SOUTHWESTERN UNIVERSITY

__________________________________________________
PHINMA

COLLEGE OF NURSING

April 22, 2021

Thursday

Level 3 Section B

Arcipe, Nathaniel Dean G.

Sir Anthony Joseph Mercado

___________________________________________
Clinical Instructor
ULCERATIVE COLITIS
PATHOPHYSIOLOGY
 Predisposing Factors: Precipitating Factors:
 Genetic susceptibility  Environmental factors
 Congenital immunological  Diet
disorders  Alcohol consumption
 Age
 Race or ethnicity
triggers
Intestinal flora

Abnormal mucosal
immune response

Release of various
immune chemicals

Cytokines Chemokines
Eicosanoids Adhesion molecules
Reactive O2 metabolites Nitric oxide
Neuropeptides Acute phase proteins

Intestinal
inflammation

Lack of immune
down regulation

Injury to intestinal
tissue

Ulcerations

Ulcerative Colitis

Damaged Bowel Tissue Chronic Diarrhea

Acute Pain Deficient Fluid Volume

Summary: Legend
Ulcerative colitis is a disease of the bowel. Although its exact cause is Part of Pathological Process

unknown, experts believe that it is caused by the improper immune Disease

Complications
response of the body towards naturally-occurring intestinal flora. This
Nursing Diagnosis
causes the occurrence of inflammation which gradually leads to tissue Summary
injury.
DRUG STUDIES

DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

ACTION
GENERIC NAME: Unknown. Thought to Ulcerative colitis; Acute  CNS: headache, depression, BEFORE
Sulfasalazine inhibit prostaglandin rheumatoid arthritis; hallucinations, insomnia,  Explain the drug and rationale
synthesis by Polyarticular-course drowsiness, vertigo, fatigue, of administration to the
BRAND NAME: interfering with juvenile rheumatoid apathy, anxiety, ataxia, patient.
Azulfidine secretions in colon arthritis polyneuritis, peripheral  Question patient about history
and causing local neuropathy of hypersensitivity reactions to
CLASSIFICATION: anti-inflammatory  EENT: periorbital edema, drug.
Anti-infective, GI tract action. optic neuritis, transient
DURING
Anti-inflammatory, myopia, tinnitus
 Give after meals and space
Antirheumatic  GI: nausea, vomiting,
doses evenly to reduce GI
abdominal pain, stomatitis,
effects.
DOSAGE: glossitis, pancreatitis, dry
 Give with a full glass of water.
500 mg/tab mouth, anorexia
 Administer delated-release
 GU: hematuria, proteinuria,
tablets whole. Do not let
ROUTE: orange-yellow urine,
patient crush or chew them.
Oral reversible oligospermia
 Monitor CBC with white cell
 Hepatic: jaundice
differential. Watch for
FREQUENCY:  Respiratory: shortness of
evidence of blood dyscrasias.
Q6 breath, pleuritis
 Stay alert for signs of
 Skin: generalized skin
erythema multiforme. Report
TIMING: eruption, urticaria, pruritus,
early signs before condition
8AM – 2PM – 8PM – alopecia, local irritation,
2AM orange-yellow skin
discoloration, exfoliative
dermatitis, photosensitivity
reaction
Source:  Other: reversible
Schull, P.D., (2013). immunoglobulin
McGraw – Hill suppression, chills, drug
Nurse’s Drug fever, hypersensitivity
Handbook 7th Edition. reactions
The McGraw – Hill
Companies, Inc. CONTRAINDICATION ADVERSE EFFECTS
Hypersensitivity to drug,  CNS: seizures
its metabolites, other  CV: allergic myocarditis or
sulfonamides, or pericarditis
salicylates; Porphyria;  GI: pseudomembranous
Urinary tract or intestinal colitis
obstruction  GU: crystalluria, toxic
nephrosis with oliguria and
anuria, renal failure
 Hematologic: megaloblastic
anemia, agranulocytosis,
aplastic anemia,
thrombocytopenia,
leukopenia, hemolytic
anemia
 Hepatic: hepatitis,
hepatocellular necrosis
can progress to Stevens-
Johnson syndrome.
 Monitor patient for signs and
symptoms of superinfection,
including fever, tachycardia,
and chills.
 Check kidney function tests
weekly.
AFTER
 Urge patient to complete full
course of treatment, even if
they feel better after a few
days.
 Instruct patient to promptly
contact prescriber if they
develop depression.
 As appropriate, review all
other significant and life-
threatening adverse reactions
and interactions.
 Respiratory: cyanosis,
allergic pneumonitis,
pulmonary infiltrate,
fibrosing alveolitis
 Skin: erythema multiforme,
epidermal necrolysis,
Stevens-Johnson syndrome
 Other: anaphylaxis, serum
sickness, lupus-like
syndrome
 DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME: Decreases Severe inflammation;  CNS: headache, BEFORE
Prednisone inflammation by Acute exacerbation of nervousness, depression,  Explain the drug and rationale
reversing increased multiple sclerosis; euphoria, personality of administration to the
BRAND NAME: cell capillary Adjunctive therapy for changes, psychosis, vertigo, patient.
Apo-Prednisone permeability and Pneumocystis jiroveci paresthesia, insomnia,  Question patient about history
inhibiting migration pneumonia in AIDS restlessness of hypersensitivity reactions to
CLASSIFICATION: of patients  CV: hypotension, drug.
Anti-inflammatory, polymorphonuclear hypertension, vasculitis,
DURING
Immunosuppressant leukocytes.  EENT: posterior subcapsular
 Give with food or milk to
Suppresses immune cataracts, glaucoma, nasal
reduce GI upset.
DOSAGE: system by reducing irritation and congestion,
 Administer once-daily dose
50 mg/tab lymphatic activity. rebound congestion,
early in the morning.
sneezing, epistaxis,
 Monitor weight, blood
ROUTE: nasopharyngeal and
pressure, and electrolyte
Oral oropharyngeal fungal
levels.
infections, perforated nasal
 Watch for cushingoid effects.
FREQUENCY: septum, anosmia,
 Check for signs and symptoms
OD dysphonia, hoarseness,
of depression and psychosis.
throat irritation
 Assess for early indications of
TIMING:  GI: nausea, vomiting,
adrenal insufficiency.
8AM abdominal distention, rectal
 Assess blood glucose level
bleeding, esophageal
carefully in diabetic patient.
candidiasis, dry mouth,
 Monitor patient for signs and
esophageal ulcer
symptoms of infection, which
 GU: amenorrhea, irregular
 menses drug may mask or exacerbate.
 Hematologic: purpura
 Metabolic: sodium and fluid AFTER
retention, hypokalemia,  Teach patient to recognize
Source: hypocalcemia, and immediately report signs
Schull, P.D., (2013). hyperglycemia, decreased and symptoms of early
McGraw – Hill carbohydrate tolerance, adrenal insufficiency and
Nurse’s Drug diabetes mellitus, growth cushingoid effects.
Handbook 7th Edition. retardation, cushingoid  Caution patient not to stop
The McGraw – Hill effects drug suddenly.
Companies, Inc.  Musculoskeletal: muscle  As appropriate, review all
weakness or atrophy, other significant and life-
myalgia, myopathy, threatening adverse reactions
osteoporosis, aseptic joint and interactions.
necrosis, spontaneous
fractures, osteonecrosis,
tendon rupture
 Respiratory: cough,
wheezing
 Skin: rash, pruritus, contact
dermatitis, acne, striae,
poor wound healing,
hirsutism, thin fragile skin,
petechiae, bruising,
subcutaneous fat atrophy,
urticaria, angioedema
 Other: bad taste, increased
 or decreased appetite,
weight gain, facial edema,
aggravation or masking of
infections, hypersensitivity
reaction

CONTRAINDICATION ADVERSE EFFECTS

Hypersensitivity to drug,  CNS: seizures, meningitis,

other corticosteroids, increased intracranial
alcohol, bisulfite, or pressure
tartrazine (with some  CV: heart failure,
products); Systemic thrombophlebitis,
fungal infections; Live- thromboembolism, fat
virus vaccines (with embolism, arrhythmias,
immunosuppressant shock
doses); Active untreated  GI: pancreatitis, peptic ulcer
infections (except in  Metabolic: hypothalamic-
selected meningitis pituitary-adrenal
patients) suppression, adrenal
suppression
 Respiratory: bronchospasm
 DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME: Prevents proliferation To prevent rejection of  CNS: malaise BEFORE
Azathioprine and differentiation of kidney transplant;  EENT: retinopathy  Explain the drug and rationale
activated B and T Rheumatoid arthritis;  GI: nausea, vomiting, of administration to the
BRAND NAME: cells by interfering Ulcerative colitis; Crohn’s diarrhea, stomatitis, patient.
Azasan with synthesis of disease; Lupus nephritis esophagitis, anorexia,  Question patient about history
purine, DNA, and mucositis, pancreatitis of hypersensitivity reactions to
CLASSIFICATION: RNA.  Hematologic: anemia drug.
Immunosuppressant  Musculoskeletal: muscle
DURING
wasting, joint and muscle
 Give after meals.
DOSAGE: pain
 Monitor CBC, platelet level,
1.5 mg/kg  Skin: rash, alopecia
and liver function test results.
 Other: chills, fever
 Assess for signs and
ROUTE:
symptoms of hepatotoxicity.
Oral
 Watch for signs and
symptoms of infection.
FREQUENCY:
 Monitor for bleeding tendency
OD
and hemorrhage.
TIMING:
AFTER
8AM
 Tell patient that drug lowers
resistance to infection.
 Instruct patient to
immediately report unusual
bleeding or bruising.
 CONTRAINDICATION ADVERSE EFFECTS  Emphasize importance of
avoiding pregnancy during
Hypersensitivity to drug;  Hematologic: therapy and for 4 months
Pregnancy or thrombocytopenia, afterward.
breastfeeding leukopenia, pancytopenia  Advise patient to minimize GI
Source:  Hepatic: hepatotoxicity upset by eating small,
Schull, P.D., (2013).  Other: serum sickness, frequent servings of food and
McGraw – Hill neoplasms, serious infection drinking plenty of fluids.
Nurse’s Drug  As appropriate, review all
Handbook 7th Edition. other significant and life-
The McGraw – Hill threatening adverse reactions
Companies, Inc. and interactions.
 DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME: Neutralizes and Rheumatoid arthritis;  CNS: fatigue, headache, BEFORE
Infliximab prevents activity of Crohn’s disease; anxiety, depression,  Explain the drug and rationale
tumor necrosis Ulcerative colitis; dizziness, insomnia, CNS of administration to the
BRAND NAME: factor-alpha (TNF- Ankylosing spondylitis; manifestation of systemic patient.
Remicade alpha) by binding to Psoriatic arthritis; Plaque vasculitis, seizures, new-  Question patient about history
soluble and psoriasis onset or exacerbation of of hypersensitivity reactions to
CLASSIFICATION: transmembrane demyelinating disorders drug.
Antirheumatic, GI anti- forms of TNF and  CV: chest pain,
DURING
inflammatory inhibiting its hypertension, hypotension,
 Know that latent TB should be
receptors, resulting tachycardia, peripheral
treated before infliximab
DOSAGE: in anti-inflammatory edema
therapy begins.
5 mg/kg and antiproliferative  EENT: conjunctivitis,
 Know that concentration of
activity. Reduces rate rhinitis, sinusitis, laryngitis,
infusion should be 0.4 mg/ml
ROUTE: of joint destruction in pharyngitis
to 4 mg/ml.
IV rheumatoid arthritis  GI: nausea, vomiting,
 Give IV infusion over at least
and eases symptoms diarrhea, constipation,
2 hours.
FREQUENCY: of Crohn’s disease. abdominal pain, dyspepsia,
 Premedicate with
Q8 flatulence, ulcerative
antihistamines,
stomatitis
acetaminophen, and
TIMING:  GU: dysuria, urinary
corticosteroids, as prescribed.
8AM – 4PM – 12AM frequency, urinary tract
 Discard unused portions of
infection
infusion solution.
 Hematologic: hematoma,
 Monitor platelets and CBC with
anemia
white cell differential.
 Hepatic: HBV reactivation
  Musculoskeletal: arthritis,
joint pain, back pain,
myalgia, involuntary muscle
contractions
 Respiratory: upper
respiratory tract infection,
bronchitis, cough, dyspnea
Source:  Skin: acne, diaphoresis, dry
Schull, P.D., (2013). skin, bruising, eczema,
McGraw – Hill erythema, flushing,
Nurse’s Drug pruritus, urticaria, rash,
Handbook 7th Edition. alopecia
The McGraw – Hill  Other: oral pain, tooth pain,
Companies, Inc. moniliasis, chills, hot
flashes, flulike symptoms,
herpes simplex, herpes
zoster, lupuslike syndrome,
serious infections,
hypersensitivity reaction
CONTRAINDICATION ADVERSE EFFECTS
 Assess for heart failure in
patients with history of
cardiac disease.
AFTER
 Advise patient not to receive
line vaccines while receiving
infliximab.
 Tell patient to report infection
symptoms such as fever,
burning on urination, cough,
or sore throat.
 As appropriate, review all
other significant and life-
threatening adverse reactions
and interactions.
Hypersensitivity to drug,  CV: worsening of heart
murine proteins, or other failure
drug components;  GI: intestinal obstruction
Dosages above 5 mg/kg  Hematologic: hemolytic
for patients with anemia, pancytopenia
moderate to severe heart  Hepatic: hepatotoxicity
failure  Other: autoimmunity,
malignancies, infusion
reactions, anaphylaxis or
serum sickness-like
reactions
PROCEDURES

TOTAL COLECTOMY
1. PRE-OPERATIVE NURSING CONSIDERATIONS
a. The nurse should ensure that the client must stop taking certain
medications. Since these drugs may raise the risk of
complications during surgery, the patient may be advised to stop
taking them before the procedure.
b. The nurse must instruct the patient to fast before the surgery as
detailed by the physician. The patient may fast for multiple
hours or even a day before the surgery.
c. Have the patient drink a bowel-clearing solution. A laxative
solution that you mix with water may be prescribed by the
physician. Following the instructions, let the patient drink the
remedy for several hours. The remedy induces diarrhea, which
aids in the emptying of the stomach. Enemas can also be
recommended by the doctor.
d. Instruct the patient to take antibiotics. In certain cases, the
physician may prescribe antibiotics to help prevent infection by
suppressing the bacteria found naturally in the colon.
2. INTRA-OPERATIVE NURSING CONSIDERATIONS
a. The nurse may assist in taking the patient to a planning room on
the day of the surgery. Assist in controlling the patient’s pulse
and blood pressure. Antibiotic can be sent to the patient through
a vein in the arm.
b. After that, transport the patient to the operating room and place
them on a table. Assist in giving a general anesthetic to the
patient to place them in a sleep-like condition so they will not be
conscious of what is going on during the procedure.
c. Assist the physician in the colectomy procedure. There are two
ways in which colon surgery may be performed:
 Open Colectomy. An open colectomy is a procedure in
which the colon is removed through an incision. To enter
the colon, open surgery necessitates a longer incision in
the abdomen. The surgeon separates the colon from the
underlying tissue with surgical instruments and removes
only a section or the whole colon.
 Laparoscopic Colectomy. A laparoscopic colectomy, also
known as a minimally invasive colectomy, is a procedure
that entails making multiple minor incisions in the
abdomen. A tiny video camera and special surgical
instruments are passed through one incision and special
surgical tools are passed through the other incisions by the
surgeon.
d. The nurse should aid the physician in fixing the patient’s
digestive tract after the colon has been healed or replaced,
allowing the body to flush waste.
3. POST-OPERATIVE NURSING CONSIDERATIONS
a. Take the patient to a treatment room after surgery and monitor
them as the anesthesia wears off. Transport them to the
emergency bed to begin their treatment.
 b. The nurse should tell the patient that they will be admitted to
the hospital before they are able to reclaim their bowel function.
This could take anything from a few days to a week.
c. Educate the patient that at first, they may not be able to
consume solid foods. Inform the patient that they will get liquid
nutrients into a vein, usually in the arm, and then switch to clear
liquids. Assist in gradually incorporating solid foods as the
intestines heal.
d. Collaborate with an ostomy nurse (if you are not one), and teach
the client how to care for their stoma if the operation had a
colostomy or ileostomy to connect the intestine to the outside of
the abdomen. The nurse will show the client how to change the
waste-collecting ostomy bag.
e. Inform the patient to expect a couple of weeks of rest at home
after leaving the hospital. Make them aware that they may feel
tired at first, but the power will gradually recover. Encourage the
patient to inquire with the doctor whether they should expect to
resume daily activities.

ILEOSTOMY
1. PRE-OPERATIVE NURSING CONSIDERATIONS
a. Discuss with the client and physician about how this
procedure will affect the patient’s sex life, work, physical
activities, and future pregnancies (if applicable).
b. The nurse must make sure that the physician is aware of any
supplements, drugs, or herbal remedies used by the client.
c. Be sure the doctor is aware of any supplements, medicines,
or herbal remedies the patient is using. Many drugs slow
down the intestine's movement, making it less effective. This
is valid with both OTC and prescription medications. The
doctor and nurse can encourage the patient to stop taking
those drugs two weeks before the surgery.
d. Ask the patient whether or not they have conditions like the
flu, cold, herpes breakout, fever, and others.
e. If the patient is a smoker, encourage them to quit as
cigarette smoking impairs healing after surgery.
f. Encourage the patient to increase water intake and maintain
a healthy diet weeks before the surgery.
g. In the days leading up to treatment, have the patient follow
the surgeon's diet guidelines. Urge the client to turn to clear
liquids only at a certain point. Inform the patient that they
will not be able to eat or drink anything until about 12 hours
before surgery, including water.
h. The surgeon may also prescribe laxatives or enemas to empty
the client’s intestines, make sure the client follows the
physician’s prescription.
2. INTRA-OPERATIVE NURSING CONSIDERATIONS
a. Assist in administering general anesthesia to the client.
b. Once knocked out, the surgeon will either make a midline cut
or do a laparoscopic operation with narrower incisions and
lighted instruments. Let the patient know which method is
best for their condition before the surgery. The doctor may
need to remove the patient’s rectum and colon, depending on
the diagnosis.
 c. There are several different types of permanent ileostomies.
i. For a standard ileostomy, the surgeon makes a small
incision that will be the site of the ileostomy. They will
pull a loop of the patient’s ileum through the incision.
This part of the patient’s intestine is turned inside out,
exposing the inner surface.
ii. Another type of ileostomy is the continent, or Kock,
ileostomy. The surgeon uses part of the patient’s small
intestine to form an internal pouch with an external
stoma that serves as a valve. These are stitched to the
abdominal wall.
iii. A different procedure, known as the J-pouch procedure,
may be performed if the patient has had their entire
colon and rectum removed. In this procedure, the
doctor creates an internal pouch from the ileum that is
then connected to the anal canal, allowing them to
expel waste through the usual route with no need for a
stoma.
3. POST-OPERATIVE NURSING CONSIDERATIONS
a. The nurse should inform the patient to expect to spend at
least three days in the hospital. It's not unusual to spend a
week or more in the hospital, particularly if the ileostomy was
performed in an emergency situation.
b. For a time, the food and water consumption would be limited.
Have ice chips available for the patient on the day of the
surgery. On the second day, clear liquids would most likely be
permitted. When the patient’s bowels adapt to the changes,
assist the patient in gradually introducing more solid foods.
c. Inform the patient that they may experience excessive
intestinal gas in the days following surgery. When the
intestines regenerate, this will lessen. The nurse may
encourage the patient to avoid certain foods for a period of
time.
d. If the patient has an internal or external pouch, teach them to
learn how to handle the pouch that will contain their waste
during recovery. Have them learn how to take care of their
stoma and surrounding tissue.
e. Educate the client that they will need to make significant
lifestyle changes. Any individuals turn to an ostomy support
network for assistance. Meeting other people who have
changed their lives following surgery and returned to their
daily routines will help to alleviate any fears the patient may
have.
f. Collaborate with nurses that specialize in ileostomy treatment
if you are not one. Make sure the client can live a normal life
with an ileostomy.
NURSING CARE PLANS
 DEFINING NURSING SCIENTIFIC NURSING
PLAN OF CARE RATIONALE EVALUATION
CHARACTERISTICS DIAGNOSIS ANALYSIS INTERVENTIONS
SUBJECTIVE: Acute Pain Acute pain is an SHORT TERM: Independent Independent After 8 hours of
“I can’t stand how related to unpleasant After 8 hours of 1. Perform a 1. To have a better nursing intervention,
painful this is,” as hyperperistalsis sensory and nursing intervention, comprehensive idea about the patient was able
verbalized by the secondary to emotional the patient will: assessment of pain patient’s to state significant
patient. A pain score ulcerative colitis experience ⮚ Report that pain 2. Note client’s locus condition reduction of pain with
of 10/10 was as evidenced by arising from is relieved or of control 2. To determine an updated pain score
reported. facial mask of actual or controlled to a 3. Accept client’s patient’s sense of 3. The patient also
pain and self- potential tissue pain score of <5 displayed proper
description of pain of responsibility
focusing damage or ⮚ Follow prescribed adherence to drug
4. Provide quiet, calm in pain
behavior described in medication regimen.
environment management
OBJECTIVE: terms of such regimen
5. Provide comfort 3. Pain is a
▪ Guarded behavior damage. The subjective (Goal Met)
LONG TERM: measures
noted patient is phenomenon
▪ Facial grimace After 2 weeks of
suffering from that cannot be
observed nursing intervention,
ulcerative colitis, felt by others
▪ Patient is having the patient will:
a chronic 4. To facilitate
expressive  Verbalize
condition of
behavior through methods that relaxation
unknown cause
crying and provide relief 5. To improve
usually starting
moaning  Demonstrate use patient’s sensory
in the rectum of relaxation skills
▪ Diaphoresis noted experience
and distal and diversional
▪ V/S taken as
portions of the activities as Collaborative Collaborative
follows:
o T – 37.2°C colon. It involves indicated for 1. Provide analgesics 1. To bring pain to
o P – 98 bpm chronic, long- individual as prescribed an acceptable
o R – 20 cpm term situation 2. Assist in treatment level
o BP – 90/60 inflammatory of underlying 2. To treat factors
mmHg episodes that disease processes that might be
o O2Sat – 100% lead to open causing pain contributing to
sores known as
pain
ulcers.

Reference:
Doenges, E., Reference:
Moorhouse, F. M., & Doenges, E., Moorhouse, F.
M., & Murr A. 2010. Nursing Reference:
Murr A. 2010.
Care Plans: Guidelines for Doenges, E., Moorhouse,
Nursing Care Plans:
Individualizing Client Care F. M., & Murr A. 2010.
Guidelines for
Across the Life Span Nursing Care Plans:
Individualizing Client
Guidelines for
 DEFINING
NURSING SCIENTIFIC NURSING
CHARACTERISTIC PLAN OF CARE RATIONALE EVALUATION
DIAGNOSIS ANALYSIS INTERVENTIONS
S
SUBJECTIVE: Deficient Fluid Deficient fluid SHORT TERM: Independent Independent After 8 hours of nursing
“I constantly feel Volume: volume (isotonic) After 8 hours of 1. Determine effects 1. Elderly individuals intervention, the patient
thirsty and weak,” Isotonic is referred to as nursing intervention, of age on hydration are at higher risk for was able to state that
as verbalized by the related to decreased the patient will: status dehydration thirst and weakness have
patient. active fluid intravascular, ⮚ Report that thirst 2. Assess vital signs 2. To evaluate severity been lifted and display
volume loss interstitial, and weakness and note strength of patient’s condition improvement of hydration
secondary to and/or have improved of peripheral pulses 3. To assess patient’s status as evidenced by
ulcerative intracellular fluid. ⮚ Display 3. Note physical signs hydration status alleviation of signs of
OBJECTIVE: colitis disease This refers to normalization of of dehydration 4. To prevent dehydration.
▪ Patient has process as dehydration, hydration status 4. Establish 24-hour peaks/valleys in fluid
decreased urine evidenced by water loss alone as evidenced by fluid replacement level (Goal Met)
output absence of signs
presence of without change needs and routes to 5. To provide easy
▪ Patient’s blood of dehydration
signs of in sodium. The be used access to fluids
pressure is below dehydration patient is 5. Keep fluids within 6. To maintain proper
usual LONG TERM:
currently client’s reach fluid volume
▪ Decreased skin After 2 weeks of
suffering from 6. Encourage frequent
turgor noted nursing intervention,
bleeding fluid intake as
▪ V/S taken as the patient will:
ulcerative colitis, appropriate
follows:  Verbalize
o T – 37.2°C which causes
understanding of Collaborative Collaborative
o P – 98 bpm episodes of causative factors
diarrhea. This 7. Administer 7. To manage
o R – 20 cpm and purpose of
facilitates appropriate drugs underlying
o BP – 90/60 therapy and
excessive fluid as prescribed conditions causing
mmHg management
o O2Sat – 100% loss and 8. Administer IV fluids fluid loss
 Demonstrate
consequently, behaviors to as indicated 8. To replace lost fluids
dehydration. monitor and efficiently
correct deficit as
indicated
Reference:
Doenges, E., Moorhouse, F.
M., & Murr A. 2010. Nursing
Care Plans: Guidelines for
Individualizing Client Care
Across the Life Span
Reference:
Doenges, E., Moorhouse, F.
M., & Murr A. 2010. Nursing
Care Plans: Guidelines for
Individualizing Client Care
Across the Life Span