care plan: inflammatory bowel disease, ulcerative colitis

[John]

Test6-32careplanulcerativecolitis.doc

INFLAMMATORY BOWEL DISEASE, ULCERATIVE COLITIS

Data Base

A.    Etiology and pathophysiology

1.    May be caused by emotional stress, an autoimmune response, or a genetic predisposition, or bacterial infection before onset

2.    Edema of mucous membrane of colon leads to bleeding and shallow ulcerations

3.    Abscess formation occurs; the bowel wall shortens and becomes thin and fragile

4.    Associated with increased risk for colon cancer

B.    Clinical findings

1.    Subjective: weakness; debilitation; anorexia: nausea; abdominal cramps

2.    Objective: dehydration with tenting of skin; passage of bloody, purulent, mucoid, water. stools; anemia; hypocalcemia; low-grade fever

C.    Therapeutic interventions

1.    Dietary management

a.    During acute episode, low-residue diet progressing to a regular diet; raw bran be effective in controlling bouts of diarrh and constipation

b.   Unrestricted fluid intake if tolerated; high-protein, high-calorie diet; avoidance of food allergens, especially milk

2.    Pharmacologic management: antiemetics, anticholinergics, corticosteroids, antibiotics sedatives, analgesics, tranquilizers, and antidiarrheals

3.    Replacement of fluids and electrolytes that are lost because of diarrhea; TPN may be instituted

4.    Surgical intervention: indicated when medical  management is unsuccessful

a.    Segmental or partial colectomy with anastomOSIS

b.   Total colectomy with ileostomy

c.    Total colectomy with continent ileostom (Koch's pouch)

d.   Total colectomy with ileoanal anastomos (creation of an ileal pouch that maintai anal sphincter function)

Nursing Care of Clients with Ulcerative Colitis

A.    Assessment

1.    Localized areas of tenderness found over diseased bowel on palpation

2.    History of patterns and characteristics of elimination

3.    Feces for color, consistency, and characteristics

4.    Temperature and weight for baseline data

5.    Presence and extent of bowel sounds

B.    AnalysiS/Nursing Diagnoses

1.    Diarrhea related to hypermotility

2.    Imbalanced nutrition: less than body requirements related to hypermotiiity an malabsorption

3.    Deficient fluid volume related to diarrhea

4.    Risk for impaired skin integrity related chemical constituents of excretions

C.    Planning/Implementation

1.    Instruct client to adhere to the following dietary program

a.    Eat small, frequent feedings of high-protein, high-calorie foods; low fat helps decrease steatorrhea; if steatorrhea is present, vitamins A and E may be required as supplements

b.   Avoid irritating foods and spices

c.   Replace iron, calcium, and zinc losses with supplements; if there is ileal involvement, intramuscular injections of vitamin B 12 may be prescribed monthly to reduce anemia

d.   Avoid all food allergens, especially milk; milk may be reintroduced when client is relatively asymptomatic; however, lactose intolerance is common and dairy restrictions may be permanent; lactase enzymes can be added to milk products to hydrolyze lactose

    2.    Involve client in dietary selection; recognize preferences as much as possible

    3.    Initiate administration and recording of fluid, electrolyte, or blood replacements

    4.    Provide gentle, thorough perineal care

    5.    Observe for complications such as rectal hemorrhage, fever, dehydration

    6.    Allow the client and family time to verbalize feelings and participate in care; encourage participation in the Crohn's and  

           Colitis Foundation of America

    7.    Provide preoperative care: a nurse specialist should assist in preoperative stoma site assessment and marking; poorly placed 

           stoma will prevent a tight seal of pouch, contributing to leakage, skin excoriation, incompatibility with clothing, and decreased

            quality of life

    8.    Provide postoperative care

a.    Maintain nasogastric suction during the immediate postoperative period

b.   Monitor fecal drainage and fluid balance

c.   Assess for signs of peritonitis

d.   Assess viability of stoma: expected-brick red; inadequate profusion-gray, pale pink, dark purple

e.   Teach client ileostomy care

(1) Ileostomy: skin care, continuous use of appliance because the stoma drains continuously

(2) Continent ileostomy (Koch's pouch): pouch will stretch over time to hold over 500 mL; must be catheterized to drain effluent every 4 to 6 hours; external appliance unnecessary; a small dressing covers the stoma

f.     Teach dietary guidelines

(1) Initial low-residue diet to promote healing

(2) Avoidance of kernels or seeds that can cause obstruction

(3) Increased fluid intake to compensate for losses

g.Provide emotional support; involve enterostomal therapy nurse; refer to local ostomy organizations

    9.  Anticipate that stress can precipitate peristalsis

D.    Evaluation/Outcomes

1.    Maintains or regains weight

2.    Adheres to dietary regimen

3.    Establishes an acceptable pattern of soft, formed bowel movements

4.    Client or family member demonstrates ability to perform ostomy care

5.    Implements strategies to reduce emotional stress