Colitis Nursing Diagnosis: Comprehensive Guide for Healthcare Professionals

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that affects the innermost lining of your large intestine (colon) and rectum. As a dedicated healthcare professional, understanding the nuances of “Colitis Nursing Diagnosis” is paramount to providing optimal patient care. This article provides a comprehensive guide to ulcerative colitis, focusing on the nursing process, assessment, interventions, and relevant nursing diagnoses to enhance your expertise and patient outcomes.

Understanding Ulcerative Colitis

Ulcerative colitis is characterized by inflammation and ulceration of the colon and rectum. While the exact etiology remains unknown, genetic predisposition and immune system dysregulation are considered significant factors. It is crucial to note that while diet and stress can exacerbate symptoms, they are not causative agents of UC.

In UC, the immune system mistakenly identifies the colonic lining and beneficial gut bacteria as foreign invaders. This misdirected immune response leads to the destruction of the colon’s lining by white blood cells, resulting in inflammation, edema, and ulcer formation. These ulcers can potentially perforate the bowel. Furthermore, the formation of scar tissue compromises the colon’s flexibility and nutrient absorption capacity.

The Nursing Process for Ulcerative Colitis

Managing ulcerative colitis requires a holistic and ongoing nursing approach. Long-term monitoring and treatment are essential to prevent relapses and manage potential complications. Regular surveillance colonoscopies, typically every one to two years, are recommended to screen for colorectal cancer, a known risk associated with chronic UC. Patients receiving biological agents also require vigilant screening for skin malignancies.

Patient education is a cornerstone of UC management. Nurses play a vital role in emphasizing medication adherence to prevent disease recurrence. Furthermore, nurses should promote preventive health measures such as routine vaccinations, diligent hand hygiene, and recommended cancer screenings. Dietary counseling, especially for patients with a stoma, is also crucial. Addressing the psychosocial aspects of UC, including the assessment and management of depression and low self-esteem, is an integral part of comprehensive nursing care.

Nursing Assessment for Ulcerative Colitis

The initial step in providing effective nursing care involves a thorough nursing assessment. This encompasses gathering comprehensive data, including physical, psychosocial, emotional, and diagnostic information. This section will detail both subjective and objective data relevant to ulcerative colitis.

Review of Health History: Subjective Data

1. General Symptom Inquiry: Elicit information about the patient’s general symptoms. Bloody diarrhea, which may or may not contain mucus, is a hallmark symptom of ulcerative colitis. Depending on disease severity, patients may report:

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

2. Ulcerative Colitis Type Determination: Identify the specific type of ulcerative colitis, as this influences symptom presentation:

• Ulcerative proctitis:
  • Location: Rectum only
  • Symptom: Rectal bleeding
• Proctosigmoiditis:
  • Location: Rectum and sigmoid colon (lower colon)
  • Symptoms: Bloody diarrhea, abdominal cramps, abdominal pain, tenesmus
• Left-sided colitis:
  • Location: Descending colon (left side of the colon)
  • Symptoms: Left-sided abdominal cramps, bloody diarrhea, weight loss
• Pancolitis:
  • Location: Entire colon
  • Symptoms: Severe bloody diarrhea, abdominal cramps, abdominal pain, fatigue, significant weight loss

3. Bowel Habit Changes: Inquire about alterations in bowel habits. UC flares often manifest with abdominal pain, cramping, and bowel urgency. Stools are typically loose and may contain blood and/or pus.

4. Risk Factor Identification: Determine the presence of both non-modifiable and modifiable risk factors:

- **Non-modifiable Risk Factors:**
    - **Ethnicity:** Higher prevalence in Caucasians and individuals of Jewish descent.
    - **Age:** Peak onset between 15 and 30 years, with a secondary peak between 50 and 70 years.
    - **Family History:** Increased risk with a first-degree relative (parent, sibling) with UC.

- **Modifiable Risk Factors:**
    - **NSAID Use:**  Non-steroidal anti-inflammatory drugs (NSAIDs) have been linked to UC.

5. Appendectomy History: Inquire about prior appendectomy. Appendectomy before age 20 is associated with a decreased incidence of ulcerative colitis.

Physical Assessment: Objective Data

1. Abdominal Examination: Perform a thorough abdominal examination. While findings may be normal, abdominal tenderness is common during flares. Other potential findings include:

• Voluntary or involuntary guarding
• Rebound tenderness (indicative of advanced colitis and potential perforation)
• Palpable mass (suggesting blockage or megacolon)
• Enlarged spleen (possible sign of primary sclerosing cholangitis or autoimmune hepatitis with portal hypertension)

2. Weight Monitoring: Regularly monitor for weight loss, a frequent finding in UC due to pain, diarrhea, and inflammation.

3. Bowel Sound Auscultation: Auscultate bowel sounds. They may be hypoactive, hyperactive, or normal in UC. Obstructions can cause high-pitched tinkling bowel sounds.

4. Perianal Examination: Conduct a perianal examination. In UC, fistulas or abscesses are typically absent. Persistent diarrhea can lead to perianal erythema, fissuring, or hemorrhoids.

5. Extraintestinal Manifestation Assessment: Assess for extraintestinal symptoms, which can occur outside the intestines:

• Joint pain
• Red, swollen, painful eyes
• Skin rashes
• Liver impairment
• Delayed growth (in children)

6. Complete Physical Assessment: Perform a comprehensive physical assessment, noting the following:

• General: Fever, weight loss, fatigue
• HEENT (Head, Eyes, Ears, Nose, Throat): Episcleritis (inflammation of the sclera), uveitis
• Gastrointestinal: Abdominal pain, bloody stools, tenesmus
• Musculoskeletal: Joint pain (large joints like hips, knees, ankles), ankylosing spondylitis (spine inflammation), osteoporosis
• Integumentary: Pallor, poor skin turgor, jaundice, erythema nodosum (skin lesions)

7. Pediatric Growth and Development: In pediatric patients, monitor for delayed growth and development, a potential complication of UC related to inflammation, malnutrition, steroid use, and immune response. This can also manifest as delayed puberty and sexual maturation.

8. Stool Characteristics: Evaluate stool characteristics. Bloody stools are typical in UC and can range from bright red to maroon or black. Pus and mucus may also be present.

Diagnostic Procedures for Ulcerative Colitis

1. Clinical Diagnosis with Supportive Findings: UC diagnosis is primarily clinical, supported by endoscopy and biopsy results. Imaging can help detect acute flares.

2. Stool Sample Analysis: Obtain stool samples for:

• White Blood Cells: Presence indicates an infectious process. Rule out parasitic or viral causes.
• Fecal Calprotectin: Elevated levels correlate with neutrophil influx in the colon, helping differentiate UC from IBS.

3. Blood Sample Analysis (Inflammatory Markers): Assess blood samples for:

• Complete Blood Count (CBC) with Metabolic Panel: Evaluates for vitamin B12 or iron deficiency anemia (common in UC), hypoalbuminemia, and electrolyte imbalances (associated with malnutrition and dehydration).
• Special Serology (p-ANCA and ASCA): Perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are frequently present in UC. Anti-Saccharomyces cerevisiae antibodies (ASCA) are less common in UC compared to Crohn’s disease.
• C-reactive protein (CRP) or Erythrocyte Sedimentation Rate (ESR): Elevated levels indicate inflammation severity in UC.

4. Imaging Scans: Schedule imaging to visualize the gut and assess inflammation:

• CT or MR Enterography: Rules out small intestine inflammation and is more sensitive for detecting intestinal inflammation than traditional imaging. MRE is radiation-free.
• CT Scan of the Abdomen: Can differentiate UC from Crohn’s disease.
• Plain X-rays: Useful for ruling out severe complications like megacolon or perforated colon as a first-line imaging modality.
• Double-contrast Barium Enema: Can detect early mucosal changes.

5. Colon Visualization:

• Colonoscopy: Essential during suspected flares to assess inflammation and mucosal changes. Biopsies are obtained for diagnosis.
• Flexible Sigmoidoscopy: Effective for assessing UC activity and treatment response, similar to colonoscopy but examines only the lower colon.

Nursing Interventions for Ulcerative Colitis

Nursing interventions are critical for managing UC symptoms, preventing complications, and improving patient quality of life.

Managing Inflammation

1. Remission Induction and Maintenance: UC management focuses on achieving and maintaining remission to improve patient well-being.

2. Anti-inflammatory Medications: Administer prescribed anti-inflammatory medications, typically 5-aminosalicylates as first-line therapy. If remission is not achieved, oral or rectal glucocorticoids may be used. Except for glucocorticoids, these medications can be used for maintenance therapy.

• 5-Aminosalicylates (sulfasalazine, mesalazine): Route of administration (oral, IV, suppository) depends on the affected colon segment.
• Corticosteroids (prednisone, budesonide): Prescribed for moderate to severe UC resistant to other treatments. Due to immunosuppressive effects and potential side effects, long-term use is generally avoided.

3. Immunosuppression: Administer immunosuppressants (cyclosporine, tacrolimus, infliximab) to suppress inflammatory triggers in UC. Combination therapy is often more effective.

4. Biologic Therapies: Consider biologics, which target specific immune system proteins. Prescribed for severe UC unresponsive to other treatments.

5. Symptom Management: Manage specific symptoms with appropriate medications, always advising patients to consult their healthcare provider before using over-the-counter drugs.

• Antidiarrheals: For severe diarrhea, but caution advised due to the risk of toxic megacolon.
• Pain Relievers: Acetaminophen is recommended for mild pain, avoiding NSAIDs like ibuprofen, naproxen, and diclofenac, which can worsen symptoms.
• Antispasmodics: May be prescribed for abdominal cramps.
• Iron Supplements: For iron deficiency anemia and intestinal bleeding.

6. Surgical Intervention: Colectomy (removal of the colon) is a curative option for UC, as it only affects the colon.

• Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA): Preferred surgical procedure.
• Proctocolectomy with Ileostomy: Option for patients not eligible for IPAA.
• Indications for Surgery: Intractable fulminant colitis, toxic megacolon, perforation, uncontrolled bleeding, severe drug side effects, strictures, dysplasia, malignancy, or growth retardation in infants.

7. Relapse Prevention: Maintenance therapy is crucial for all UC patients to prevent relapse. Individualized drug regimens are necessary to manage symptoms effectively.

Preventing Flare-ups

1. Healthy Gut Promotion: Probiotics may aid in maintaining remission by fostering a healthy gut bacteria balance.

2. Trigger Food Avoidance: Advise patients to identify and avoid trigger foods, as individual reactions vary to dairy, fiber, sugar, spicy foods, caffeine, and alcohol. Food diaries can be helpful.

3. Small, Frequent Meals: Recommend small, frequent meals and snacks during flares to prevent malnutrition, as eating may be unpleasant.

4. Dehydration Prevention: Advise adequate daily fluid intake, especially water. Caution against carbonated drinks (gas-producing) and alcohol (intestinal stimulant, worsens diarrhea).

5. Dietitian Consultation: Refer patients to a dietitian specializing in IBD nutrition for personalized dietary guidance.

Establishing Regular Elimination

1. Elimination Pattern Monitoring: Monitor bowel movement frequency, color, odor, and consistency. Mild UC: <4 bowel movements/day; moderate-severe UC: >4 stools/day. All may involve rectal bleeding.

2. Straining Avoidance: Educate patients on proper defecation techniques (squatting, avoiding straining). Increase fluid and fiber intake (when appropriate) to promote regular bowel movements without constipation or diarrhea.

3. Complication Monitoring: Monitor for signs of complications like bleeding, fecal impaction, or intestinal obstruction.

Assisting with Coping

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

2. UC Education: Educate patients about UC to enhance their sense of control and enable informed decision-making.

3. Pediatric Patient Support: Provide family-centered support for pediatric patients. Family counseling can help children cope with UC challenges.

4. Bathroom Access Card: Recommend carrying a bathroom access card to reduce anxiety when traveling or socializing. These cards can be downloaded online and discreetly presented for bathroom access.

Ulcerative Colitis Nursing Care Plans: Addressing Key Nursing Diagnoses

After completing a thorough assessment and identifying relevant nursing diagnoses, nursing care plans guide the prioritization of assessments and interventions for both short-term and long-term patient care goals. The following are examples of nursing care plan for common nursing diagnoses associated with ulcerative colitis.

Acute Pain

Nursing Diagnosis: Acute Pain

Related to: Inflammation of the intestines, hyperactive bowels (hyperperistalsis), persistent diarrhea, anal/rectal irritation, fistula formation, joint arthralgias, scleritis.

As evidenced by: Complaints of abdominal pain/cramping, facial grimacing, guarding/distraction behaviors, restlessness, self-focusing.

Expected Outcomes: Patient will report pain relief, demonstrate pain management strategies, and appear calm and rested.

Assessments:

1. Pain Assessment: Location, duration, severity (0-10 scale), and characteristics of abdominal pain/cramping. Document changes.
2. Bowel Sounds Auscultation: Increased bowel sounds due to hyperperistalsis.
3. Nonverbal Pain Cues: Restlessness, facial expressions, guarding, distraction behaviors.
4. Triggering Factors: Stress, fatty/spicy/sugary foods, caffeine, alcohol, carbonated drinks.

Interventions:

1. Comfortable Positioning: Assist patient to find comfortable positions, considering the location of pain.
2. Medication Education: Administer and educate on appropriate pain medications (acetaminophen for mild pain, antispasmodics for cramps, avoid NSAIDs).
3. Opioids and Adjuvants: For severe pain, opioid narcotics may be needed. Antidepressants as adjuvant analgesics.
4. Psychotherapy: Cognitive Behavioral Therapy (CBT) for chronic pain management and improved quality of life.
5. Trigger Factor Avoidance: Stress management and appropriate diet to prevent exacerbations.
6. Rectal Pain Relief: Warm sitz baths, gentle rectal hygiene with soft wipes.

Diarrhea

Nursing Diagnosis: Diarrhea

Related to: Inflammation of the colon lining, frequent bowel movements, persistent colon contraction.

As evidenced by: Loose/watery stools, bloody stools (red, maroon, black), stool with pus/mucus, foul-smelling stool, abdominal pain/cramping, tenesmus, rectal pain, hyperactive bowel sounds, weight loss, dehydration.

Expected Outcomes: Patient will report decreased stool frequency and urgency (<3 stools/day), demonstrate normal bowel sounds, and pass stool without blood/mucus.

Assessments:

1. Bowel Movement Pattern: Onset, triggers, frequency, baseline assessment for flare monitoring.
2. Stool Characteristics: Color, blood, mucus.
3. Stool Culture: Fecal calprotectin to differentiate UC from non-inflammatory bowel conditions.

Interventions:

1. Dietary Modifications: NPO initially, then clear liquids to low-fiber diet as tolerated during acute phases.
2. Meal Planning: Low-fiber, high-protein diet with vitamin/iron supplements. Avoid gas-producing foods, dairy, raw fruits/vegetables, whole grains, nuts, pepper, alcohol, caffeine.
3. Medication Administration: Salicylate compounds, corticosteroids, immunosuppressants, antidiarrheals as prescribed.
4. Surgical Preparation: If symptoms worsen or complications arise, prepare for potential colectomy.
5. IBD Specialist Referral: For expert evaluation and management.
6. Dietitian/Nutritionist Referral: For personalized dietary guidance to prevent flare-ups.

Dysfunctional Gastrointestinal Motility

Nursing Diagnosis: Dysfunctional Gastrointestinal Motility

Related to: Disease process, inflammatory process, medications, malnutrition, fluid/electrolyte imbalance.

As evidenced by: Diarrhea, abdominal pain/cramping, nausea/vomiting, altered bowel sounds, tenesmus, malnutrition, dehydration, weight loss.

Expected Outcomes: Patient will maintain appropriate weight, report appetite, and have ≤3 formed bowel movements per day.

Assessments:

1. Laboratory Values: CRP levels (inflammatory marker).
2. Stool Characteristics and Bowel Patterns: Bloody/mucoid stools, tenesmus, abdominal pain relieved by defecation.
3. Appetite and Weight: Impact of symptoms on appetite and weight loss.

Interventions:

1. Medication Administration: Aminosalicylates to reduce inflammation and improve motility.
2. Antidiarrheals: Loperamide for severe diarrhea (caution: toxic megacolon risk).
3. Enteral Feedings: Preferred over parenteral nutrition for malnourished patients.
4. Medication Review: Avoid NSAIDs, which can worsen symptoms.
5. Activity and Rest: Light activity with rest periods. Rest during exacerbations to reduce intestinal activity.

Ineffective Tissue Perfusion (Gastrointestinal)

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to: Intestinal inflammation, disease process, intestinal/rectal bleeding, obstruction.

As evidenced by: Abdominal pain/cramping/distension, anemia, rectal bleeding, bloody stools, weight loss, fluid/electrolyte imbalance, malnutrition, fatigue.

Expected Outcomes: Patient will demonstrate hemoglobin, RBC, and iron levels within normal limits and will not experience rectal bleeding or bloody stools.

Assessments:

1. Diagnostic Imaging Results: Colonoscopy findings (loss of vascular pattern, erythema, erosions, ulcerations, bleeding).
2. Complication Monitoring: Signs/symptoms of GI bleeding, dehydration, perforation, cancer.
3. Laboratory Test Results: Hematocrit/hemoglobin levels, ferritin, iron, TIBC, MCV for anemia.

Interventions:

1. Medication Administration: Aminosalicylates, immunomodulators/biologics (severe UC), steroids (acute flares).
2. Anemia Management: Vitamin B12, iron supplementation (oral/IM), blood transfusions (severe bleeding).
3. Fluid and Electrolyte Replacement: IV fluids for hemodynamic support and tissue perfusion, electrolyte supplementation.
4. Rectal Bleeding Management: Steroid suppositories, warm sitz baths.
5. Bleeding Education: Instruct patient to seek prompt medical attention for bloody stools or rectal bleeding.

Risk for Deficient Fluid Volume

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related to: Persistent diarrhea, excessive fluid loss.

As evidenced by: (Risk diagnosis – no current evidence, interventions are preventive)

Expected Outcomes: Patient will verbalize dehydration signs/symptoms and preventive strategies, and maintain fluid/electrolyte balance.

Assessments:

1. Fluid Intake and Output: Monitor and document accurately, especially loose stools.
2. Electrolyte Review: Serum sodium and potassium levels, urinalysis for imbalances.
3. Dehydration Signs and Symptoms: Thirst, headache, weakness, poor skin turgor, flushed skin, dry mouth, hypotension, rapid heart rate.

Interventions:

1. Dehydration Prevention: Address underlying cause (diarrhea management).
2. Hydration: IV fluids and electrolytes as prescribed.
3. Oral Fluid Encouragement: Water, electrolyte drinks, broths, soups (if tolerated).
4. Dietary Implementation: Follow prescribed diet to minimize diarrhea.
5. Dehydration Prevention Education: Recommended fluid intake, water-rich foods, moderate alcohol, limit caffeine.