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The following is a scenario of a patient with toxic megacolon:

Mary Cole, a 50-year-old female with a known history of ulcerative colitis (UC) and anemia, was driven to the emergency department (ED) by her daughter, Cindy, on April 11, 2019, just after 1000. The reason for her visit was due to complaints of severe abdominal pain/swelling and bloody diarrhea over the past four days.

Vital signs were taken in the ED showing a blood pressure (BP) of 96/50, heart rate (HR) 113 bpm, respiratory rate (RR) of 29, tympanic temperature of 38.9°C, oxygen saturation (O2 sat.) of 97% on room air, and a pain of 9/10 (using the verbal numeric pain scale) located in her left lower abdominal quadrant that is sharp, constant, and aggravated by movement. Mary states, “my stomach hurts so much I can barely take the pain”. She claims that she has been taking extra-strength Advil (ibuprofen 400mg) for the pain. Her vitals were reassessed after 20 minutes showing a decrease in BP to 85/47, HR 130, RR 29, tympanic temperature of 38.9°C, O2 sat. 96%, and pain still at 9/10.

Upon further assessment, Mrs. Cole appeared uncomfortable and was quietly crying and lying on her left side with her knees flexed and arms holding her abdomen. She was alert and oriented to person, place, time, and situation and was demonstrating appropriate responses and PERRLA. Her face was flushed and her skin felt warm and dry to touch. There was slight skin tenting at her clavicle and she admitted to not being able to “eat or drink very much over the past few days” due to her abdominal pain and discomfort. She claims to have been having diarrhea that “looks kind of bloody” and hasn’t been voiding as often as she “normally does”, approximately twice a day over these past few days. Her abdomen is visibly distended and tender/firm upon palpation. Upon auscultation, she has hypoactive bowel sounds in all four quadrants and her pain is noted to be in the left lower quadrant. She is tachycardic and has a clear S1S2 heartbeat with diminished pedal pulses;  tachypnea is noted, lung sounds are clear in all lobes. Her strengths in both upper and lower extremities are slightly weak and her daughter states that her mother has been “dizzy when getting up and has difficulty walking at times”.

While in the ED, the nurse inserted an 18-gauge intravenous (IV) to the left antecubital fossa (AC) and administered a 1 L normal saline (NS) bolus. Mary’s labs (CBC, CMP, cultures) were drawn, an x-ray and abdominal CT scan were performed, and a stool sample was ordered. She was administered 1 mg of morphine sulfate IV push at 1115 for her pain. In 15 minutes, her pain was reassessed and was reported as 8/10 using the numeric pain scale. She received an additional dose of 2 mg morphine sulfate IV push and reassessed after 15 minutes, stating a pain of 6/10; continuous pain assessment and management were performed. She was ordered NPO for bowel rest. The ED nurse administered 500 mg of metronidazole IV to prevent septic complications.

Mary’s labs revealed the following: elevated C-reactive protein of 16, positive antineutrophil cytoplasmic antibodies (ANCA), Hgb: 7.8, Hct: 23%, Platelets: 100,000, WBC: 13000, potassium: 3.3, sodium: 128, pH: 7.26, HCO3: 18, CO2: 31 (metabolic acidosis), lactic acid of 3.8, and the stool showed presence of blood and WBCs. Mary’s abdominal CT revealed colonic dilation of more than 6 cm in the transverse colon. Once results were in from the labs, x-ray, and CT scan, Mary was diagnosed with toxic megacolon resulting from a flare-up of UC and sent to the intensive care unit (ICU) for close observation and monitoring.

Once in the ICU, an NG tube was placed for gastric decompression due to the CT result of a 6 cm dilation of the colon. Her labs were closely monitored for electrolyte imbalance and further decline due to possible perforation of the colon (i.e. Hgb, Hct). Nursing priorities included focused assessments, monitoring for signs/symptoms of shock (perforation) such as rigid abdomen, severe abdominal pain, nausea/vomiting (N/V), fever, chills, and rectal bleeding. Mary was prescribed 400 mg of hydrocortisone IV to decrease inflammation and her pain was being monitored and managed with scheduled IV infusion of acetaminophen (Ofirmev) 1000 mg every 6 hours and 1 mg morphine sulfate IV push for breakthrough pain. Lactic acid was monitored every two hours until the levels fell below 2; she received Zosyn IV running at 25 mL/hr every four hours. Medical treatment was continued in cooperation with the gastroenterologist, intensivist, and surgeons to monitor for sepsis and the need for surgical intervention.

When Mary was stable, she was transferred to the direct observation unit (DOU) floor for observation and case management. On the floor, the patient was educated regarding toxic megacolon and taught about the need to continue her UC medication—Vedolizumab (Entyvio)—which, if taken correctly, should decrease the chance of  recurrence of UC flare-up and risk of toxic megacolon. Lastly, she met with case management and was educated on ulcerative colitis support groups and an appointment was schedule in May with her primary healthcare provider for follow-up.

Open-Ended Questions:

1. Which areas of our nursing assessment should we closely monitor and what are we looking for?
2. What are the major concerns with toxic megacolon related to bowel perforation?
3. What other possible diagnoses should be considered and ruled out?
4. What are the primary nursing diagnosis for Mrs. Cole?

Answer Key

1. Areas of nursing assessment we want to closely monitor include a focused GI assessment, signs and symptoms of shock, and pain (related to dilation of colon).We would also monitor our lab values for any further indications that may show infection, fluid/electrolyte imbalances, and decrease in Hct/Hgb. It is important to remain cognizant of further deviations from the norm in order to prevent bowel perforation and/or treat the patient in a timely manner to reduce the chance of further complications (i.e. shock from perforation, sepsis).
2. Biggest concern related to bowel perforation from toxic megacolon is infection from bacteria being released into abdomen; this places the patient at risk for septic shock.
3. Other possible diagnosis that needed to be ruled out include: bowel obstruction peritonitis, pancreatitis, peptic ulcer, and kidney stones.
4. Primary nursing diagnoses for Mrs. Cole include:
   1. Risk for infection
   2. Deficient fluid volume
   3. Diarrhea
   4. Risk for decreased cardiac tissue perfusion
   5. Dysfunctional gastrointestinal motility
   6. Acute pain

References

Basson, M. D. (2018). Ulcerative colitis workup: approach considerations, serologic markers, other laboratory studies. Medscape. Retrieved from https://emedicine.medscape.com/article/183084-workup#showall Feuerstein, J. D., & Cheifetz, A. S. (2014). Ulcerative colitis: Epidemiology, diagnosis, and management. Mayo Clinic Proceedings, 89(11), 1553-1563. http:dx.doi.org/10.1016/j.mayocp.2014.07.002

Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & suddarth’s textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Unbound Medicine, Inc. (2014). Nursing Central (1.22) [Mobile application software]. Retrieved from <http://itunes.apple.com> Woodhouse, E. (2016). Toxic megacolon: A review for emergency department clinicians. Journal of Emergency Nursing, 42(6), 481-486. https://doi.org/10.1016/j.jen2016.04.007