abscesses, and hemorrhage. For unknown reasons, patients with ulcerative colitis also have a high risk for arthritis and cancer.
Research has not established a specific cause for ulcerative colitis. Several theories are being pursued, including infectious agents such as a virus or bacteria, an autoimmune reaction, environmental factors such as geographic location, and genetic factors. Current thinking holds that psychosomatic factors such as emotional stress are a result of the chronic and severe symptoms of ulcerative colitis rather than a cause, as was once thought.
Nursing care plan assessment and physical examination
A patient with acute ulcerative colitis typically reports numerous episodes of bloody diarrhea. The number of stools may range from 4 to 5 to 10 to 25 per day during severe episodes, often causing sleepless nights. In addition, the patient may report abdominal pain and cramping that is relieved with defecation. Other symptoms may include fatigue, diminished appetite with weight loss, low-grade fever, and nausea with vomiting.
Because ulcerative colitis is a chronic disease, which may cause periods of anorexia, diarrhea, and intestinal malabsorption, inspect for the signs of malnutrition and dehydration: dry mucous membranes, poor skin turgor, muscle weakness, and lethargy. Palpate the patient’s abdomen for tenderness and pain. Typically, pain is noted in the left lower quadrant of the abdomen. Auscultate the patient’s abdomen; bowel sounds are often hyperactive during the inflammatory process. Assess the patient for infection. During the acute inflammatory process, monitor the patient’s vital signs every 4 hours or more frequently if the patient’s condition is unstable. Watch for temperature elevations and rapid heart rate, which often indicate an infectious process.
The effects of chronic illness and debilitating symptoms often result in psychological problems for the patient with this disease. Note the patient’s current psychological status because depression is common for those with ulcerative colitis. Because emotional stress increases bowel activity and plays a critical role in the exacerbation of the disease, it is also important to assess the patient’s current life stressors. In addition, determine the need for instruction on stress reduction techniques.
Nursing care plan primary nursing diagnosis: Alteration in nutrition: Less than body requirements related to anorexia, diarrhea, and decreased absorption of the intestines.
Nursing care plan intervention and treatment plan
Drug therapy is the typical method used to control the inflammatory process. Sulfasalazine is the primary drug used to achieve remission. After remission is established, dosages are generally reduced, and patients continue on this agent for at least 1 year after an acute attack. To maintain fluid and electrolyte balance during acute attacks, intravenous (IV) fluids are generally prescribed, and electrolytes may be added to the solutions as needed. Blood transfusions may also be prescribed if the patient is anemic because of numerous bloody diarrheal stools. To achieve bowel “rest,” the patient is usually given nothing by mouth. During this time, nutritional deficits may be managed through the use of total parenteral nutrition with vitamin supplements. Helping patients maintain an adequate nutritional status, fluid balance, and electrolyte balance is a priority nursing measure. Record intake and output accurately every shift. Note the number of stools and stool characteristics. Gradually, as the acute attack subsides and inflammation clears, the patient is placed on a low-residue, low-fat, high-calorie, high-protein, lactose-free diet.
Surgery may be performed when patients fail to respond to conservative treatment, if acute episodes are frequent, or when a complication such as bleeding or perforation occurs. The standard surgical procedure, when performed, is a total proctocolectomy with ileostomy. This procedure is considered a permanent cure for ulcerative colitis. To prepare the patient for surgery, administer bowel preparations such as laxatives and enemas.
Promote patient physical and emotional comfort. Encourage the patient to assume the position of comfort. Instruct in distraction techniques as needed. Promote mental comfort by encouraging the patient to share thoughts and feelings and provide supportive, empathetic care. Discuss measures to decrease life stressors. Teach the patient about the disease process and the typical treatment regimen. Areas to include in the teaching plan include the signs of disease complications, the importance of rest and stress reduction, and any dietary adjustments.
If the patient requires surgery, several nursing interventions are important in the preoperative phase. First, conduct preoperative teaching sessions on deep-breathing techniques and leg exercises. Also, discuss the operative procedure and the typical postoperative course. When appropriate, discuss with the patient information on stoma placement and stoma care. After surgery, ensure a healthy respiratory status for the patient by encouraging the patient to cough and deep-breathe every 1 to 2 hours. Manage patient pain and discomfort with prescribed analgesics and proper positioning techniques. Monitor for adequate wound healing by checking the color and approximation of the wound and noting any wound drainage or odor. Note the stoma size and color during every shift and immediately report any duskiness noted at the stoma site. Note the condition of the skin around the stoma; protect the skin with appropriate barrier products because ileostomy drainage is extremely caustic to skin tissues. Finally, encourage the patient’s participation in ostomy care. Assess whether a community resource person from the United Ostomy Association is needed to offer the patient additional support.
Nursing care plan discharge and home health care guidelines
The patient must understand all prescribed medications, including actions, side effects, dosages, and routes. Emphasize ways to prevent future episodes of inflammation (rest, relaxation, stress reduction, well-balanced diet). Review the symptoms of inflammation. Teach the patient to seek medical attention if such symptoms occur. Be certain the patient understands symptoms of complications, such as hemorrhage, bowel strictures and perforation, and infection. The patient must know to seek medical attention if these complications should occur. Ensure that the patient understands the importance of close follow-up because of the high incidence of colon and rectal cancer in patients with ulcerative colitis.