Ulcerative Colitis Nursing Care Plan

This paper discusses the nursing care planning of a patient with ulcerative colitis. It includes using the clinical reasoning cycle to assess the patient situation, gather relevant information and clues, and process the information through a discussion on risk factors, aggravators, precipitators, pathophysiology and correlation with the clinical manifestation.

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ULCERATIVE COLITIS NURSING CARE PLAN
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Introduction
Ulcerative colitis is among the spectrum of inflammatory bowel diseases together with
Crohn’s disease. The current paper is a discussion of the nursing care planning of a patient with
ulcerative colitis. This is in response to a case study of a patient, Mr. Brown, who was diagnosed
with the condition. The scope of the discussion will include using the clinical reasoning cycle to
assess the patient situation, gather relevant information and clues, and process the information
through a discussion on risk factors, aggravators, precipitators, pathophysiology and correlation
with the clinical manifestation. Finally, the nursing care plan will be outlined, identifying the
priority nursing diagnoses, achievable goals, interventions and expected outcomes.
Patient situation
The patient is Mr. Brown, a 32-year-old male who presented with severe abdominal pain
and bloody diarrhea. He is currently post-operative after a 7-hour total colectomy procedure for
the diagnosis of fulminant ulcerative colitis. He was discharged to the ward for monitoring with a
left lower quadrant ileostomy. He was screaming in pain (9/10), had an IV line in situ running
Hartman’s solution, a nasogastric tube with free drainage and an indwelling urinary catheter in
situ. The ileostomy was draining a bloody discharge.
Cues and other relevant information.
Mr. Brown has had ulcerative colitis for 10 years now. In the past weeks, he had been
transfused 4 units of blood due to persistent bleeding from the large bowel. He had been in
severe pain often requiring large doses of analgesia such as codeine phosphate. He reported a
loss of weight of about 20 kilograms over the past few weeks. On presentation, he had moderate

ULCERATIVE COLITIS NURSING CARE PLAN 3
nausea and vomiting with moderate bloody diarrhea. He was in severe pain (9/10). His vitals
were deranged with a tachycardia of 128 beats per minute, a tachypnea of 32 breaths per minute,
a fever of 380c and a reduced oxygen saturation of 96%. His other vitals were normal with a
blood pressure of 100/60. He, however, had a total colectomy for his condition and discharged to
the ward.
On examination, his ileostomy site was draining bloody discharge and he was in severe
pain. his vitals were; a pulse rate of 120 bpm, respiratory rate of 20, blood pressure of 100/60,
the temperature of 38, and oxygen saturation of 98%. His hemoglobin level was at 9 g/dl
showing a slight anemia. His ESR was at 40 mm/hr. which was markedly raised. He was put on
morphine, maxolon, vancomycin, and hydrocortisone.
Six days postoperative, the pain was under control and the nasogastric tube was removed.
The ileostomy was working. He was on intravenous fluids as tolerated using normal saline. Ten
days post-operative, he was discharged home with a weight of 65 kilograms.
Processing the information
Ulcerative colitis: Pathophysiology
The exact cause of ulcerative colitis is still unknown (Kumar, Abbas, & Aster, 2017). It
is, however, postulated to be due to a complex interplay between intestinal microbiota, intestinal
epithelial dysfunction and dysfunctional mucosal immune responses leading to a chronic,
relapsing inflammatory bowel (Walker & Colledge, 2013). There are also environmental
influences and a significant genetic component.
The exact mechanism of this interplay is proposed to involve an aggressive T-cell
mediated immune response to commensal microbiota (Moayyedi et al., 2015). Environmental

ULCERATIVE COLITIS NURSING CARE PLAN 4
factors lead to a break in the mucosal lining, together with the genetically susceptible defective
tight junctions leads to an influx of bacterial components into the mucosal cells (Johansson et al.,
2013). This is postulated to activate an immune response that produces cytokines such as IL-13
and TNF which further increase mucosal permeability. These events may initiate a self-
amplifying cycle leading to the involvement of any part of the bowel or the entire segment
(Conrad, Roggenbuck, & Laass, 2014).
The pathology seen in ulcerative colitis involves the rectum and spreads proximally to
affect the rest of the colon. If the entire colon is affected it is termed pancolitis. The mucosa of
the colon has extensive broad-based ulcers along the long axis of the colon. Inflammation is
usually localized to the mucosa and submucosa with epithelial metaplasia, crypt abscesses, and
distortions of the crypts (Kumar, Abbas, & Aster, 2017).
Medication such as steroids are helpful. Steroid help through immunosuppression leading
to a reduction in the immune response (Li et al., 2015). This, however, is not a long-lasting
remedy as relapses are common and discontinuation of the medication leads to a flare-up of the
disease. Surgical excision of the diseased segment is the only cure for ulcerative colitis
(Feuerstein & Cheifetz, 2014).
Ulcerative Colitis: Clinical Manifestations
Patients present with rectal bleeding, usually with mucoid, foul-smelling diarrhea. These
are associated with bouts of abdominal cramps, and pain usually relieved mildly by defecation
(Walker & Colledge, 2013). These symptoms usually occur in a relapsing, recurring manner but
can occur as a fulminant colitis with severe bloody diarrhea, abdominal pain, leukocytosis and
distension of the abdomen (Walker & Colledge, 2013).

ULCERATIVE COLITIS NURSING CARE PLAN 5
The patient presented with signs of weight loss, severe abdominal pain, and bloody
diarrhea. He also had deranged vital signs with tachycardia, fever, and tachypnea. These can all
be correlated with the pathophysiology of his disease. Severe abdominal pain is in ulcerative
colitis affects more than 50% of patients and is related to the chronic inflammatory process
(Coates et al., 2013). Inflammation with the release of cytokines and reactive oxygen species
directly causes pain through interaction with nociceptors. Morphine was prescribed to this
patient for the management of this pain (Katzung, Masters, & Trevor, 2015).
Diarrhea is a frequent complaint in ulcerative colitis. it is due to the increased
permeability of the mucosal wall to efflux of fluids and electrolytes (Walker & Colledge, 2013).
Combined with the chronic, ulcerative inflammation, there is a mixture of blood leading to
chronic bloody diarrhea. Bleeding can be so severe as to cause a microcytic anemia (Ghassemi &
Jensen, 2013). The patient received 4 pints of blood due to blood loss and anemia. On
presentation, his hemoglobin level was low at 9 g/dl.
Nausea and vomiting do occur in ulcerative colitis but are not common features. These
can result from complications of the inflammatory process. Inflammation can be severe to cause
a transient megacolon with reduction or cessation of colonic motility (Walker & Colledge,
2013). This leads to a dynamic intestinal obstruction that can present as nausea, intense
abdominal pain, and vomiting. A nasogastric tube is inserted as a measure to decompress the
abdomen and relieve abdominal distension. Maxalon was prescribed in this patient as an anti-
nausea medication (Katzung, Masters, & Trevor, 2015).
Fever is another common manifestation. It is related to the release of inflammatory
cytokines that reset the body’s thermoregulatory center leading to a dysfunctional
thermoregulation. In ulcerative colitis, there is a constant release of cytokines and other

ULCERATIVE COLITIS NURSING CARE PLAN 6
inflammatory mediators from the mucosa and submucosa. Anti-bacterial drugs such as
vancomycin in this patient have shown to be effective in reducing inflammation and fever
(Katzung, Masters, & Trevor, 2015).
The patient underwent a total colectomy as a curative procedure. However, due to this the
normal flow of intestinal contents is disrupted leading to a need for stool diversion. This was the
need for an ileostomy, a stoma for the diversion of stool to the outside to be collected through a
bag (Feuerstein & Cheifetz, 2014). The ileostomy, however, has multiple complications, one of
which is a loss of water due to the high output of the ileostomy (Finlay, Sexton, & McDonald,
2018). This leads to high fluid needs necessitating insertion of an intravenous line running
Hartman’s solution. It is preferred as it is a good replacement fluid for most electrolytes and will
replace the lost fluid (Brunner, 2014). Due to the high fluid monitoring requirements, an
indwelling catheter is standard practice as it allows for adequate monitoring of output so that
input is measured. The patient is under 8L oxygen therapy after the procedure. This is termed
hyperbaric oxygen therapy and is helpful in healing of poorly oxygenated tissues, in this case the
anastomosis sites and also improves kidney functions (Boersema et al., 2016).

ULCERATIVE COLITIS NURSING CARE PLAN 7
Ulcerative colitis: Nursing care planning
Nursing
Diagnosis
Goal Intervention Rationale Expected outcome
Acute pain
related to
surgical
intervention due
to ulcerative
colitis evidenced
by reports of
abdominal pain,
restlessness,
guarding and
facial grimacing.
The patient
can verbalize
pain relief to
comfortable
levels within
a week.
Demonstrate
a relaxed
posture. Long
term goals
include
complete pain
relief by the
time of
discharge.
Note reports of patient pain
including reports of the
duration, severity, intensity,
character, onset and associated
factors. The pain is rated on a
scale of 1-10.
Note the aggravating and
relieving factors of the pain
Assess for non-verbal cues of
pain expression including
guarding, restlessness, sweating,
palpitations or tachycardia and
compare with the verbal reports
of pain. Note any discrepancies.
Provide comforting measures
such as frequent position
change, back rub and other non-
pharmacologic pain
management tools such as
music, soothing environment.
Provide medication as charted
including Morphine 10 mg IM
4 hourly.
The assessment of pain and
its origin may give
important clues about the
possible causes and guide
management (Glynn,
Drake, & Hutchison, 2013).
This may guide
management and treatment
goals as aggravating factors
can be avoided while
relieving factors can be
enhanced.
Correlation of all pain
expression modes could
help differentiate physical
pain from psychological or
psychiatric pain. ulcerative
colitis has a large
psychiatric component with
some patients reporting
pain when there are no
physical lesions (Coates et
al., 2013).
Helps with patient
relaxation and shown to
reduce pain (Gelinas,
Arbour, Michaud, Robar, &
Côté, 2013)
Opioid analgesics are
among the most powerful
analgesics in use today.
The patient reports
that pain is well
controlled and is
able to rest without
major discomfort

ULCERATIVE COLITIS NURSING CARE PLAN 8
They are effective in the
treatment of acute and
chronic pain and pain relief
is dose-dependent
(Katzung, Masters, &
Trevor, 2015).
Imbalanced
nutrition less
than body
requirements
related to
medically
restricted intake,
hypermetabolic
state of
inflammation
and altered
absorption as
evidenced by
weight loss.
There should
be
demonstrated
stable weight
gain towards
normal weigh
and normal
lab values for
nutrition
within the
period of
hospital stay.
Long term
goals include
maintenance
of normal
weight gained
and normal
nutrition
values on
follow up
after
discharge.
Weigh the patient daily and
assess body mass of the patient,
age, height and exercise level.
Keep the patient nil per oral as
indicated.
Encourage the patient to rest
and sleep adequately in the
acute phases of the illness.
Record the patient’s intake
including the food, amount,
tolerability and changes I
symptoms.
Resume and advance feeds as
indicated starting with clear
fluids, progressing to low
Provides baseline data on
weight and helps formulate
dietary needs. It also shows
treatment effectiveness
(Ross, Caballero, Cousins,
Tucker, & Ziegler, 2014).
Bowel rest following total
colectomy is indicated to as
it promotes ileostomy
healing, reduces abdominal
pain and promotes the
gradual introduction of
feeds. Feeding should be
maximized through
parenteral feeding (Ross,
Caballero, Cousins, Tucker,
& Ziegler, 2014).
Rest reduces caloric
consumption and reduces
the metabolic needs of the
body leading to an anabolic
weight gaining state (Ross,
Caballero, Cousins, Tucker,
& Ziegler, 2014).
This is helpful in
determining the
gastrointestinal response to
those foods and identifying
specific deficiencies that
might be encountered from
the diet (Ross, Caballero,
Cousins, Tucker, & Ziegler,
2014).
Progressive advancement
The patient reports
weight gain and
there is
normalization of
lab values for
nutrition.

ULCERATIVE COLITIS NURSING CARE PLAN 9
residue then protein-rich,
calorie-rich foods, avoiding
foods rich in fiber, spices or
caffeine.
of food bulk and quantity
allows for intestinal
readjustment to the
digestive process. In
patients with ileostomy, the
food should be low fiber
and low residue to reduce
bulk, and non-spicy to
reduce foul smelling
ileostomy stomas (Finlay,
Sexton, & McDonald,
2018).
Risk for
deficient fluid
volume related
to excessive
losses through
ileostomy
drainage,
vomiting, and
inadequate
intake.
Maintain an
adequate
fluid volume
with stable
vital signs,
good
capillary
refill, skin
turgor,
smooth
mucous
membranes,
urine of
normal
amount and
concentration
with a
balanced
fluid intake
and output
during the
shift. Long
term goals
include
adequate
balance of
fluids with no
signs of fluid
deficit or
overload
before
discharge..
Monitor fluid input and output
noting the drainage from
ileostomy, vomiting, urine
output in the IDC, and
insensible losses.
Monitor vital signs including
blood pressure, pulse rate,
temperature and respiratory
rate.
Observe for signs such as dry
mucous membranes, reduced
skin turgor and slow capillary
refill and patient reports of
thirst.
Weigh the patient daily
Administer intravenous fluids
and blood as indicated. The
patient was indicated IV normal
saline 12/24.
Offers fluid balance state
and provides for guidelines
for adequate titration of
fluid replacements
(Brunner, 2014).
Vitals provide an overall
condition of the patient.
Deranged vitals such as
hypotension and
tachycardia can point to
fluid loss and hypovolemia
which needs to be corrected
(Brunner, 2014).
These are signs of
dehydration and point to a
deficient fluid intake or
balance (Brunner, 2014).
This is a baseline indicator
of nutritional and fluid
balance. Fluid overload
such as edema will cause
increased weight (Brunner,
2014).
This is fluid intake to
correct fluid losses and
blood may be indicated to
correct anemia from overt
bleeding (Brunner, 2014).
There is a
normalization of
vital signs
There are no signs
of dehydration.
There is a
progressive weight
gain without edema
or fluctuating
weight.

ULCERATIVE COLITIS NURSING CARE PLAN 10
Risk for
infection related
to surgery,
broken mucosal
integrity and
chronic illness.
The patient
should
remain
infection free
evidenced by
normal vital
signs and
absence of
signs of
infection
during the 3
days post
operative.
In the long
term, the
stoma should
remain clean
and non-
tender with
no signs of
infection.
Monitor the patient’s lab works
especially the white blood cell
count
Assess the patient’s weight and
nutritional status.
Assess for the signs of infection
including fever, redness,
swelling or purulent discharge
from drains and incision sites.
Use aseptic techniques when
handling patients for example
wound dressing or insertion of
peripheral lines and encourage
proper handwashing by the
patient and the staff.
Administer medications as
prescribed including
antibacterial such as
vancomycin
Increased white cell count
indicates onset of acute
infection. The normal range
is 4.5 to 11.0 × 109/L and
any value above this is
elevated (Rosenberger,
Politano, & Sawyer, 2011).
Poor nutritional status is a
risk factor for infection as
one is unable to mount a
proper immune response.
This is worsened in this
patient who has
inflammatory bowel
disease that presents with
diarrhea and has undergone
colectomy (Tang, Smit, &
Semba, 2013).
Fevers of more than 38oC
and these signs show onset
of acute infection needing
urgent intervention and
prevention of progression
to sepsis and shock
(Rosenberger, Politano, &
Sawyer, 2011).
This reduces contact with
microorganism that may
cause infection in the
patient (Rosenberger,
Politano, & Sawyer, 2011)
Antimicrobials can be
administered to reduce
microbial burden in patients
with IBD but also as a
prophylaxis against post-
operative infection
(Rosenberger, Politano, &
Sawyer, 2011)
The patient remains
free of infection
with absence of
symptoms and
normal lab values
Deficient The patient Determine the patient’s views Provides a baseline The patient can

ULCERATIVE COLITIS NURSING CARE PLAN 11
knowledge
condition,
prognosis,
treatment, self-
care needs and
discharge needs
related to
unfamiliar
resources
evidenced by
requests for
information.
should be
able to
verbalize
understanding
of the disease
process,
treatment,
and needs on
discharge. In
the long term,
the patient
should be
able to carry
out discharge
needs on
follow up.
on the disease process and
treatment.
Review with the patient the
disease process, the treatment,
precipitating factors.
Review with the patient the care
of ileostomies including skin
care, dietary changes, use of
bags and observing for
complications.
Review with the patient the
prescribed medication, their
uses, dosages and adverse
effects
Emphasize the need for close
monitoring, periodic follow-up
and reevaluation.
knowledge level and
learning needs.
Informs the patient of the
needed knowledge
concerning his condition.
Factors such as aggravating
factors can be avoided.
Promotes understanding of
permanent ileostomies and
reduce complication rates
(Feuerstein & Cheifetz,
2014)
Promotes understanding of
the disease pharmacology
and may improve
compliance.
Regular evaluation is
required since colorectal
cancer is a chronic
relapsing disease and is a
risk factor for developing
colorectal cancer (Rogler,
2014).
verbalize the
disease process, the
treatment offered,
the medications
prescribed and the
care of his
ileostomy.
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ULCERATIVE COLITIS NURSING CARE PLAN 12
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