7 Inflammatory Bowel Disease (IBD) Nursing Care Plans

Inflammatory bowel disease (IBD) Nursing Care Plans is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. It 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. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.

The two major types of inflammatory bowel disease are ulcerative colitis (UC) and Crohn disease (CD).

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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 (Crohn’s 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.

Diagnosis

Your doctor will likely diagnose inflammatory bowel disease only after ruling out other possible causes for your signs and symptoms. To help confirm a diagnosis of IBD, you may have one or more of the following tests and procedures:

Blood tests

Tests for anemia or infection. Your doctor may suggest blood tests to check for anemia — a condition in which there aren’t enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection from bacteria or viruses.

Fecal occult blood test. You may need to provide a stool sample so that your doctor can test for hidden blood in your stool.

Endoscopic procedures

Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis.

Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to examine the rectum and sigmoid, the last portion of your colon. If your colon is severely inflamed, your doctor may perform this test instead of a full colonoscopy.

Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the esophagus, stomach and first part of the small intestine (duodenum). While it is rare for these areas to be involved with Crohn’s disease, this test may be recommended if you are having nausea and vomiting, difficulty eating or upper abdominal pain.

Capsule endoscopy. This test is sometimes used to help diagnose Crohn’s disease involving your small intestine. You swallow a capsule that has a camera in it. The images are transmitted to a recorder you wear on your belt, after which the capsule exits your body painlessly in your stool. You may still need an endoscopy with a biopsy to confirm a diagnosis of Crohn’s disease.

Balloon-assisted enteroscopy. For this test, a scope is used in conjunction with a device called an overtube. This enables the doctor to look further into the small bowel where standard endoscopes don’t reach. This technique is useful when a capsule endoscopy shows abnormalities, but the diagnosis is still in question.

X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.

Computerized tomography (CT) scan. You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.

Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. An MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography). Unlike a CT, there is no radiation exposure with an MRI.

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Inflammatory bowel disease (IBD) care at Mayo Clinic

Barium enema

Colonoscopy

Treatment

The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission and reduced risks of complications. IBD treatment usually involves either drug therapy or surgery.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. Anti-inflammatories include corticosteroids and aminosalicylates, such as mesalamine (Asacol HD, Delzicol, others), balsalazide (Colazal) and olsalazine (Dipentum). Which medication you take depends on the area of your colon that’s affected.

Immune system suppressors

These drugs work in a variety of ways to suppress the immune response that releases inflammation-inducing chemicals in the intestinal lining. For some people, a combination of these drugs works better than one drug alone.

Some examples of immunosuppressant drugs include azathioprine (Azasan, Imuran), mercaptopurine (Purinethol, Purixan), cyclosporine (Gengraf, Neoral, Sandimmune) and methotrexate (Trexall).

One class of drugs called tumor necrosis factor (TNF)-alpha inhibitors, or biologics, works by neutralizing a protein produced by your immune system. Examples include infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). Other biologic therapies that may be used are natalizumab (Tysabri), vedolizumab (Entyvio) and ustekinumab (Stelara).

Antibiotics

Antibiotics may be used in addition to other medications or when infection is a concern — in cases of perianal Crohn’s disease, for example. Frequently prescribed antibiotics include ciprofloxacin (Cipro) and metronidazole (Flagyl).

Other medications and supplements

In addition to controlling inflammation, some medications may help relieve your signs and symptoms, but always talk to your doctor before taking any over-the-counter medications. Depending on the severity of your IBD, your doctor may recommend one or more of the following:

Anti-diarrheal medications. A fiber supplement — such as psyllium powder (Metamucil) or methylcellulose (Citrucel) — can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium A-D) may be effective.

Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). However, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diclofenac sodium (Voltaren) likely will make your symptoms worse and can make your disease worse as well.

Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia and need to take iron supplements.

Calcium and vitamin D supplements. Crohn’s disease and steroids used to treat it can increase your risk of osteoporosis, so you may need to take a calcium supplement with added vitamin D.

Nutritional support

Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat your IBD. This can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term.

If you have a stenosis or stricture in the bowel, your doctor may recommend a low-residue diet. This will help to minimize the chance that undigested food will get stuck in the narrowed part of the bowel and lead to a blockage.

Surgery

If diet and lifestyle changes, drug therapy, or other treatments don’t relieve your IBD signs and symptoms, your doctor may recommend surgery.

Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy).

In most cases, this involves a procedure called an ileal pouch anal anastomosis. This procedure eliminates the need to wear a bag to collect stool. Your surgeon constructs a pouch from the end of your

small intestine. The pouch is then attached directly to your anus, allowing you to expel waste relatively normally.

In some cases a pouch is not possible. Instead, surgeons create a permanent opening in your abdomen (ileal stoma) through which stool is passed for collection in an attached bag.

Surgery for Crohn’s disease. Up to one-half of people with Crohn’s disease will require at least one surgery. However, surgery does not cure Crohn’s disease.

During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. Surgery may also be used to close fistulas and drain abscesses.

The benefits of surgery for Crohn’s disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. The best approach is to follow surgery with medication to minimize the risk of recurrence.

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Lifestyle and home remedies

Sometimes you may feel helpless when facing inflammatory bowel disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.

Diet

There’s no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up.

It can be helpful to keep a food diary to keep track of what you’re eating, as well as how you feel. If you discover some foods are causing your symptoms to flare, you can try eliminating those foods. Here are some suggestions that may help:

Limit dairy products. Many people with inflammatory bowel disease find that problems such as diarrhea, abdominal pain and gas improve by limiting or eliminating dairy products. You may be lactose intolerant — that is, your body can’t digest the milk sugar (lactose) in dairy foods. Using an enzyme product such as Lactaid may help as well.

Try low-fat foods. If you have Crohn’s disease of the small intestine, you may not be able to digest or absorb fat normally. Instead, fat passes through your intestine, making your diarrhea worse. Try avoiding butter, margarine, cream sauces and fried foods.

Take care with fiber. If you have inflammatory bowel disease, high-fiber foods, such as fresh fruits and vegetables and whole grains, may make your symptoms worse. If raw fruits and vegetables bother you, try steaming, baking or stewing them.

In general, you may have more problems with foods in the cabbage family, such as broccoli and cauliflower, and nuts, seeds, corn and popcorn.

Avoid other problem foods. Spicy foods, alcohol and caffeine may make your signs and symptoms worse.

Other dietary measures

Eat small meals. You may find you feel better eating five or six small meals a day rather than two or three larger ones.

Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.

Consider multivitamins. Because Crohn’s disease can interfere with your ability to absorb nutrients and because your diet may be limited, multivitamin and mineral supplements are often helpful. Check with your doctor before taking any vitamins or supplements.

Talk to a dietitian. If you begin to lose weight or your diet has become very limited, talk to a registered dietitian.

Smoking

Smoking increases your risk of developing Crohn’s disease, and once you have it, smoking can make it worse. People with Crohn’s disease who smoke are more likely to have relapses and need medications and repeat surgeries.

Smoking may help prevent ulcerative colitis. However, its harm to overall health outweighs any benefit, and quitting smoking can improve the general health of your digestive tract, as well as provide many other health benefits. Nicotine patches have been used to treat ulcerative colitis, but the results have been disappointing.

Stress

The association of stress with Crohn’s disease is controversial, but many people who have the disease report symptom flares during high-stress periods. If you have trouble managing stress, try one of these strategies:

Exercise. Even mild exercise can help reduce stress, relieve depression and normalize bowel function. Talk to your doctor about an exercise plan that’s right for you.

Biofeedback. This stress-reduction technique may train you to reduce muscle tension and slow your heart rate with the help of a feedback machine. The goal is to help you enter a relaxed state so that you can cope more easily with stress

Regular relaxation and breathing exercises. One way to cope with stress is to regularly relax and use techniques such as deep, slow breathing to calm down. You can take classes in yoga and meditation or use books, CDs or DVDs at home.

Alternative medicine

Many people with digestive disorders have used some form of complementary and alternative medicine (CAM). However, there are few well-designed studies of their safety and effectiveness.

Some commonly used therapies include:

Probiotics. Researchers suspect that adding more of the beneficial bacteria (probiotics) that are normally found in the digestive tract might help combat IBD. Although research is limited, there is some evidence that adding probiotics along with other medications may be helpful, but this has not been proved.

Fish oil. Fish oil acts as an anti-inflammatory, and there is a suggestion that it could relieve intestinal inflammation related to IBD, but this has not been proved.

Aloe vera. Aloe vera gel may have an anti-inflammatory effect for people with ulcerative colitis, but it can also cause diarrhea.

Turmeric. Curcumin, a compound found in the spice turmeric, has been combined with standard ulcerative colitis therapies in clinical trials. There is some evidence of benefit, but more research is needed.

Acupuncture. Only one clinical trial has been conducted regarding its benefit. The procedure involves the insertion of fine needles into the skin, which may stimulate the release of the body’s natural painkillers.

Prebiotics. Unlike probiotics — which are beneficial live bacteria that you consume — prebiotics are natural compounds found in plants, such as artichokes, that help fuel beneficial intestinal bacteria. Studies have not shown positive results of prebiotics for people with Cohn’s disease.

Coping and support

IBD doesn’t just affect you physically — it takes an emotional toll as well. If signs and symptoms are severe, your life may revolve around a constant need to run to the toilet. Even if your symptoms are mild, it can be difficult to be out in public. All of these factors can alter your life and may lead to depression. Here are some things you can do:

Be informed. One of the best ways to be more in control is to find out as much as possible about inflammatory bowel disease. Look for information from reputable sources such as the Crohn’s & Colitis Foundation of America (CCFA).

Join a support group. Although support groups aren’t for everyone, they can provide valuable information about your condition as well as emotional support. Group members frequently know about the latest medical treatments or integrative therapies. You may also find it reassuring to be among others with IBD.

Talk to a therapist. Some people find it helpful to consult a mental health professional who’s familiar with inflammatory bowel disease and the emotional difficulties it can cause.

Although living with IBD can be discouraging, research is ongoing, and the outlook is improving.

Preparing for your appointment

Symptoms of inflammatory bowel disease may first prompt a visit to your family doctor or general practitioner. However, you may then be referred to a doctor who specializes in treating digestive disorders (gastroenterologist).

Because appointments can be brief, and there’s often a lot of information to discuss, it’s a good idea to be well-prepared. Here’s some information to help you get ready and what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.

Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you made the appointment.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, including over-the-counter medications and any vitamins or supplements that you’re taking.

Take a family member or friend along. Sometimes it can be difficult to remember everything during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Time with your doctor is limited, so preparing a list of questions beforehand may help you make the most of your visit. List your questions from most important to least important in case time runs out. For inflammatory bowel disease, some basic questions to ask your doctor include:

  • What’s causing these symptoms?
  • Are there other possible causes for my symptoms?
  • What kinds of tests do I need? Do these tests require any special preparation?
  • Is this condition temporary or long lasting?
  • What treatments are available, and which do you recommend?
  • Are there any medications that I should avoid?
  • What types of side effects can I expect from treatment?
  • What sort of follow-up care do I need? How often do I need a colonoscopy?
  • Are there any alternatives to the primary approach that you’re suggesting?
  • I have other health conditions. How can I best manage them together?
  • Do I need to follow any dietary restrictions?
  • Is there a generic alternative to the medicine you’re prescribing?
  • Are there brochures or other printed material that I can take with me? What websites do you recommend?
  • Is there a risk to me or my child if I become pregnant?
  • Is there a risk of complications to my partner’s pregnancy if I have IBD and father a child?
  • What is the risk to my child of developing IBD if I have it?
  • Are there support groups for people with IBD and their families?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or intermittent?
  • How severe are your symptoms?
  • Do you have abdominal pain?
  • Have you had diarrhea? How often?
  • Do you awaken from sleep during the night because of diarrhea?
  • Is anyone else in your home sick with diarrhea?
  • Have you lost weight unintentionally?
  • Have you ever had liver problems, hepatitis or jaundice?
  • Have you had problems with your joints, eyes or skin — including rashes and sores — or had sores in your mouth?
  • Do you have a family history of inflammatory bowel disease?
  • Do your symptoms affect your ability to work or do other activities?
  • Does anything seem to improve your symptoms?
  • Is there anything that you’ve noticed that makes your symptoms worse?
  • Do you smoke?
  • Do you take nonsteroidal anti-inflammatory drugs (NSAIDs), for example, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or diclofenac sodium (Voltaren)?
  • Have you taken antibiotics recently?
  • Have you recently traveled? If so, where?

Inflammatory Bowel Disease Nursing Care Plans

Nursing care management of patients with inflammatory bowel diseases (IBD) includes control of diarrhea and promoting optimal bowel function; minimize or prevent complications; promote optimal nutrition, and provide information about the disease process and treatment needs.

Here are seven (7) nursing care plans (NCP) and nursing diagnosis for patients with inflammatory bowel diseases: ulcerative colitis, Crohn’s disease, and ileocolitis:

  1. Diarrhea
  2. Risk for Deficient Fluid Volume
  3. Anxiety
  4. Acute Pain
  5. Ineffective Coping
  6. Imbalanced Nutrition: Less Than Body Requirements
  7. Deficient Knowledge
  8. Other Possible Nursing Care Plans

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Diarrhea

Nursing Diagnosis

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
  • Hyperactive bowel sounds
  • 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

Ascertain onset and pattern of diarrhea To assess etiology. Chronic diarrhea (caused by irritable bowel syndrome, infectious diseases affecting colon such as IBD).
Observe and record stool frequency, characteristics, amount, and precipitating factors. Helps differentiate individual disease and assesses severity of episode.
Observe for presence of associated factors, such as fever, chills, abdominal pain,cramping, bloody stools, emotional upset, physical exertion and so forth. To assess causative factors and etiology.
Promote bedrest, provide bedside commode.Inflammatory Bowel Disease (IBD) Nursing Care Plans 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 or falls if facilities are not close at hand.
Remove stool promptly. Provide room deodorizers. Reduces noxious odors to avoid undue patient embarrassment.
Identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products). Avoiding intestinal irritants promote intestinal rest and reduce intestinal workload.
Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids. Provides colon rest by omitting or decreasing the stimulus of foods and 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 or have occurred, necessitating immediate medical intervention.

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