NURSING PROCESS:MANAGEMENT OF THE PATIENT WITH INFLAMMATORY BOWEL DISEASE
The nurse takes a health history to identify the onset, duration, and characteristics of abdominal pain; the presence of diarrhea or fecal urgency, straining at stool (tenesmus), nausea, anorexia, or weight loss; and family history of IBD. It is important to discuss dietary patterns, including the amounts of alcohol, caffeine, and nicotine containing products used daily and weekly. The nurse asks about patterns of bowel elimination, including character, fre-quency, and presence of blood, pus, fat, or mucus. It is important to note allergies and food intolerance, especially milk (lactose) in-tolerance. The patient may identify sleep disturbances if diarrhea or pain occurs at night.
Assessment includes auscultating the abdomen for bowel sounds and their characteristics; palpating the abdomen for distention, tenderness, or pain; and inspecting the skin for evidence of fistula tracts or symptoms of dehydration. The stool is inspected for blood and mucus.
With regional enteritis, pain is usually localized in the right lower quadrant, where hyperactive bowel sounds can be heard be-cause of borborygmus and increased peristalsis. Abdominal ten-derness is noticed on palpation. The most prominent symptom is intermittent pain that occurs with diarrhea but does not de-crease after defecation. Pain in the periumbilical region usually indicates involvement of the terminal ileum. With ulcerative colitis, the abdomen may be distended, and rebound tenderness may be present. Rectal bleeding is a significant sign.
Based on the assessment data, the nursing diagnoses may include the following:
• Diarrhea related to the inflammatory process
• Acute pain related to increased peristalsis and GI inflam-mation
• Deficient fluid volume deficit related to anorexia, nausea, and diarrhea
• Imbalanced nutrition, less than body requirements, related to dietary restrictions, nausea, and malabsorption
• Activity intolerance related to fatigue
• Anxiety related to impending surgery
• Ineffective coping related to repeated episodes of diarrhea
• Risk for impaired skin integrity related to malnutrition and diarrhea
• Risk for ineffective therapeutic regimen management related to insufficient knowledge concerning the process and man-agement of the disease
Potential complications that may develop include the following:
• Electrolyte imbalance
• Cardiac dysrhythmia related to electrolyte depletion
• GI bleeding with fluid volume loss
• Perforation of the bowel
The major goals for the patient include attainment of normal bowel elimination patterns, relief of abdominal pain and cramp-ing, prevention of fluid volume deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reducing anxiety, pro-moting effective coping, absence of skin breakdown, learning about the disease process and therapeutic regimen, and avoidance of complications.
The nurse determines if there is a relationship between diarrhea and certain foods, activity, or emotional stress. Identifying pre-cipitating factors, the frequency of bowel movements, and the character, consistency, and amount of stool passed is important. The nurse provides ready access to a bathroom, commode, or bedpan and keeps the environment clean and odor free. It is im-portant to administer antidiarrheal medications as prescribed, to record the frequency and consistency of stools after therapy is ini-tiated, and to encourage bed rest to decrease peristalsis.
The character of the pain is described as dull, burning, or crampy. Asking about its onset is relevant. Does it occur before or after meals, during the night, or before elimination? Is the pattern con-stant or intermittent? Is it relieved with medications? The nurse administers anticholinergic medications as prescribed 30 minutes before a meal to decrease intestinal motility and administers anal-gesics as prescribed for pain. Position changes, local application of heat (as prescribed), diversional activities, and the prevention of fatigue also are helpful for reducing pain.
To detect fluid volume deficit, the nurse keeps an accurate record of oral and intravenous fluids and maintains a record of output (ie, urine, liquid stool, vomitus, and wound or fistula drainage). The nurse monitors daily weights for fluid gains or losses and as-sesses the patient for signs of fluid volume deficit (ie, dry skin and mucous membranes, decreased skin turgor, oliguria, exhaustion, decreased temperature, increased hematocrit, elevated urine spe-cific gravity, and hypotension). It is important to encourage oral intake of fluids and to monitor the intravenous flow rate. The nurse initiates measures to decrease diarrhea (eg, dietary restrictions, stress reduction, antidiarrheal agents).
Parenteral nutrition (PN) is used when the symptoms of IBD are severe. With PN, the nurse maintains an accurate record of fluid intake and output as well as the patient’s daily weight. The pa-tient should gain 0.5 kg daily during PN therapy. Because PN is very high in glucose and can cause hyperglycemia, blood glucose levels are monitored every 6 hours. Elemental feedings high in protein and low in fat and residue are instituted after PN ther-apy because they are digested primarily in the jejunum, do not stimulate intestinal secretions, and allow the bowel to rest. The nurse notes intolerance if the patient exhibits nausea, vomiting, diarrhea, or abdominal distention.
If oral foods are tolerated, small, frequent, low-residue feed-ings are given to avoid overdistending the stomach and stimu-lating peristalsis. It is important for the patient to restrict activity to conserve energy, reduce peristalsis, and reduce calorie requirements.
The nurse recommends intermittent rest periods during the day and schedules or restricts activities to conserve energy and reduce the metabolic rate. It is important to encourage activity within the limits of the patient’s capacity. The nurse suggests bed rest for a patient who is febrile, has frequent diarrheal stools, or is bleeding. The patient on bed rest should perform active exercises to maintain muscle tone and prevent thromboembolic compli-cations. If the patient is unable to perform these active exercises, the nurse performs passive exercises and joint range of motion. Activity restrictions are modified as needed on a day-to-day basis.
Rapport can be established by being attentive and displaying a calm, confident manner. The nurse allows time for the patient to ask questions and express feelings. Careful listening and sensitiv-ity to nonverbal indicators of anxiety (eg, restlessness, tense facial expressions) are helpful. The patient may be emotionally labile because of the consequences of the disease; the nurse tailors in-formation about possible impending surgery to the patient’s level of understanding and desire for detail. If surgery is planned, pic-tures and illustrations help to explain the surgical procedure and help the patient to visualize what a stoma looks like.
Because the patient may feel isolated, helpless, and out of control, understanding and emotional support are essential. The patient may respond to stress in a variety of ways that may alienate others, including anger, denial, and social self-isolation.
The nurse needs to recognize that the patient’s behavior may be affected by a number of factors unrelated to inherent emo-tional characteristics. Any patient suffering the discomforts of frequent bowel movements and rectal soreness is anxious, dis-couraged, and depressed. It is important to develop a relationship with the patient that supports all attempts to cope with these stresses. It is also important to communicate that the patient’s feelings are understood by encouraging the patient to talk and ex-press his or her feelings and to discuss any concerns. Stress re-duction measures that may be used include relaxation techniques, visualization, breathing exercises, and biofeedback. Professional counseling may be needed to help the patient and family manage issues associated with chronic illness.
The nurse examines the patient’s skin frequently, especially the perianal skin. Perianal care, including the use of a skin barrier, is important after each bowel movement. The nurse gives immediate attention to reddened or irritated areas over a bony prominence and uses pressure-relieving devices to prevent skin breakdown. Consultation with a wound care specialist or enterostomal ther-apist is often helpful.
Serum electrolyte levels are monitored daily, and electrolyte re-placements are administered as prescribed. It is important to re-port evidence of dysrhythmias or change in level of consciousness immediately.
The nurse closely monitors rectal bleeding and administers blood component therapy and volume expanders as prescribed to prevent hypovolemia. It is important to monitor the blood pres-sure for hypotension and to obtain coagulation and hematocrit and hemoglobin profiles frequently. Vitamin K may be prescribed to increase clotting factors.
The nurse closely monitors the patient for indications of per-foration (ie, acute increase in abdominal pain, rigid abdomen, vomiting, or hypotension) and obstruction and toxic megacolon (ie, abdominal distention, decreased or absent bowel sounds, change in mental status, fever, tachycardia, hypotension, dehy-dration, and electrolyte imbalances).
The nurse assesses the patient’s understanding of the disease process and his or her need for additional information about medical management (eg, medications, diet) and surgical inter-ventions. The nurse provides information about nutritional man-agement; a bland, low-residue, high-protein, high-calorie, and high-vitamin diet relieves symptoms and decreases diarrhea. It is important to provide the rationale for the use of corticosteroids and anti-inflammatory, antibacterial, antidiarrheal, and antispas-modic medications. The nurse emphasizes the importance of tak-ing medications as prescribed and not abruptly discontinuing them (especially corticosteroids) to avoid development of serious medical problems (Chart 38-3). The nurse reviews ileostomy care as necessary (see Nursing Management of the Patient with an Ileostomy). Patient education information can be obtained from the National Foundation for Ileitis and Colitis.
Patients with chronic inflammatory disease are managed at home with follow-up care by their physician or through an outpatient clinic. Those whose nutritional status is compromised and who are receiving PN need home care nursing to ensure that their nutri-tional requirements are being met and that they or their caregivers can follow through with the instructions for PN. Patients who are medically managed need to understand that their disease can be controlled and that they can lead a healthy life between exacerba-tions. Control implies management based on an understanding of the disease and its treatment. Patients in the home setting need in-formation about their medications (ie, name, dose, side effects, and frequency of administration) and need to take medications on schedule. Medication reminders such as containers that separate pills according to day and time or daily checklists are helpful.
During a flare-up, the nurse encourages patients to rest as needed and to modify activities according to their energy levels. Patients should limit tasks that impose strain on the lower ab-dominal muscles. They should sleep in a room close to the bath-room because of the frequent diarrhea (10 to 20 times per day); quick access to a toilet helps alleviate the worry of embarrassment if an accident occurs. Room deodorizers help control odors.
Dietary modifications can control but not cure the disease; the nurse recommends a low-residue, high-protein, high-calorie diet, especially during an acute phase. It is important to encourage pa-tients to keep a record of the foods that irritate the bowel and to eliminate them from the diet and to remind patients to drink at least eight glasses of water each day.
The prolonged nature of the disease has an impact on the patient and often strains his or her family life and financial resources as well. Family support is vital; however, some family members may be re-sentful, guilty, and tired and feel unable to continue coping with the emotional demands of the illness and the physical demands of car-ing for another. Some patients with IBD do not socialize for fear of being embarrassed. Many prefer to eat alone. Because they have lost control over elimination, they may fear losing control over other as-pects of their lives. They need time to express their fears and frus-trations. Individual and family counseling may be helpful.
Expected patient outcomes may include the following:
1) Reports a decrease in the frequency of diarrhea stools
a. Complies with dietary restrictions; maintains bed rest
b. Takes medications as prescribed
2) Has reduced pain
3) Maintains fluid volume balance
a. Drinks 1 to 2 L of oral fluids daily
b. Has a normal body temperature
c. Displays adequate skin turgor and moist mucous membranes
4) Attains optimal nutrition; tolerates small, frequent feed-ings without diarrhea
5) Avoids fatigue
a. Rests periodically during the day
b. Adheres to activity restrictions
6) Is less anxious
7) Copes successfully with diagnosis
a. Expresses feelings freely
b. Uses appropriate stress reduction behaviors
8) Maintains skin integrity
a. Cleans perianal skin after defecation
b. Uses lotion or ointment as skin barrier
9) Acquires an understanding of the disease process
a. Modifies diet appropriately to decrease diarrhea
b. Adheres to medication regimen
10) Recovers without complications
a. Maintains electrolytes within normal ranges
b. Maintains normal sinus or baseline cardiac rhythm
c. Maintains fluid balance
d. Experiences no perforation or rectal bleeding
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