Ulcerative Colitis Nursing Guide

Content Creator: Edward Bartels, RN, BSN, MICN 

Ulcerative Colitis Overview

This content is intended as a Quick Reference for Ulcerative Colitis and will provide an overview as well as nursing considerations utilizing the nursing process.

Ulcerative Colitis Etiology and Epidemiology

Ulcerative colitis, also called UC, is a chronic inflammatory condition of the bowel. UC affects the colonic mucosal surfaces of the rectum, colon, or cecum. Key distinctions of UC include:

• Occurs at any age, but most often in people between 15 and 30 years old
• Higher prevalence in those of Jewish descent
• Shows symptoms ranging from mild to severe
• Involves inflammation of the GI transmural mucosa
• Affects any part of the GI tract from mouth to anus
• Usually starts in the rectum
• Rarely affects small intestine
• Does not affect full wall thickness
• Pitting ulcers and sores develop

A specific cause for UC remains elusive but is believed to involve many factors. Causative or exacerbating factors include:

• Inflammatory response to microbiome changes
• Overactive immune response
• Barrier defects to the mucosal lining
• Environmental factors:
  • Diet
  • Drugs
  • Infection
  • Stress
• Genetic predispositions

Risk factors for UC include:

• Familial history
• Environmental:
  • Urban living
  • Higher educated
  • Social status
  • Iron content in water
• Frequent NSAID use
• Past history of tobacco use
• Infections:
  • Salmonella
  • Campylobacter

Prevalence of UC remains stabilized but high in North America and Europe with developing regions experiencing increasing incidence (DynaMed, 2018). The regions with the highest incidence:

• Northern Europe: 24.3 per 100,000
• Canada: 19.2 per 100,000
• Australia: 17.3 per 100,000

The regions with the highest prevalence:

• Europe: 505 per 100,000
• Canada: 248 per 100,000
• U.S.: 214 per 100,000

Ulcerative Colitis Diagnosis

Ulcerative colitis varies by extent, location, and severity of colon involvement. Upwards of 15% of those afflicted will present with severe disease (DynaMed, 2018). Confirmation of UC is achieved through symptoms presentation, endoscopic or imaging studies, and histologic exam. Presenting symptomology depends on the portion of the colon involved. Typical symptoms reported include:

• Symptomatic flare-ups lasting days
• Violent diarrhea
• Stool incontinence
• Bloody and mucous-filled diarrhea
• High fever
• Abdominal pain and distention
• Occasionally peritonitis
• Bowel urgency and tenesmus
• Fatigue
• Anemia
• Proctitis

Laboratory findings suggestive of inflammation and disease process include:

• Electrolytes
• CBC
• Serum proteins and albumin
• Serum C-reactive protein
• Sedimentation rate
• Stool analysis

Endoscopic study findings may reveal:

• Loss of vascular markings
• Granularity and friable mucosa
• Deep ulcerations and bleeding
• Erosions

Histology findings may reveal:

• Distorted crypt structure
• Shortening of crypt
• Lymphocyte increase and basal plasmacytosis
• Depletion of mucin
• Metaplasia of the paneth cells
• Villous surface irregularity

Other diagnostic studies considered include:

• Abdominal X-rays (barium installation)
• CT
• MRI

During diagnostic consideration, other causes of colitis as well as infectious sources must be ruled out.

Ulcerative Colitis Management

The American College of Gastroenterology proposes the Ulcerative Colitis activity Index for treatment guidance (DynaMed, 2018):

• Mild UC:
  • Erythema
  • Diminished vascular configurations
  • Slight friability
• Moderate UC:
  • Noticeable erythema
  • Absent vascular configurations
  • Friability
  • Erosions
  • Spontaneous hemorrhaging or ulceration
• Fulminant UC:
  • Spontaneous hemorrhaging
  • Ulceration

Pathways for acute and maintenance UC management and medication use centers around:

• Severity of the disease
• Dietary management
• Close monitoring for signs of perforation
• Antidiarrheals:
  • Loperamide (Diamode®)
• Aminosalicylates:
  • Sulfasalazine (Azulfidine®)
  • Olsalazine (Dipentum®)
  • Mesalamine (Cansa®, Delzicol®)
  • Balsalazide (Giazo®, Colazal®)
• Corticosteroids:
  • Prednisone (Deltasone®)
• Immunomodulating drugs:
  • Azathioprine (Imuran®, Azasan®)
  • Mercaptopurine (Purinethol®, Purixan®)
  • Cyclosporine (Sandimmune®, Neoral®)
  • Tacrolimus (Protopic®, Envarsus®)
• Biologic and related agents:
  • Infliximab (Remicade®)
  • Vedolizumab (Entyvio®)
  • Ustekinumab (Stelara®)
  • Tofacitinib (Xeljanz®)
• Optional surgery (Rarely required):
  • Approximately 30% of those afflicted suffer from extensive symptoms requiring surgery (Walfish & Companioni, 2020)
  • Total proctocolectomy
  • Ileostomy
  • Proctocolectomy with ileal pouch-anal anastomosis
• Behavioral coaching and cognitive therapy to reduce or eliminate:
  • Stress
  • Depression
  • Anxiety
• Promotion of medication compliance
• Dietary modification
• Up to date vaccinations
• Risk screening for opportunistic conditions
• Monitoring bone density
• Routine monitoring for neoplasias

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for ulcerative colitis are listed below.

Ulcerative Colitis Nursing Care Plan

Assessment

During the nursing assessment, emphasis should be placed on the person’s abdomen, rectum, and head, eyes, ears, and throat. The assessment may show:

• Abdominal tenderness or distension
• Tympany on percussion
• Rebound or guarding
• Ileus
• Rectal blood detected on exam
• Fissures and skin tags present
• Fistulas
• Episcleritis
• Scleritis
• Uveitis
• Pyostomatitis
• Non-specific oral lesions and conditions

Additional parameters of assessment:

• Auscultate bowel sounds for pitch and frequency
• Fluid and electrolyte status
• Evidence of weight loss
• Review stool frequency, characteristics, and amount
• Examine for dermatologic manifestations
• Check for symptoms of dehydration, bleeding, and infection including:
  • Frequent bloody diarrhea
  • Poor skin turgor
  • Dry mucous membranes
  • Sunken eyes

Ulcerative Colitis Nursing Diagnosis/Risk For

• Imbalanced nutrition, less than body requirements related to impaired absorption as evidenced by:
  • Alterations in mental state
  • Weakness
  • Tachycardia
  • Weak pulse
  • Weight loss
  • Concentrated urine
  • Decreased urine output
  • Dry mucous membranes
  • Sunken eyes
  • Decreased skin turgor
  • Decreased blood pressure
  • Postural hypotension
• Diarrhea related to bowel inflammation as evidenced by:
  • Increased bowel sounds/peristalsis
  • Hyperactive bowel sounds
  • Frequent watery stools
  • Changes in stool color
  • Abdominal pain
  • Urgency
  • Cramping
• Acute pain related to GI tract inflammation as evidenced by:
  • Reports of pain
  • Distraction
  • Guarding
  • Autonomic responses
• Deficit in knowledge of symptom prevention and condition management as evidenced by:
  • Request for information
  • Verbalization of problems
  • Presence of preventable complications
• Anxiety related to stress as evidenced by:
  • Increased tension
  • Apprehension
  • Concern regarding injury and loss of normal function

Interventions

• Manage pain control.
• Administer IV fluids.
• Observe for:
  • Fever
  • Tachycardia
  • Lethargy
  • Leukocytosis
  • Decreased serum protein
  • Anxiety and prostration
• Bowel management:
  • Enemas
  • Suppositories
  • Bowel decompression
  • Observe and record stool frequency
• Guaiac occult blood stool testing
• Assess for baseline lab values.
• Assess for contraindications, action, and side effects of medications.
• Promote rest, comfort, and safety.

Expected Outcomes

• Demonstrates improved hydration and electrolyte balance
• Regains stable bowel function
• Maintains optimal nutritional status
• Demonstrates positive coping skills
• Reports decreased pain
• Reports decreased anxiety

Individual/Caregiver Education

• Diagnosis and treatments
• Diarrhea management
• Signs of potential complications
• Proper diet and avoidance of foods that trigger symptoms
• Take their medicine as directed.
• Avoid over the counter medications such as salicylates and NSAIDs.
• Call the provider or seek medical care if:
  • Symptoms worsen.
  • There are questions or concerns about the condition or care.
• Recommended follow-up with healthcare provider

Additional Information

Course Contributor

The content for this course was created by Edward Bartels, RN, BSN, MICN 

Ed has over 30 years of clinical and teaching experience, and his areas of expertise are emergency and critical care, skilled nursing, behavioral health, occupational health, and safety, and home care. Ed served in several senior nursing leadership roles including: Emergency Services Director, Physician Practices Director, and Administrative Director of Nursing at the executive level. Ed is certified in LEAN efficiency fundamentals and tactics, which he has successfully deployed over the years in multiple settings resulting in cost savings, improved quality, and patient safety. Ed is a certified clinical nursing instructor in North Carolina. He earned his Diploma in Nursing from St. Vincent's School of Nursing in Staten Island, New York, in 1990 and Bachelor of Science in Nursing from the University of North Carolina, Greensboro in 2006. Ed is retired from the U.S. Coast Guard with 34 years.

Resources

Crohn’s & Colitis Foundation.

https://nationalhealthcouncil.org/member/crohns-colitis-foundation/

References

Walfish, A., & Campanioni, R. (2020). Ulcerative colitis. https://www.merckmanuals.com/home/digestive-disorders/inflammatory-bowel-diseases-ibd/ulcerative-colitis 

DynaMed. (2018). Ulcerative Colitis. Retrieved on November 4, 2021. https://www.dynamed.com/condition/ulcerative-colitis-in-adults

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