Inflammatory bowel disease (IBD): Researchers believe that IBD may result from a complex interplay between genetic and environmental factors. Similarities involve (1) chronic inflammation of the alimentary tract and (2) periods of remission interspersed with episodes of acute inflammation.
Ulcerative colitis (UC): A chronic condition of unknown cause usually starting in the rectum and distal portions of the colon and possibly spreading upward to involve the sigmoid and descending colon or the entire colon. It is usually intermittent (acute exacerbation with long remissions), but some individuals (30%–40%) have continuous symptoms. Cure is effected only by total removal of colon and rectum/rectal mucosa.
Regional enteritis (Crohn’s disease, ileocolitis): May be found in portions of the alimentary tract from the mouth to the anus but is most commonly found in the small intestine (terminal ileum). It is a slowly progressive chronic disease of unknown cause with intermittent acute episodes and no known cure. UC and regional enteritis share common symptoms but differ in the segment and layer of intestine involved and the degree of severity and complications. Therefore, separate databases are provided.
CARE SETTING
Usually handled at the community level; however, severe exacerbations requiring advanced pain control, nutrition, rehydration may necessitate short stay in acute care medical unit.
RELATED CONCERNS
Fecal diversions: postoperative care of ileostomy and colostomy
Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
Peritonitis
Psychosocial aspects of care
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database—Ulcerative Colitis
ACTIVITY/REST
May report: Weakness, fatigue, malaise, exhaustion
Insomnia, not sleeping through the night because of diarrhea
Feeling restless
Restriction of activities/work due to effects of disease process
CIRCULATION
May exhibit: Tachycardia (response to fever, dehydration, inflammatory process, and pain)
Bruising, ecchymotic areas (insufficient vitamin K)
BP: Hypotension, including postural changes
EGO INTEGRITY
May report: Anxiety, apprehension, emotional upsets, e.g., feelings of helplessness/hopelessness
Acute/chronic stress factors, e.g., family/job-related, expense of treatment
Cultural factor—increased prevalence in Jewish population
May exhibit: Withdrawal, narrowed focus, depression
ELIMINATION
May report: Stool texture varying from soft-formed to mush or watery
Unpredictable, intermittent, frequent, uncontrollable episodes of bloody diarrhea (as many
as 20–30 stools/day); sense of urgency/cramping (tenesmus); passing blood/
pus/mucus with or without passing feces
Rectal bleeding
History of renal stones (dehydration)
May exhibit: Diminished or hyperactive bowel sounds, absence of peristalsis or presence of visible peristaltic waves
Hemorrhoids, anal fissures (25%); perianal fistula (more frequently with Crohn’s disease)
Oliguria
FOOD/FLUID
May report: Anorexia; nausea/vomiting
Weight loss (not common, but can occur as a result of decreased intake)
Dietary intolerances/sensitivities, e.g., raw fruits/vegetables, dairy products, fatty foods
May exhibit: Decreased subcutaneous fat/muscle mass
Weakness, poor muscle tone and skin turgor
Mucous membranes pale; sore, inflamed buccal cavity; dry, cracking of tongue (dehydration/malnutrition)
HYGIENE
May report: Inability to maintain self-care
May exhibit: Stomatitis reflecting vitamin deficiency
Unkempt appearance; body odor
PAIN/DISCOMFORT
May report: Mild abdominal cramping to severe pain/tenderness in lower-left quadrant (may be relieved with defecation)
Migratory joint pain, tenderness (arthritis)
Eye pain, photophobia (iritis)
May exhibit: Abdominal tenderness, distension, rigidity
SAFETY
May report: History of lupus erythematosus, hemolytic anemia, vasculitis
Arthritis (worsening of symptoms with exacerbations in bowel disease)
Temperature elevation 104°F–105°F (acute exacerbation)
Blurred vision
Allergies to foods/milk products (release of histamine into bowel has an inflammatory effect)
May exhibit: Skin lesions may be present; e.g., erythema nodosum (raised, tender, red, and swollen) on arms, face; pyoderma gangrenosum (purulent pinpoint lesion/boil with a purple border) on trunk, legs, ankles
Ankylosing spondylitis
Uveitis, conjunctivitis/iritis
SEXUALITY
May report: Reduced frequency/avoidance of sexual activity
SOCIAL INTERACTION
May report: Relationship/role problems related to condition
Inability to be active socially
TEACHING/LEARNING
May report: Family history of IBD, immune disorders
Discharge plan
DRG projected mean length of inpatient stay: 4.9 days
Assistance with dietary requirements, medication regimen, psychological support
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Stool specimens (examinations are used in initial diagnosis and in following disease progression): Mainly composed of mucus, blood, pus, and intestinal organisms, especially Entamoeba histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract. Stool positive for bacterial pathogens, ova and parasites or clostridium indicates infections. Stool positive for fat indicates malabsorption.
Proctosigmoidoscopy: Visualizes ulcerations, edema, hyperemia, and inflammation (result of secondary infection of the mucosa and submucosa). Friability and hemorrhagic areas caused by necrosis and ulceration occur in 85% of these patients.
Cytology and rectal biopsy: Differentiates between infectious process and carcinoma (occurs 10–20 times more often than in general population). Neoplastic changes can be detected, as well as characteristic inflammatory infiltrates called crypt abscesses.
Barium enema: May be performed after visual examination has been done, although rarely done during acute, relapsing stage, because it can exacerbate condition.
Endoscopic examinations, e.g., sigmoidoscopy, esophagogastroduodenoscopy, or colonoscopy: Identifies adhesions, changes in luminal wall (narrowing/irregularity); rules out bowel obstruction and allowed biopsy for features of Crohn’s disease or ulcerative colitis.
Abdominal magnetic resonance imaging (MRI)/computed tomography (CT) scan, ultrasound: Detects abscesses, masses, strictures, or fistulas.
CBC: May show hyperchromic anemia (active disease generally present because of blood loss and iron deficiency); leukocytosis may occur, especially in fulminating or complicated cases and in patients on steroid therapy.
Erythrocyte sedimentation rate (ESR): Elevated in acute inflammation according to severity of disease.
Serum iron levels: Lowered because of blood loss or poor dietary intake.
PT: Prolonged in severe cases from altered factors VII and X caused by vitamin K deficiency.
Thrombocytosis: May occur as a result of inflammatory disease process.
Electrolytes: Decreased potassium, magnesium, and zinc are common in severe disease.
Prealbumin/albumin level: Decreased because of loss of plasma proteins/disturbed liver function, decreased dietary intake.
Alkaline phosphatase: Increased, along with serum cholesterol and hypoproteinemia, indicating disturbed liver function (e.g., cholangitis, cirrhosis).
Disease-specific antibodies, ANCA (antineutrophil cyctoplasmic antibodies): Positive result increases suspicion of UC, but negative result does not rule out diagnosis.
Bone marrow: A generalized depression is common in fulminating types/after a long inflammatory process.
Patient Assessment Database—Regional Enteritis (Crohn’s Disease, Ileocolitis)
ACTIVITY/REST
May report: Weakness, fatigue, malaise, exhaustion
Feeling restless
Restriction of activities/work due to effects of disease process
EGO INTEGRITY
May report: Anxiety, apprehension, emotional upsets, feelings of helplessness/hopelessness
Acute/chronic stress factors, e.g., family/job-related expense of treatment
Cultural factor—increased prevalence in Jewish population, frequency increasing in individuals of Northern European and Anglo-Saxon derivation
May exhibit: Withdrawal, narrowed focus, depression
ELIMINATION
May report: Unpredictable, intermittent, frequent, uncontrollable episodes of nonbloody diarrhea, soft or semi-liquid with flatus; foul-smelling and fatty stools (steatorrhea)
Intermittent constipation
History of renal stones (increased oxalates in the urine)
May exhibit: Hyperactive bowel sounds with gurgling, splashing sound (borborygmus)
Visible peristalsis
FOOD/FLUID
May report: Anorexia; nausea/vomiting
Weight loss; failure to grow
Dietary intolerance/sensitivity, e.g., dairy products, fatty foods
May exhibit: Decreased subcutaneous fat/muscle mass
Weakness, poor muscle tone and skin turgor
Mucous membranes pale
HYGIENE
May report: Inability to maintain self-care
May exhibit: Unkempt appearance; body odor
PAIN/DISCOMFORT
May report: Tender abdomen with cramping pain in lower right quadrant (inflammation involving all layers of bowel wall and possibly the mesentery); pain in midlower abdomen (jejunal involvement)
Referred tenderness to periumbilical region
Perineal tenderness/pain
Migratory joint pain, tenderness (arthritis)
Eye pain, photophobia (iritis)
May exhibit: Abdominal tenderness/distension
SAFETY
May report: History of arthritis, systemic lupus erythematosus (SLE), hemolytic anemia, vasculitis
Temperature elevation (low-grade fever)
Blurred vision
May exhibit: Skin lesions may present: erythema nodosum (raised tender, red swelling) on face, arms; pyoderma gangrenosum (purulent pinpoint lesion/boil with a purple border) on trunk, legs, ankles; perineal lesions/anorectal fistulas
Ankylosing spondylitis
Uveitis, conjunctivitis/iritis
SOCIAL INTERACTION
May report: Relationship/role problems related to condition; inability to be active socially
TEACHING/LEARNING
May report: Family history of IBD, immune disorders
Discharge plan
DRG projected mean length of inpatient stay: 4.9 days
Assistance with dietary requirements, medication regimen, psychological support
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Stool examination: Occult blood may be positive (mucosal erosion); steatorrhea and bile salts may be found.
X-rays: Barium swallow may demonstrate luminal narrowing in the terminal ileum, stiffening of the bowel wall, mucosal irritability or ulceration.
Barium enema: Small bowel is nearly always involved, but the rectal area is affected only 50% of the time. Fistulas are common and are usually found in the terminal ileum but may be present in segments throughout the GI tract.
Sigmoidoscopic examination: Can demonstrate edematous hyperemic colon mucosa, transverse fissures, or longitudinal ulcers.
Endoscopy: Provides visualization of involved areas.
Abdominal MRI/CT scan, ultrasound: Detects infections/inflammatory conditions
CBC: Anemia (hypochromic, occasionally macrocytic) may occur because of malnutrition or malabsorption or depressed bone marrow function (chronic inflammatory process); increased white blood cells (WBCs).
ESR: Increased, reflecting inflammation
Prealbumin/albumin/total protein: Decreased.
Cholesterol: Elevated (may have gallstones).
Serum iron-binding folic acid capacity/transferrin levels: Decreased because of chronic infection or secondary to blood loss.
Clotting studies: Alterations may occur because of poor vitamin B12 absorption.
Electrolytes: Decreased potassium, calcium, and magnesium, with increased sodium.
Urine: Hyperoxaluria (can cause kidney stones).
Urine culture: If Escherichia coli organisms are present, suspect fistula formation into the bladder.
ASCA (antisaccharomyces antibodies): Positive result increases suspicion of Crohn’s disease, but negative result does not rule out diagnosis.
NURSING PRIORITIES
1. Control diarrhea/promote optimal bowel function.
2. Minimize/prevent complications.
3. Promote optimal nutrition.
4. Minimize mental/emotional stress.
5. Provide information about disease process, treatment needs, and long-term aspects/potential complications of recurrent disease.
DISCHARGE GOALS
1. Bowel function stabilized.
2. Complications prevented/controlled.
3. Dealing positively with condition.
4. Disease process/prognosis, therapeutic regimen, and potential complications are understood.
5. Plan in place to meet needs after discharge.
Ulcerative colitis (UC): A chronic condition of unknown cause usually starting in the rectum and distal portions of the colon and possibly spreading upward to involve the sigmoid and descending colon or the entire colon. It is usually intermittent (acute exacerbation with long remissions), but some individuals (30%–40%) have continuous symptoms. Cure is effected only by total removal of colon and rectum/rectal mucosa.
Regional enteritis (Crohn’s disease, ileocolitis): May be found in portions of the alimentary tract from the mouth to the anus but is most commonly found in the small intestine (terminal ileum). It is a slowly progressive chronic disease of unknown cause with intermittent acute episodes and no known cure. UC and regional enteritis share common symptoms but differ in the segment and layer of intestine involved and the degree of severity and complications. Therefore, separate databases are provided.
CARE SETTING
Usually handled at the community level; however, severe exacerbations requiring advanced pain control, nutrition, rehydration may necessitate short stay in acute care medical unit.
RELATED CONCERNS
Fecal diversions: postoperative care of ileostomy and colostomy
Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
Peritonitis
Psychosocial aspects of care
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database—Ulcerative Colitis
ACTIVITY/REST
May report: Weakness, fatigue, malaise, exhaustion
Insomnia, not sleeping through the night because of diarrhea
Feeling restless
Restriction of activities/work due to effects of disease process
CIRCULATION
May exhibit: Tachycardia (response to fever, dehydration, inflammatory process, and pain)
Bruising, ecchymotic areas (insufficient vitamin K)
BP: Hypotension, including postural changes
EGO INTEGRITY
May report: Anxiety, apprehension, emotional upsets, e.g., feelings of helplessness/hopelessness
Acute/chronic stress factors, e.g., family/job-related, expense of treatment
Cultural factor—increased prevalence in Jewish population
May exhibit: Withdrawal, narrowed focus, depression
ELIMINATION
May report: Stool texture varying from soft-formed to mush or watery
Unpredictable, intermittent, frequent, uncontrollable episodes of bloody diarrhea (as many
as 20–30 stools/day); sense of urgency/cramping (tenesmus); passing blood/
pus/mucus with or without passing feces
Rectal bleeding
History of renal stones (dehydration)
May exhibit: Diminished or hyperactive bowel sounds, absence of peristalsis or presence of visible peristaltic waves
Hemorrhoids, anal fissures (25%); perianal fistula (more frequently with Crohn’s disease)
Oliguria
FOOD/FLUID
May report: Anorexia; nausea/vomiting
Weight loss (not common, but can occur as a result of decreased intake)
Dietary intolerances/sensitivities, e.g., raw fruits/vegetables, dairy products, fatty foods
May exhibit: Decreased subcutaneous fat/muscle mass
Weakness, poor muscle tone and skin turgor
Mucous membranes pale; sore, inflamed buccal cavity; dry, cracking of tongue (dehydration/malnutrition)
HYGIENE
May report: Inability to maintain self-care
May exhibit: Stomatitis reflecting vitamin deficiency
Unkempt appearance; body odor
PAIN/DISCOMFORT
May report: Mild abdominal cramping to severe pain/tenderness in lower-left quadrant (may be relieved with defecation)
Migratory joint pain, tenderness (arthritis)
Eye pain, photophobia (iritis)
May exhibit: Abdominal tenderness, distension, rigidity
SAFETY
May report: History of lupus erythematosus, hemolytic anemia, vasculitis
Arthritis (worsening of symptoms with exacerbations in bowel disease)
Temperature elevation 104°F–105°F (acute exacerbation)
Blurred vision
Allergies to foods/milk products (release of histamine into bowel has an inflammatory effect)
May exhibit: Skin lesions may be present; e.g., erythema nodosum (raised, tender, red, and swollen) on arms, face; pyoderma gangrenosum (purulent pinpoint lesion/boil with a purple border) on trunk, legs, ankles
Ankylosing spondylitis
Uveitis, conjunctivitis/iritis
SEXUALITY
May report: Reduced frequency/avoidance of sexual activity
SOCIAL INTERACTION
May report: Relationship/role problems related to condition
Inability to be active socially
TEACHING/LEARNING
May report: Family history of IBD, immune disorders
Discharge plan
DRG projected mean length of inpatient stay: 4.9 days
Assistance with dietary requirements, medication regimen, psychological support
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Stool specimens (examinations are used in initial diagnosis and in following disease progression): Mainly composed of mucus, blood, pus, and intestinal organisms, especially Entamoeba histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract. Stool positive for bacterial pathogens, ova and parasites or clostridium indicates infections. Stool positive for fat indicates malabsorption.
Proctosigmoidoscopy: Visualizes ulcerations, edema, hyperemia, and inflammation (result of secondary infection of the mucosa and submucosa). Friability and hemorrhagic areas caused by necrosis and ulceration occur in 85% of these patients.
Cytology and rectal biopsy: Differentiates between infectious process and carcinoma (occurs 10–20 times more often than in general population). Neoplastic changes can be detected, as well as characteristic inflammatory infiltrates called crypt abscesses.
Barium enema: May be performed after visual examination has been done, although rarely done during acute, relapsing stage, because it can exacerbate condition.
Endoscopic examinations, e.g., sigmoidoscopy, esophagogastroduodenoscopy, or colonoscopy: Identifies adhesions, changes in luminal wall (narrowing/irregularity); rules out bowel obstruction and allowed biopsy for features of Crohn’s disease or ulcerative colitis.
Abdominal magnetic resonance imaging (MRI)/computed tomography (CT) scan, ultrasound: Detects abscesses, masses, strictures, or fistulas.
CBC: May show hyperchromic anemia (active disease generally present because of blood loss and iron deficiency); leukocytosis may occur, especially in fulminating or complicated cases and in patients on steroid therapy.
Erythrocyte sedimentation rate (ESR): Elevated in acute inflammation according to severity of disease.
Serum iron levels: Lowered because of blood loss or poor dietary intake.
PT: Prolonged in severe cases from altered factors VII and X caused by vitamin K deficiency.
Thrombocytosis: May occur as a result of inflammatory disease process.
Electrolytes: Decreased potassium, magnesium, and zinc are common in severe disease.
Prealbumin/albumin level: Decreased because of loss of plasma proteins/disturbed liver function, decreased dietary intake.
Alkaline phosphatase: Increased, along with serum cholesterol and hypoproteinemia, indicating disturbed liver function (e.g., cholangitis, cirrhosis).
Disease-specific antibodies, ANCA (antineutrophil cyctoplasmic antibodies): Positive result increases suspicion of UC, but negative result does not rule out diagnosis.
Bone marrow: A generalized depression is common in fulminating types/after a long inflammatory process.
Patient Assessment Database—Regional Enteritis (Crohn’s Disease, Ileocolitis)
ACTIVITY/REST
May report: Weakness, fatigue, malaise, exhaustion
Feeling restless
Restriction of activities/work due to effects of disease process
EGO INTEGRITY
May report: Anxiety, apprehension, emotional upsets, feelings of helplessness/hopelessness
Acute/chronic stress factors, e.g., family/job-related expense of treatment
Cultural factor—increased prevalence in Jewish population, frequency increasing in individuals of Northern European and Anglo-Saxon derivation
May exhibit: Withdrawal, narrowed focus, depression
ELIMINATION
May report: Unpredictable, intermittent, frequent, uncontrollable episodes of nonbloody diarrhea, soft or semi-liquid with flatus; foul-smelling and fatty stools (steatorrhea)
Intermittent constipation
History of renal stones (increased oxalates in the urine)
May exhibit: Hyperactive bowel sounds with gurgling, splashing sound (borborygmus)
Visible peristalsis
FOOD/FLUID
May report: Anorexia; nausea/vomiting
Weight loss; failure to grow
Dietary intolerance/sensitivity, e.g., dairy products, fatty foods
May exhibit: Decreased subcutaneous fat/muscle mass
Weakness, poor muscle tone and skin turgor
Mucous membranes pale
HYGIENE
May report: Inability to maintain self-care
May exhibit: Unkempt appearance; body odor
PAIN/DISCOMFORT
May report: Tender abdomen with cramping pain in lower right quadrant (inflammation involving all layers of bowel wall and possibly the mesentery); pain in midlower abdomen (jejunal involvement)
Referred tenderness to periumbilical region
Perineal tenderness/pain
Migratory joint pain, tenderness (arthritis)
Eye pain, photophobia (iritis)
May exhibit: Abdominal tenderness/distension
SAFETY
May report: History of arthritis, systemic lupus erythematosus (SLE), hemolytic anemia, vasculitis
Temperature elevation (low-grade fever)
Blurred vision
May exhibit: Skin lesions may present: erythema nodosum (raised tender, red swelling) on face, arms; pyoderma gangrenosum (purulent pinpoint lesion/boil with a purple border) on trunk, legs, ankles; perineal lesions/anorectal fistulas
Ankylosing spondylitis
Uveitis, conjunctivitis/iritis
SOCIAL INTERACTION
May report: Relationship/role problems related to condition; inability to be active socially
TEACHING/LEARNING
May report: Family history of IBD, immune disorders
Discharge plan
DRG projected mean length of inpatient stay: 4.9 days
Assistance with dietary requirements, medication regimen, psychological support
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Stool examination: Occult blood may be positive (mucosal erosion); steatorrhea and bile salts may be found.
X-rays: Barium swallow may demonstrate luminal narrowing in the terminal ileum, stiffening of the bowel wall, mucosal irritability or ulceration.
Barium enema: Small bowel is nearly always involved, but the rectal area is affected only 50% of the time. Fistulas are common and are usually found in the terminal ileum but may be present in segments throughout the GI tract.
Sigmoidoscopic examination: Can demonstrate edematous hyperemic colon mucosa, transverse fissures, or longitudinal ulcers.
Endoscopy: Provides visualization of involved areas.
Abdominal MRI/CT scan, ultrasound: Detects infections/inflammatory conditions
CBC: Anemia (hypochromic, occasionally macrocytic) may occur because of malnutrition or malabsorption or depressed bone marrow function (chronic inflammatory process); increased white blood cells (WBCs).
ESR: Increased, reflecting inflammation
Prealbumin/albumin/total protein: Decreased.
Cholesterol: Elevated (may have gallstones).
Serum iron-binding folic acid capacity/transferrin levels: Decreased because of chronic infection or secondary to blood loss.
Clotting studies: Alterations may occur because of poor vitamin B12 absorption.
Electrolytes: Decreased potassium, calcium, and magnesium, with increased sodium.
Urine: Hyperoxaluria (can cause kidney stones).
Urine culture: If Escherichia coli organisms are present, suspect fistula formation into the bladder.
ASCA (antisaccharomyces antibodies): Positive result increases suspicion of Crohn’s disease, but negative result does not rule out diagnosis.
NURSING PRIORITIES
1. Control diarrhea/promote optimal bowel function.
2. Minimize/prevent complications.
3. Promote optimal nutrition.
4. Minimize mental/emotional stress.
5. Provide information about disease process, treatment needs, and long-term aspects/potential complications of recurrent disease.
DISCHARGE GOALS
1. Bowel function stabilized.
2. Complications prevented/controlled.
3. Dealing positively with condition.
4. Disease process/prognosis, therapeutic regimen, and potential complications are understood.
5. Plan in place to meet needs after discharge.
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