Comprehensive GI Nursing Care and Ulcerative Colitis Case Study

Course Schedule and Upcoming Assessments

• Weekly Deadlines

  • Quiz 4: This assessment occurs this Thursday and focuses on clinical fundamentals.
  • Quiz 5: Scheduled for next Thursday. This quiz will cover hematology and related topics.
  • CJM (Clinical Judgment Model): This will be conducted on Tuesday. Students will take the CJM and may go home afterward.
  • Presentations: The presentations originally scheduled for this Thursday have been moved to next Thursday, following Quiz 5. This adjustment allows for additional CJM review.

• Week 8 Planning

  • Musculoskeletal Content: For the Tuesday of Week 8, materials such as detailed notes (similar to the GI study guide) and Brainshark lectures will be provided for self-study.
  • Exam 2 Review: Tuesday of Week 8 will be primarily designated for Exam 2 review and preparation. Practice questions incorporating musculoskeletal topics will be provided.
  • Week 8 Attendance: Following the completion of Exam 2 in Week 8, students are permitted to leave. A relearning assignment related to the exam will be assigned at a later date.

Patient Case Study: Maria Fernanda

• Patient Profile

  • Name: Maria Fernanda
  • Age: $46$ years old
  • Admission Reason: Acute exacerbation of Ulcerative Colitis (UC)
  • Medical History: Ulcerative Colitis (diagnosed $8$ years ago), Anemia, and Gastroesophageal Reflux Disease (GERD).
  • Home Medications: Mesalamine and Pantoprazole ($40\,mg$).
  • Allergies: No known drug allergies.

• Subjective Findings and Chief Complaint

  • Maria reports worsening abdominal pain and frequent diarrhea over the previous $4$ days.
  • Diarrhea Frequency: Approximately $10$ to $12$ bowel movements per day.
  • Consistency: Stool contains blood and mucus, often described as having a "strawberry jam" consistency.
  • Associated Symptoms: Fatigue, dizziness when standing (orthostatic symptoms), decreased appetite, and an unintended weight loss of $6\,lb$ over the past week.

Clinical Manifestations of Ulcerative Colitis

• Pathophysiology

  • Ulcerative Colitis is characterized by inflammation and ulceration of the intestinal mucosa.
  • It typically begins in the rectum and may extend proximally through the entire colon.

• Common Manifestations

  • Bloody diarrhea and rectal bleeding.
  • Tenesmus (the feeling of needing to pass stool, even if the bowels are empty).
  • Lower abdominal pain.
  • Mucus-like, bloody stools.

Emergency Triage and Physical Assessment

• Vital Signs

  • Blood Pressure: Labeled as on the "soft side" (hypotensive).
  • Heart Rate: On the higher end (tachycardic).
  • Oxygen Saturation ($SpO_2$): Within normal limits.
  • Respiratory Rate: Within normal limits.
  • Temperature: Elevated, though not initially classified as a high fever.

• Physical Assessment Findings

  • Dry oral mucosa and pale skin.
  • Weak peripheral pulses and delayed capillary refill.
  • Patient report of feeling like they might pass out upon standing.

• Prioritization of Care

  • The highest priority problem is fluid volume deficit/hypovolemia, evidenced by low blood pressure, high heart rate, dry mucosa, and dizziness.
  • The first nursing action is to initiate IV fluid resuscitation ("fill the tank") to address the deficit before performing other tasks such as ambulation.

Diagnostic Testing and Laboratory Analysis

• Laboratory Values

  • Potassium ($K^+$): $3.0\,mEq/L$. This is a critical finding requiring immediate attention due to the risk of cardiac dysrhythmias, such as Ventricular Tachycardia ($V-Tach$) or Torsades de Pointes.
  • White Blood Cell ($WBC$) Count: Elevated (expected during an acute flare-up).
  • Sodium ($Na^+$): $132\,mEq/L$ (mildly hyponatremic).
  • Hemoglobin ($Hb$): In the $8s\,g/dL$. While low, hospitals typically do not transfuse until the level is less than $7.0\,g/dL$.
  • Albumin: $3.5\,g/dL$. Low albumin indicates nutritional compromise, but it is less acute than the potassium deficit.
  • Fecal Occult Blood: Positive (expected in UC).

• Diagnostic Procedures

  • Colonoscopy with Biopsy: Performed to visualize the colon directly and obtain tissue samples for definitive diagnosis.
  • Stool Culture and Fecal Calprotectin: Ordered to rule out infection and measure intestinal inflammation.

Medical and Nursing Interventions

• Pharmacological Orders

  • IV Normal Saline: For volume replacement.
  • Potassium Replacement: For electrolyte correction.
  • IV Methylprednisolone (Solu-Medrol): A corticosteroid used to reduce acute inflammation.
  • Mesalamine: Continued for long-term management of inflammatory bowel disease.

• Nursing Monitoring

  • Strict Intake and Output ($I\&Os$): Essential for monitoring fluid balance.
  • Daily Weights: The single most effective nursing intervention to evaluate if fluid balance is improving or if edema is resolving.
  • Blood Glucose Monitoring: Vital for patients on IV corticosteroids ($Solu-Medrol$), as steroids significantly increase blood sugar levels.
  • Mood Assessment: Steroids can cause "Hulk-like" mood swings, hyperactivity, and increased hunger.

Dietary Management and Nutrition

• Acute Phase Management

  • The patient should remain NPO (Nothing by Mouth) during the initial acute exacerbation to "rest the gut."
  • Once the gut is rested and white blood cell counts improve, the diet should transition to low-residue, low-fat foods with small, frequent meals.

• Appropriate Food Choices for IBD Flare-ups

  • Ideal Meal: Baked chicken, white rice, and applesauce (bland and low residue).
  • Avoid: Spicy foods, high-fiber/high-residue foods (such as seeds or popcorn), and high-fat foods.

Critical Complications and Toxic Megacolon

• Toxic Megacolon Symptoms

  • Severe abdominal distension and tenderness.
  • Fever (e.g., $102^{\circ}F$).
  • Tachycardia and hypotension.
  • Decreased or absent bowel sounds.
  • Anxious and pale appearance.

• Nursing Priority

  • Toxic megacolon is a medical emergency due to the risk of perforation, peritonitis, and sepsis leading to multi-organ failure.
  • The first action is to notify the surgical or medical team immediately as the patient is hemodynamically unstable.

Surgical Management and Ileostomy Care

• Total Proctocolectomy

  • Surgical removal of the colon effectively cures Ulcerative Colitis because the disease is confined to the colon. Unlike Crohn's disease, which is sporadic and can return elsewhere in the GI tract, UC does not recur after the colon is removed.

• Stoma Assessment

  • Expected Finding (Healthy): Moist, pinkish-red, and mildly swollen (in the immediate post-operative period). Small amounts of liquid drainage are expected.
  • Immediate Intervention Required: If the stoma becomes dusky, purple, gray, or ashen. This indicates a lack of perfusion (ischemia) and potential necrosis. This is a surgical emergency.

• Ileostomy Self-Management

  • The ileostomy pouch should be emptied when it is one-third ($1/3$) full to prevent the weight of the pouch from pulling on the skin barrier.

Comparative Pathology of IBD

• Ulcerative Colitis (UC)

  • Location: Confined to the colon and rectum.
  • Stool: Bloody diarrhea with mucus.
  • Curability: Curable via surgical removal of the colon.

• Crohn's Disease

  • Location: Sporadic; can affect any part of the GI tract from mouth to anus with "skip lesions."
  • Curability: Not cured by surgery; it can return anywhere else in the bowel.

Questions & Discussion

• Q: Why does frequent diarrhea place a patient at risk for hypokalemia?

• A: The rapid transit of intestinal contents prevents the reabsorption of electrolytes, essentially causing the body to lose potassium through the stool.

• Q: Why is a low-residue diet used during an IBD exacerbation?

• A: The primary goal is to rest the gut and prevent further irritation and exacerbation caused by bulky fiber.

• Q: What are Turner’s and Cullen’s signs?

• A: These are signs of retroperitoneal or intra-abdominal bleeding (discoloration of the flanks or around the umbilicus), which could indicate a worsening cascade leading to sepsis or organ failure.

• Q: How often should blood glucose be monitored for patients on tube feeds or parenteral nutrition?

• A: Blood sugars should be checked every $6$ hours because these formulas contain high concentrations of sugar.

• Q: What is "Dumping Syndrome"?

• A: It occurs when tube feeds or food enter the small intestine too quickly, usually due to high infusion rates. The intestine cannot absorb it, leading to liquid diarrhea, hypovolemia, and electrolyte loss.