learning zone - Nursing management of patients with … · 2017-09-12 · Discuss the nursing care...

48 december 16 :: vol 24 no 15-17 :: 2009 NURSING STANDARD

learning zoneCONTINUING PROFESSIONAL DEVELOPMENT

Aims and intended learning outcomes

This article aims to provide nurses with acomprehensive overview of the assessment andmanagement of a patient presenting with a severeexacerbation of ulcerative colitis. After readingthis article and completing the time out activitiesyou should be able to:

�Provide an overview of ulcerative colitis,including the causes and treatments.

�Describe the assessment and relevantinvestigations required for a patient presentingwith a severe flare-up of the condition.

�Outline the medical management of a patientdiagnosed with a severe flare-up of ulcerativecolitis.

�Discuss the nursing care of a patient with severe ulcerative colitis and give the rationalefor each intervention.

Introduction

Ulcerative colitis and Crohn’s disease areclassified under the umbrella term ofinflammatory bowel disease (IBD). While bothconditions are similar, in terms of symptoms andtreatments, there are also many differencesbetween the two. Clinical guidelines for IBD,including the management of severe ulcerativecolitis, have been produced by the British Societyof Gastroenterology (BSG) (Carter et al 2004).However, these guidelines have not beenreviewed to take into account emerging evidenceand to ensure that practice is up to date. Morerecently, the IBD Standards Working Group(2008) has developed service standards forpatients with IBD.

An IBD nurse-led service has been shown to reduce the admission rate of patients with IBD by 20% (Nightingale et al 2000), andpatients with the condition are generally moreindependent and mobile than other patients onthe ward. These trends may reinforce a tendencyto underestimate the severity of the disease.However, severe ulcerative colitis is potentiallylife-threatening and this patient group requirestimely intervention and expert monitoring.Advances in medical therapy and expert surgicalinput have reduced the mortality rate to less than1% (Truelove and Witts 1955).

Patients with severe ulcerative colitis who do not respond to intravenous corticosteroids

NS523 Sephton M (2009) Nursing management of patients with severe ulcerative colitis. Nursing Standard. 24, 15-17, 48-57. Date of acceptance: June 17 2009.

SummaryUlcerative colitis is a relapsing chronic disease that has anunpredictable course. A relapse in the condition requires timelyintervention and expert monitoring. A severe flare-up will oftennecessitate admission to hospital. This article provides an overviewof the medical management of severe ulcerative colitis and the nursing interventions required.

AuthorMark Sephton, inflammatory bowel disease specialist nurse,Endoscopy Unit, University Hospital Aintree, Liverpool. Email: [email protected]

KeywordsGastrointestinal disorders, incontinence, inflammatory boweldisease, ulcerative colitis

These keywords are based on subject headings from the BritishNursing Index. This article has been subject to double-blind review.For author and research article guidelines visit the Nursing Standardhome page at nursingstandard.rcnpublishing.co.uk. For relatedarticles visit our online archive and search using the keywords.

Nursing management of patientswith severe ulcerative colitis

Page 58Ulcerative colitis multiplechoice questionnaire

Page 59Read Suzanne Douglas’practice profile on community nursing

Page 60Guidelines on how towrite a practice profile

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have the option of either second-line medicaltherapies such as ciclosporin or anti-TNFtherapy, or colectomy. Where surgery isindicated, this should be done in a timely fashion.A delay in surgical intervention generally leads to poor patient outcomes. The UK IBD Audit in2006 recorded 25 deaths that were directlylinked to ulcerative colitis, with 15 of these casesinvolving patients who had undergone surgery(UK IBD Audit Steering Group 2007).

Overview of ulcerative colitis

Inflammation in ulcerative colitis affects thesuperficial mucosa layer of the colon (largeintestine) (Figure 1). It almost always involvesthe rectum and extends in continuity along the colon, with a demarcation line occurringbetween the healthy areas and the inflamedareas. Ulcerative colitis is characterised bywatery diarrhoea containing blood, mucus and pus in varying amounts. It is common for a diagnosis to be made in individuals between 15 and 45 years, with a second peak at 55-70 years (Royal College of Nursing (RCN)2007). Ulcerative colitis is estimated to affect up to 120,000 people in the UK, equating to one in 500 people, and between 6,000 and12,000 new cases are diagnosed every 12 months (National Association of Crohn’s and Colitis 2007).

Ulcerative colitis is classified by how far up the colon the disease extends (Figure 1). It mayinclude (Carter et al 2004):

�Proctitis – confined to the rectum.

�Proctosigmoiditis – extends to therectosigmoid junction.

�Left-sided colitis – extends to the splenicflexure.

�Extensive colitis – extends to the hepaticflexure.

�Pancolitis – extends from the rectum to thececum and involves the entire colon.

Ulcerative colitis can generally be cured withsurgery, but surgery carries a significant risk of morbidity. Therefore, medical management is in the patient’s best interest and is usually thepreferred option. The exact aetiology ofulcerative colitis is unknown (Carter et al 2004)and consequently, treatment involves reducinginflammation of the colon wall and, frequently,suppression of the immune system (RCN 2007).Urgent bloody diarrhoea associated withabdominal pain is the most commonly citedsymptom (Carter et al 2004). The condition can be complicated by infections such as Clostridium difficile toxin and toxic megacolon

(where the colon becomes grossly dilated). This is a serious complication of ulcerativecolitis, which may lead to bowel perforation,septicaemia and even death.

Treatment of ulcerative colitis depends on the extent of involvement and disease severity.Standard treatment for mild to moderateulcerative colitis involves the administration of5-aminosalicylic acid (5-ASA) (Metcalf 2002).This can be administered orally and/or rectallydepending on the extent of the disease. Therapyinvolving 5-ASA has been shown to reduce therisk of flare-ups; patients who do not adhere totheir 5-ASA therapy regimens are at a fivefoldgreater risk of a flare-up of ulcerative colitis(Kane et al 2003). Patients with ulcerative colitisare at risk of developing colorectal cancer afterten to 15 years, depending on the extent of thedisease. However, regular 5-ASA therapy reducesthis risk (Velayos et al 2005)

Corticosteroids such as oral prednisolone canbe used for patients who relapse or do notrespond following optimisation of their 5-ASAtherapy regimen. Some patients requireimmunosuppressive drugs such as azathioprineor 6-mercaptopurine when disease becomessteroid dependent or refractory (Chande et al2007). Methotrexate is occasionally used inpatients who fail to respond to azathioprine or 6-mercaptopurine, or who experience sideeffects. However, there is little robust evidence tosupport its use in ulcerative colitis, and its usecould expose patients to side effects with littleimprovement in their disease (Chande et al 2007).

december 16 :: vol 24 no 15-17 :: 2009 49NURSING STANDARD

Anatomy of the large intestine (colon)

FIGURE 1

Transverse colonHepaticflexure

Ascendingcolon

Caecum Appendix

Ileum

Rectosigmoidjunction

Splenic flexure

Descendingcolon

Sigmoid colon

RectumAnal canal

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Surgery, involving the removal of the colonand rectum, is the principal cure for patients with severe ulcerative colitis. However, despiterecent advances in minimally invasive surgicaltechniques, such as keyhole surgery, which offer additional benefits including reducedhospital stay and faster recovery, surgery is not well received by young and physically active patients (Becker and Stucchi 2009). The patient’s age and circumstances will dictatethe procedure of choice. Non-hospitalisedpatients with chronic disease that has notresponded well to medical management areconsidered for surgery.

Patients with pancolitis and ongoing diseaseactivity have a 20-30% chance of undergoingcolectomy (Carter et al 2004). This group ofpatients will usually undergo proctocolectomy(removal of the entire colon including theexcision of the rectum) potentially withreconstructive surgery in the form of an ilealpouch-anal anastomosis (Figure 2).

An ileal pouch-anal anastomosis can beperformed in one, two or three stages. It israrely performed in one stage because of thesignificant risk of pouch failure; therefore atemporary stoma is required to divert the faecalstream through the abdominal wall.

The most appropriate surgical procedure for a severely unwell patient is a sub-totalcolectomy with end ileostomy because it isrelatively uncomplicated and avoids the risk of pelvic dissection of the rectum (Becker and Stucchi 2009). Patients will then be considered for completion of proctocolectomy(removal of the rectal stump) and/or an ilealpouch-anal anastomosis at a later date, oncethey have recovered fully and corticosteroidshave been discontinued.

Adacolumn apheresis is another treatmentoption, which involves the use of a blood circuitthat removes blood from a peripheral vein. This blood is then filtered using special beads before being returned to the patient. The processremoves from the blood active granulocytes,monocytes and macrophages, which are thoughtto play a crucial role in active ulcerative colitis(Sands et al 2008). There is, however, debateregarding the efficacy of adacolumn apheresis(Sands et al 2008).

For patients with severe ulcerative colitis,hospital admission may be required for theadministration of intravenous corticosteroids,such as hydrocortisone or methylprednisolone.Patients who fail to respond to intravenouscorticosteroids have the option of second-linemedical therapy or surgery. Second-line therapyconsists of either ciclosporin or anti-TNFtherapy. Of patients presenting with acute severecolitis, 40% will respond well to intravenouscorticosteroids, 30% will require colectomy and 30% will respond partially to intravenouscorticosteroids (Jakobovits and Travis 2006).Management therefore requires careful patientassessment and a discussion about the benefits of commencing therapy such as ciclosporin or anti-TNF therapy, which should be weighedagainst the possibility of surgery (Jakobovits and Travis 2006).

Immunosuppressant therapies such asazathioprine or 6-mercaptopurine andmethotrexate have no role in the treatment of severe ulcerative colitis at this time as they can take up to 12 weeks to provide therapeuticbenefit. Patients should be sufficiently stable to consider prioritising second-line medicaltherapy over surgical intervention. Ciclosporin,a calcineurin inhibitor, is an immunosuppressantdrug that inhibits T cell response by binding to an intercellular protein called immunophilins(Taylor et al 2004). This has a beneficial effect on the immune system of patients with ulcerativecolitis by reducing inflammation in the colonwall. Alternatively, anti-TNF therapy isavailable. The only anti-TNF therapy licensedfor use in patients with ulcerative colitis isinfliximab, which works by recognising and binding to the protein tumour necrosisfactor-alpha (TNF-�). High concentrations ofTNF-� are found in the lining of the inflamedcolon and are believed to be responsible forinflammation and ulceration in IBD. Binding and neutralising TNF-� in the wall of the coloncan reduce the inflammation and relieve thesymptoms of ulcerative colitis.

learning zone gastrointestinal nursing


An ileal pouch-anal anastomosis

FIGURE 2

Ilealpouch

Anal sphinctermuscle

Anal canal Site of anastomosis

Temporaryileostomy

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Assessment and management

The overall aims of assessing patients with a flare-up of ulcerative colitis are to confirmdisease activity and severity, and to predictcomplications early enough to enable timelyand effective intervention. It is important toremember that patients presenting withsymptoms suggestive of an exacerbation couldhave other associated complications such asinfection. For example, abdominal pain couldbe a symptom of pancreatitis, appendicitis oreven unknown pregnancy in female patients.

Patients presenting with typical symptoms of a flare-up, for example abdominal pain anddiarrhoea containing blood, should havevenous blood samples taken and sent to thepathology laboratory, a process that should berepeated on a daily basis for the duration of thepatient’s hospital stay (Carter et al 2004).Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be elevated insome patients with acute severe colitis, but notin all. ESR measures the rate at which the redblood cells separate from the plasma. ESRindicates that inflammation is present in thebody. CRP or acute phase proteins increase with certain diseases that cause inflammation(Patient UK 2006). A full blood count is also auseful diagnostic test – an elevated white celland neutrophil count may indicate infection,although the result will not be reliable inpatients who have been taking corticosteroidsbefore admission, as such therapies can elevatethese counts. Severe ulcerative colitis can alsoproduce further haematological abnormalities,for example low haemoglobin levels and araised platelet count. The reason for this is notyet fully understood.

Abnormal liver function tests (LFTs) and lowalbumin levels are suggestive of colonic disease or active sepsis, although abnormal LFTs couldalso be secondary to medication. Patients shouldundergo a full liver screen if the abnormal LFTs do not return to the normal range on remission, asprimary sclerosing cholangitis is closely associated

with ulcerative colitis, with a prevalence of up to6.2% in patients with extensive colitis (Terg et al2008). Primary sclerosing cholangitis is a diseaseof the liver that destroys the entire network ofvariously sized ducts branching throughout theliver and prevents bile drainage, leading to liverfailure in the long term (Broomé et al 1995).Diagnosis and treatment is important becauseprimary sclerosing cholangitis in ulcerative colitis increases the risks of colorectal cancer (Terg et al 2008).

Urea and electrolytes are not diagnostic ofdisease severity, but will indicate dehydration as a result of ongoing diarrhoea. Hypokalaemia(low potassium) is common in patientsexperiencing diarrhoea and can be exacerbatedfurther by the use of corticosteroids.Dehydration and hypokalaemia should becorrected appropriately. If abdominal pain is a presenting complaint, then a pregnancy testshould be performed on female patients. A number of medications used in ulcerativecolitis, for example 5-ASA, azathioprine, 6-mercaptopurine and prednisolone, have thepotential to cause pancreatitis, and therefore an amylase level may be a useful marker for pancreatitis; however, it is not conclusive.

A series of three stool cultures should be sentto the microbiology laboratory for microscopy,sensitivity and culture, and for C. difficile toxintesting. As there is only around 90% sensitivityto identifying C. difficile toxin in a stool culture(Fedorko et al 1999), it is good practice to sendmore than one stool culture to be tested.

Studies have shown that 5-20% of patientswith an IBD flare-up will have their conditioncomplicated by C. difficile toxin. Recent foreigntravel and antibiotic use in the previous threemonths are relevant indicators when taking thepatient’s history. However, a study in the UnitedStates showed that three quarters of cases of C. difficile toxin were community acquired andover half of these patients had not previouslytaken antibiotics, suggesting that C. difficiletoxin is common in IBD (Issa et al 2007,Rodermann et al 2007). Gastroenteritis isgenerally self-limiting and does not require any antibiotics. However, it can precipitate aflare-up of ulcerative colitis.

Antibiotics are required to treat C. difficiletoxin and include medications such asmetronidazole or vancomycin. In cases ofmoderate to severe C. difficile toxin, it may benecessary to combine these drugs, depending on local hospital policy. Oral vancomycin shouldbe prescribed as intravenous vancomycin isineffective in C. difficile toxin and there is littleevidence-based research for the routineadministration of antibiotics. Empiricalantibiotics (used to treat a broad range of


Time out 1Now that you have read the firstsection of this article, revisit thecurrent treatments available forulcerative colitis and list themunder the following headings:

�Mild to moderate disease.�Moderate to severe disease.�Steroid dependence or refractory.�Failed medical management.�Severe disease.

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(Jakobovits and Travis 2006). Where there is noevidence of toxic megacolon, there should be alow threshold for a repeat abdominal film if thepatient’s condition deteriorates, to ensure thecondition has not developed.

A rigid sigmoidoscopy should be performedwhere there is no immediate plan to perform aflexible-sigmoidoscopy (Carter et al 2004), asthis is the only way of assessing and grading thecolonic mucosa. A flexible-sigmoidoscopy issuperior to a rigid sigmoidoscopy because itprovides optimal views of colonic mucosa. The procedure should be performed withoutgiving the patient any bowel preparation,because this can exacerbate inflammation in the colon wall. Endoscopy scoring systems havebeen devised for the purposes of research, andthese may be used by clinicians treating anexacerbation of ulcerative colitis. The modifiedBaron Score is an example of an endoscopyscoring system (Feagan et al 2005) (Box 1). The presence of pseudomembranes(yellow/whitish plaques that adhere to thecolonic mucosa) on sigmoidoscopy can indicateC. difficile toxin and, in the absence of any local rectal medication such as 5-ASA orcorticosteroids to account for rectal sparing (noinflammation in the rectum, but present in thecolon) on sigmoidoscopy, then the preliminarydiagnosis of severe ulcerative colitis should bequestioned as infection often presents withrectal sparing (Jakobovits and Travis 2006).

Biopsies should be taken regardless of thegrade of mucosa ulceration (Carter et al 2004)because this will also help to grade inflammationand rule out pseudomembranous colitis. It ispossible to diagnose infective colitis on biopsyeven when stool cultures are negative. The IBDStandards Working Group (2008) states thathistology reports should be available within fivedays, but a system to report urgent sampleswithin two days is also required.

Cytomegalovirus is particularly common inimmunosuppressed patients and a test for the virus should also be requested on biopsysamples, as it is believed to account for 10% ofcorticosteroid failures (failure to respond to intravenous steroids because of viral infection) (Cottone et al 2001). Treatment ofcytomegalovirus could prevent patients having to undergo colectomy (Cottone et al 2001).

There are a number of scoring systemsavailable to classify disease activity, includingthose used in clinical trials. Truelove and Witts’(1955) disease activity score has been used formore than 50 years (Table 1). If a severe flare-upof ulcerative colitis is suspected or confirmed,400mg intravenous hydrocortisone divided intofour doses, or 60mg methylprednisolone, shouldbe administered each day (Carter et al 2004).

common organisms) should be given in thepresence of toxic megacolon or perforation of thebowel to protect the individual against infection(Carter et al 2004). Current recommendations do not state that patients with severe ulcerativecolitis require isolation, but this will depend onlocal hospital policy given the additionalprecautions being taken by hospital trusts toreduce C. difficile toxin infection rates.

A plain abdominal X-ray should be performedand reviewed within 24 hours of patientadmission. Patients with evidence of toxicmegacolon should be referred for an urgentsurgical review. Toxic megacolon occurs when the transverse colon dilates to more than5.5cm or the caecum dilates to more than 9cm.The bowel is then at risk of perforating and thepatient may develop peritonitis (Carter et al2004). It is reasonable to continue medicalmanagement for 48 hours if toxic megacolon issuspected and if the patient is sufficiently stable,but he or she should have daily abdominal X-rays. The patient should be reviewed daily by a gastroenterologist and a colorectal surgeon



BOX 1

Modified Baron Score

0 = Normal mucosa.

1 = Granular mucosa with an abnormal vascular pattern.

2 = Friable mucosa.

3 = Micro-ulceration of the mucosa with spontaneous bleeding.

4 = Gross ulceration.

(Feagan et al 2005)

Truelove and Witts’ (1955) disease activity score

Parameter Mild Moderate Severe

Number of bloody <4 4-6 >6stools (per day)

Temperature Afebrile Intermediate >37.8(Celsius)

Heart rate Normal Intermediate >90(beats per minute)

Haemoglobin (g/dl) >11 10.5-11.0 <10.5

Erythrocyte <20 20-30 >30sedimentationrate (mm/hr)

TABLE 1

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Prophylactic bone protection therapy should beco-prescribed with corticosteroids in the form ofcalcium and vitamin D3. If the patient is morethan 65 years of age then treatment with abisphosphonate is also recommended (BSG2007). A bone mineral density scan should bearranged for patients under the age of 65 yearswho have been on corticosteroids for more thanthree months. This scan can diagnoseosteoporosis, often referred to as thinning of thebones (Cluett 2003). The measurement of bonedensity is reported as a T score. A mean T score ofminus 1.5 is evidence of reduced bone mineraldensity (osteopaenia) and the BSG (2007)guidelines recommend commencing such patientson bisphosphonate therapy.

Carter et al (2004) suggested that, unlesscontraindicated, prophylactic low molecularweight heparin should also be given, even if thepatient is mobile, because patients with activecolonic disease have a higher risk of embolism,for reasons that are not yet understood fully. A study by Bernstein et al (2001) showed thatpatients with IBD have a threefold increased riskof developing embolism. There are few situationswhere heparin is contraindicated; rectal bleedingis not one of them.

A severe flare-up of ulcerative colitis can causesignificant abdominal pain. Non-steroidal anti-inflammatory drugs should be avoidedbecause they have been implicated in the exacerbation of ulcerative colitis, and theirtoxicity is not confined to the stomach orduodenum (Thiéfin and Beaugerie 2005). If an opioid analgesia is required in addition toparacetamol then one with a less potent effect onthe motility of the gut, such as tramadol, shouldbe used. Opioid analgesia and anti-diarrhoealmedication should be avoided as they increase the risk of colonic dilation, which may lead topossible perforation (Carter et al 2004).

Response to treatment

Patients should be monitored continuously for improvement or deterioration, and a formalreview should take place on day three oftreatment. Patients with a CRP greater than 45 mg/L (normal range is 0-10 mg/L), or stillopening their bowels more than eight times per day (suggesting that the patient has not

responded adequately to corticosteroid therapy),have an 85% chance of requiring an emergencycolectomy during the same admission(Jakobovits and Travis 2006).

Patients who have responded well tointravenous hydrocortisone should be switchedto 40mg oral prednisolone once a day (Carter et al2004). An eight-week reducing course is oftennecessary because the colon becomes dependenton corticosteroid therapy and shorter coursesoften lead to an early relapse followingwithdrawal of this therapy.

Patients who do not respond to intravenouscorticosteroids or relapse on switching to oralprednisolone should be reviewed by a colorectalsurgeon. In collaboration with the patient, anassessment and decision should be made toimplement second-line treatment in the form ofciclosporin or anti-TNF therapy (infliximab), orto undergo surgical intervention. The risks andbenefits of treatment should be discussed anddocumented in the patient’s clinical notes, as anti-TNF and ciclosporin are powerful andpotentially toxic drugs. This is important becausedata suggest that patients who fail to respond tocorticosteroids have an 80% chance of requiringcolectomy within ten years (Bojic et al 2005).

The long-term safety of these drugs is still notunderstood fully, and guidance from the NationalInstitute for Health and Clinical Excellence(2008) recommends that infliximab should be used only in the treatment of patients withsevere ulcerative colitis in whom ciclosporin iscontraindicated or clinically inappropriate. A number of patients who respond to ciclosporin will relapse on discontinuation of this therapy; however, its use may allow otherimmunosuppressants that have a six to 12-weektherapeutic benefit, such as azathioprine or 6-mercaptopurine, to take effect (Lichtiger2009). Patients whose condition does notimprove with either infliximab or ciclosporinshould proceed with colectomy. Combined use of infliximab and ciclosporin is not recommended(Jakobovits and Travis 2006).Ciclosporin Traditionally ciclosporin was thefirst drug used if patients failed to respond tocorticosteroid therapy; however, there has been a decline in its use because of its toxicity and poor data regarding its ability to preventcolectomy in the long term. Studies showing thesame efficacy and reduced risk of toxicity inlower doses (de Saussure et al 2005, Durai andHawthorne 2005) have been overshadowed bythe introduction of infliximab. A possible reasonfor this could be that gastroenterologists havemore experience in using infliximab (Jakobovitsand Travis 2006).

Ciclosporin is also not licensed for use inpatients with ulcerative colitis, so it should only


Time out 2A patient in your care requires aflexible-sigmoidoscopy. Howwould you explain the procedureto him or her? Think about theparticular value it has in the management of severe ulcerative colitis.

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sodium chloride (Schering-Plough 2009).Infliximab should be administeredintravenously over two hours via a low binding protein filter (Schering-Plough 2009).There have been no studies evaluating itsstability when used with other drugs; thereforeno other drugs should be administered throughthe same cannula. Adverse reactions wereobserved in approximately 60% of patientstreated with infliximab and 40% of patients on placebo in clinical trials. Infusion-relatedreactions were the most common adversereactions reported and included dyspnoea,urticaria and headaches (Schering-Plough2009). Cases of anaphylactic-like reactions and seizures have been reported in post-marketing experience, but remain rare. If further induction doses are required, theseshould be administered at week two and week six (Schering-Plough 2009).

Surgery If surgery is necessary and there is time,patients should be referred to a stoma care nursebeforehand so that they are given support,information and advice regarding stomamanagement. Stoma care services should alsoextend outside the hospital setting to ensurepatients receive adequate follow-up support inthe community. Stoma formation will havemajor implications for the patient, includinghow the individual will manage his or her dailyactivities and the effect it may have on bodyimage (Younge and Norton 2007). Black (2004)suggested that patients experience psychologicalissues concerning altered body image and sexualactivity as a result of stoma formation.

Nursing interventions

Nursing observations are vital in monitoringpatients for improvement or deterioration in their condition. Patients should have theirtemperature, pulse, respiratory rate and bloodpressure recorded. The frequency of monitoringwill depend on the patient’s condition and localhospital policy; however, a minimum of fourtimes a day is recommended (Carter et al 2004).Pyrexia and a rising tachycardia could be awarning sign of patient deterioration and theneed for further medical review. Respiratory rate is also a useful indicator of deterioration.

be initiated by a consultant gastroenterologist.Before starting ciclosporin, the patient shouldhave a negative stool culture result and thereshould be no evidence of sepsis. The wardpharmacist should review concurrent medicationfor interactions that could increase or decreaseciclosporin levels. Ciclosporin can be givenorally or intravenously – there are no studies thathave compared the efficacy of the differentroutes of administration. Starting doses, targetblood levels and monitoring will vary fromhospital to hospital.

The risks of side effects following intravenousadministration of ciclosporin are higher thanthose when it is given orally. Patients should beobserved for uncontrolled hypertension,hypomagnesium (low concentration ofmagnesium in the blood), hypolipidaemia (low cholesterol), seizures, and renal and liver impairment. Patients should continueintravenous corticosteroid therapy for a further seven days while receiving ciclosporin.Individuals should be observed for any signs ofsepsis, according to local hospital policy, andantibiotics should be considered as prophylaxisagainst opportunistic infections. Patients whorespond well to the treatment should continuetaking oral ciclosporin for up to three months(Durai and Hawthorne 2005).Infliximab Patients about to commenceinfliximab should be able to provide a negativestool culture result and there should be noevidence of sepsis. Individuals should have a chest X-ray to screen for active or latenttuberculosis, as anti-TNF therapy has thepotential to reactivate the disease. Patients with an abnormal chest X-ray should be referredto a respiratory physician (Rampton 2005). The focus on screening patients for hepatitis Bhas increased because anti-TNF has the potentialto reactivate the condition (Esteve et al 2004).

Infliximab is not licensed for use in pregnancy,and women should be informed to use adequatecontraception for at least six months after their last infusion (Schering-Plough 2009).However, there have been 300 post-marketingcase reports suggesting that there are no adverse effects associated with the use ofinfliximab in pregnancy (Schering-Plough 2009).Breastfeeding is also not recommended whiletaking infliximab. A profile of the risks andbenefits associated with the use of infliximabwould need to be considered against the benefitsof surgical intervention.

The starting dose of infliximab is 5mg/kg and it should be mixed in 250ml of 0.9%



Time out 3How might the formation of astoma affect a patient? Ask astoma care nurse what support,information and advice is offeredto patients with a stoma to enablethem to continue with daily activities.

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Blood pressure tends to be the last parameter tobecome abnormal (Higgins et al 2008).

Completion of an early warning assessmenttool, such as the modified early warning score(MEWS), should be performed and followed as per hospital policy. MEWS is a simplephysiological scoring system that identifiesmedical patients at risk of deterioration in theclinical area, and helps to ensure that appropriateactions are taken (Subbe et al 2001). Recognisingwhen a patient’s condition is deteriorating is a keyaspect of patient safety. An early warning scoringsystem should be integral to nursing observations(Higgins et al 2008).

A stool chart can be used to measureimprovement or deterioration in a patient’scondition. Depending on local hospital policy, the Bristol Stool Chart can be useful whendescribing the type of stool (Figure 3) (Lewis and Heaton 1997). Where possible, the patientshould be involved in this process, because thisencourages the individual to participate activelyin his or her care.

Other documentation should be implementedand completed, including a food chart if there is concern regarding nutritional status and a fluid balance chart where intravenous fluid isadministered, or where there is concern regardingfluid intake or urine output. Fluid balance chartsare an important part of hydration monitoring(National Confidential Enquiry intoPerioperative Death 1999).

The importance of ruling out infection hasalready been discussed, and the collection of aseries of three stool cultures (one each day)should be performed and sent to a microbiologylaboratory for microscopy, sensitivity andculture, as well as testing for C. difficile toxin, as soon as possible. Recent foreign travel andantibiotic use in the previous three monthsshould be documented on the microbiologyrequest form. A documented history of foreigntravel will trigger additional tests to beperformed by the laboratory (Thomas et al2003). Where antibiotics have been prescribed,these should be given after the first stool has beencollected, except in an emergency.

Patients should be referred to a dietician for nutritional therapy and support, and advised to commence a low residue/high protein diet. A low residue diet is similar to a low fibre diet,reducing stool frequency. All patients should beweighed (IBD Standards Working Group 2008).There is no evidence of a need for fasting inpatients with severe ulcerative colitis unlessbowel perforation is suspected or surgery ispending. Twice-weekly weight measurement will ensure that nutritional status is monitored for improvement or deterioration. Where there isan IBD specialist nurse in post, an early referral

should be made so that the patient can bediscussed and transferred to the care of agastroenterologist within 24 hours of admission(IBD Standards Working Group 2008). The IBDspecialist nurse can co-ordinate and provideadvice to medical and nursing staff and offersupport and advice to the patient.

Patients with a severe flare-up of ulcerativecolitis generally require emotional support.Patients tend to lose time from work oreducation. They may become embarrassedbecause of the need to use the toilet frequently.The condition may also affect finances andrelationships. Emotional support is vital and is an important aspect of holistic care provision(Metcalf 2007). The UK IBD Audit SteeringGroup (2007) highlighted that there wereinsufficient toilets in hospitals, with a median of4.5 beds per toilet compared to a recommendedthree beds per toilet. This is a difficult problem toresolve, because it could involve extensive wardrenovation. Therefore nurses should consider


Stool chart

FIGURE 3

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additional nursing interventions will berequired, depending on local hospital policy.Regular nursing observations, includingtemperature, pulse, respiratory rate and bloodpressure should be recorded while administeringinfliximab infusions. Intravenous ciclosporincan cause uncontrolled hypertension, andnursing observations may need to be increasedduring administration of this therapy. Patientsshould be observed for delayed hypersensitivityreactions and will also need to be assessed for infection and seizures. Ciclosporin bloodlevels will need to be taken and dose adjustmentsmade to avoid toxicity. This will require closecommunication between the medical staff and

where, for example, they position patients withsevere ulcerative colitis in relation to toiletfacilities. Patients should be placed where they can be offered any additional priorityor privacy.

Although not essential and no reference is made to blood glucose monitoring in the guidelines, random blood glucose monitoring will detect early symptoms ofcorticosteroid-induced diabetes.

If second-line medical therapy is implementedin the form of ciclosporin or inflixmab, then



Becker JM, Stucchi AF (2009)Treatment of choice for acute severesteroid-refractory ulcerative colitis iscolectomy. Inflammatory Bowel Diseases.15, 1, 146-149.

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Conclusion

A severe flare-up of ulcerative colitis can bedebilitating and even life-threatening for thepatient. A good working knowledge of ulcerative colitis will allow the nurse to plan and implement essential care, thereby improvingthe patient’s quality of life NS


Time out 4Using your knowledge andexperience of ulcerative colitis,and having read this article, writeup a care plan with a rationale for each nursing intervention for apatient who has been admitted to your areawith a severe flare-up of ulcerative colitis.

Time out 5Now that you have completedthis article you might like towrite a practice profile. Guidelinesto help you are on page 60.

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