Ulcerative colitis (UC) is a chronic inflammatory bowel disease that causes continuous inflammation and ulcers in the inner lining of the colon, starting at the rectum. It comes and goes in flares, with bloody diarrhea, urgency, and cramping abdominal pain. The nursing diagnoses used most often are Diarrhea, Acute Pain, Risk for Deficient Fluid Volume, and Inadequate Protein-Energy Nutritional Intake. Nursing care during a flare centers on tracking stools and fluid balance, watching for toxic megacolon and bleeding, giving medicines safely, protecting the skin, and supporting nutrition.
At a glance
- What it is
- A lifelong inflammatory bowel disease limited to the colon. Inflammation starts in the rectum and spreads upward without gaps, and it affects only the inner lining (mucosa) of the bowel wall.
- Common causes
- The exact cause is unknown. It involves an abnormal immune response to gut bacteria in a person with a genetic tendency. Flares can be set off by stopping maintenance medicine, infections such as C. difficile, NSAIDs, and sometimes stress.
- Key signs
- Bloody diarrhea with mucus, urgency, tenesmus (feeling of needing to pass stool even when the bowel is empty), cramping lower abdominal pain, stools at night, fatigue, and weight loss. Severe flares add fever, fast heart rate, and anemia.
- Nursing focus
- Stool chart, intake and output, daily weight, abdominal checks, electrolytes and hemoglobin, safe use of steroids and other medicines, clot prevention, perianal skin care, nutrition, and emotional support.
- Act now
- A distended, very tender abdomen, absent bowel sounds, high fever, rising heart rate, or a sudden drop in stool frequency with the client looking sicker may mean toxic megacolon or perforation. Heavy rectal bleeding, dizziness, or low blood pressure also need the provider or rapid response team right away.
Why ulcerative colitis happens
In UC, the immune system in the bowel wall overreacts to the normal bacteria in the colon. Inflammation damages the mucosa, the inner lining, which becomes red, swollen, and fragile and bleeds easily. Shallow ulcers form. The damaged lining cannot absorb water and salts well, and it leaks blood, mucus, and fluid. The result is frequent, loose, bloody stools.
UC always starts in the rectum and spreads upward in one continuous stretch. It may stay in the rectum (ulcerative proctitis), involve the left side of the colon (left-sided colitis), or reach the whole colon (extensive colitis or pancolitis). The more colon involved, the more severe the symptoms tend to be. It does not affect the small bowel.
This is the key difference from Crohn’s disease, the other main inflammatory bowel disease. Crohn’s can affect any part of the gut from mouth to anus, often in patches (“skip lesions”), and goes through the full thickness of the bowel wall, so it can cause fistulas and strictures.
UC can also cause problems outside the bowel, such as joint pain and arthritis, red or sore eyes, skin lesions (erythema nodosum, pyoderma gangrenosum), and liver disease (primary sclerosing cholangitis). Serious complications include severe bleeding, toxic megacolon (a sudden, dangerous widening of the inflamed colon), perforation, blood clots, and a higher long-term risk of colorectal cancer.
How severe is the flare?
Nurses often hear flares described with the Truelove and Witts criteria. Your provider and facility may use a different scoring tool.
| Severity | Bloody stools per day | Body-wide signs |
|---|---|---|
| Mild | Fewer than 4 | No fever or fast heart rate; hemoglobin and ESR normal or close to normal |
| Moderate | 4 to 6 | Minimal signs of body-wide illness |
| Severe | 6 or more | Plus at least one of: temperature above 37.8°C (100°F), heart rate above 90, hemoglobin below 10.5 g/dL, or ESR above 30 mm/hr |
A severe flare usually means hospital admission for IV corticosteroids, IV fluids, close monitoring, and a plan for “rescue” treatment or surgery if the client does not improve within a few days.
Nursing assessment
Subjective data
- Number of stools in 24 hours, how much blood and mucus, stools at night, urgency, tenesmus, and any accidents
- Location, timing, and severity of abdominal pain, and whether it eases after a bowel movement
- Appetite, what the client is eating and drinking, foods they are avoiding, and recent weight loss
- Dizziness on standing, thirst, fatigue, and shortness of breath (fluid loss or anemia)
- Current UC medicines and whether any doses were missed or stopped, plus recent antibiotics and NSAID use
- Recent travel, sick contacts, or hospital stays (possible infection)
- Joint pain, eye pain or redness, skin changes, and how the disease affects work, school, sleep, and mood
Objective data
- Temperature, heart rate, blood pressure (including orthostatic readings), respiratory rate, and oxygen saturation, trended over time
- Stool chart: frequency, consistency, blood, and volume
- Abdomen: distension, tenderness, guarding, rebound tenderness, and bowel sounds
- Fluid status: mucous membranes, skin turgor, urine output and color, intake and output, and daily weight
- Perianal skin for redness, breakdown, or fissures
- Pallor, joints, eyes, and skin for signs outside the bowel
- Lab results as ordered: CBC (hemoglobin, white cells, platelets), electrolytes including potassium and magnesium, albumin, C-reactive protein, ESR, liver tests, stool studies for C. difficile and other infection, and fecal calprotectin
- Diagnostics as ordered: flexible sigmoidoscopy or colonoscopy with biopsy, and abdominal X-ray or CT if toxic megacolon or perforation is suspected
Nursing diagnoses used with ulcerative colitis
- Diarrhea — frequent loose, bloody stools from an inflamed colon
- Acute Pain — cramping and tenesmus during a flare
- Risk for Deficient Fluid Volume — fluid and electrolyte loss in stool, fever, and poor intake
- Inadequate Protein-Energy Nutritional Intake — poor appetite, pain with eating, and higher needs during inflammation
- Risk for Impaired Skin Integrity — perianal skin exposed to frequent liquid stool
- Fatigue — inflammation, anemia, and broken sleep from night-time stools
- Anxiety — urgency, fear of accidents, and an unpredictable illness
- Disturbed Body Image — after an ileostomy, or from steroid side effects
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 24-year-old woman with left-sided ulcerative colitis diagnosed two years ago. She stopped her daily oral mesalamine six weeks ago because she felt well. For five days she has had 8 to 10 bloody, loose stools a day, including at night, with urgency, tenesmus, and cramping lower abdominal pain that she rates 6 out of 10 before each stool. She has been eating little and has lost 3 kg (from 61 kg to 58 kg) in four weeks. Temperature is 37.9°C (100.2°F), heart rate 98, blood pressure 114/70 with no change on standing, respiratory rate 18, and oxygen saturation 98% on room air. Her mucous membranes are moist and her urine is pale yellow. Her abdomen is soft and tender in the left lower quadrant, not distended, with bowel sounds present. Labs show hemoglobin 10.2 g/dL, potassium 3.4 mEq/L, albumin 3.1 g/dL, and a raised C-reactive protein; her stool test for C. difficile is negative. She is admitted with a severe flare and started on IV corticosteroids, IV fluids with potassium, and clot prevention as ordered, with a flexible sigmoidoscopy planned.
1. Diarrhea
Problem-focusedSubjective: “I’m going 8 or 10 times a day, and I wake up at night to go. When I have to go, I have to run.”
Objective: Nine loose stools with visible blood and mucus charted in the last 24 hours, two of them overnight. Hyperactive bowel sounds. Potassium 3.4 mEq/L.
Diarrhea related to inflammation and ulceration of the colon lining, as evidenced by 8 to 10 loose, bloody stools per day, night-time stools, urgency, and cramping.
- Stool frequency and visible blood decrease each day during treatment
- Client has no night-time stools before discharge
- Potassium returns to the range the provider sets
- Keep a stool chart: number, consistency, blood, and night-time stools; ask the client to call you or use a hat in the toilet so each stool can be checked
- Give IV corticosteroids and other UC medicines as ordered and on time
- Do not give antidiarrheal, opioid, or anticholinergic medicines unless the provider specifically orders them for this client
- Send stool samples for infection as ordered
- Monitor potassium and magnesium, and give replacement as ordered
- Keep a bedside commode or a clear path to the bathroom, and answer the call light quickly
- Provide privacy, air freshener, and easy access to perianal wipes and barrier cream
By day 4 she had 3 stools a day with small streaks of blood and no night-time stools. Potassium was back in range. Goal partly met; continue plan and stool chart.
2. Acute Pain
Problem-focusedSubjective: “It cramps really badly right before I go, and then it eases off a bit. I feel like I still need to go even when nothing comes.”
Objective: Rates pain 6/10, cramping, left lower quadrant. Guards her abdomen and grimaces before stools. Abdomen soft and not distended.
Acute Pain related to inflammation and spasm of the colon, as evidenced by reported cramping pain of 6/10, tenesmus, guarding, and grimacing.
- Client reports pain at or below her own acceptable level within 48 hours
- Client is able to rest and sleep between stools
- Any change in the type of pain is found and reported at once
- Assess pain with a pain scale every shift and before and after each intervention
- Assess the abdomen with each pain check: distension, rigidity, rebound tenderness, and bowel sounds
- Report pain that becomes constant, severe, or widespread, or that comes with distension or fever, right away
- Give pain relief as ordered, usually acetaminophen; avoid NSAIDs, which can worsen a flare
- Use opioids only if ordered and with caution, because they slow the bowel and can hide signs of toxic megacolon
- Offer comfort measures: position of comfort, warm blanket, relaxation breathing, and a quiet room
- Cluster care so she can rest between stools
By day 3 she rated pain 2/10, slept through most of the night, and her abdomen stayed soft and not distended. Goal met; continue plan.
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3. Risk for Deficient Fluid Volume
Risk diagnosis- Large fluid and electrolyte losses in 8 to 10 liquid stools a day
- Poor oral intake
- Fever, which increases fluid loss
- Ongoing blood loss in stool
No “as evidenced by” — she does not have a fluid deficit yet. Her blood pressure does not drop on standing, her mucous membranes are moist, and her urine is pale yellow. Her heart rate of 98 is being trended along with her fever.
Risk for Deficient Fluid Volume related to excessive fluid loss through stool, decreased intake, and fever.
- Blood pressure and heart rate stay within the limits the provider sets, with no drop on standing
- Urine output stays at or above the level the provider sets
- Intake keeps pace with output, and electrolytes stay in range
- Measure intake and output, including an estimate of stool volume, and weigh her daily on the same scale at the same time
- Check vital signs and orthostatic blood pressure as ordered and report a falling blood pressure or rising heart rate
- Give IV fluids and potassium as ordered, using an infusion pump
- Encourage oral fluids she tolerates; an oral rehydration solution can help
- Monitor hemoglobin, electrolytes, and kidney function, and report changes
- Have her get up slowly and call for help the first time she stands, because fluid loss and anemia raise her fall risk
Blood pressure stayed steady with no change on standing, urine stayed pale and adequate, and her heart rate settled as the fever resolved. She had no dizziness. Goal met; continue monitoring until stools slow.
4. Inadequate Protein-Energy Nutritional Intake
Problem-focusedSubjective: “Every time I eat, I have to run to the bathroom, so I’ve mostly stopped eating. I’m not hungry anyway.”
Objective: Weight 58 kg, down from 61 kg in four weeks (about 5%). Eats less than half of each meal. Fatigued. Albumin 3.1 g/dL, which reflects inflammation as much as nutrition, so weight and intake guide the plan.
Inadequate Protein-Energy Nutritional Intake related to poor appetite, pain and urgency after eating, and fear of triggering stools, as evidenced by 3 kg weight loss in four weeks, eating less than half of meals, and fatigue.
- Client eats at least half of each meal plus supplements by day 4
- Weight stays stable during the hospital stay
- Client names foods she tolerates and a plan for eating during flares
- Screen nutrition with your facility’s tool and refer to a dietitian
- Record intake at every meal and weigh daily
- Offer small, frequent meals and oral nutrition supplements as ordered
- During the flare, offer lower-fiber foods if they ease her symptoms, as the dietitian advises
- Time pain relief so she is comfortable at meals, and keep the bathroom close
- Give iron, folic acid, vitamin D, calcium, or other supplements as ordered
- Explain that eating does not make the inflammation worse and that bowel rest is not usually needed
By day 4 she was eating about two-thirds of each meal plus two supplement drinks a day, and her weight was stable at 58 kg. She listed three foods she tolerates. Goal met; continue with dietitian follow-up.
Interventions and rationales
Client and family teaching
- UC is a lifelong condition that cycles between flares and remission; keep taking maintenance medicine even when you feel well
- Do not stop steroids suddenly; follow the taper schedule exactly
- Avoid NSAIDs such as ibuprofen and naproxen unless your provider approves; ask before taking any new over-the-counter medicine
- Do not take antidiarrheal medicine during a flare unless your provider tells you to
- There is no single UC diet. Keep a food and symptom diary, eat small, frequent meals, and work with a dietitian; lower-fiber foods may ease symptoms during a flare
- Drink enough fluids, especially when stools are frequent or it is hot
- Wash hands often and report signs of infection, especially if you take steroids, immune-suppressing medicine, or a biologic
- Keep vaccines up to date; ask your provider before any live vaccine
- Keep regular colonoscopy appointments; long-standing UC raises the risk of colorectal cancer, and screening catches changes early
- Carry a small kit with wipes, barrier cream, and a change of clothes, and plan bathroom access when you go out
- Call your provider for more stools than usual, more blood, fever, or worsening pain; seek emergency care for a swollen, hard, or very painful abdomen, heavy bleeding, fainting, or a high fever
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A priority item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
A client admitted with a severe ulcerative colitis flare had 10 bloody stools yesterday and only 2 today. The client now reports worse abdominal pain. The abdomen is distended, bowel sounds are absent, temperature is 38.9°C (102°F), and heart rate is 124. Which action should the nurse take first?
Why C. Fewer stools with a distended, silent abdomen, fever, and a fast heart rate point to toxic megacolon, a surgical emergency. The provider needs to know now. The drop in stools is not improvement, loperamide slows the bowel and can make megacolon worse, and walking delays care for a possible perforation. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the priority nursing diagnosis for ulcerative colitis?
During a flare, Diarrhea and Risk for Deficient Fluid Volume are usually the priorities, because fluid and electrolyte loss can become dangerous quickly. Acute Pain and Inadequate Protein-Energy Nutritional Intake follow. Any sign of toxic megacolon, perforation, or heavy bleeding takes priority over everything else.
What is the difference between ulcerative colitis and Crohn’s disease?
UC affects only the colon, starts at the rectum, spreads in one continuous stretch, and involves only the inner lining. Crohn’s can affect any part of the gut from mouth to anus, often in patches, and goes through the full bowel wall, so it can cause fistulas and strictures.
What is toxic megacolon?
A rare but life-threatening complication in which the inflamed colon suddenly widens and stops moving. Signs are a distended, tender abdomen, absent bowel sounds, fever, fast heart rate, and often fewer stools. It can lead to perforation and needs immediate medical care.
Why are antidiarrheal drugs and NSAIDs avoided in ulcerative colitis?
Antidiarrheal and opioid drugs slow the bowel and can bring on toxic megacolon during a severe flare. NSAIDs can trigger or worsen flares. Either should be used only if the provider approves.
What should a client with ulcerative colitis eat?
There is no single diet for UC. During a flare, small, frequent meals and lower-fiber foods may ease symptoms, along with plenty of fluids. In remission, most clients eat a normal, balanced diet. A food diary and a dietitian help identify personal trigger foods.
Can ulcerative colitis be cured?
Medicines can control UC and keep it in remission, but they do not cure it. Surgery to remove the colon and rectum, with an ileostomy or an internal ileal pouch, removes the diseased bowel, though some problems outside the bowel can continue.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Rubin, D. T., Ananthakrishnan, A. N., Siegel, C. A., Sauer, B. G., & Long, M. D. ACG clinical guideline: ulcerative colitis in adults. American Journal of Gastroenterology, 2019;114(3):384–413.
- Feuerstein, J. D., Isaacs, K. L., Schneider, Y., et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology, 2020;158(5):1450–1461.
- Raine, T., Bonovas, S., Burisch, J., et al. ECCO guidelines on therapeutics in ulcerative colitis: medical treatment. Journal of Crohn’s and Colitis, 2022;16(1):2–17.
- Ungaro, R., Mehandru, S., Allen, P. B., Peyrin-Biroulet, L., & Colombel, J. F. Ulcerative colitis. The Lancet, 2017;389(10080):1756–1770.
- Truelove, S. C., & Witts, L. J. Cortisone in ulcerative colitis: final report on a therapeutic trial. British Medical Journal, 1955;2(4947):1041–1048.
- Cai, Z., Wang, S., & Li, J. Treatment of inflammatory bowel disease: a comprehensive review. Frontiers in Medicine, 2021;8:765474.
- Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer, 2022.
Flare severity criteria, vital sign and lab reference ranges, corticosteroid and other medication choices and doses, potassium and fluid replacement, clot prevention, use of antidiarrheal and pain medicines, diet orders, screening before biologics, and surgical timing vary by client, by provider, and by facility. Follow the provider’s written orders and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
