Ulcerative colitis (UC) is an inflammatory bowel disease affecting the rectum and extending proximally toward the colon. The specific cause is unknown, but there is a genetic predisposition. There may also be a higher incidence among Jewish populations. Peak incidence often occurs between 15-30 years of age. Although food and stress do not cause it, they may worsen symptoms.
With ulcerative colitis, the immune system believes that the cells that line the colon, good gut bacteria, are the invaders. Instead of protecting, white blood cells damage the colon’s lining. The colon or large intestine’s lining is irritated, inflamed, edematous, and vulnerable to ulcers that may perforate. As scar tissue grows, flexibility and the capacity to absorb nutrients are lost.
Bloody diarrhea, whether or not mucus is present, is the primary symptom of ulcerative colitis. Depending on the degree and severity of the condition, other symptoms may include tenesmus (urgency to pass stools), abdominal discomfort, fatigue, weight loss, and fever. Remissions and exacerbations are expected.
Types of ulcerative colitis:
Ulcerative proctitis
Location: localized to the rectum
Symptom: rectal bleeding
Proctosigmoiditis
Location: rectum and the sigmoid colon (lower part of the colon)
Symptoms: bloody diarrhea, abdominal cramps, abdominal pain, tenesmus
Left-sided colitis
Location: Left side colon
Symptoms: left side abdominal cramps, bloody diarrhea, and weight loss
Pancolitis
Location: entire colon
Symptoms: severe bloody diarrhea, abdominal cramps, abdominal pain, fatigue, and significant weight loss
Ulcerative colitis may also cause extraintestinal symptoms, including joint pain, red, swollen eyes, skin rashes, and liver impairment.
An endoscopy, biopsy, and negative stool exam confirm the clinical diagnosis of ulcerative colitis. During an acute flare, laboratory analysis will show an increase in inflammatory markers (ESR, CRP, leukocytosis).
The severity and scope of the disease influence the treatment options for ulcerative colitis.
Surgery, medication, and dietary changes are options for treating ulcerative colitis. Patients may undergo surgery to remove the colon (colectomy) and rectum (proctectomy). Surgical removal of the affected section is considered curative but is only recommended when treatment fails or the patient experiences severe complications.
5-aminosalicylates and sulfasalazine are the first-line treatments. If remission is not achieved within two weeks, oral or rectal glucocorticoids may be given. All of these medications, except glucocorticoids, can be used to maintain remission. Some studies show that probiotics aid in achieving remission, while fecal microbiota transplantation to treat colitis and promote a balanced gut microbiome is also promising.
Nursing Process
Patients with ulcerative colitis require ongoing observation and lifelong treatment to prevent relapses. Every one to two years, surveillance colonoscopies should be performed because of the possibility of colorectal cancer. Additionally, because patients are treated with biological agents, they should receive screenings for skin malignancies.
Teach the patient the value of medication adherence to prevent a recurrence. Regular vaccines, hand washing, and cancer screening should be encouraged. Inform the patient on what foods to eat and what not to eat, particularly if they have a stoma. The nurse should also remain active in assessing emotional concerns such as depression and low self-esteem.
Nursing Care Plans Related to Ulcerative Colitis
Diarrhea
Diarrhea associated with ulcerative colitis can be caused by inflammation of the colon and the presence of toxins. It leads to persistent contraction and malabsorption of the colon, producing frequent bowel movements. Ulcers may form when inflammation damages the lining of the gut, causing bloody diarrhea.
Nursing Diagnosis: Diarrhea
Related to:
- Inflammation of the lining of the colon
- Frequent bowel movements
- Persistent contraction of the colon
As evidenced by:
- Loose and watery stools
- Bloody stools (bright red, maroon, or black stools)
- Stool with pus or mucus
- Foul-smelling stool
- Abdominal pain
- Abdominal cramping
- Tenesmus (urgency to pass stools)
- Pain in the rectum
- Increased bowel sounds upon auscultation
- Weight loss
- Dehydration
Expected outcomes:
- Patient will report a decrease in frequency and urgency to less than three stools per day.
- Patient will be able to demonstrate bowel sounds within normal limits upon auscultation.
- Patient will be able to pass stool without blood or mucus.
Assessment:
1. Analyze the onset and pattern of bowel movements.
Note the onset of symptoms, triggering factors, and frequency of diarrhea. Assess the patient’s baseline to monitor for flares.
2. Assess the characteristics of stools.
Note the color and characteristics (if there is any presence of blood or mucus).
3. Obtain a sample for stool culture.
Although it is nonspecific, fecal calprotectin testing correlates with increased neutrophils in the colon to rule out a noninflammatory bowel illness.
Interventions:
1. Gradually change the diet as ordered.
Maintain NPO status followed by diet changes from clear liquids to a low-fiber diet as prescribed and tolerated during the acute phase of colitis. Not giving anything by mouth at the start of diarrhea will help decrease bowel movements.
2. Assist the patient in creating a meal plan.
A low-fiber and high-protein diet supplemented with vitamins and iron supplements is recommended. Avoid foods that cause gas, dairy products, raw fruits and vegetables, whole grains, nuts, pepper, alcohol, and caffeine-containing items.
3. Administer medications as prescribed.
This includes a combination of medications such as salicylate compounds, corticosteroids, immunosuppressants, and antidiarrheals.
- Anti-inflammatory (salicylate compounds) medications are the first line of treatment for ulcerative colitis.
- Time-limited corticosteroid treatment induces remission. Steroids have anti-inflammatory and immunosuppressive properties.
- Immunosuppressants block the immunological response causing the body to release substances that cause inflammation.
- Antidiarrheals give stool more volume, and a fiber supplement helps ease mild to moderate diarrhea. Loperamide is for more severe diarrhea.
4. Prepare the patient for surgery.
Surgery may be needed if symptoms become worse and more complicated. Surgery includes the removal of the entire colon and rectum, and an internal pouch connected to the anus will enable bowel movements without a bag. A pouch may sometimes be appropriate—instead, creating a stoma in the abdomen. A bag attached to the stoma will collect the stool.
5. Refer to an IBD specialist.
Inflammatory bowel disease (IBD) refers to conditions that affect the tissues in your digestive tract and are long-lasting (chronic). Ulcerative colitis is a type of IBD. A specialist role can evaluate and follow patients receiving therapy and offer professional advice and expertise on all aspects of inflammatory bowel disease.
6. Refer the patient to a dietitian or nutritionist.
Following the recommended diet will help prevent colitis flare-ups. A dietician can educate about food recommended for colitis and help tailor a specialized diet for the patient.
Acute Pain
Acute pain associated with ulcerative colitis is a common cause of poor quality of life.
Nursing Diagnosis: Acute Pain
Related to:
- Inflammation of the intestines
- Hyperactive bowels (hyperperistalsis)
- Persistent diarrhea
- Irritation in the anus
- Irritation in the rectum
- Fistula formation
- Joint arthralgias
- Scleritis
As evidenced by:
- Complaints of abdominal pain
- Reports of abdominal cramping
- Facial grimacing
- Guarding behaviors
- Distraction behaviors
- Restlessness
- Self-focusing
Expected outcomes:
- Patient will report relief from abdominal cramping.
- Patient will report two strategies to relieve abdominal pain.
- Patient will be able to manifest a calm and well-rested appearance.
Assessment:
1. Assess for abdominal pain.
Investigate complaints of abdominal pain or cramping caused by ulcerative colitis, and note the location, duration, and severity (0–10 scale). Document any changes in the characteristics of pain.
2. Auscultate for bowel sounds.
Colitis causes increased peristalsis, producing increased bowel sounds, abdominal cramping, and pain.
3. Note nonverbal cues.
Observe nonverbal cues of abdominal cramping or pain, such as restlessness, facial expression, guarding, and distraction behaviors.
4. Identify triggering factors.
Stress can aggravate abdominal pain. Fatty and spicy foods, and foods high in sugar, caffeine, alcohol, and carbonated drinks can also worsen the pain and cramping.
Interventions:
1. Position the patient comfortably.
The left side of the abdomen or the rectum often hurts in colitis. Certain positions can worsen ulcerative colitis pain depending on which side of the intestinal tract is inflamed.
2. Instruct on appropriate medications.
Administer acetaminophen for mild colitis pain. Antispasmodic medications can relieve abdominal cramps. In contrast, do not give ibuprofen, naproxen, or diclofenac, as they can exacerbate abdominal discomfort.
3. Administer opioids and adjuvants.
Severe colitis pain may require opioid narcotics. Antidepressants are recommended adjuvant analgesics.
4. Encourage psychotherapy.
Cognitive behavioral therapy can be useful as a complementary treatment when pain is chronic and cannot be completely relieved. CBT can also improve quality of life.
5. Encourage the patient to avoid triggering factors.
Stress and improper diet trigger exacerbation of symptoms. Stress management and an appropriate diet can help prevent inflammation, abdominal pain, and cramping due to colitis.
6. Relieve rectal pain.
Rectal pain and skin irritation are common with frequent loose stools. Offer a warm sitz bath for comfort and clean the rectal area with soft, cool wipes.
Risk for Deficient Fluid Volume
The risk for deficient fluid volume associated with ulcerative colitis can result from persistent diarrhea and excessive fluid loss.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related to:
- Persistent diarrhea
- Excessive fluid loss
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will be able to verbalize dehydration signs and symptoms
- Patient will verbalize two strategies to prevent dehydration
- Patient will manifest fluid and electrolyte balance within normal limits as evidenced by electrolytes within expected limits
Assessment:
1. Monitor for fluid intake and output.
Record the fluid intake and output of the patient. Maintain accurate documentation of loose stools.
2. Review electrolytes.
Dehydration and electrolyte imbalances can result from severe or persistent diarrhea. Review laboratory findings (urinalysis) and blood tests (particularly the serum sodium and potassium levels) to determine any imbalances caused by ulcerative colitis.
3. Assess for signs and symptoms of dehydration.
Examine the patient for the following signs and symptoms of dehydration:
- Increased thirst
- Headache
- Weakness
- Poor skin turgor
- Flushed skin
- Dry mouth
- Low blood pressure
- Rapid heart rate
Interventions:
1. Prevent dehydration.
Diarrhea can cause dehydration. Therefore, it is best to first address the underlying cause by controlling the fluid loss and managing diarrhea.
2. Hydrate the patient.
Administer prescribed amounts of fluids and electrolytes intravenously.
3. Encourage increased oral fluids.
Promote an increase in oral fluids if tolerated and not contraindicated in ulcerative colitis. Encourage the patient to sip water, electrolyte drinks, broths, and soups. Oral fluid can replenish insensible fluid losses, increase bodily fluids, and moisten the mouth.
4. Implement the recommended diet.
Follow the prescribed diet for the patient, whether in the acute or exacerbation phase of colitis. Proper diet and avoidance of triggering food may help decrease the risk of deficient fluid volume caused by diarrhea.
5. Ask the patient to list the preventive measures for dehydration.
Advise the patient of the following preventive measures:
- Drink recommended fluid intake
- Consume foods high in water content (such as fruits and vegetables when not in a flare)
- Eliminate or use alcohol in moderation
- Limit consumption of caffeinated beverages (such as coffee, tea, and carbonated drinks)
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Mayo Clinic. (2020, November 7). Inflammatory bowel disease (IBD) – Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/symptoms-causes/syc-20353315
- Mayo Clinic. (2022, September 16). Ulcerative colitis – Diagnosis and treatment – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/ulcerative-colitis/diagnosis-treatment/drc-20353331
- National Center for Biotechnology Information. (2022, June 11). Ulcerative colitis – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459282/
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- WebMD. (2004, July 9). Ulcerative colitis treatments and surgery. Retrieved January 2, 2023, from https://www.webmd.com/ibd-crohns-disease/ulcerative-colitis/digestive-diseases-ulcerative-colitis-treatment
