In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a p… - DHS 2018 shift 1st

DHS 2018 shift 1st

Medical Surgical Nursing

Hard

Appeared in: DHS 2018 shift 1st

Explanation

Ulcerative colitis is an inflammatory bowel disease characterized by severe, frequent, and often bloody diarrhea.
This condition causes rapid and significant losses of fluid and electrolytes, leading to a fluid volume deficit.
According to prioritization principles (Maslow's Hierarchy, ABCs), fluid volume deficit is a primary physiological need directly impacting circulation.
Addressing this deficit is the highest priority to prevent life-threatening complications such as hypovolemic shock and cardiac dysrhythmias.

Option A: Anxiety is a psychosocial diagnosis. According to Maslow's hierarchy of needs, physiological needs must be stabilized before addressing psychosocial concerns.
Option B: While frequent diarrhea creates a high risk for perianal skin breakdown, this issue is not as immediately life-threatening as circulatory collapse from severe dehydration.
Option D: Altered nutrition is a significant long-term problem in ulcerative colitis due to malabsorption and anorexia. However, it is a chronic issue, whereas acute fluid loss is a more immediate danger.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing diagnoses for inflammatory bowel disease to guide bedside assessment, documentation, and the next nursing action.
A core nursing responsibility for patients with an acute ulcerative colitis flare-up is meticulous monitoring of fluid balance, including intake, output (especially stool volume/frequency), vital signs, and daily weights.
Early recognition of the signs of hypovolemia (tachycardia, hypotension, dizziness, decreased urine output) and prompt escalation of care are critical to prevent the patient from progressing to shock.
What if? If the patient presented with mild, infrequent diarrhea but also had a new, painful perianal fistula, 'Impaired Skin Integrity' might become a higher priority, assuming their vital signs and fluid status were stable.

How to Approach the Question

First, identify the keyword in the question: 'priority'. This signals that you must determine the most urgent issue.
Next, recall the primary pathophysiology of the condition mentioned, ulcerative colitis. The hallmark symptom is severe diarrhea.
Apply a standard nursing prioritization framework, such as Maslow's Hierarchy of Needs (physiological needs first) or the ABCs (Airway, Breathing, Circulation).
Evaluate each option against this framework. 'Fluid volume deficit' directly relates to 'Circulation' and is a fundamental physiological need.
Compare the immediacy of the threat posed by each option. Severe dehydration can be fatal in the short term, making it a higher priority than anxiety, potential skin breakdown, or chronic nutritional deficits.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing diagnoses for inflammatory bowel disease.
Stem keywords: ulcerative colitis, planning care, nursing diagnosis, priority
Lead-in keywords: priority
Clinical cues: A diagnosis of ulcerative colitis implies a high risk for severe diarrhea and subsequent dehydration.

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 63-65

E6 Nursing Fundamentals Taylor p. 504-506