Nursing Diagnosis Nursing Care Plan for Ulcerative Colitis: A Comprehensive Guide

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that affects the innermost lining of the large intestine (colon) and rectum. This condition is characterized by inflammation and ulceration, primarily impacting the rectum and extending upwards into the colon. The exact etiology remains elusive, though genetic predisposition plays a significant role. Certain populations, such as those of Jewish descent, may exhibit a higher incidence. While diet and stress are not causative factors, they can exacerbate existing symptoms.

In UC, the body’s immune system mistakenly identifies the colon’s lining cells and beneficial gut bacteria as foreign invaders. This misdirected immune response leads to white blood cells attacking and damaging the colon’s lining. Consequently, the colon becomes inflamed, irritated, and edematous, making it susceptible to ulcers and potential perforation. Over time, scar tissue formation diminishes the colon’s flexibility and nutrient absorption capacity.

Nursing Process in Ulcerative Colitis Management

Managing ulcerative colitis necessitates continuous monitoring and lifelong treatment to mitigate relapses. Regular surveillance colonoscopies, typically every one to two years, are crucial due to the elevated risk of colorectal cancer in UC patients. Furthermore, given the use of biological agents in treatment, routine screenings for skin malignancies are also recommended.

Patient education is paramount, emphasizing the importance of medication adherence in preventing disease recurrence. Nurses should promote proactive health measures, including regular vaccinations, diligent hand hygiene, and cancer screenings. Dietary guidance, particularly for patients with a stoma, is essential. Equally important is the nurse’s role in addressing the emotional well-being of patients, monitoring for conditions like depression and low self-esteem that can frequently accompany chronic illnesses.

Nursing Assessment for Ulcerative Colitis

The initial phase of nursing care involves a thorough nursing assessment, encompassing the collection of physical, psychosocial, emotional, and diagnostic data. This section delves into the subjective and objective data pertinent to ulcerative colitis.

Review of Health History

1. Inquire about General Symptoms: Bloody diarrhea, often accompanied by mucus, is a hallmark symptom of ulcerative colitis. The severity of UC can manifest in a spectrum of symptoms, including:

• Rectal bleeding
• Tenesmus (a persistent urge to defecate)
• Abdominal discomfort and cramping
• Rectal pain
• Fatigue
• Loss of appetite

2. Determine the Type of Ulcerative Colitis: Ulcerative colitis is classified based on its location and extent within the colon, influencing the symptom presentation:

• Ulcerative Proctitis:
  • Location: Confined to the rectum.
  • Symptom: Predominantly rectal bleeding.
• Proctosigmoiditis:
  • Location: Affects the rectum and sigmoid colon (the lower segment of the colon).
  • Symptoms: Bloody diarrhea, abdominal cramps, abdominal pain, and tenesmus.
• Left-sided Colitis:
  • Location: Involves the left side of the colon (descending colon and sigmoid colon).
  • Symptoms: Left-sided abdominal cramps, bloody diarrhea, and unintentional weight loss.
• Pancolitis:
  • Location: Extends throughout the entire colon.
  • Symptoms: Severe bloody diarrhea, abdominal cramps, abdominal pain, fatigue, and significant weight loss.

3. Investigate Changes in Bowel Habits: Ulcerative colitis flare-ups are frequently marked by abdominal pain and cramping coupled with bowel urgency. Stools are typically loose and may contain blood and/or pus.

4. Identify Risk Factors: Understanding risk factors aids in patient assessment and risk stratification.

Non-modifiable risk factors:

• Ethnicity: Caucasians and individuals of Jewish ancestry exhibit a higher prevalence of UC.
• Age: Onset peaks between 15 and 30 years of age, with a secondary, smaller peak between 50 and 70 years old.
• Family History: The risk increases if a first-degree relative (parent, sibling, or child) has ulcerative colitis.

Modifiable risk factors:

5. Review NSAID Use: Non-steroidal anti-inflammatory drugs (NSAIDs) have been linked to the development or exacerbation of ulcerative colitis.

6. Ask about History of Appendectomy: An appendectomy before the age of 20 is associated with a decreased incidence of ulcerative colitis, which may be relevant in differential diagnosis.

Physical Assessment

1. Perform an Abdominal Examination: While abdominal findings may be normal, tenderness is commonly present during a flare. Other potential findings include:

• Voluntary or involuntary guarding
• Rebound tenderness (suggestive of advanced colitis or potential perforation)
• Palpable mass (may indicate blockage or toxic megacolon)
• Enlarged spleen (potential sign of primary sclerosing cholangitis or autoimmune hepatitis with portal hypertension)

2. Monitor for Weight Loss Regularly: Weight loss is a frequent manifestation of ulcerative colitis, resulting from pain, diarrhea, and the inflammatory process itself.

3. Auscultate Bowel Sounds: Bowel sounds in UC can be hypoactive, hyperactive, or normal. Obstructions may produce high-pitched tinkling sounds.

4. Perform a Perianal Examination: A perianal examination in UC patients should typically be negative for fistulas or abscesses. However, persistent diarrhea can lead to perianal erythema, fissuring, or hemorrhoids.

5. Assess for Extraintestinal Manifestations: Ulcerative colitis can affect organs beyond the intestines, presenting with extraintestinal symptoms:

• Joint pain (arthritis)
• Red, swollen, and painful eyes (uveitis, episcleritis)
• Skin rashes (erythema nodosum, pyoderma gangrenosum)
• Liver impairment (primary sclerosing cholangitis)
• Delayed growth (in pediatric patients)

6. Conduct a Complete Physical Assessment: A comprehensive assessment should include:

• General: Fever, weight loss, fatigue levels.
• HEENT: Assess for episcleritis and uveitis.
• Gastrointestinal: Characterize abdominal pain, stool consistency and presence of blood, tenesmus.
• Musculoskeletal: Evaluate for joint pain in large joints (hips, knees, ankles), and signs of ankylosing spondylitis. Assess for osteoporosis risk factors.
• Integumentary: Note pallor, poor skin turgor (dehydration), jaundice (liver involvement), and erythema nodosum.

7. Note Delayed Growth and Development in Pediatric Patients: Growth failure is a significant complication in children with UC, resulting from inflammation, immune response, malnutrition, and steroid use. Puberty and sexual maturation may also be delayed.

8. Check Stool Characteristics: Bloody stools are characteristic of UC. Blood may appear bright red, pink, maroon, or, less commonly, black. Pus and mucus may also be present.

Diagnostic Procedures

1. Clinical Diagnosis with Supportive Findings: Ulcerative colitis diagnosis is primarily clinical, supported by endoscopic and biopsy findings. Imaging studies help detect acute flares and complications.

2. Stool Sample Testing:

• White blood cells (WBCs) in stool: Indicate inflammation and can help rule out infectious etiologies.
• Fecal calprotectin: Elevated levels correlate with neutrophil infiltration in the colon, aiding in differentiating IBD from irritable bowel syndrome (IBS).

3. Blood Sample Analysis for Inflammatory Markers and Systemic Effects:

• Complete blood count (CBC) with metabolic panel: Assesses for anemia (iron deficiency, vitamin B12 deficiency) common in UC. Hypoalbuminemia and electrolyte imbalances may indicate malnutrition and dehydration.
• Serology (p-ANCA and ASCA): Perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are frequently present in UC, while anti-Saccharomyces cerevisiae antibodies (ASCA) are more associated with Crohn’s disease.
• Inflammatory markers (CRP and ESR): C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels increase with the severity of inflammation in UC.

4. Imaging Scans: Visualize the gastrointestinal tract to identify inflammation and complications.

• CT enterography/MR enterography (MRE): Excellent for ruling out small intestine involvement and detecting intestinal inflammation. MRE is radiation-free.
• CT scan of the abdomen: Can differentiate UC from Crohn’s disease and assess for complications.
• Plain X-rays: Useful as a first-line modality to rule out severe complications like toxic megacolon or perforated colon.
• Double-contrast barium enema: Can detect early mucosal changes, although less commonly used now with the advent of advanced endoscopy.

5. Colon Visualization:

• Colonoscopy: Essential during suspected flares to assess inflammation, mucosal changes, and obtain biopsies for definitive UC diagnosis.
• Flexible sigmoidoscopy: Effective for assessing UC activity and treatment response, particularly in cases limited to the rectum and sigmoid colon.

Nursing Interventions for Ulcerative Colitis

Nursing interventions and holistic care are crucial for patient recovery and long-term management of ulcerative colitis. The following sections outline key nursing interventions.

Managing Inflammation

1. Induce and Maintain Remission: The primary goal of UC treatment is to induce clinical remission (resolution of symptoms) and maintain it, thereby improving the patient’s quality of life.

2. Administer Anti-inflammatory Medications: These are the cornerstone of UC treatment. 5-aminosalicylates (5-ASAs) are typically the first-line agents. If remission is not achieved within a couple of weeks, oral or rectal glucocorticoids may be added. Except for glucocorticoids (due to long-term side effects), these medications can be used for maintenance therapy.

• 5-Aminosalicylates (sulfasalazine, mesalamine, olsalazine, balsalazide): Choice and route of administration (oral, topical enema/suppository) depend on the location of disease.
• Corticosteroids (prednisone, budesonide): Used for moderate to severe UC to induce remission, particularly when 5-ASAs are insufficient. Generally not for long-term maintenance due to side effects.

3. Immunosuppression: Immunosuppressants modify the immune system to reduce inflammation.

• Thiopurines (azathioprine, 6-mercaptopurine): Used as steroid-sparing agents and for maintenance of remission.
• Cyclosporine and tacrolimus: Potent immunosuppressants, sometimes used for severe, refractory UC, often in the hospital setting.

4. Biologic Therapies: Target specific components of the immune system involved in inflammation.

• Anti-TNF agents (infliximab, adalimumab, golimumab, certolizumab pegol): Block tumor necrosis factor (TNF), a key inflammatory cytokine.
• Anti-integrin agents (vedolizumab): Block leukocyte trafficking to the gut.
• Anti-IL-12/23 agents (ustekinumab): Block interleukin-12 and interleukin-23, cytokines involved in inflammation.
• Anti-JAK inhibitors (tofacitinib): Inhibit Janus kinase (JAK) enzymes, intracellular signaling molecules involved in inflammation.

5. Symptom Management: Medications to alleviate specific symptoms. Patients should always consult their healthcare provider before using over-the-counter medications.

• Antidiarrheals (loperamide, diphenoxylate/atropine): Used to manage severe diarrhea but should be used cautiously due to the risk of toxic megacolon.
• Pain relievers (acetaminophen): Recommended for mild pain. NSAIDs like ibuprofen, naproxen, and diclofenac should be avoided as they can worsen UC symptoms.
• Antispasmodics (hyoscyamine, dicyclomine): Occasionally prescribed to relieve abdominal cramps.
• Iron supplements: To address iron deficiency anemia due to intestinal bleeding.

6. Surgical Intervention: Colectomy (surgical removal of the colon) is curative for ulcerative colitis, as the disease is limited to the colon.

• Proctocolectomy with ileal pouch-anal anastomosis (IPAA): The preferred surgical approach, creating an internal pouch from the ileum connected to the anus, allowing for near-normal bowel function.
• Proctocolectomy with ileostomy: An alternative for patients not suitable for IPAA, resulting in a permanent ileostomy (external stoma).

Indications for surgery include:

• Fulminant colitis unresponsive to medical therapy
• Toxic megacolon
• Perforation
• Uncontrollable hemorrhage
• Intolerable drug side effects
• Strictures causing obstruction
• High-grade dysplasia or malignancy
• Growth retardation in children

7. Relapse Prevention: Maintenance therapy is crucial to prevent disease recurrence. Individualized medication regimens are tailored to each patient’s needs and disease characteristics.

Preventing Flare-ups

1. Promote a Healthy Gut Microbiome: Probiotics may help maintain remission by fostering a balanced gut bacteria environment. Further research is ongoing in this area.

2. Identify and Avoid Trigger Foods: Dietary triggers vary among individuals. Common culprits include dairy products, high-fiber foods, sugary foods, spicy foods, caffeine, and alcohol. Food diaries can help patients identify their specific triggers.

3. Recommend Small, Frequent Meals: Eating smaller, more frequent meals may be better tolerated during flares and can help prevent malnutrition.

4. Maintain Hydration: Adequate fluid intake, especially water, is essential to prevent dehydration, particularly with diarrhea. Carbonated drinks can cause gas, and alcohol can exacerbate diarrhea.

5. Dietary Consultation: A registered dietitian specializing in IBD can provide personalized dietary guidance and meal plans.

Establishing Regular Elimination

1. Monitor Bowel Elimination Patterns: Mild UC may involve fewer than four bowel movements daily, while moderate to severe UC can result in more than four. Monitor frequency, consistency, color, odor, and presence of blood or mucus.

2. Avoid Straining During Defecation: Educate patients on proper defecation techniques, including optimal positioning (squatting) and avoiding straining. Adequate fluid and fiber intake (when tolerated) can promote regular bowel movements.

3. Monitor for Complications: Closely observe for signs of complications such as bleeding, fecal impaction, or intestinal obstruction.

Supporting Coping Mechanisms

1. Stress Management: While stress doesn’t cause UC, it can worsen symptoms and trigger flares. Encourage stress-reducing activities like exercise, meditation, walking, and journaling.

2. Patient Education about UC: Empowering patients with knowledge about their condition is crucial for self-management and control. Provide comprehensive information about UC, treatment options, and lifestyle modifications.

3. Support for Pediatric Patients and Families: Children with UC require comprehensive family support. Family counseling can be beneficial to address the emotional and practical challenges of managing UC in children.

4. Bathroom Access Strategies: Bathroom access cards can alleviate anxiety related to needing immediate restroom access when traveling or in public places.

Nursing Care Plans for Ulcerative Colitis

Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Examples of nursing care plans for common ulcerative colitis-related nursing diagnoses are provided below.

Acute Pain

Acute pain is a significant concern for individuals with ulcerative colitis, often impacting their quality of life.

Nursing Diagnosis: Acute Pain

Related to:

• Intestinal inflammation
• Hyperactive bowel motility (hyperperistalsis)
• Persistent diarrhea
• Anal and rectal irritation
• Fistula formation
• Joint arthralgias
• Scleritis

As evidenced by:

• Reports of abdominal pain and cramping
• Facial grimacing
• Guarding behaviors
• Distraction behaviors
• Restlessness
• Self-focusing

Expected Outcomes:

• Patient will report a reduction in abdominal pain intensity using a pain scale.
• Patient will verbalize and utilize at least two effective pain management strategies.
• Patient will demonstrate relaxed body language and improved comfort.

Assessments:

1. Assess and characterize abdominal pain: Investigate reports of abdominal pain, noting location, onset, duration, character, aggravating/relieving factors, and severity using a pain scale (e.g., 0-10). Document any changes in pain characteristics.
2. Auscultate bowel sounds: Increased peristalsis due to colitis can result in hyperactive bowel sounds, abdominal cramping, and pain.
3. Observe nonverbal pain cues: Monitor for nonverbal indicators of pain such as restlessness, facial expressions (grimacing, furrowed brow), guarding, and distraction behaviors.
4. Identify pain triggers: Explore factors that exacerbate pain, such as stress, specific foods (fatty, spicy, sugary foods, caffeine, alcohol, carbonated drinks).

Nursing Interventions:

1. Optimize patient positioning: Assist the patient to find a comfortable position. Lateral positions or positions that reduce abdominal muscle tension may be beneficial.
2. Educate on and administer appropriate medications: Administer prescribed analgesics as ordered. Acetaminophen may be suitable for mild pain. Antispasmodics can help alleviate abdominal cramps. Avoid NSAIDs (ibuprofen, naproxen, diclofenac) as they can worsen UC symptoms.
3. Administer opioids and adjuvant analgesics as prescribed: Severe pain may require opioid analgesics. Adjuvant analgesics, such as certain antidepressants (e.g., tricyclic antidepressants), may be considered for chronic pain components.
4. Encourage non-pharmacological pain management techniques: Explore and encourage non-pharmacological approaches such as relaxation techniques, deep breathing exercises, guided imagery, heat or cold applications (as tolerated and preferred by the patient), and distraction techniques.
5. Promote stress management strategies: Address the role of stress in pain exacerbation. Encourage stress reduction techniques like mindfulness, meditation, gentle exercise, and hobbies.
6. Provide rectal comfort measures: Frequent loose stools can cause rectal pain and skin irritation. Offer warm sitz baths for soothing relief. Clean the perianal area gently with soft, cool wipes after each bowel movement. Consider barrier creams to protect perianal skin.

Diarrhea

Diarrhea is a hallmark symptom of ulcerative colitis, resulting from colonic inflammation, altered motility, and malabsorption.

Nursing Diagnosis: Diarrhea

Related to:

• Inflammation of the colonic mucosa
• Increased frequency of bowel movements
• Altered colonic motility
• Presence of inflammatory exudates and blood

As evidenced by:

• Frequent, loose, watery stools
• Bloody stools (bright red, maroon, or black)
• Stools containing pus or mucus
• Foul-smelling stools
• Abdominal pain and cramping
• Tenesmus
• Rectal pain
• Hyperactive bowel sounds
• Weight loss
• Dehydration

Expected Outcomes:

• Patient will experience a decrease in stool frequency and urgency, reporting fewer than three bowel movements per day, ideally with improved stool consistency.
• Patient will demonstrate normoactive bowel sounds upon auscultation.
• Patient will pass stools without blood or mucus.
• Patient will maintain adequate hydration, as evidenced by stable vital signs and urine output.

Assessments:

1. Analyze bowel movement patterns: Assess the onset, duration, frequency, and characteristics of diarrhea. Identify potential triggers (foods, medications, stress). Establish the patient’s baseline bowel pattern to monitor for changes during flares.
2. Assess stool characteristics: Document stool color, consistency, odor, and presence of blood, mucus, or pus. Quantify stool output if necessary.
3. Obtain stool sample for culture and testing as ordered: Stool studies may be ordered to rule out infectious etiologies and assess for fecal calprotectin levels to monitor inflammation.

Nursing Interventions:

1. Implement dietary modifications as prescribed: During acute flares, maintain NPO status initially to rest the bowel, followed by a gradual dietary progression as tolerated. Typically, a transition from clear liquids to a low-fiber, low-residue diet is recommended.
2. Collaborate with a dietitian to create a personalized meal plan: A low-fiber, high-protein diet, supplemented with vitamins and iron as needed, is often recommended. Advise patients to avoid gas-producing foods, dairy products (if lactose intolerant), raw fruits and vegetables, whole grains, nuts, seeds, pepper, alcohol, and caffeine-containing beverages.
3. Administer medications as prescribed: Administer anti-inflammatory medications (5-ASAs, corticosteroids), immunosuppressants, and biologic therapies as ordered to manage the underlying inflammation. Antidiarrheal medications (loperamide, diphenoxylate/atropine) may be used judiciously for symptomatic relief, but use with caution due to the risk of toxic megacolon, and only under physician guidance.
4. Prepare patient for potential surgical interventions: If medical management fails and complications arise, prepare the patient physically and emotionally for potential surgical procedures, including colectomy with IPAA or ileostomy. Provide pre- and post-operative care as needed.
5. Refer to an IBD specialist: Ensure referral to a gastroenterologist specializing in IBD for comprehensive management and ongoing care.
6. Refer to a dietitian or nutritionist: Dietary counseling is crucial. Refer patients to a registered dietitian or nutritionist for personalized dietary education and support in managing UC through diet.
7. Monitor fluid and electrolyte balance: Diarrhea can lead to dehydration and electrolyte imbalances. Monitor fluid intake and output, assess for signs of dehydration, and monitor serum electrolyte levels. Replace fluids and electrolytes as prescribed.
8. Provide perianal skin care: Frequent diarrhea can cause perianal skin breakdown. Provide meticulous perianal care, including gentle cleansing after each bowel movement, use of soft wipes, sitz baths, and barrier creams to protect the skin.

Dysfunctional Gastrointestinal Motility

Dysfunctional gastrointestinal motility is a key feature of ulcerative colitis, contributing to symptoms like diarrhea, abdominal pain, and altered bowel habits.

Nursing Diagnosis: Dysfunctional Gastrointestinal Motility

Related to:

• Ulcerative colitis disease process
• Inflammatory processes in the colon
• Medication effects
• Malnutrition
• Fluid and electrolyte imbalances

As evidenced by:

• Diarrhea
• Abdominal pain and cramping
• Nausea and Vomiting
• Altered bowel sounds (hyperactive or hypoactive)
• Tenesmus
• Malnutrition
• Dehydration
• Weight loss

Expected Outcomes:

• Patient will achieve and maintain a weight appropriate for age and body frame, demonstrating improved nutritional status and appetite.
• Patient will experience a reduction in diarrhea, with bowel movements becoming more formed and less frequent (ideally no more than three per day).
• Patient will report reduced abdominal pain and cramping.
• Patient will maintain fluid and electrolyte balance within normal limits.

Assessments:

1. Monitor laboratory values, particularly inflammatory markers: Assess CRP and ESR levels as indicators of disease activity and inflammation. Monitor electrolytes, albumin, and prealbumin levels to assess nutritional status and fluid balance.
2. Assess stool characteristics and bowel patterns: Document stool frequency, consistency, color, and presence of blood or mucus. Assess for tenesmus and abdominal pain patterns.
3. Evaluate the impact on appetite and weight: Monitor for anorexia, nausea, vomiting, and weight loss. Assess dietary intake and nutritional status.

Nursing Interventions:

1. Administer medications as prescribed to regulate motility and reduce inflammation: Administer aminosalicylates, corticosteroids, immunosuppressants, and biologics as ordered to manage the underlying UC and improve gastrointestinal motility.
2. Administer antidiarrheal medications cautiously and as prescribed: Loperamide and other antidiarrheals may be used to slow bowel motility and reduce diarrhea, but use with caution due to the risk of toxic megacolon. Administer only under physician guidance.
3. Provide nutritional support: Enteral nutrition (tube feeding) may be preferred over parenteral nutrition (IV nutrition) for malnourished patients with UC, as it helps stimulate the GI system. Consult with a dietitian to optimize nutritional intake.
4. Educate patients about medications that can worsen symptoms: Review the patient’s medication list and advise them to avoid NSAIDs (ibuprofen, naproxen) as they can exacerbate UC symptoms.
5. Encourage appropriate activity and rest: Encourage light physical activity (walking) as tolerated, as it may not aggravate motility issues. During exacerbations, promote rest and comfort to reduce intestinal activity and promote healing.
6. Manage nausea and vomiting: Administer antiemetics as prescribed to alleviate nausea and vomiting.
7. Monitor fluid and electrolyte balance: Closely monitor for signs of dehydration and electrolyte imbalances. Replace fluids and electrolytes as ordered.

Ineffective Tissue Perfusion (Gastrointestinal)

Inflammation and ulceration in ulcerative colitis can compromise blood flow and tissue perfusion in the gastrointestinal tract.

Nursing Diagnosis: Ineffective Tissue Perfusion (Gastrointestinal)

Related to:

• Intestinal inflammation
• Ulcerative colitis disease process
• Intestinal or rectal bleeding
• Potential for obstruction or stricture formation

As evidenced by:

• Abdominal pain and cramping
• Abdominal distension
• Anemia (fatigue, pallor, weakness)
• Rectal bleeding or bloody stools
• Weight loss
• Fluid and electrolyte imbalances
• Malnutrition

Expected Outcomes:

• Patient will demonstrate stable hemoglobin, hematocrit, RBC count, and iron levels within acceptable limits.
• Patient will exhibit resolution of rectal bleeding and bloody stools.
• Patient will maintain adequate fluid and electrolyte balance.
• Patient will demonstrate improved energy levels and reduced fatigue.

Assessments:

1. Review diagnostic imaging results, particularly colonoscopy reports: Assess colonoscopy findings for evidence of inflammation, ulceration, loss of vascular pattern, and bleeding.
2. Monitor for signs and symptoms of complications: Closely monitor for complications such as gastrointestinal bleeding (hematemesis, melena, hematochezia), severe dehydration, perforation (severe abdominal pain, rigidity), and signs of toxic megacolon (abdominal distension, fever, tachycardia).
3. Assess laboratory test results: Monitor CBC for anemia (decreased hemoglobin, hematocrit, RBC count). Assess iron studies (ferritin, iron, TIBC, MCV) to evaluate iron deficiency anemia. Monitor electrolytes and renal function.

Nursing Interventions:

1. Administer medications as ordered to reduce inflammation and improve tissue perfusion: Administer aminosalicylates, corticosteroids, immunomodulators, and biologics as prescribed to reduce intestinal inflammation and promote healing, thereby improving tissue perfusion.
2. Treat and prevent anemia: Administer iron supplements (oral or IV) and vitamin B12 as prescribed to address deficiencies. Blood transfusions may be necessary for significant intestinal bleeding and severe anemia.
3. Administer intravenous fluids and electrolytes: Provide fluid resuscitation with IV fluids to maintain hemodynamic stability and improve gastrointestinal tissue perfusion, especially in cases of bleeding or dehydration. Replace electrolyte losses as indicated.
4. Manage rectal bleeding: Administer steroid suppositories or enemas to reduce rectal inflammation. Provide warm sitz baths for comfort. Address underlying causes of rectal bleeding.
5. Educate patient on when to seek immediate medical assistance for bleeding: Instruct the patient to promptly report any new or worsening rectal bleeding, bloody stools, or signs of anemia (fatigue, dizziness, pallor) to their healthcare provider. Emphasize that bloody stools are not expected when UC is well-controlled.

Risk for Deficient Fluid Volume

Persistent diarrhea, a hallmark of ulcerative colitis, places patients at significant risk for fluid volume deficit and dehydration.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related to:

• Excessive fluid loss secondary to persistent diarrhea
• Increased intestinal fluid secretion
• Reduced fluid intake due to anorexia or nausea

As evidenced by:

A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.

Expected Outcomes:

• Patient will verbalize understanding of the signs and symptoms of dehydration.
• Patient will identify and implement at least two strategies to prevent dehydration.
• Patient will maintain fluid and electrolyte balance within normal limits, as evidenced by stable vital signs, adequate urine output, and electrolytes within expected ranges.

Assessments:

1. Monitor fluid intake and output (I&O): Accurately record oral intake, intravenous fluids, and output, including stool volume and frequency. Document characteristics of stools.
2. Review electrolyte levels: Monitor serum electrolyte levels (sodium, potassium, magnesium, calcium) to detect imbalances resulting from diarrhea and fluid loss. Review urinalysis for signs of dehydration (e.g., concentrated urine).
3. Assess for signs and symptoms of dehydration: Conduct regular assessments for clinical indicators of dehydration:
   • Increased thirst
   • Headache
   • Weakness and fatigue
   • Poor skin turgor (tenting)
   • Dry mucous membranes and mouth
   • Decreased urine output or concentrated urine
   • Lightheadedness or dizziness, especially upon standing (orthostatic hypotension)
   • Rapid heart rate (tachycardia)
   • Low blood pressure (hypotension) in severe cases

Nursing Interventions:

1. Prioritize dehydration prevention: Focus on managing diarrhea to reduce fluid losses. Address the underlying cause of diarrhea (UC flare) with appropriate medical therapies.
2. Promote and administer hydration: Administer intravenous fluids and electrolytes as prescribed to correct existing deficits and maintain hydration.
3. Encourage increased oral fluid intake: If oral intake is tolerated and not contraindicated, encourage the patient to increase oral fluid consumption. Recommend sipping water frequently, electrolyte-rich drinks (oral rehydration solutions), clear broths, and soups.
4. Implement dietary modifications: Follow the prescribed diet (initially NPO, then clear liquids, then low-residue) during acute flares to reduce bowel stimulation and diarrhea.
5. Educate the patient about dehydration prevention: Instruct the patient on preventive measures:
   • Drink the recommended daily fluid intake, even when not thirsty.
   • Consume foods with high water content (fruits and vegetables when tolerated outside of flares).
   • Limit or avoid alcohol consumption, as it can have a diuretic effect and worsen dehydration.
   • Moderate intake of caffeinated beverages (coffee, tea, carbonated drinks), as caffeine can also have a mild diuretic effect.
   • Recognize and respond promptly to early signs of dehydration.
   • Discuss strategies for managing fluid intake during travel or activities that may increase fluid loss (exercise, hot weather).

References

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Alt text: Doctor explaining ulcerative colitis diagnosis to patient, emphasizing patient education and clear communication.

Alt text: Nurse educating senior patient about ulcerative colitis medication, highlighting medication adherence and patient empowerment.

Alt text: Doctor and patient shaking hands, symbolizing the collaborative relationship in ulcerative colitis management and ongoing care.