When caring for a client with ulcerative colitis, which nursing activities are appropriate

Summary

Ulcerative colitis is a relapsing chronic disease that has an unpredictable course. A relapse in the condition requires timely intervention and expert monitoring. A severe flare-up will often necessitate admission to hospital. This article provides an overview of the medical management of severe ulcerative colitis and the nursing interventions required.

Keywords

Gastrointestinal disorders, incontinence, inflammatory bowel disease, ulcerative colitis

These keywords are based on subject headings from the British Nursing Index. This article has been subject to double-blind review, For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

Aims and intended learning outcomes

This article aims to provide nurses with a comprehensive overview of the assessment and management of a patient presenting with a severe exacerbation of ulcerative colitis. After reading this article and completing the time out activities you should be able to

* Provide an overview of ulcerative colitis, including the causes and treatments.

* Describe the assessment and relevant investigations required for a patient presenting with a severe flare-up of the condition.

* Outline the medical management of a patient diagnosed with a severe flare-up of ulcerative colitis.

Discuss the nursing care of a patient with severe ulcerative colitis and give the rationale for each intervention.

Introduction

Ulcerative colitis and Crohn's disease are classified under the umbrella term of inflammatory bowel disease (IBD). While both conditions are similar, in terms of symptoms and treatments, there are also many differences between the two. Clinical guidelines for IBD, including the management of severe ulcerative colitis, have been produced by the British Society of Gastroenterology (BSG) (Carter et al 2004). However, these guidelines have not been reviewed to take into account emerging evidence and to ensure that practice is up to date. More recently, the IBD Standards Working Group (2008) has developed service standards for patients with IBD.

An IBD nurse-led service has been shown to reduce the admission rate of patients with IBD by 20 % (Nightingale et al 2000), and patients with the condition are generally more independent and mobile than other patients on the ward. These trends may reinforce a tendency to underestimate the severity of the disease. However, severe ulcerative colitis is potentially life-threatening and this patient group requires timely intervention and expert monitoring. Advances in medical therapy and expert surgical input have reduced the mortality rate to less than 1% (Truelove and Witts 1955).

Patients with severe ulcerative colitis who do not respond to intravenous corticosteroids have the option of either second-line medical therapies such as ciclosporin or anti-TNF therapy, or colectomy. Where surgery is indicated, this should be done in a timely fashion.

A delay in surgical intervention generally leads to poor patient outcomes. The UK IBD Audit in 2006 recorded 25 deaths that were directly linked to ulcerative colitis, with 15 of these cases involving patients who had undergone surgery (UK IBD Audit Steering Group 2007).

Overview of ulcerative colitis

Inflammation in ulcerative colitis affects the superfcial mucosa...

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Correct answer:

Irritable bowel syndrome (IBS)

Explanation:

The most likely diagnosis in this patient is "Irritable bowel syndrome (IBS)." 

IBS is a gastrointestinal condition characterized by abdominal pain or cramps, as well as acute episodes of diarrhea and/or constipation that is often triggered by psychological stressors such as depression or anxiety, or a preceding gastrointestinal infection. IBS is more common in young females than other demographics, and often can be co-morbid with clinical depression or anxiety disorders. Its pathophysiology has not yet been fully characterized. There is no definitive diagnostic test to confirm a diagnosis of IBS, but the lack of blood or mucus in the stool, as well as the lack of a fever or elevated white blood cell count all are consistent with a diagnosis of IBS. Further, in this patient, given that she is a young female whose symptoms for this episode and prior episodes coincided with psychological stressors and resolved with bowel movements and resolution of her stressors, and who also had no fever, elevated white blood cell count, vital sign abnormalities, or concerning historical details (foreign travel, dietary changes, sick contacts), IBS is the most likely diagnosis.

Ulcerative colitis would be more likely to present with recurrent episodes of bloody and/or mucoid diarrhea, as opposed to non-bloody, non-mucoid diarrhea. Further, given this patient's relationship of symptoms to immediate psychological stressors, her symptoms are more consistent with IBS than ulcerative colitis. 

Colon cancer would be an unlikely diagnosis in a young, otherwise healthy patient with no family history of colon cancer. The fact that she is experiencing non-bloody, non-mucoid diarrhea does not in and of itself provide evidence for colon cancer. Colon cancer may present with occult blood in the stool, melanotic stools, or blood streaked stools, but would be highly, highly unlikely in a healthy young patient.

Gluten intolerance and lactose intolerance are reasonable thoughts when evaluating a young, otherwise healthy patient with non-bloody, non-mucoid diarrhea. Lactose intolerance would likely present at a younger age though, and the patient's diet reportedly has not changed prior to her diarrhea episodes, which would argue against a dietary etiology of her diarrhea. Further, given the close relationship of her symptoms to acute psychological stressors, IBS is the most fitting diagnosis.

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Cirrhosis is a chronic disease that affects which organ?

Possible Answers:

Explanation:

Cirrhosis is a chronic liver disease, usually caused by alcoholism. It is characterized by fibrosis and destruction of the normal liver tissue. Patient's who have cirrhosis may have hepatomegaly on physical exam, which is enlargement of the liver (e.g., it may be felt on the abdomen).

Which of the following describes a calcium carbonate preparation?

Possible Answers:

Slow-acting; Contains significant amounts of sodium

Rapid-acting; Is also a saline laxative

Rapid-acting; releases carbon dioxide in the stomach, causing belching and flatulence

Rapid onset and liberates carbon dioxide; Increases intra-abdominal pressure and promotes flatulence

Correct answer: Rapid-acting; releases carbon dioxide in the stomach, causing belching and flatulence

Explanation: Calcium carbonate preparation is rapid-acting, releasing carbon dioxide in the stomach, causing belching and flatulence. Calcium carbonate is an antacid which reacts quicly with HCl to form CaCL2 and carbon dioxide.

Which of the following does the nurse not recognize as a medication regimen for treating Helicobacter Pylori infections?

Possible Answers:

Triple Therapy-Metronidazole, omeprazole plus clarithromycin

Quadruple Therapy-Colloidal bismuth subnitrate, tetracycline, metronidazole plus omeprazole

Single therapy-Colestipol

Dual Therapy-Ranitidine bismuth citrate plus clarithromycin Omeprazole plus clarithromycin

Correct answer: Single therapy-Colestipol

Explanation: Multiple therapies are required to treat Helicobacter Pylori infections. Colestipol is a bile acid sequestrant used to lower blood cholesterol, which is not used to treat Helicobacter Pylori infections ( a bacterium that colonizes the human stomach).

What foods must be avoided in Celiac disease?

Possible Answers:

Foots containing red meat

Correct answer:

Foods containing gluten

Explanation:

Celiac disease is an autoimmune condition that is triggered by ingestion of gluten, a protein found in wheat, barley, and rye. A wheat-free diet is not sufficient for a patient with Celiac disease, as many other products contain elements of barley or rye and thus also contain gluten.

Oat, while often avoided by individuals with Celiac disease due to cross-contamination during processing, does not contain gluten. Whole dairy products are also generally gluten-free and considered safe for patients with Celiac disease.

Samantha is a registered nurse working in the intensive care unit with a patient recently diagnosed with Clostridium difficile. She violates Clostridium difficile contact precautions by __________. 

Possible Answers:

donning only gloves and a gown before entering the room

cleaning surfaces with hypochlorite-based disinfectants

cleansing her hands with only alcohol-based gel before leaving the room

placing the patient in a private room

placing the client in a semi-private room with another patient diagnosed with Clostridium difficile

Correct answer:

cleansing her hands with only alcohol-based gel before leaving the room

Explanation:

Clostridium difficile (C. diff) is an infection caused by Clostridium difficile bacteria and requires contact precautions. Contact precautions state that nurses must wear gloves and a gown while caring for the patient. Nurses must also preform adequate hand hygiene before and after the use of gloves. Additionally, because C. diff infections are caused by spores, alcohol gel alone may not be sufficient to eliminate the bacteria. Current practice is the use of soap and water to cleanse hands. Afterwards, nurses may utilize alcohol-based hand gel. It is acceptable to place a C. diff patient in a semi-private room with another C. diff patient if private rooms are unavailable.

Carrie is caring for an 85-year-old woman in a long-term care facility. Her patient has been taking antibiotics for the past two weeks to treat a severe case of cellulitis. Carrie notices that her patient has developed a fever, has refused her last two meal trays, and is complaining of abdominal pain. Which of the following samples should Carrie seek permission to obtain? 

Possible Answers:

Correct answer:

A stool sample

Explanation:

It is possible that this patient is suffering from a Clostridium difficile infection caused by bacteria. The presence of an underlying condition, increasing age, and antibiotic use are all risk factors for contracting Clostridium difficile. A stool sample is commonly used to test for the bacteria. Until the results are available, Carrie should place the patient under proper C. difficile contact precautions.

A female client with advanced cirrhosis of the liver has noticed that her abdomen has become greatly distended and she is concerned about her body image. The client asks the nurse "What is causing my stomach to look so big?"

The nurse responds based on her knowledge of liver disease and possible signs and symptoms. She tells the client which of the following explanations for her distended abdomen?

Possible Answers:

Elevated blood pressure in the liver and the liver's inability to synthesize albumin causes fluid shifts in the abdomen

Cirrhosis is highly associated with severe constipation and the accumulation of gas in the peritoneal cavity causing distention

An accumulation of nitrogen waste in the bloodstream due to the liver's inability to transform the waste to non toxic substances causes ascites

The liver is producing excess cholesterol and it has accumulated in the interstitial spaces of the abdomen

The liver's inability to make clotting factors due to vitamin K deficiency causes internal bleeding into the abdominal cavity

Correct answer:

Elevated blood pressure in the liver and the liver's inability to synthesize albumin causes fluid shifts in the abdomen

Explanation:

Portal hypertension causes proteins to move from the bloodstream into the lymphatics which cannot handle the excess and they leak into to abdominal cavity. The proteins causes an osmotic pressure pulling fluid into the space leading to ascites. Hypoalbuminemia will lead to decreased colloid oncotic pressure as well, also contributing to ascites.  

Which of the following bacterial species is responsible for the development of peptic ulcers?

Possible Answers:

Correct answer:

Helicobacter pylori

Explanation:

Helicobacter pylori or H. pylori is the bacterial cause of peptic ulcers. Staphylococcus aureus is a bacteria that frequently causes skin infections along with other conditions such as toxic shock syndrome. Streptococcus faecalis is responsible for many urinary tract infections and contracting Viridans streptococci may result in endocarditis. Treponema pallidum bacteria cause syphilis.

The nurse is caring for a 25-year old-patient diagnosed with a poorly functioning lower esophageal sphincter. The nurse may advise the patient to do which of the following?

Possible Answers:

Lay down immediately following meals

Avoid ingestion of antacids

Avoid alcoholic beverages

Correct answer:

Avoid alcoholic beverages

Explanation:

Several foods can cause relaxation or irritation of the lower-esophageal sphincter. Alcohol, carbonated beverages, and chocolate are a few examples. Advise the patient to remain upright after meals, to utilize antacids when appropriate, and to practice a balanced diet.

Which of the following GERD medications works by neutralizing stomach acid? 

Possible Answers:

Correct answer:

Magnesium hydroxide

Explanation:

Magnesium hydroxide is a strong base. It works by neutralizing the acid in the stomach, forming water and magnesium chloride. All other listed medications work to prevent the stomach from over-producing acid, rather than neutralizing the existing acid in the stomach.

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