Nursing Care Plan (NCP) for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
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Outline
Lesson Objectives for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Understanding the Pathophysiology:
- Gain a comprehensive understanding of the pathophysiology of Inflammatory Bowel Disease (IBD), distinguishing between Ulcerative Colitis and Crohn’s Disease.
- Identify key factors contributing to the chronic inflammatory process in the gastrointestinal tract.
- Differentiating Between Ulcerative Colitis and Crohn’s Disease:
- Differentiate the clinical manifestations and characteristics of Ulcerative Colitis and Crohn’s Disease.
- Understand how the location and nature of inflammation in the gastrointestinal tract vary between the two conditions.
- Assessment Skills for IBD:
- Develop skills for a thorough nursing assessment specific to patients with Inflammatory Bowel Disease.
- Learn to recognize signs and symptoms, including abdominal pain, diarrhea, weight loss, and complications such as strictures or fistulas.
- Management Strategies and Medication Education:
- Explore nursing interventions and management strategies for patients with IBD, including the administration of prescribed medications.
- Provide patient education on the importance of medication adherence, dietary modifications, and lifestyle changes in managing IBD.
- Psychosocial Support and Coping Strategies:
- Recognize the psychosocial impact of living with a chronic condition like IBD and learn strategies to offer emotional support.
- Explore coping mechanisms for patients dealing with the challenges of Inflammatory Bowel Disease.
Pathophysiology of Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Chronic Inflammation:
- Both Ulcerative Colitis and Crohn’s Disease involve chronic inflammation of the gastrointestinal (GI) tract.
- In Ulcerative Colitis, inflammation is limited to the colon and rectum, primarily affecting the mucosal lining.
- Crohn’s Disease can affect any part of the GI tract, from the mouth to the anus, and involves deeper layers of the intestinal wall.
- Immune System Dysregulation:
- Immune system dysregulation plays a key role in the pathogenesis of Inflammatory Bowel Disease.
- An exaggerated immune response targets the GI tract, leading to sustained inflammation and tissue damage.
- Microbial Factors:
- Dysbiosis, an imbalance in the gut microbiota, may contribute to the development of IBD.
- Environmental factors, such as infections or alterations in the microbiome, can trigger an abnormal immune response in genetically susceptible individuals.
- Formation of Ulcers and Fistulas:
- Ulcerative Colitis is characterized by the formation of continuous mucosal ulcers, leading to surface inflammation.
- Crohn’s Disease can cause transmural inflammation, leading to the formation of ulcers, strictures, and fistulas, which can extend through multiple layers of the intestinal wall.
- Complications and Systemic Effects:
- Chronic inflammation in both conditions can result in complications such as strictures, abscesses, and perforation.
- Systemic effects may include malnutrition due to nutrient malabsorption, weight loss, and an increased risk of colorectal cancer in long-standing cases.
Etiology of Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Genetic Predisposition:
- There is a significant genetic component to the development of Inflammatory Bowel Disease.
- Individuals with a family history of IBD are at a higher risk, and specific genetic variants are associated with increased susceptibility.
- Immune System Dysfunction:
- Dysfunction of the immune system, particularly an abnormal response to the gut microbiota, is a central etiological factor.
- Inappropriate immune activation leads to chronic inflammation in the gastrointestinal tract.
- Environmental Factors:
- Environmental factors, such as diet, smoking, and exposure to certain infections, can influence the development and exacerbation of IBD.
- Changes in the gut microbiome due to environmental factors may contribute to the pathogenesis.
- Dysregulation of Gut Microbiota:
- Alterations in the composition and function of the gut microbiota, known as dysbiosis, are observed in individuals with IBD.
- Imbalances in the microbial community may trigger and perpetuate the inflammatory response.
- Epigenetic Factors:
- Epigenetic modifications, changes in gene expression that do not involve alterations in the DNA sequence, play a role in IBD.
- Epigenetic changes may contribute to the persistent inflammation seen in Ulcerative Colitis and Crohn’s Disease.
Desired Outcome for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Disease Remission:
- Achieve and maintain periods of symptom-free intervals to allow the affected bowel to heal.
- Minimize the frequency and intensity of disease flares.
- Improved Quality of Life:
- Enhance the patient’s overall well-being by managing symptoms such as abdominal pain, diarrhea, and fatigue.
- Address psychosocial aspects to improve mental health and emotional resilience.
- Prevention of Complications:
- Prevent and manage complications associated with IBD, such as strictures, fistulas, and abscesses.
- Monitor for and address extraintestinal manifestations of the disease.
- Nutritional Optimization:
- Ensure adequate nutrition to support overall health and compensate for nutritional deficiencies common in IBD.
- Manage malabsorption issues and promote a diet that supports gastrointestinal health.
- Normalization of Inflammatory Markers:
- Achieve and maintain normal levels of inflammatory markers in blood tests.
- Monitoring inflammatory markers helps assess the degree of disease activity and response to treatment.
Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease) Nursing Care Plan
Subjective Data:
- Severe diarrhea
- Abdominal pain and cramping
- Rectal pain
- Fatigue
- Reduced appetite
- Urgency to defecate
- Inability to defecate despite urgency
Objective Data:
- Blood or pus in stool
- Weight loss
- WBC in stool
- Multiple stools daily
Nursing Assessment for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Health History:
- Collect detailed information about the patient’s medical history, including previous diagnoses, treatments, and surgeries related to IBD.
- Inquire about family history of IBD or other gastrointestinal conditions.
- Symptom Assessment:
- Evaluate the nature, frequency, and severity of gastrointestinal symptoms such as abdominal pain, diarrhea, rectal bleeding, and weight loss.
- Assess extraintestinal symptoms, including joint pain, skin rashes, and eye problems.
- Nutritional Assessment:
- Conduct a nutritional assessment to identify malnutrition or nutritional deficiencies.
- Monitor dietary habits and restrictions, as well as the impact of symptoms on the patient’s ability to maintain a balanced diet.
- Psychosocial Evaluation:
- Assess the patient’s emotional well-being and mental health, considering the potential impact of chronic symptoms on daily life.
- Identify stressors, coping mechanisms, and support systems in place.
- Physical Examination:
- Perform a thorough abdominal examination to assess for tenderness, distension, and palpable masses.
- Examine the perianal area for signs of fistulas, abscesses, or skin manifestations.
- Laboratory and Diagnostic Tests:
- Order and interpret laboratory tests, including inflammatory markers (CRP, ESR), complete blood count (CBC), and electrolyte levels.
- Schedule diagnostic imaging studies such as endoscopy, colonoscopy, and imaging scans to assess the extent and severity of bowel involvement.
- Medication Review:
- Review the patient’s current and past medications, including compliance, side effects, and any adjustments made to the treatment plan.
- Assess the patient’s response to medications and the need for modifications.
- Educational Needs Assessment:
- Identify the patient’s understanding of IBD, its chronic nature, and the importance of treatment adherence.
- Assess the patient’s knowledge of dietary management, symptom recognition, and when to seek medical attention.
Implementation for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Medication Administration and Monitoring:
- Administer prescribed medications, such as anti-inflammatory drugs, immunosuppressants, and biologics, as per the healthcare provider’s orders.
- Monitor for medication side effects and assess the patient’s response to treatment.
- Nutritional Support:
- Collaborate with a dietitian to develop a nutrition plan tailored to the patient’s needs, addressing potential nutrient deficiencies and supporting overall well-being.
- Educate the patient on dietary modifications, including avoiding trigger foods and maintaining a balanced diet.
- Pain Management:
- Implement pain management strategies to address abdominal pain and discomfort, such as the use of heat packs or relaxation techniques.
- Coordinate with the healthcare team to adjust pain medications as needed.
- Education and Self-Management:
- Provide comprehensive education about the nature of IBD, its chronicity, and the importance of treatment adherence.
- Teach the patient self-management techniques, including symptom monitoring, recognizing signs of exacerbation, and seeking prompt medical attention.
- Psychosocial Support:
- Facilitate access to support groups, counseling, or mental health services to address the emotional and psychological impact of living with a chronic condition.
- Encourage open communication with the healthcare team and involve family members in the patient’s care as needed.
Nursing Interventions and Rationales
- Monitor vital signs
Watch for signs / symptoms of hypovolemia including:
- Hypotension
- Tachycardia
- Fever
- Perform perineal care
Severe diarrhea may lead to incontinence of bowels, especially in patients with limited mobility. Provide perineal care every 2-4 hours or as needed to prevent breakdown of skin and infections. Make sure to clean from front to back, and between skin folds of the buttocks and scrotum. Apply barrier cream as appropriate to protect skin.
- Collect and monitor labs
- Stool sample- used to determine if there is blood or WBCs in the stool
- Blood sample – check for anemia and signs of infection, evaluate electrolytes
- Rule out bacterial, viral or parasitic infection
- Determine if supplementation is necessary
- Potassium
- Magnesium
- Sodium
- Acid-base balance
- Promote bedrest
Rest decreases intestinal motility when diarrhea is a problem. If patient has frequent urge to defecate, provide bedside commode to prevent incontinence and reduce risk of falls
- Monitor I & O
Note number, character, and amount of stools to determine renal function, bowel disease control and need for fluid replacement; daily weights may be necessary
- Prep patient / assist with colonoscopy, sigmoidoscopy or upper endoscopy
- Patients must be fasting, no food or drink for 4-8 hours prior to the procedure
- Administer conscious sedation
- Monitor vitals while patient is sedated per facility policy
- Assist with ambulation immediately following procedure until sedation is fully worn off
- NPO until gag reflex returns
- Provide oral care at least every 12 hours until
Dry mouth from an NPO status can cause a build up of bacteria and fungus in the mouth resulting in ulcerations, thrush and cavities.
- Assess oral mucosa and inspect for dried secretions in the roof of the mouth that may impair breathing.
- Swab mouth every 2-4 hours for hydration and comfort
- Use wet toothbrush without toothpaste to clean teeth, gums and tongue to prevent aspiration
- Suction secretions as necessary
- Administer Medications per order or facility protocol
- Anti-inflammatories– corticosteroids such as prednisone or hydrocortisone
- Immunosuppressants– azathioprine, cyclosporine
- Antibiotics– metronidazole, ciprofloxacin
- Anti-diarrheal– loperamide
- Pain reliever– acetaminophen (NSAIDS are contraindicated)
- Iron supplements– as needed for iron-deficiency anemia due to intestinal bleeding
- Perform and educate patient to perform stoma care if ileostomy is necessary
- Change ostomy system as needed per facility protocol, usually every 2-4 days
- Empty the ostomy pouch when ⅓ full
- Clean stoma with each bag change, using soap and warm water, avoiding alcohol based cleaners.
- Assess the skin around the stoma for bruising or ulceration
- The stoma should be pink or red
- Encourage patient to make healthy lifestyle choices
- Limit or avoid alcohol which may increase diarrhea
- Exercise- healthy diet and exercise help to normalize bowel function
- Stop smoking- smoking increases the risk of Crohn’s and the frequency of recurrences
- Reduce stress- many patients report symptom flares during periods of high stress
- Provide nutrition education
- Limit dairy products due to correlation with lactose intolerance
- Increase low-fat foods- with Crohn’s disease, fat passes through the intestine instead of being absorbed making diarrhea worse
- Limit fiber- includes raw fruits, vegetables and whole grains
- Limit other problem foods- spicy foods, alcohol, caffeine
- Eat small frequent meals
- Drink plenty of fluids- water is best
Potential Nursing Diagnosis for Ulcerative Colitis
Nurses play a critical role in caring for individuals with Ulcerative Colitis (UC), a chronic inflammatory bowel disease. The nursing diagnosis for patients with UC typically includes:
- Risk for Imbalanced Nutrition: Due to the inflammation and ulceration in the colon, patients with UC are at risk of imbalanced nutrition. Assessing dietary intake, monitoring weight changes, and collaborating with dietitians are essential in addressing this concern.
- Acute Pain: Patients with UC often experience abdominal pain during flare-ups. Nursing care involves assessing the location, intensity, and duration of pain, and implementing pain management strategies.
- Impaired Skin Integrity: Skin rashes and extraintestinal symptoms can occur in UC patients. Nurses should assess and monitor the skin for rashes and implement preventive measures to maintain skin integrity.
- Anxiety: Chronic illnesses like UC can lead to anxiety. Nursing interventions may include providing emotional support, teaching coping strategies, and involving mental health professionals if needed.
- Risk for Infection: Immunosuppressive medications used to manage UC can increase the risk of infection. Nurses should monitor for signs of infection and educate patients on infection prevention.
These nursing diagnoses help guide care planning and ensure that patients with UC receive comprehensive and individualized care. The specific nursing diagnosis may vary based on the patient’s condition and needs.
Evaluation for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
- Symptom Assessment:
- Regularly evaluate the patient’s gastrointestinal symptoms, including abdominal pain, diarrhea, and rectal bleeding, to determine the effectiveness of the treatment plan.
- Medication Adherence and Response:
- Assess the patient’s adherence to prescribed medications and evaluate their response to the pharmacological interventions. Adjustments may be made based on treatment efficacy.
- Nutritional Status:
- Monitor the patient’s nutritional status and assess for any signs of malnutrition or nutrient deficiencies. Evaluate the success of dietary modifications and nutritional support interventions.
- Pain Management Effectiveness:
- Evaluate the effectiveness of pain management strategies in alleviating abdominal pain and discomfort. Adjust pain management plans if necessary based on the patient’s feedback.
- Psychosocial Well-being:
- Assess the patient’s emotional and psychological well-being, considering the impact of the chronic condition on their quality of life. Address any emerging psychosocial concerns and assess the need for ongoing support.
References
- https://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/diagnosis-treatment/drc-20353320
- https://www.cdc.gov/ibd/what-is-IBD.htm
- http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/
- https://www.medicinenet.com/inflammatory_bowel_disease_intestinal_problems/article.htm
- https://medlineplus.gov/ency/patientinstructions/000204.htm
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Transcript
In this nursing care plan, we will explore inflammatory bowel disease, including both ulcerative colitis and Crohn’s disease. So in this nursing care plan for inflammatory bowel disease, we’re going to look at the outcome, the subjective and objective data and the nursing interventions along with the rationales for each.
Our medical diagnosis for a patient is inflammatory bowel disease and we’re going to explore both ulcerative colitis and Crohn’s disease. Inflammatory bowel disease is a term that describes two conditions that are both characterized by inflammation in the GI tract. Ulcerative colitis causes long lasting inflammation and ulcers in the digestive track on the innermost lining. Crohn’s disease causes the inflammation deep within those layers and is throughout the entire GI tract. The causes are not completely understood, but it’s believed to be an immune system dysfunction and also hereditary. The desired outcome is to have normal stools be free from pain and infection and to have periods of remission.
Now, let’s take a look at our care plan. So the subjective data that you might see in your patient is that they might be experiencing severe diarrhea, abdominal cramping and pain, rectal pain, fatigue, reduced appetite, urgency or the inability to defecate. All of these symptoms are all because of the inflammation and irritation in the bowels.
For the patient’s objective data, we’re going to probably see some blood or even pus in the stool. The patient might experience weight loss. If they’ve been having a lot of diarrhea or are unable to eat, they might experience some white blood cells in the stool and like I said previously, they might be having multiple stools daily.
Now let’s take a look at our nursing interventions and the rationales for each. So our first nursing intervention is to monitor their vital signs. You’re going to be watching for hypovolemia like low blood pressure, high heart rate, or fevers. You’re also going to be performing perineal care in your patient. Remember, this is going to cause some diarrhea in your patient, which can even lead to incontinence. So, we want to keep them clean, provide the peri care every two to four hours to prevent skin breakdown, and we don’t want to get any infections. You will want to collect and monitor labs and collect a stool sample to look for blood and white blood cells. You will have them draw blood to look for anemia, signs of infection, and electrolyte imbalances. You’re going to rule out any bacterial, viral or parasitic infections in the patient.
For your patient with inflammatory bowel disease, you want to try to promote bed rest, because rest decreases intestinal motility to try to help slow things down and decrease that diarrhea. If your patient has really frequent urges to defecate, or maybe they’re having some problem with some incontinence, just provide a commode at the bedside and maybe that will help them and also reduce the risk of falls.
So, the next nursing intervention is to monitor the intake and output of your patient. Now, I want you to note the number, character and amount of stools to determine hydration and control of the disease. Your patient might have to have a colonoscopy, sigmoidoscopy or an upper endoscopy, depending on what the doctor chooses. So, you’ll prep the patient according to your policy and prepare them for the procedure. You might have to provide bowel prep the night before to clean their bowels out so that they can see with the camera. The patient’s going to be NPO at least four to eight hours before the procedure as well. So, the patient has to be monitored during the procedure, including their vital signs, while they’re sedated per facility policy. Immediately after, help them with their ambulation until that sedation has worn off and keep that patient NPO until their gag reflex comes back. You want to avoid any aspiration.
You should provide oral care at least every 12 hours on your patient while they’re NPO, because dry mouth from an NPO status can cause the buildup of bacteria and fungus in the mouth resulting in ulcerations, thrush, cavities, and even pneumonia. Assess their mouth, look for any dry crusty chunks that might be stuck in the back of the mouth, because those can break out and obstruct the airway. Swab the mouth every two to four hours or as needed and you can use a toothbrush without toothpaste, just to clean the teeth, the gums, and the tongue, get any of those secretions out, and you can suction as needed to avoid aspiration.
For your patient with inflammatory bowel disease, you’re going to administer medications per order, or facility protocol. These medications might help to decrease the inflammation, relieve pain, decrease diarrhea, or treat anemia infection as needed.
Our next nursing intervention is to educate the patient to perform stoma care if an ileostomy was necessary. You will teach them how to assess, clean and change the bag and keep the area clean and free from infection or ulcerations. You’ll want to prevent that bag from overfilling. I like to empty it when it’s at least a third full, just so that way it doesn’t get too full and break off and cause a big mess. You’ll want to encourage your patient to make healthy lifestyle choices. This is going to help to decrease flare ups as a lot of foods can cause inflammation in the bowels. You want to decrease things like dairy. You’ll want to tell them to try to avoid caffeine, alcohol, and try to tell them to work on having a low fat diet, because that’s going to make it a little easier to digest. Encourage your patients to find ways, I know it’s hard, but find ways to decrease stress because that will help limit that irritation and the flare ups. Encourage them to also eat frequent small meals and increase their fluids. We want to keep them hydrated. They should also try to limit their fiber such as raw fruits, or raw vegetables, because when you have all that fiber in there it kind of makes things even worse.
We love you guys. Now go out and be your best self today and as always, happy nursing!
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Nursing Care Plans
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