7 Inflammatory Bowel Disease (IBD) Nursing Care Plans

Diarrhea

The intestinal immune system is key to the pathogenesis of inflammatory bowel disease (IBD). The intestinal epithelium prevents bacteria or antigen entry into the circulation by sealed intercellular junctions. In IBD, these junctions are defective from either a primary barrier function failure or as a result of severe inflammation (McDowell et al., 2022). During an IBD flare, the lining of the intestines becomes inflamed and cannot absorb all fluid. This results in stools being loose and watery, or even entirely liquid. The looser stool can also move more rapidly through the colon, causing more frequent bowel movements (Crohn’s and Colitis Canada, 2020).

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
• 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

• The client will report a reduction in the frequency of stools and return to more normal stool consistency.
• The client will identify/avoid contributing factors.

Nursing Assessment and Rationales

1. Ascertain onset and pattern of diarrhea
Ulcerative colitis most commonly presents as bloody diarrhea with or without mucus. According to the World Gastroenterology Organization, diarrhea may also occur at night and fecal incontinence is not uncommon (McDowell et al., 2022).

2. Observe and record stool frequency, characteristics, amount, and precipitating factors.
This helps differentiate individual diseases and assesses the severity of episodes. Stools may be formed, but loose stools predominate if the colon or the terminal ileum is involved extensively. Constipation may be the primary symptom of ulcerative colitis when the disease is limited to the rectum; obstipation may occur and may proceed to bowel obstruction (Rowe & Anand, 2020).

3. Observe for the presence of associated factors, such as fever, chills, abdominal pain, cramping, bloody stools, emotional upset, physical exertion, and so forth.
Grossly bloody stools, occasionally with tenesmus, although typical of ulcerative colitis, are less common in Crohn’s disease. Abdominal cramping and pain are commonly present in the right lower quadrant in Crohn’s disease. It can occur periumbilical or in the left lower quadrant in moderate to severe ulcerative colitis (Rowe & Anand, 2020).

4. Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety, and prostration.
This may signify that toxic megacolon or perforation and peritonitis are imminent or have occurred, necessitating immediate medical intervention. Complications of ulcerative colitis include toxic megacolon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue. In toxic megacolon, the inflammatory process extends into the muscularis, inhibiting its ability to contract and resulting in colonic distention.

Nursing Interventions and Rationales

1. Promote bedrest and provide bedside commode.
Rest decreases intestinal motility and reduces the metabolic rate when infection or hemorrhage is a complication. The urge to defecate may occur without warning and be uncontrollable, increasing the risk of incontinence or falls if facilities are not close at hand. the nurse must provide ready access to a bathroom, commode, or bedpan and keep the environment clean and odor free. This protects the client’s safety, reduces stress, and enables the client to cope with diarrhea more effectively.

2. Remove stool promptly. Provide room deodorizers.
Emptying the bedpan or commode promptly reduces noxious odors to avoid undue client embarrassment. This intervention will control odor and decrease the client’s anxiety and self-consciousness.

3. Identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, and milk products).
Avoiding intestinal irritants promotes intestinal rest and reduces intestinal workload. Raw vegetables and fruits, gas-forming foods, and alcohol can also precipitate diarrhea and cramping. When remission occurs, a less restricted diet can be tailored to the individual client, excluding foods known to precipitate symptoms. 

4. Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids.
This 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. A liquid diet seemed superior to a regular diet for reducing inflammation. The problem with using enteral diets is that palatability limits the intake of adequate energy to meet client requirements (Rowe & Anand, 2020).

5. Provide an opportunity to vent frustrations related to the disease process.
The presence of a disease with an unknown cause that is difficult to cure and that may require surgical intervention can lead to stress reactions that may aggravate the condition.

6. Eliminate or decrease the fat content in the diet.
Fat can increase diarrhea in individuals with malabsorption syndrome. Consuming high-fat foods can also trigger symptoms such as abdominal pain, bloating, and diarrhea because they take longer to digest, stimulating the bowel to contract. Additionally, fat can increase the secretion of bile and pancreatic enzymes, contributing to diarrhea and other digestive issues.

7. Administer cholestyramine as indicated.
In clients with Crohn’s disease who have a significant ileal disease or who have had an ileal resection, diarrhea may sometimes occur due to bile salt malabsorption. In such clients, treatment with bile-binding resins, such as cholestyramine, may be helpful in managing diarrhea (Rowe & Anand, 2020).

8. Administer topical corticosteroids or aminosalicylate preparations as prescribed.
These agents reduce mucosal inflammation in clients with mild disease limited to the rectum and sigmoid colon. In clients with acute moderate to severe disease and with more extensive (pan colonic) disease, oral or intravenous corticosteroid therapy is initiated. In clients not responding to steroids or aminosalicylates, immunosuppressive immunomodulatory therapy may be initiated to reduce inflammation.

9. Administer antibiotics as indicated.
The antibiotics metronidazole and ciprofloxacin are the most commonly used antibiotics in persons with IBD. Antibiotics are used only sparingly in persons with ulcerative colitis because of limited treatment efficacy and efficacy. In persons with Crohn’s disease, antibiotics are used for various indications, most commonly for perianal disease, fistulas, and intra-abdominal inflammatory masses (Rowe & Anand, 2020).

10. Administer probiotics or fish oil.
Probiotics are beneficial bacteria that restore balance to the intestinal environment, with a resulting reduction in inflammation. Omega-3 fatty acids found in fish oil appear to benefit clients with active UC by decreasing inflammation; they must be taken in large quantities.