# Situation: A 32-year-old woman with ulcerative colitis is admitted for a flare. She has 8 bloody stools a day, a temperature of 38.2 °C, a heart rate of 104/min, and a hemoglobin of 9.8 g/dL (98 g/L). Stool tests for Clostridioides difficile and other pathogens are pending. The provider writes the following orders. Which order should the nurse question?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 32-year-old woman with ulcerative colitis is admitted for a flare. She has 8 bloody stools a day, a temperature of 38.2 °C, a heart rate of 104/min, and a hemoglobin of 9.8 g/dL (98 g/L). Stool tests for Clostridioides difficile and other pathogens are pending.

The provider writes the following orders. Which order should the nurse question?

## 보기

1. Methylprednisolone 60 mg intravenously every 24 hours
2. Heparin 5,000 units subcutaneously every 8 hours
3. Loperamide 2 mg orally after each loose stool **✔ 정답**
4. Potassium chloride 20 mEq in each liter of intravenous fluid

**정답: 3**

## 해설

In acute severe ulcerative colitis, antidiarrheals, opioids, and anticholinergics are avoided because they can precipitate toxic megacolon. Intravenous corticosteroids are first-line therapy, and heparin prophylaxis is given because the clotting risk outweighs the bleeding concern in most clients. Potassium replacement corrects losses from diarrhea.

## 심화 해설

Clinical context Acute severe ulcerative colitis (ASUC) is a life-threatening gastroenterological emergency. The patient’s presentation — 8 bloody stools daily, fever 38.2 °C, tachycardia 104/min, and anemia with hemoglobin 9.8 g/dL — meets criteria for a severe flare requiring prompt, protocol-driven management. Among the four orders, only loperamide should be questioned.

Why loperamide is contraindicated Loperamide is an opioid-receptor agonist that reduces intestinal motility. In ASUC, slowing peristalsis does not treat the underlying mucosal inflammation; instead, it prolongs contact between the inflamed colonic wall and luminal contents, increases intraluminal pressure, and can precipitate colonic dilatation. Antidiarrheals, opioids, and anticholinergics are avoided in acute severe ulcerative colitis because they can precipitate toxic megacolon, a potentially fatal complication. Watch out! The presence of bloody diarrhea does not justify symptomatic suppression with antimotility agents. The diarrhea is a consequence of mucosal destruction and inflammatory exudate, not a primary motility disorder. Suppressing it masks clinical deterioration and delays recognition of worsening colitis.

Why the other orders are appropriate Intravenous methylprednisolone 60 mg every 24 hours is first-line therapy for ASUC. Corticosteroids rapidly reduce mucosal inflammation and are the standard initial medical intervention. Early identification of patients at risk of corticosteroid failure is critical for timely therapeutic escalation, which is why the patient must be monitored closely for response over the first 3–5 days [1]. If steroids fail, rescue therapy or colectomy is considered [2].

Heparin 5,000 units subcutaneously every 8 hours is venous thromboembolism (VTE) prophylaxis. Patients with active inflammatory bowel disease have a substantially increased clotting risk due to systemic inflammation, dehydration, and immobility. In most clients with ASUC, the thrombotic risk outweighs the concern for worsening gastrointestinal bleeding, so pharmacologic VTE prophylaxis is indicated. The hemoglobin of 9.8 g/dL reflects chronic or subacute blood loss and is not a contraindication to prophylactic-dose heparin in the absence of hemodynamic instability or active exsanguination.

Potassium chloride 20 mEq per liter of intravenous fluid addresses the large intestinal potassium losses from frequent bloody diarrhea. Hypokalemia can worsen colonic smooth muscle dysfunction and contribute to ileus or toxic megacolon, so replacement is a standard supportive measure.

Infectious workup and diagnostic caution Stool tests for Clostridioides difficile and other pathogens are pending. In patients with suspected or confirmed infectious diarrhea, antimotility agents are also discouraged because they can prolong pathogen exposure and worsen outcomes . Although this patient’s primary diagnosis is ulcerative colitis, the same principle applies: until infection is excluded, suppressing diarrhea is unsafe. The overlapping concern reinforces that loperamide is the order to question.

Key comparison for the licensure exam

| Order | Rationale in ASUC | Nursing action |
| --- | --- | --- |
| Methylprednisolone IV | First-line anti-inflammatory therapy; reduces mucosal inflammation | Administer as prescribed; monitor for response and hyperglycemia |
| Heparin SC | VTE prophylaxis; clotting risk exceeds bleeding risk | Administer; monitor for bleeding and injection-site bruising |
| Loperamide PO | Antimotility agent; may precipitate toxic megacolon | Question the order; do not administer |
| Potassium chloride IV | Replaces potassium lost through diarrhea | Administer; monitor serum potassium and cardiac rhythm |

Key point! The single most dangerous order in an acute severe ulcerative colitis flare is an antidiarrheal, opioid, or anticholinergic. These drugs increase the risk of toxic megacolon by reducing colonic motility while inflammation remains active. Intravenous corticosteroids remain the cornerstone of initial medical management, and the patient must be reassessed early for signs of steroid failure [1][2].References (research sources)

- [1]Early Predictors of Steroid Failure in Acute Severe Ulcerative Colitis: A Retrospective Study With the Evaluation of the Admission Model for Intensification of Therapy in Acute Severe Colitis (ADMIT-ASC) Score.Research articleMerzouki O, Mliyahe S, Meyiz H, El Fadli I, Aziz M, Ghannami Y, Ouaya H, Akjay A, Mellouki I. (2026) · DOI: 10.7759/cureus.109276

- [2]Upadacitinib as rescue therapy for acute severe ulcerative colitis and severe Crohn's disease - current knowledge and future directions.Research articleCaban M, Dudek P, Strigáč A, Szałwińska P, Talar-Wojnarowska R. (2026) · DOI: 10.1007/s43440-025-00803-9

## 임상 시나리오

Acute Severe UC: Medication SafetyWhich order to question in a severe flare
In acute severe ulcerative colitis, antidiarrheals, opioids, and anticholinergics are avoided because they can precipitate toxic megacolon. Loperamide reduces intestinal motility, increasing intraluminal pressure and delaying recognition of worsening colitis.

IV methylprednisolone 60 mg every 24 hours is first-line therapy to reduce mucosal inflammation. Heparin 5,000 units subcutaneously every 8 hours is appropriate because clotting risk outweighs bleeding concern. Potassium chloride 20 mEq per liter of IV fluid replaces losses from diarrhea.

CautionBloody diarrhea is not a primary motility disorder; suppressing it with antimotility agents masks clinical deterioration and delays recognition of worsening colitis or toxic megacolon.

## 핵심 개념

- **Toxic megacolon** — A life-threatening complication of severe colitis characterized by colonic dilatation and systemic toxicity, which can be precipitated by antimotility agents.
- **Acute severe ulcerative colitis (ASUC)** — A severe flare of ulcerative colitis meeting criteria such as frequent bloody stools, fever, tachycardia, and anemia, requiring prompt protocol-driven management.
- **Loperamide** — An opioid-receptor agonist that reduces intestinal motility; contraindicated in acute severe ulcerative colitis due to risk of toxic megacolon.
- **Methylprednisolone** — An intravenous corticosteroid used as first-line therapy to rapidly reduce mucosal inflammation in acute severe ulcerative colitis.
- **Heparin prophylaxis** — Subcutaneous anticoagulation given in acute severe ulcerative colitis because the increased clotting risk outweighs the bleeding concern in most clients.

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