Caring for a patient like Hal Smith, who presents with ulcerative colitis

QUESTION

Ulcerative colitis

Hal smith is a 35-year-old male with a known history of ulcerative colitis and bipolar disorder. Hal has had 3 episodes of flare ups this year. Recently admitted to your unit from his practitioner’s office with a five-day history of bloody diarrhea with puss and mucus and severe lower abdominal pain. Hal reports he has pain, cramping and swelling in his abdomen. He feels bloated and he has not eaten in two days. He ranks his pain a 10/10 and states he loss five pounds in two days. He also reports how depressed he is and states “I cannot go anywhere without having to go to the bathroom every five minutes”

PMH:

Ulcerative colitis X 20 years

Bipolar Disorder

DM Type 2

Arthritis

Initial examination: 

AOX4 withdrawn, teary

Erythema nodosum on arms

Five bloody stools Reported today

Lying in bed, knee to chest position, Pain abdominal 10/10

BS hyperactive, lungs clear bilaterally, normal heart rhythm, tachycardia.

BP 100/60, P102, R22, Temp 37.7 C, O2 sat 97%RA.

1. What are the primary tasks that should be completed in caring for this patient? 

(Please identify these steps and what time frame they must be completed by if appropriate).

2. What major symptoms would you expect to see with this diagnosis?

ANSWER

Caring for a patient like Hal Smith, who presents with ulcerative colitis, involves several primary tasks that should be completed promptly to ensure his well-being and effective management of his condition.

1. Assessment and Stabilization: The first and immediate task is to assess and stabilize the patient. Hal is in severe distress with a pain rating of 10/10, significant weight loss, bloody stools, and symptoms of dehydration. The assessment should include vital signs, pain assessment, abdominal examination, and monitoring for signs of dehydration or shock. This initial assessment should be completed within minutes of his arrival.

2. Pain Management: Given Hal’s excruciating abdominal pain, effective pain management is crucial. Intravenous pain medications, such as opioids, should be administered promptly to relieve his suffering. Pain relief should be achieved within a reasonable timeframe, typically within 15 to 30 minutes.

3. Fluid and Electrolyte Replacement: Hal has been experiencing severe diarrhea, which can lead to dehydration and electrolyte imbalances. Intravenous (IV) fluids should be initiated to address his fluid deficit. This task should be initiated within an hour of his arrival.

4. Laboratory and Diagnostic Testing: To confirm the diagnosis and assess the severity of the ulcerative colitis flare-up, laboratory tests, including complete blood count (CBC), C-reactive protein (CRP), and fecal calprotectin, should be ordered. Diagnostic imaging such as abdominal CT scans may also be necessary. These tests should be initiated within a few hours to a day.

5. Medication Management: Hal’s known history of ulcerative colitis requires medication management. His current medication regimen should be reviewed and adjusted as necessary. Medications like corticosteroids, immunomodulators, or biologics may be prescribed to induce remission. This should be addressed within a day.

6. Psychosocial Assessment and Support: Hal reports feeling depressed, which is not uncommon in patients with chronic illnesses like ulcerative colitis. A psychosocial assessment should be conducted to evaluate his mental health, and appropriate interventions, such as counseling or psychiatric evaluation, should be initiated. Mental health support should be ongoing during his hospitalization.

7. Nutritional Assessment and Support: Hal mentions not eating for two days and significant weight loss. A nutritional assessment should be performed by a registered dietitian to develop a plan for enteral or parenteral nutrition support as needed. Nutritional support should be initiated within a day.

Symptoms that can be expected with a diagnosis of ulcerative colitis include:

Bloody Diarrhea: Persistent diarrhea with blood, pus, and mucus in the stool.
Abdominal Pain and Cramping: Severe abdominal pain and cramps, often in the lower abdomen.
Dehydration: Due to diarrhea and fluid loss.
Weight Loss: Chronic inflammation can lead to malabsorption and weight loss.
Fatigue: As a result of chronic inflammation and anemia.
Frequent Bowel Movements: Urgency and the need to go to the bathroom frequently.
Anemia: Chronic bleeding can lead to iron-deficiency anemia.

In summary, the primary tasks in caring for Hal involve rapid assessment, pain management, fluid and electrolyte replacement, diagnostic testing, medication management, psychosocial and nutritional support. These tasks should be completed within appropriate time frames to ensure effective care and symptom relief for the patient.