Calcium Carbonate (1 tab tid) Classification: Electrolyte replacement or supplements.

Antacid Desired Dosage: 500 mg (200 mg Ca), 600 mg (240 mg Ca), 650 mg (260 mg Ca), 667 mg (266.8 mg Ca), 1 g (400 mg Ca), 1.25 mg (500 mg Ca), 1.5 mg (600 mg Ca) Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for bone formation and blood coagulation. It is also used a replacement of calcium in deficiency states. It controls of hyperphosphatemia in end -stage renal disease without promoting aluminum absorption. Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may decrease the absorption of orally administered tetracyclines, fluoroquinolones, phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia. Side Effects: CNS: syncope, tingling CV: cardiac arrest, arrythmias, bradycardia GI: constipation, nausea, vomting GU: calculi, hypercalciuruia Local: phlebitis (IV only)

Nursing Responsibilities: 1. Monitor VS especially BP and PR. 2. Obtain ECG result. 3. Asses for heartburn, indigestion, abdominal pain. 4. Monitor serum calcium before treatment.

5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.

Why is this medication prescribed?

Magnesium is an element your body needs to function normally. Magnesium oxide may be used for different reasons. Some people use it as an antacid to relieve heartburn, sour stomach, or acid indigestion. Magnesium oxide also may be used as a laxative for short-term, rapid emptying of the bowel (before surgery, for example). It should not be used repeatedly. Magnesium oxide also is used as a dietary supplement when the amount of magnesium in the diet is not enough. Magnesium oxide is available without a prescription.

How should this medicine be used?

Magnesium oxide comes as a tablet and capsule to take by mouth. It usually is taken one to four times daily depending on which brand is used and what condition you have. Follow the directions on the package or on your prescription label carefully, and ask your doctor or pharmacist to explain any part you

do not understand. Take magnesium oxide exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Take any other medicine and magnesium oxide at least 2 hours apart. If you are using magnesium oxide as a laxative, take it with a full glass (8 ounces [240 milliliters]) of cold water or fruit juice. Do not take a dose late in the day on an empty stomach. Do not take magnesium oxide as an antacid for longer than 2 weeks unless your doctor tells you to. Do not take magnesium oxide as a laxative for more than 1 week unless your doctor tells you to.

Before taking magnesium oxide,

tell your doctor and pharmacist if you are allergic to magnesium oxide, other antacids or laxatives, or any other drugs. tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially other antacids or laxatives, anticoagulants ('blood thinners') such as warfarin (Coumadin), aspirin, diuretics ('water pills'), medicine for ulcers (cimetidine [Tagamet], ranitidine [Zantac]), and vitamins. tell your doctor if you have or have ever had heart, kidney, liver, or intestinal disease or high blood pressure. tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking magnesium oxide, call your doctor immediately. tell your doctor if you are on a low-salt, low-sugar, or other special diet.

What side effects can this medication cause?

Return to top

Magnesium oxide may cause side effects. To avoid unpleasant taste, take the tablet with citrus fruit juice or carbonated citrus drink. Tell your doctor if either of these symptoms are severe or do not go away:
cramping diarrhea

If you experience any of the following symptoms, call your doctor immediately:
rash or hives itching dizziness or lightheadedness mood or mental changes unusual tiredness weakness nausea vomiting

How does it work?

Asacol suppositories, Asacol foam enema and Asacol MR tablets all contain the active ingredient mesalazine, which is a type of medicine called an aminosalicylate. It is used to reduce inflammation in the intestines in a condition called ulcerative colitis. Ulcerative colitis is a condition in which there is inflammation of the large intestine. This results in ulceration and bleeding in the intestine and causes symptoms that include abdominal pain and diarrhoea that is mixed with blood, pus and mucus. Mesalazine works by reducing the inflammation in the intestine, which in turn reduces the symptoms of the disease. The way in which mesalazine does this is not fully understood. Asacol suppositories and foam enema are administered into the back passage (rectum) to deliver the mesalazine directly to the site of inflammation in the lower end of the large intestine and rectum. They are used for the short-term treatment of attacks of ulcerative colitis, particularly when the inflammation is largely in this area of the bowel. The suppositories can also be used on a continuous basis to help prevent attacks. Asacol MR tablets are taken by mouth. The tablets have a special coating that allows the medicine to pass through the stomach and be released in the intestine. They are used for the short-term treatment of symptoms and can also be taken on a continuous basis to control the inflammation in the intestine and help prevent attacks.

What is it used for?

Ulcerative colitis. All forms of Asacol can be used on a short-term basis to treat mild to moderate symptoms of ulcerative colitis. Asacol suppositories and Asacol MR tablets can also be used continuously to help prevent attacks. Asacol MR tablets can be taken continuously to help prevent attacks in Crohn's disease affecting the lower part of the small intestine and the large intestine (Crohn's ileo-colitis).

How do I use this medicine?

Asacol MR tablets are taken by mouth. The tablets should be swallowed whole with a glass of water. They must not be broken, crushed or chewed, as this would damage the special coating of the tablets that allows them to work in the intestine. The tablets can be taken either with or without food. Asacol suppositories and Asacol enema are for administration into the back passage (rectum). They must not be taken by mouth. Follow this link for instructions on how to use suppositories. The dose prescribed will vary from person to person. It is important to follow the instructions given by your doctor. These will also be printed on the dispensing label that your pharmacist has put on the packet of medicine. If you forget to take a dose take it as soon as you remember, unless it is nearly time for your next dose. In this case skip the missed dose and take your next scheduled dose as normal. Do not take a double dose to make up for a missed dose.

Warning!

Your kidney and liver function should be checked before you start treatment with this medicine. Your kidney function should then be monitored every three months for the first year of treatment and at least once a year thereafter, or as your doctor feels necessary. This medicine may rarely cause a decrease in the normal amounts of blood cells in the blood. For this reason you should consult your doctor immediately if you experience any of the following symptoms while using this medicine: unexplained bruising or bleeding, purple spots, sore throat, mouth ulcers, high temperature (fever), feeling tired or general illness. Your doctor may want to take a blood test to check your blood cells. There are several different brands and forms of mesalazine available in the UK (see end of factsheet). The way that the mesalazine is released from these different products varies and allows the mesalazine to be released in specific areas of the intestine. You will be prescribed the brand that allows the mesalazine to be released in the part of your intestine that needs it most. For this reason, it is important that you always use the same brand of mesalazine. You should make sure you know which brand you normally have and check that you have been given the correct one each time your medicine is dispensed. (Your pharmacist will usually ask you, or call your doctor if this is not written on your prescription).

Use with caution in

Elderly people. Decreased kidney function. Decreased liver function. Asthma. People who are allergic to a related medicine called sulfasalazine.

Not to be used in

People who are allergic to salicylates (eg aspirin). People with blood disorders. Severely decreased kidney function. Severely decreased liver function. Asacol suppositories and foam enema and Asacol MR tablets are not recommended for children under 12 years of age. This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Side effects
Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect. The more serious side effects listed here occur rarely. Diarrhoea. Nausea and vomiting. Abdominal pain or bloating. Excess gas in the stomach and intestines (flatulence). Anal or rectal irritation with the suppositories and enema. Headache. Dizziness. Inflammation around the heart. Tell your doctor if you experience chest pains or palpitations. Decrease in the normal numbers of blood cells in the blood - see the warning section above for symptoms to look out for. Allergic skin rashes. Worsening of colitis symptoms. Pain in the muscles or joints. Hair loss. Inflammation of the pancreas (pancreatitis). Inflammation of the liver (hepatitis). Kidney problems, such as inflammation of the kidneys or kidney failure. Lung problems, such as shortness of breath, cough or breathing difficulties.

Mesalazine (INN, BAN), also known as mesalamine (USAN) or 5-aminosalicylic acid (5-ASA), is [1] an anti-inflammatory drug used to treatinflammatory bowel disease, such as ulcerative colitis and mild[2] to-moderate Crohn's disease. Mesalazine is a bowel-specific aminosalicylate drug that acts locally in the [3] gut and has its predominant actions there, thereby having few systemic side effects. As a derivative of salicylic acid, mesalazine is also thought to be an antioxidant that traps free radicals, [3] which are potentially damaging byproducts of metabolism. Mesalazine is the active moiety of sulfasalazine, which is metabolized to sulfapyridine and mesalazine.
[4]

Mesalazine is formed from the prodrug balsalazide along with the inert carrier molecule 4-aminobenzoyl[5] beta-alanine. Commonly: Diarrhea Nausea Cramping Flatulence
[6]

nephritis and lupus erythematosus-like syndrome) Hair loss

Rarely: Acute pancreatitis Hepatitis Nephrotic syndrome Blood disorders (including agranulocytosis, aplastic anaemia, leukopenia, neutropenia, thrombo cytopenia) Fever
[7]

Uncommonly: Headache Exacerbation of the colitis Hypersensitivity reactions (including rash, urticaria aka hives, interstitial

Mesalazine avoids the sulfonamide side effects of sulfasalazine (which contains additional sulfapyridine), but carries additional rare risks of: Allergic lung reactions Allergic myocarditis Methaemoglobinaemia

What is flexible sigmoidoscopy?

Flexible sigmoidoscopy is a procedure used to see inside the sigmoid colon and rectum. Flexible sigmoidoscopy can detect inflamed tissue, abnormal growths, and ulcers. The procedure is used to look for early signs of cancer and can help doctors diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss.

Flexible sigmoidoscopy is a routine outpatient procedure in which the inner lining of the lower large intestine is examined. Flexible sigmoidoscopy is commonly used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding, or changes in bowel habits. It is also performed to screen people older than age 50 for colon and rectal cancer. During the procedure, a doctor uses a sigmoidoscope, a long, flexible, tubular instrument about 1/2 inch in diameter, to view the lining of the rectum and the lower third of the colon (the sigmoid colon).

There are no diet or fluid restrictions before a flexible sigmoidoscopy. But, your bowel must be cleansed in order for sigmoidoscopy to be successful. You will receive two enemas before the procedure since the rectum and lower intestine must be empty so that the intestinal walls can be seen. You will need to try to hold the enema solution for at least five minutes before releasing it. How Is a Flexible Sigmoidoscopy Performed? A flexible sigmoidoscopy is performed by a doctor experienced in the procedure, and usually lasts from 10 minutes to 20 minutes. No sedation is required. Your doctor will have you lie on your left side, with your knees drawn up. The sigmoidoscope is inserted through the rectum and passes slowly into the sigmoid colon. A small amount of air is used to expand the colon so the doctor can see the colon walls. You may feel mild cramping during the procedure. You can reduce the cramping by taking several slow, deep breaths during the procedure. When the doctor has finished, the sigmoidoscope is slowly withdrawn while the lining of your bowel is carefully examined. What Happens After a Flexible Sigmoidoscopy? After the procedure your doctor will discuss the results of your flexible sigmoidoscopy with you. You may feel some cramping or a sensation of having gas, but this usually passes quickly. You may resume your normal diet and activities.

How to Prepare for a Flexible Sigmoidoscopy

To prepare for a flexible sigmoidoscopy, one or more enemas are performed about 2 hours before the procedure to remove all solids from the sigmoid colon. An enema is performed by flushing water, laxative, or sometimes a mild soap solution into the anus using a special wash bottle. In some cases, the entire gastrointestinal tract must be emptied by following a clear liquid diet for 1 to 3 days before the proceduresimilar to the preparation for colonoscopy. Patients should not drink beverages containing red or purple dye. Acceptable liquids include fat-free bouillon or broth strained fruit juice water plain coffee plain tea sports drinks, such as Gatorade gelatin A laxative or an enema may also be required the night before a flexible sigmoidoscopy. A laxative is medicine that loosens stool and increases bowel movements. Laxatives are usually swallowed in pill form or as a powder dissolved in water. Patients should inform their doctor of all medical conditions and any medications, vitamins, or supplements taken regularly, including aspirin arthritis medications blood thinners diabetes medications vitamins that contain iron

How is a flexible sigmoidoscopy performed?

Examination of the Sigmoid Colon During a flexible sigmoidoscopy, patients lie on their left side on an examination table. The doctor inserts a long, flexible, lighted tube called a sigmoidoscope, or scope, into the anus and slowly guides it through the rectum and into the sigmoid colon. The scope inflates the colon with air to give the doctor a better view. A small camera mounted on the scope transmits a video image from inside the colon to a computer screen, allowing the doctor to carefully examine the tissues lining the sigmoid colon and rectum. The doctor may ask the patient to move periodically so the scope can be adjusted for better viewing. When the scope reaches the transverse colon, the scope is slowly withdrawn while the lining of the colon is carefully examined again. Biopsy and Removal of Colon Polyps The doctor can remove growths, called polyps, during flexible sigmoidoscopy using special tools passed through the scope. Polyps are common in adults and are usually harmless. However, most colon cancer begins as a polyp, so removing polyps early is an effective way to prevent cancer. If bleeding occurs, the doctor can usually stop it with an electrical probe or special medications passed through the scope. During a flexible sigmoidoscopy, the doctor can also take samples from abnormal-looking tissues. Called a biopsy, this procedure allows the doctor to later look at the tissue with a microscope for signs of disease. Tissue removal and the treatments to stop bleeding are usually painless. If polyps or other abnormal tissues are found, the doctor may suggest examining the rest of the colon with a colonoscopy. Recovery A flexible sigmoidoscopy takes about 20 minutes. Cramping or bloating may occur during the first hour after the procedure. Bleeding and puncture of the large intestine are possible but uncommon complications. Discharge instructions should be carefully read and followed. Patients who develop any of these rare side effects should contact their doctor immediately: severe abdominal pain fever bloody bowel movements dizziness weakness

Points to Remember
Flexible sigmoidoscopy is a procedure used to see inside the sigmoid colon and rectum. One or more enemas are performed about 2 hours before the procedure to remove all solids from the sigmoid colon. In some cases, the entire gastrointestinal tract must be emptiedsimilar to the preparation for colonoscopy. A sigmoidoscope transmits a video image from inside the colon to a computer screen. A doctor can biopsy abnormal-looking tissues during a flexible sigmoidoscopy. Polyps can be removed using special tools passed through the sigmoidoscope. If polyps or other abnormal tissues are found, the doctor may suggest examining the rest of the colon with a colonoscopy. A flexible sigmoidoscopy takes about 20 minutes.

What is meningitis?
Meningitis is an infection of the membranes (meninges) surrounding the brain and spinal cord. Meningitis can be caused by a bacterial, fungal or viral infection. Meningitis can be acute, with a quick onset of symptoms, it can be chronic, lasting a month or more, or it can be mild or aseptic. Anyone experiencing symptoms of meningitis should see a doctor immediately.

What is bacterial meningitis?

Acute bacterial meningitis is the most common form of meningitis. Approximately 80 percent of all cases are acute bacterial meningitis. Bacterial meningitis can be life threatening. The infection can cause the tissues around the brain to swell. This in turn interferes with blood flow and can result in paralysis or even stroke.

What causes bacterial meningitis?

The bacteria most often responsible for bacterial meningitis are common in the environment and can also be found in your nose and respiratory system without causing any harm. Sometimes meningitis occurs for no known reason. Other times it occurs after a head injury or after you have had an infection and your immune system is weakened.

Who gets bacterial meningitis?

Children between the ages of one month and two years are the most susceptible to bacterial meningitis. Adults with certain risk factors are also susceptible. You are at higher risk if you abuse alcohol, have chronic nose and ear infections, sustain a head injury or get pneumococcal pneumonia. You are also at higher risk if you have a weakened immune system, have had your spleen removed, are on corticosteroids because of kidney failure or have a sickle cell disease. Additionally, if you have had brain or spinal surgery or have had a widespread blood infection you are also a higher risk for bacterial meningitis. Outbreaks of bacterial meningitis also occur in living situations where you are in close contact with others, such as college dormitories or military barracks.

What are the symptoms of bacterial meningitis?

You want to watch for high fever, headaches, and an inability to lower your chin to your chest due to stiffness in the neck. In older children and adults, you may see confusion, irritability, increasing drowsiness. Seizures and stroke may occur. In young children, the fever may cause vomiting and they may refuse to eat. Young children may become very irritable and cry. There may be seizures. Also, because the fluid around the skull may become blocked their heads may swell. The onset of symptoms is fast, within 24 hours. If allowed to progress, you can die from bacterial meningitis.

How is bacterial meningitis diagnosed?

It is important that you seek immediate medical assistance if you suspect meningitis. Your doctor will conduct a physical exam. Your doctor will look for a purple or red rash on the skin. Your doctor will check your neck for stiffness and will exam hip and knee flexion. Your doctor will have to decide if the cause is bacterial, viral or fungal and will have to analyze your spinal fluid so a spinal tap will be ordered. Your blood and urine may also be analyzed as well as the mucous from your nose and throat.

How is bacterial meningitis treated?

Bacterial meningitis is treated with antibiotics. A general intravenous antibiotic with a corticosteroid to bring down the inflammation may be prescribed even before all the test results are in. When the specific bacteria are identified, your doctor may decide to change antibiotics. In addition to antibiotics, it will be important to replenish fluids lost from loss of appetite, sweating, vomiting and diarrhea.

Can bacterial meningitis be cured?

There is a 10 percent death rate from bacterial meningitis but if diagnosed and treated early enough, most people recover.

Are there ever complications?

Unfortunately, if treatment is not undergone immediately, there may be permanent damage. Seizures, mental impairment and paralysis may be life long.

Is bacterial meningitis contagious?

You should encourage anyone who you have come into close contact with to seek preventative treatment. Anyone who you have had casual contact should not be affected.

Is there a vaccine for bacterial meningitis?

Yes, a vaccine is available, and the Centers for Disease Control and Prevention has specific guidelines regarding who should receive the vaccine.

The CDC recommends the meningococcal vaccine for:

All children and adolescents ages 11 through 18 College freshmen living in dormitories Military recruits Scientists routinely exposed to meningococcal bacteria Anyone traveling to or living in a part of the world where the disease is common, such as Africa Anyone with a damaged spleen or who has had his or her spleen removed Anyone who has terminal complement component deficiency (an immune system disorder)

Crohn's disease
[6]

Ulcerative colitis

Defecation

Often porridge-like , Often mucus-like [6] sometimes steatorrhea and with blood
[6]

Tenesmus Less common Fever Fistulae Common Common

[6] [7]

More common

[6] [6]

Indicates severe disease Seldom More seldom

Weight loss Often

Crohn's disease Mesalamine Less useful Antibiotics

[21]

Ulcerative colitis More useful

[21]

Effective in long[22] term

Generally not [23] useful

Surgery

Often returns Usually cured by following removal removal of affected of colon part

Mesalamine Less useful[21]

More useful[21]

Antibiotics

Effective in longterm[22]

Generally not useful[23]

Surgery

Often returns Usually cured by following removal removal of affected of colon part

Definition
Inflammatory bowel disease (IBD) results from a complex interplay between genetic and environmental factors. Similarities involve (1) chronic inflammation of the alimentary tract and (2) periods of remission interspersed with episodes of acute inflammation. Ulcerative colitis (UC): A chronic condition of unknown cause usually starting in the rectum and distal portions of the colon and possibly spreading upward to involve the sigmoid and descending colon or the entire colon. It is usually intermittent (acute exacerbation with long remissions), but some individuals (30%40%) have continuous symptoms. Cure is effected only by total removal of colon and rectum/rectal mucosa. Regional enteritis (Crohns disease, ileocolitis): May be found in portions of the alimentary tract from the mouth to the anus but is most commonly found in the small intestine (terminal ileum). It is a slowly progressive chronic disease of unknown cause with intermittent acute episodes and no known cure. UC and regional enteritis share common symptoms but differ in the segment and layer of intestine involved and the degree of severity and complications. Therefore, separate databases are provided.

Nursing Priorities
1. Control diarrhea/promote optimal bowel function. 2. Minimize/prevent complications. 3. Promote optimal nutrition. 4. Minimize mental/emotional stress. 5. Provide information about disease process, treatment needs, and long-term aspects/potential complications of recurrent disease.

Discharge Goals
1. Bowel function stabilized. 2. Complications prevented/controlled. 3. Dealing positively with condition. 4. Disease process/prognosis, therapeutic regimen, and potential complications are understood. 5. Plan in place to meet needs after discharge.

Diagnostic Studies

Stool specimens (examinations are used in initial diagnosis and in following disease progression): Mainly composed of mucus, blood, pus, and intestinal organisms, especially Entamoeba histolytica (active stage). Fecal leukocytes and RBCs indicate inflammation of GI tract. Stool positive for bacterial pathogens, ova and parasites or clostridium indicates infections. Stool positive for fat indicates malabsorption. Proctosigmoidoscopy: Visualizes ulcerations, edema, hyperemia, and inflammation (result of secondary infection of the mucosa and submucosa). Friability and hemorrhagic areas caused by necrosis and ulceration occur in 85% of these patients. Cytology and rectal biopsy: Differentiates between infectious process and carcinoma (occurs 1020 times more often than in general population). Neoplastic changes can be detected, as well as characteristic inflammatory infiltrates called crypt abscesses. Barium enema: May be performed after visual examination has been done, although rarely done during acute, relapsing stage, because it can exacerbate condition. Endoscopic examinations, e.g., sigmoidoscopy, esophagogastroduodenoscopy, or colonoscopy: Identifies adhesions, changes in luminal wall (narrowing/irregularity); rules out bowel obstruction and allowed biopsy for features of Crohns disease or ulcerative colitis. Abdominal magnetic resonance imaging (MRI)/computed tomography (CT) scan, ultrasound: Detects abscesses, masses, strictures, or fistulas. CBC: May show hyperchromic anemia (active disease generally present because of blood loss and iron deficiency); leukocytosis may occur, especially in fulminating or complicated cases and in patients on steroid therapy. Erythrocyte sedimentation rate (ESR): Elevated in acute inflammation according to severity of disease. Serum iron levels: Lowered because of blood loss or poor dietary intake. PT: Prolonged in severe cases from altered factors VII and X caused by vitamin K deficiency. Thrombocytosis: May occur as a result of inflammatory disease process. Electrolytes: Decreased potassium, magnesium, and zinc are common in severe disease. Prealbumin/albumin level: Decreased because of loss of plasma proteins/disturbed liver function, decreased dietary intake. Alkaline phosphatase: Increased, along with serum cholesterol and hypoproteinemia, indicating disturbed liver function (e.g., cholangitis, cirrhosis). Disease-specific antibodies, ANCA (antineutrophil cytoplasmic antibodies): Positive result increases suspicion of UC, but negative result does not rule out diagnosis. Bone marrow: A generalized depression is common in fulminating types/after a long inflammatory process.

Nursing Care Plans

Here are 7 Nursing Care Plan (NCP) for inflammatory bowel disease

Diarrhea
NURSING DIAGNOSIS: Diarrhea May be related to

Inflammation, irritation, or malabsorption of the bowel Presence of toxins Segmental narrowing of the lumen

Possibly evidenced by Increased bowel sounds/peristalsis

Frequent, and often severe, watery stools (acute phase) Changes in stool color Abdominal pain; urgency (sudden painful need to defecate), cramping

Desired Outcomes Report reduction in frequency of stools, return to more normal stool consistency.

Identify/avoid contributing factors.

Nursing Interventions Rationale

Observe and record stool frequency, characteristics, amount, and precipitating factors.

Helps differentiate individual disease and assesses severity of episode.

Promote bedrest, provide bedside commode.

Rest decreases intestinal motility and reduces the metabolic rate when infection or hemorrhage is a complication. Urge to defecate may occur without warning and be uncontrollable, increasing risk of incontinence/falls if facilities are not close at hand.

Remove stool promptly. Provide room deodorizers.

Reduces noxious odors to avoid undue patient embarrassment.

Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products.

Avoiding intestinal irritants promotes intestinal rest.

Restart oral fluid intake gradually. Offer

Provides colon rest by omitting or decreasing the stimulus of

clear liquids hourly; avoid cold fluids.

foods/fluids. Gradual resumption of liquids may prevent cramping and recurrence of diarrhea; however, cold fluids can increase intestinal motility.

Provide opportunity to vent frustrations related to disease process.

Presence of disease with unknown cause that is difficult to cure and that may require surgical intervention can lead to stress reactions that may aggravate condition.

Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety, and prostration.

May signify that toxic megacolon or perforation and peritonitis are imminent/have occurred, necessitating immediate medical intervention.

Risk for Deficient Fluid Volume

NURSING DIAGNOSIS: Risk for Deficient Fluid Volume Risk factors may include Excessive losses through normal routes (severe frequent diarrhea, vomiting)

Hypermetabolic state (inflammation, fever) Restricted intake (nausea/anorexia)

Desired Outcomes Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal concentration/amount.
Nursing Interventions Rationale

Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria.

Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

Assess vital signs (BP, pulse, temperature).

Hypotension (including postural), tachycardia, fever can indicate response to and/or effect of fluid loss.

Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.

Indicates excessive fluid loss/resultant dehydration.

Weigh daily.

Indicator of overall fluid and nutritional status.

Maintain oral restrictions, bedrest; avoid exertion.

Colon is placed at rest for healing and to decrease intestinal fluid losses.

Observe for overt bleeding and test stool daily for occult blood.

Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk of hemorrhage.

Note generalized muscle weakness or cardiac dysrhythmias.

Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms.

Administer parenteral fluids, blood transfusions as indicated.

Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: Fluids containing sodium may be restricted in presence of regional enteritis.

Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).

Determines replacement needs and effectiveness of therapy.

Anxiety
NURSING DIAGNOSIS: Anxiety [specify level] May be related to Physiological factors/sympathetic stimulation (inflammatory process)

Threat to self-concept (perceived or actual) Threat to/change in health status, socioeconomic status, role functioning, interaction patterns

Possibly evidenced by Exacerbation of acute stage of disease Increased tension, distress, apprehension Expressed concern regarding changes in life Somatic complaints Focus on self

Desired Outcomes Appear relaxed and report anxiety reduced to a manageable level.

Verbalize awareness of feelings of anxiety and healthy ways to deal with them.

Nursing Interventions

Rationale

Note behavioral clues, e.g., restlessness, irritability, withdrawal, lack of eye contact, demanding behavior.

Indicators of degree of anxiety/stress, e.g., patient may feel out of control at home/work managing personal problems. Stress may develop as a result of physical symptoms of condition and the reaction of others.

Encourage verbalization of feelings. Provide feedback.

Establishes a therapeutic relationship. Assists patient/SO in identifying problems causing stress. Patient with severe diarrhea may hesitate to ask for help for fear of becoming a burden to the staff.

Acknowledge that the anxiety and problems are similar to those expressed by others. Active-Listen patients concerns.

Validation that feelings are normal can help reduce stress/isolation and belief that I am the only one.

Provide accurate, concrete information about what is being done, e.g., reason for bedrest, restriction of oral intake, and procedures.

Involving patient in plan of care provides sense of control and helps decrease anxiety.

Provide a calm, restful environment.

Removing patient from outside stressors promotes relaxation; helps reduce anxiety.

Encourage staff/SO to project caring, concerned attitude.

A supportive manner can help patient feel less stressed, allowing energy to be directed toward healing/recovery.

Help patient identify/initiate positive coping behaviors used in the past.

Successful behaviors can be fostered in dealing with current problems/stress, enhancing patients sense of self-control.

Assist patient to learn new coping mechanisms, e.g., stress management techniques, organizational skills.

Learning new ways to cope can be helpful in reducing stress and anxiety, enhancing disease control.

Acute Pain
NURSING DIAGNOSIS: Pain, acute May be related to Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation, fissures, fistulas

Possibly evidenced by Reports of colicky/cramping abdominal pain/referred pain

Guarding/distraction behaviors, restlessness Facial mask of pain; self-focusing

Desired Outcomes Report pain is relieved/controlled.

Appear relaxed and able to sleep/rest appropriately.

Nursing Interventions Rationale

Encourage patient to report pain.

May try to tolerate pain rather than request analgesics.

Assess reports of abdominal cramping or pain, noting location, duration, intensity (010 scale). Investigate and report changes in pain characteristics

Colicky intermittent pain occurs with Crohns disease

Note nonverbal cues, e.g., restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues.

Body language/nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent/severity of the problem.

Review factors that aggravate or alleviate pain.

May pinpoint precipitating or aggravating factors (such as stressful events, food intolerance) or identify developing complications.

Encourage patient to assume position of comfort, e.g., knees flexed.

Reduces abdominal tension and promotes sense of control.

Provide comfort measures (e.g., back rub, reposition) and diversional activities.

Promotes relaxation, refocuses attention, and may enhance coping abilities.

Cleanse rectal area with mild soap and water/wipes after each stool and provide skin care, e.g., A&D ointment, Sween ointment, karaya gel, Desitin, petroleum jelly.

Protects skin from bowel acids, preventing excoriation.

Provide sitz bath as appropriate.

Enhances cleanliness and comfort in the presence of

perianal irritation/fissures.

Observe for ischiorectal and perianal fistulas.

Fistulas may develop from erosion and weakening of intestinal bowel wall.

Observe/record abdominal distension, increased temperature, decreased BP.

May indicate developing intestinal obstruction from inflammation, edema, and scarring.

Implement prescribed dietary modifications, e.g., commence with liquids and increase to solid foods as tolerated.

Complete bowel rest can reduce pain, cramping.

Ineffective Coping
NURSING DIAGNOSIS: Ineffective Coping May be related to Multiple stressors, repeated over period of time; situational crisis

Unpredictable nature of disease process Personal vulnerability; inadequate coping method; lack of support systems Severe pain Lack of sleep, rest

Possibly evidenced by Verbalization of inability to cope, discouragement, anxiety

Preoccupation with physical self, chronic worry, emotional tension, poor self-esteem Depression and dependency

Desired Outcomes Assess the current situation accurately.

Identify ineffective coping behaviors and consequences. Acknowledge own coping abilities. Demonstrate necessary lifestyle changes to limit/prevent recurrent episodes.
Nursing Interventions Rationale

Assess patients/SOs understanding and previous methods of dealing with disease process.

Enables the nurse to deal more realistically with current problems. Anxiety and other problems may have interfered with previous health teaching/patient learning.

Determine outside stressors, e.g., family, relationships, social or work environment.

Stress can alter autonomic nervous response, affecting the immune system and contributing to exacerbation of disease. Even the goal of independence in the dependent patient can be an added stressor.

Provide opportunity for patient to discuss how illness has affected relationship, including sexual concerns.

Stressors of illness affect all areas of life, and patient may have difficulty coping with feelings of fatigue/pain in relation to relationship/sexual needs.

Help patient identify individually effective coping skills.

Use of previously successful behaviors can help patient deal with current situation/plan for future.

Provide emotional support:ActiveListen in a nonjudgmental manner;Maintain nonjudgmental body language when caring for patient;

Aids in communication and understanding patients viewpoint. Adds to patients feelings of self-worth.Prevents reinforcing patients feelings of being a burden, e.g., frequent need to empty bedpan/commode.Provides a more therapeutic environment and lessens the stress of constant adjustments.

Assign same staff as much as possible. Provide uninterrupted sleep/rest periods. Exhaustion brought on by the disease tends to magnify problems, interfering with ability to cope.

Encourage use of stress management skills, e.g., relaxation techniques, visualization, guided imagery, deep-breathing exercises.

Refocuses attention, promotes relaxation, and enhances coping abilities.

Include patient/SO in team conferences to develop individualized program.

Promotes continuity of care and enables patient/SO to feel a part of the plan, imparting a sense of control and increasing cooperation with therapeutic regimen.

Administer medications as indicated: antianxiety agents, e.g., lorazepam (Ativan), alprazolam (Xanax).

Aids in psychological/physical rest. Conserves energy and may strengthen coping abilities.

Refer to resources as indicated, e.g., local support group, social worker, psychiatric clinical nurse specialist, spiritual advisor.

Additional support and counseling can assist patient/SO in dealing with specific stress/problem areas.

Imbalanced Nutrition: Less Than Body Requirements

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements May be related to

Altered absorption of nutrients Hypermetabolic state Medically restricted intake; fear that eating may cause diarrhea

Possibly evidenced by Weight loss; decreased subcutaneous fat/muscle mass; poor muscle tone Hyperactive bowel sounds; steatorrhea Pale conjunctiva and mucous membranes Aversion to eating Demonstrate stable weight or progressive gain toward goal with normalization of laboratory values and absence of signs of malnutrition.
Nursing Interventions Rationale

Desired Outcomes

Weigh daily.

Provides information about dietary needs/effectiveness of therapy.

Encourage bedrest and/or limited activity during acute phase of illness.

Decreasing metabolic needs aids in preventing caloric depletion and conserves energy.

Recommend rest before meals.

Quiets peristalsis and increases available energy for eating.

Provide oral hygiene.

A clean mouth can enhance the taste of food.

Serve foods in well-ventilated, pleasant surroundings, with unhurried atmosphere, congenial company.

Pleasant environment aids in reducing stress and is more conducive to eating.

Avoid/limit foods that might cause/exacerbate abdominal cramping,

Individual tolerance varies, depending on stage of disease and area

flatulence (e.g., milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, orange juice).

of bowel affected.

Record intake and changes in symptomatology.

Useful in identifying specific deficiencies and determining GI response to foods.

Promote patient participation in dietary planning as possible.

Provides sense of control for patient and opportunity to select foods desired/enjoyed, which may increase intake.

Encourage patient to verbalize feelings concerning resumption of diet.

Hesitation to eat may be result of fear that food will cause exacerbation of symptoms.

Keep patient NPO as indicated.

Resting the bowel decreases peristalsis and diarrhea, limiting malabsorption/loss of nutrients.

Resume/advance diet as indicated, e.g., clear liquids progressing to bland, low residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as indicated.

Allows the intestinal tract to readjust to the digestive process. Protein is necessary for tissue healing integrity. Low bulk decreases peristaltic response to meal. Note: Dietary measures depend on patients condition, e.g., if disease is mild, patient may do well on low-residue, low-fat diet high in protein and calories with lactose restriction. In moderate disease, elemental enteral products may be given to provide nutrition without overstimulating the bowel. Patient with toxic colitis is NPO and placed on parenteral nutrition.

Knowledge Deficit
NURSING DIAGNOSIS: Knowledge Deficit May be related to Information misinterpretation, lack of recall

Unfamiliarity with resources

Possibly evidenced by Questions, request for information, statements of misconceptions

Inaccurate follow-through of instructions Development of preventable complications/exacerbations

Desired Outcomes Verbalize understanding of disease processes, possible complications.

Identify stress situations and specific action(s) to deal with them.

Verbalize understanding of therapeutic regimen. Participate in treatment regimen. Initiate necessary lifestyle changes.
Nursing Interventions Rationale

Determine patients perception of disease process.

Establishes knowledge base and provides some insight into individual learning needs.

Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions.

Precipitating/aggravating factors are individual; therefore, patient needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for patient to make informed decisions/choices about future and control of chronic disease. Although most patients know about their own disease process, they may have outdated information or misconceptions.

Review medications, purpose, frequency, dosage, and possible side effects.

Promotes understanding and may enhance cooperation with regimen.

Remind patient to observe for side effects if steroids are given on a longterm basis, e.g., ulcers, facial edema, muscle weakness.

Steroids may be used to control inflammation and to effect a remission of the disease; however, drug may lower resistance to infection and cause fluid retention.

Stress importance of good skin care, e.g., proper handwashing techniques and perineal skin care.

Reduces spread of bacteria and risk of skin irritation/breakdown, infection.

Recommend cessation of smoking.

Can increase intestinal motility, aggravating symptoms.

Emphasize need for long-term followup and periodic reevaluation.

Patients with IBD are at increased risk for colon/rectal cancer, and regular diagnostic evaluations may be required.

Identify appropriate community resources, e.g., Crohns and Colitis Foundation of America, (CCFA), United

Patient may benefit from the services of these agencies in coping with chronicity of the disease and evaluating treatment options.

Ostomy Association, home healthcare providers/visiting nurse services, dietitian, and social services.

Other Possible Nursing Care Plans

Pain, acutehyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation, fissures, fistulas. Coping, ineffectivemultiple stressors, repeated over period of time; unpredictable nature of disease process; personal vulnerability; severe pain; situational crisis. Infection, risk fortraumatized tissue, change in pH of secretions, altered peristalsis, suppressed inflammatory response, chronic disease, malnutrition. Therapeutic Regimen: ineffective managementcomplexity of therapeutic regimen, perceived benefit, powerlessness.