COLLABORATIVE

MEDICAL. Drug therapy is the typical method used to control the inflammatory process. Sulfasalazine is the primary drug used to achieve remission. After remission is established, dosages are generally reduced, and patients continue on this agent for at least 1 year after an acute attack.

To maintain fluid and electrolyte balance during acute attacks, intravenous (IV) fluids are generally prescribed, and electrolytes may be added to the solutions as needed. Blood transfusions may also be prescribed if the patient is anemic because of numerous bloody diarrheal stools. To achieve bowel "rest," the patient is usually given nothing by mouth. During this time, nutritional deficits may be managed through the use of total parenteral nutrition with vitamin supplements. Helping patients maintain an adequate nutritional status, fluid balance, and electrolyte balance is a priority nursing measure. Record intake and output accurately every shift. Note the number of stools and stool characteristics.

Gradually, as the acute attack subsides and inflammation clears, the patient is placed on a low-residue, low-fat, high-calorie, high-protein, lactose-free diet.

SURGICAL. Surgery may be performed when patients fail to respond to conservative treatment, if acute episodes are frequent, or when a complication such as bleeding or perforation occurs. The standard surgical procedure, when performed, is a total proctocolectomy with ileostomy. This procedure is considered a permanent cure for ulcerative colitis. To prepare the patient for surgery, administer bowel preparations such as laxatives and enemas.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Mesalamine (5-aminosalicylic acid; 5-ASA) (Asacol, Pentasa)	800–1,600 mg PO tid	Anti-inflammatory agent, 5-ASA	5-ASA preparations like mesalamine have become treatment of choice and can be used in people who cannot tolerate sulfasalazine
Other anti-inflammatories	Varies with drug: Sulfasalazine, 0.5–1.0 g PO qid; prednisone, 10–40 mg PO tid; methylprednisolone, 20–40 mg IV q 12 hr; hydrocortisone, 100 mg IV q 6 hr	Sulfasalazine (Azulfidine); corticosteroids	Slow the inflammatory process; sulfasalazine is not used in treatment of disease confined to small intestine; glucocorticoids such as prednisone are used in acute exacerbations—agents are administered until clinical symptoms subside, at which time steroidal agents are tapered off
Immunosuppressive agents	Varies with drug	Azathioprine (Imuran) 6-mercaptopurine	Decrease inflammation and symptoms if steroids fail; decrease steroid requirements

Other Drugs: Balsalazide (Colazal), infliximab (Remicade), cyclosporine (Neoral, Sandimmune). Antidiarrheal agents to alleviate symptoms of abdominal cramping and diarrhea in patients with mild symptoms or postresection diarrhea. Metronidazole (Flagyl) is effective in colon disease; it treats infections with fistulae and perianal skin breakdown and is beneficial in patients who have not responded to other agents. Some patients suffering with severe abdominal pain may require narcotic analgesics such as meperidine (Demerol). Also, patients who develop deficiencies because of problems of malabsorption may require vitamin B₁₂ injections monthly or iron replacement therapy. Other nutritional supplements include calcium, magnesium, folate, and other micronutrients.

INDEPENDENT

Promote patient physical and emotional comfort. Encourage the patient to assume the position of comfort. Instruct in distraction techniques as needed. Promote mental comfort by encouraging the patient to share thoughts and feelings and provide supportive, empathetic care. Discuss measures to decrease life stressors. Teach the patient about the disease process and the typical treatment regimen. Areas to include in the teaching plan include the signs of disease complications, the importance of rest and stress reduction, and any dietary adjustments.

If the patient requires surgery, several nursing interventions are important in the preoperative phase. First, conduct preoperative teaching sessions on deep-breathing techniques and leg exercises. Also, discuss the operative procedure and the typical postoperative course. When appropriate, discuss with the patient information on stoma placement and stoma care. After surgery, ensure a healthy respiratory status for the patient by encouraging the patient to cough and deep-breathe every 1 to 2 hours. Manage patient pain and discomfort with prescribed analgesics and proper positioning techniques. Monitor for adequate wound healing by checking the color and approximation of the wound and noting any wound drainage or odor. Note the stoma size and color during every shift and immediately report any duskiness noted at the stoma site. Note the condition of the skin around the stoma; protect the skin with appropriate barrier products because ileostomy drainage is extremely caustic to skin tissues. Finally, encourage the patient's participation in ostomy care. Assess whether a community resource person from the United Ostomy Association is needed to offer the patient additional support.