A patient with ulcerative colitis is experiencing worsening symptoms, including anemia and elevated fecal calprotectin levels. Recent diagnostic tests reveal extensive colonic ulcerations and early signs of toxic megacolon. The healthcare team has initiated intravenous corticosteroids and infliximab. Which nursing intervention is the highest priority to address the current clinical status of this patient?

A) Monitor the patient's intake and output closely to assess for fluid balance and potential hypovolemia.

B) Educate the patient on the side effects of infliximab therapy to ensure informed consent.

C) Schedule regular assessments for signs of infection due to immune suppression from corticosteroids.

D) Encourage the patient to increase oral fluid intake to reduce the risk of dehydration.

A patient with worsening anemia and increased intestinal inflammation has been started on intravenous corticosteroids and infliximab. The patient is also receiving total parenteral nutrition (TPN) due to poor oral intake. During your assessment, you note a heart rate of 112 bpm and a blood pressure of 98/58 mmHg. What nursing action is most appropriate at this time?

C) Administer a prescribed bolus of intravenous fluids to address potential hypovolemia.

A) Increase the rate of TPN to provide additional fluid volume.

B) Notify the physician immediately about the potential for circulatory overload.

C) Administer a prescribed bolus of intravenous fluids to address potential hypovolemia.

D) Prepare the patient for immediate surgery due to suspected toxic megacolon.

A patient with ulcerative colitis is being closely monitored for complications while receiving enhanced medical therapy. The patient now presents with increased abdominal pain, distention, and significant colonic dilation on imaging, with a white blood cell count of 14,000/mm³. What is the nurse's priority intervention at this time?

B) Prepare the patient for possible surgical intervention and ensure NPO status.

A) Administer prescribed analgesics and reassess pain levels.

B) Prepare the patient for possible surgical intervention and ensure NPO status.

C) Increase the rate of intravenous fluids to prevent hypovolemia.

D) Educate the patient about the signs and symptoms of toxic megacolon.

The patient with ulcerative colitis is experiencing increased abdominal pain and distention with findings suggestive of toxic megacolon. As a nurse, which intervention is the most critical to prioritize in managing this patient’s condition?

B) Preparing the patient for an urgent surgical consultation

A) Administering prescribed corticosteroids to reduce inflammation

B) Preparing the patient for an urgent surgical consultation

C) Increasing the rate of total parenteral nutrition (TPN) to improve nutritional status

D) Providing detailed education about the benefits and risks of colectomy

A patient with ulcerative colitis presents with signs of peritoneal irritation, fever, tachycardia, and abdominal distention. A CT scan confirms free air under the diaphragm, indicating a perforation. What is the nurse's priority intervention prior to the patient undergoing an emergent colectomy?

A) Administer intravenous fluids to manage hypovolemia

B) Prepare the patient for a colonoscopy to confirm the diagnosis

C) Educate the patient about the risks of surgery

D) Schedule a follow-up appointment with a gastroenterologist

A patient with ulcerative colitis has developed signs of peritoneal irritation and a confirmed perforation on CT scan. Which nursing intervention is the priority to address the patient's current hemodynamic instability?

C) Initiate intravenous fluid resuscitation to manage hypovolemia.

A) Administer broad-spectrum antibiotics to prevent infection.

B) Prepare the patient for an emergent colectomy to repair the perforation.

C) Initiate intravenous fluid resuscitation to manage hypovolemia.

D) Monitor vital signs every 30 minutes to assess for changes in condition.

A patient in the ICU following emergent colectomy exhibits signs of acute respiratory distress and is diagnosed with acute respiratory distress syndrome (ARDS). The arterial blood gas analysis shows respiratory acidosis. Which nursing intervention is most appropriate to address the patient's current respiratory status?

B) Initiate prone positioning to enhance alveolar ventilation and oxygenation.

A) Increase the oxygen flow rate to improve oxygen saturation.

B) Initiate prone positioning to enhance alveolar ventilation and oxygenation.

C) Administer sodium bicarbonate to correct the acidosis.

D) Encourage deep breathing exercises to increase lung expansion.

A patient in the ICU post-emergent colectomy is exhibiting signs of acute respiratory distress syndrome (ARDS) and has been placed on mechanical ventilation. The patient's arterial blood gas shows a pH of 7.30, PaCO2 of 50 mmHg, and PaO2 of 55 mmHg on a 50% oxygen mask. Which nursing intervention is most appropriate to improve the patient’s oxygenation and prevent further lung injury?

B) Implement prone positioning to improve ventilation-perfusion matching.

A) Increase the tidal volume on the ventilator to enhance oxygenation.

B) Implement prone positioning to improve ventilation-perfusion matching.

C) Administer high-dose corticosteroids to reduce inflammation.

D) Increase the FiO2 to 100% to rapidly correct hypoxemia.

A patient in the ICU following a colectomy is suspected of having septic shock due to an intra-abdominal infection. The healthcare team has initiated broad-spectrum antibiotics and vasopressor support. The patient's blood pressure remains labile, and her heart rate is elevated. Which nursing intervention is most critical in the immediate management of this patient?

B) Prepare the patient for immediate percutaneous drainage under radiological guidance.

A) Increase the rate of IV fluid administration to improve blood pressure.

B) Prepare the patient for immediate percutaneous drainage under radiological guidance.

C) Monitor lactate levels to assess the effectiveness of current interventions.

D) Adjust the mechanical ventilator settings to improve oxygenation.

ulcerative colitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Ulcerative colitis is an inflammatory bowel disease characterized by chronic inflammation of the colon's mucosal layer. This inflammation is driven by an inappropriate immune response, where the body's immune system mistakenly attacks the colon's lining, leading to the formation of ulcers and erosions.

• Secondary mechanism: The persistent inflammation results in an influx of inflammatory cells, such as T-cells, into the colon tissue. These cells release cytokines, which are signaling molecules that perpetuate inflammation and tissue damage, disrupting the normal function of the colon and causing symptoms like diarrhea and abdominal pain.

• Key complication: Chronic inflammation and ulceration increase the risk of complications such as colorectal cancer and toxic megacolon, a life-threatening condition characterized by rapid widening of the colon, potentially leading to perforation.

Patient Profile

Demographics:

35-year-old female, office manager

History:

• Key past medical history: Diagnosed with ulcerative colitis 5 years ago, history of iron deficiency anemia

• Current medications: Mesalamine, ferrous sulfate, oral contraceptive

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased abdominal pain and bloody diarrhea

• Key symptoms: Frequent bowel movements, fatigue, unintentional weight loss

• Vital signs: Temperature 100.4°F, heart rate 102 bpm, blood pressure 100/60 mmHg, respiratory rate 20 breaths per minute

Section 1

As the clinical team continues to evaluate the patient's condition, they observe new diagnostic results that suggest a development of moderate complications. Laboratory tests reveal a significant drop in hemoglobin levels to 8.5 g/dL, indicating worsening anemia. The fecal calprotectin level is markedly elevated, which correlates with increased intestinal inflammation. An urgent colonoscopy is performed, revealing extensive ulcerations and pseudopolyps throughout the colon, with some areas of the colon appearing significantly distended, raising concerns for early signs of toxic megacolon. The presence of these findings necessitates a reconsideration of her current management plan.

In response to these results, the healthcare team decides to intensify her treatment regimen. Intravenous corticosteroids are initiated to rapidly reduce inflammation and prevent further deterioration. Additionally, the patient is started on infliximab, a biologic therapy, aiming to modulate the immune response more effectively. The patient's nutritional status is also addressed with the introduction of total parenteral nutrition (TPN) to support her caloric needs due to her inability to maintain adequate oral intake.

Clinically, the patient remains tachycardic with a heart rate of 112 bpm, and her blood pressure has dropped slightly to 98/58 mmHg, indicating potential hypovolemia or an evolving systemic response to the inflammation. The healthcare team closely monitors her for signs of improvement or further complications, such as perforation or systemic infection. These changes in her clinical management and the vigilant observation of her response to treatment will be crucial in guiding the next steps of her care journey.

Section 2

Following the intensification of the treatment regimen, the healthcare team closely monitors the patient's vitals and laboratory parameters for any signs of improvement or escalation of her condition. On the second day of the enhanced therapy, the patient's heart rate has decreased slightly to 105 bpm, and her blood pressure stabilizes at 102/60 mmHg. Although these changes are marginal, they suggest a slight positive response to the interventions. However, her hemoglobin remains critically low, at 8.2 g/dL, indicating a persistent need for close monitoring of her anemia and potential transfusion support.

Despite the initial stabilization, the patient begins to experience increased abdominal pain and distention, raising concerns about further complications. Repeat imaging studies, including an abdominal X-ray, reveal significant colonic dilation, confirming the progression towards toxic megacolon. Her white blood cell count has also risen to 14,000/mm³, suggesting an inflammatory or infectious process. These findings necessitate a multidisciplinary discussion to evaluate the potential need for surgical intervention versus continued aggressive medical management.

The clinical team must weigh the risks and benefits of surgical intervention, considering the patient's current stability and the potential for further deterioration. The decision to involve surgical colleagues for an urgent consultation is made, as they consider the possibility of a colectomy if medical management fails to halt the progression of her condition. The team also emphasizes the importance of ongoing supportive care, including continued TPN and close monitoring of her fluid status to prevent complications associated with hypovolemia. This critical juncture in her care underscores the complexity of managing ulcerative colitis with complications and highlights the need for dynamic clinical reasoning and adaptive management strategies.

Section 3

As the clinical team continues to manage the patient, they note a further change in her status. On the third day of enhanced therapy, the patient's abdominal distention has worsened, and she now exhibits signs of peritoneal irritation, such as guarding and rebound tenderness upon palpation. Her temperature has increased to 101.5°F, and she is tachycardic again, with a heart rate of 118 bpm. These signs raise suspicion for perforation, a severe complication of toxic megacolon. In response to these alarming developments, an urgent CT scan of the abdomen is ordered, revealing free air under the diaphragm, confirming the presence of a perforation.

The patient's laboratory results further indicate a critical shift in her condition. Her hemoglobin level has decreased to 7.6 g/dL, suggesting ongoing blood loss or hemolysis, while her white blood cell count has escalated to 17,000/mm³, reinforcing the likelihood of an infectious process secondary to perforation. Her lactate level is elevated at 3.5 mmol/L, indicative of poor tissue perfusion and the onset of systemic inflammatory response syndrome (SIRS). The clinical team recognizes the need for immediate surgical intervention to address the perforation and prevent further deterioration.

The decision is made to proceed with an emergent colectomy. The surgical team is swiftly mobilized, and the patient is prepped for the operating room with a focus on stabilizing her hemodynamics. Intravenous fluids are administered to manage her hypovolemia, and broad-spectrum antibiotics are initiated to cover potential peritoneal contamination. This critical point in the patient's journey highlights the importance of timely surgical intervention in the face of rapidly escalating complications and underscores the necessity of integrated, multidisciplinary care in managing complex cases of ulcerative colitis.

Section 4

Following the emergent colectomy, the patient is moved to the intensive care unit for close monitoring and continued management. Despite the initial surgical success, the clinical team remains vigilant, aware of the potential for further complications. Within hours, the patient exhibits signs of acute respiratory distress. Her respiratory rate has increased to 30 breaths per minute, and her oxygen saturation has dropped to 88% on room air. Given her recent surgery and ongoing systemic inflammatory response, the team suspects the development of acute respiratory distress syndrome (ARDS), a known complication in the context of sepsis and major abdominal surgery.

A chest X-ray is promptly ordered, revealing diffuse bilateral pulmonary infiltrates consistent with ARDS. Concurrently, arterial blood gas analysis shows a pH of 7.30, PaCO2 of 50 mmHg, and PaO2 of 55 mmHg on a 50% oxygen mask, confirming the presence of respiratory acidosis and significant hypoxemia. The intensivist decides to initiate mechanical ventilation with a low tidal volume strategy to optimize oxygenation and minimize lung injury.

The patient's hemodynamics are also carefully reassessed, with a mean arterial pressure of 60 mmHg despite aggressive fluid resuscitation. This finding prompts the initiation of vasopressor support to maintain adequate perfusion. The integrated efforts of the multidisciplinary team aim to stabilize the patient while addressing the complex interplay of respiratory and circulatory challenges. As the team continues to monitor and adjust the management plan, they remain attentive to the potential need for further interventions to mitigate the risks of multi-organ dysfunction.

Section 5

As the multidisciplinary team continues to manage the patient's condition in the ICU, they observe a notable change in her hemodynamic status. Despite the initiation of vasopressor support, the patient's blood pressure remains labile, with systolic readings fluctuating between 80 to 95 mmHg. Her heart rate is persistently elevated at 120 beats per minute, indicating a compensatory response to the ongoing circulatory insufficiency. Given the patient's recent colectomy and the current clinical picture, the team suspects the possibility of septic shock secondary to intra-abdominal infection or anastomotic leak, a known complication after bowel surgery.

To further investigate, the team orders a CT scan of the abdomen with contrast, which reveals a localized fluid collection near the surgical site, suggestive of an abscess. Laboratory studies return with a white blood cell count of 18,000/mm³, indicating persistent leukocytosis, and elevated lactate levels at 3.8 mmol/L, reinforcing concerns of inadequate tissue perfusion and systemic infection. Blood cultures are taken to identify any potential pathogens, and broad-spectrum antibiotics are adjusted to cover a wider range of potential organisms.

In response to these findings, the team deliberates on the necessity of percutaneous drainage of the abscess under radiological guidance to control the source of infection. The patient's fluid management is carefully balanced to prevent fluid overload while maintaining adequate perfusion, and vasopressor therapy is titrated to sustain a mean arterial pressure above 65 mmHg. The patient's respiratory status under mechanical ventilation remains closely monitored, ensuring optimal oxygenation as the team addresses the suspected septic focus. This coordinated approach aims to stabilize the patient's condition and prevent further deterioration, while continually reassessing for any signs of multi-organ dysfunction.