NUR 126 Exam 3

signs and symptoms that are seen in both Crohns and ulcerative colitis:

- fever -malaise -arthralgia -diaphoresis

Complications of Crohn's Disease

-intestinal obstructions - stricture formation -perianal disease - electrolyte imbalances - enterocutaneous fistula -colon cancer

Signs and symptoms of IBS

-pain -bloating -abdominal distention

what age are you typically Dx with Inflammatory bowel disease?

15- 40 yrs Secondary peak at 55-60 yrs

What innervates the GI tract?

Autonomic nervous system - Sympathetic - parasympathetic

what does low-FODMAP stand for:

Fermentable Oligosaccharides (wheat, rye, asparagus, garlic, onions) Disaccharides (milk, yogurt) Monosaccharides (honey, agave, nectar) Polyols (blackberries, lychee, low- calorie sweeteners)

Assessment of IBD:

Health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history Discuss dietary patterns, alcohol, caffeine, and nicotine use, intolerance of foods Assess bowel elimination patterns and stool, characteristics, frequency Abdominal assessment

intussusception

One part of the intestine slips into another part located below it (like a telescope shortening); occurs more commonly in infants than adults Result: The intestinal lumen becomes narrowed, and blood supply becomes strangulated.

Discuss nursing management for SBO

REPORTING DISCREPANCIES - I/O -pain -abd distention -if the pt is not improving with interventions prepare for surgery -pre OP education

Give an example of an extrinsic lesion:

adhesions, hernia, and abscesses

Describe pathophysiology of Crohn's disease:

crypt inflammation and abscesses which develop into small ulcers, lesions, and fissures. -cobblestone-like appearance - skip lesions -bowel wall thickens and becomes fibrotic which causes the lumen to narrow

What causes IBS?

disorder of intestinal motility that may be related to neuroendocrine dysregulation.

What can be a life threatening result of a large bowel obstruction?

if the blood supply is cut off, intestinal strangulation and necrosis can occur.

Give an example of an intrinsic lesion:

intestinal tumors, strictures, intraluminal lesions

what are the main enzymes in the small intestine?

tripsin, amylase, lipase

Cause for inflammatory bowel disease:

unknown: underlying factors- - genetic -altered immune -altered gut micromes

Medications for IBD:

*salicylates*: sulfasalazine, mesalamine; induce and maintain remission for mild to moderate IBD, more effective in UC. - given edema or suppository. *antimicrobials*: metronidazole, ciprofloxacin, clarithromycin; first line of Crohn's disease. want to monitor for risk of C-diff. *immunosuppresants*: methotrexate, cyclosporine, azathioprine -slow onset response used for maintenance -routine CBC for bone density -hepatotoxic - increased risk of pneumonia *steroids*: prednisone, hydrocortisone, corticosteroids; reduce inflammation. -short-term use. can interfere with intestine wound healing. Monoclonal antibodies: -stop inflammatory effects if cyotkine T/F in the gut - moderate ot severe IBD BOTH: IV "infliximade" - watch for flu symptoms - screen for TB and heptatitis Pre assessment *biologics*: mAB drugs - (the ones you see on afternoon TV ads) - Remicade, Humira, Cimzia, Tysabri

Therapeutic management for Crohn's disease

- Corticosteroids (aminosalicylates) -Immunomodulators -antibiotics -parenteral nutrition partial or complete colectomy with ileostomy or anastomosis

Interventions for large bowel obstruction

- NG aspiration - Colonoscopy - rectal tube - Colonic stent -***surgical resection**

what are some interventions for a SBO

- NG tube: decompress and rest the bowel - hypertonic water soluble GI contrast: stimulate peristalsis - Provide IV fluids: restore electrolytes

Signs and symptoms of GERD

- Pyrosis (heartburn), dyspepsia (indigestion)(severe GERD, pain occurring after every meal) - Regurgitation, coughing, dysphagia, dental erosion, hoarseness at night, painful swallowing, hypersalivation

Triggers of IBD flares:

- air pollutants -food -tabacco - viral illnesses

Assessments done for large bowel obstruction

- assess abdomen and bowel sounds -hyper resonate abdoment - CT/ XR -monitor WBC - electrolyte imbalances

discuss assessment of SBO

- assess bowel sounds -obtain CT scan: location and severity of obstruction -CBC/CMB: for dehydration and monitor electrolytes

How does the gut microbiome impact health?

- assist in the breakdown of waste material - protection again invading pathogens - provokes immune response (inflammation) - major component of the large intestine

Assessment/ Dx

- barium swallow test -PPI inhibitory trial -transnasal endoscopy -hernias - pH monitoring

Factors that affect IBS

- chronic stress - sleep deprivation - surgery -infections -diverticulitis -certain food

Complications for IBD:

- electrolyte imbalance - cardiac arrhythmias -GI bleeding with fluids volume loss - perforation of the bowel - decreased intake

factors that can cause GERD:

- incompetent lower esophageal sphincter - pyloric stenosis - hiatal hernia -motility disorders -IBD -older ages -COPD/ other pulmonary disorders -h. pylori infections

Gerontologic Considerations

- irritable bowel syndromes decrease over time - general loss of appetite - less control of rectal sphincter - difficulty chewing/swallowing - increased GERD - Decreased vitamin absorption - decreased motility = constipation/ indigestion

Name factors that affect severity of bowel obstruction:

- region (where the obstruction is) - how much of the lumen is blocked (full or partial blockage) - vascular supply to the affected area

Education of IBD:

- state the impact of IBD on physiologic functioning - ADL's roles -high protein/ high vitamin diet -medication regimen - Tx symptoms of exacerbation - fluid balance - rest/ exercise - cessation of smoking/ drinking

Therapeutic management of Ulcerative Colitis:

-Bulk hydrophilic agents - Corticosteroids (aminosalicylates) -Immunomodulators -antibiotics - Proctocolectomy with ileostomy

Medications for IBS:

-Bulk-forming laxatives (Psyllium) to help reduce reduce bowel spasm and normalize the number of bowel movements; -anticholinergic (Bentyl) to inhibit bowel motility by interfering with parasympathetic stimulation of the GI tract; -antidepressants (SSRIs or TCAs) may help relieve abdominal pain -Loperamide -mineral oil

Signs of small bowel obstruction

-crampy wavelike colicky pain -absence of fecal matter -Vomiting -signs of dehydration flatus -abdominal distention - metabolic acidosis -hypovolemic shock/ sepsis -hyperactive bowel sounds -late stage is absent bowel sounds

Signs and symptoms of ulcerative colitis:

-diarrhea -mucus, pull, or blood in stool - six or more liquid stools per day - LLQ pain -tenessmus -mild or sever pallor -anemia -electrolyte impalamces -skin/ eye lesions -joint abnormalities -liver disease

nursing management of IBD:

-maintain normal elimination pan - relief of pain - proper rest -fluid intake/ nutrition - preventing skin break down

what are some nursing management considerations?

-monitor for symptoms that indicate worsening - administer IV fluids and electrolytes - pre OP education

What are complications of a large bowel obstruction?

-perforation: leaking bowel contents -peritonitis: inflammation -sepsis

Complications of Ulcerative colitis:

-postitive stool pathogen test -perforation - toxic mega-colon (colon distension)

The nurse in the outpatient clinic instructs a client taking lansoprazole for the first time. The nurse determines further teaching is required if the client makes which statement? 1. "I should take the medication on a full stomach" 2. "The capsules are not to be crushed or chewed" 3. "I can take this medication with antacids" 4. "I can open the capsule and sprinkle the contents on soft food, such as applesauce, and swallow immediately"

1. "I should take the medication on a full stomach" reasoning: lansoprazole is a proton-pump inhibitor and is used for the Tx of GERD and ulcers; take BEFORE meals

What is the function of the GI tract:

1. Breakdown: food particles into the molecular form for digestion (mouth and stomach 2. Absorption: into the bloodstream of small nutrient molecules produced by digestion (small intestine) 3. Elimination: of undigested unabsorbed foodstuffs and other waste products (large intestine/ colon)

What causes an impede flow?

1. Mechanical: extrinsic or intrinsic lesions 2. Functional or paralytic obstruction: intestinal musculature cannot propel the contents further down the GI tract due to interruption of innervation or vascular supply to the bowel.

Vomiting results in which of the following acid-base imbalances? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic alkalosis Reason: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

What are the five veins in the venous portal system?

1. Superior mesenteric 2. Inferior mesenteric 3. gastric 4. splenic 5. cystic

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? 1. lack of free water intake 2. lack of solid food 3. lack of exercise 4. increased fiber

1. lack of free water intake Reason: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? 1. uncontrolled rhythmic movements of the face or limbs 2. anxiety or irritability 3. hyperactivity 4. dry mouth not relieve by sugar-free hard candy

1. uncontrolled rhythmic movements of the face or limbs reason: Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.

Which drug is considered a stimulant laxative? 1. Magnesium hydroxide 2. Bisacodyl 3. Mineral oil 4. Psyllium hydrophilic mucilloid

2. Bidacodyl Reasoning: Bisacodyl is a stimulant laxative. Magnesium hydroxide is a saline agent. Mineral oil is a lubricant. Psyllium hydrophilic mucilloid is a bulk-forming agent.

The nurse provides education to an adult client to facilitate bowel elimination. Which action should the nurse encourage? 1. Engaging in sedentary activity 2. Increasing dietary bulk 3. Decreasing fluid intake 4. Using oral laxatives

2. Increasing dietary bulk Reasoning: Foods that contain cellulose (wheat bread, fruits, and grains) will increase the bulk in the stool which facilitates bowel elimination.

The nurse recognizes which change of the GI system is an age-related change? 1. hypertrophy of the small intestine 2. weakened gag reflex 3. increased mucus secretion 4. increased motility

2. weakened gag reflex reason: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? 1. Obtain complete food history 2. Provide adequate quantity of food 3. Assist client to increase dietary fiber 4. Obtain medical and allergy history

3. Assist client to increase dietary fiber Reason: The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? 1. coffee- ground like 2. Clay-colored 3. Black and Tarry 4. Bright red

3. Black and tarry Reason: Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A patient is not having daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use? 1. When taking the laxatives, plenty of fluid should be taken as well. 2. The laxatives should be taken no more than 3 times a week or laxative addiction will result. 3. Laxatives should not be routinely taken due to destruction of nerve endings in the colon. 4. Laxatives should never be the first response for the treatment of constipation; natural methods should be employed first.

3. Laxatives should not be routinely taken due to destruction of nerve endings in the colon. Reason: Laxative abuse, particularly the anthracene derivatives such as senna and cascara, can lead to destruction of the nerves of the colon that are essential for normal peristalsis (Apau, 2010a).

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? 1. instruct the client to avoid prune or apple juice 2. assist the client regarding the correct diet or to minimize food intake 3. Suggest fluid intake of at least 2L/day 4. Instruct the client to keep a record of food intake

3. Suggest fluid intake of at least 2L/day Reason: The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for: 1. hyperkalemia 2. hyponatremia 3. hypokalemia 4. hypernatremia

3. hypokalemia Reason: The older client taking digoxin must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? 1. Establishing a predetermined fluid intake pattern for the client 2. Encouraging the client to increase the time between voidings 3. Restricting fluid intake to reduce the need to void 4. Assessing present voiding patterns

4. Assessing present voiding patterns reason: The guidelines for initiating bladder retraining include assessing the client's present intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom? 1. Hiatal hernia 2. Gastroesophageal reflux disease 3. Gastritis 4. Esophageal tumor

4. Esophageal tumor reason: Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

Clients with inflammatory bowel disease (IBD) are at significantly increased risk for which condition? 1. hypotension 2. DVT 3. pneumonia 4. osteoporosis

4. osteoporosis reason: Clients with IBD also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density. Clients are not at increased risk of DVT, hypotension, or pneumonia.

Tumor

A tumor that exists within the wall of the intestine extends into the intestinal lumen, or a tumor outside the intestine causes pressure on the wall of the intestine. Most common type is colorectal adenocarcinoma Result: Intestinal lumen becomes partially obstructed; if the tumor is not removed, complete obstruction results.

Volvulus

Bowel twists and turns on itself and occludes the blood supply Result: Intestinal lumen becomes obstructed. Gas and fluid accumulate in the trapped bowel.

Main causes of small bowel obstruction:

Chron's disease, intussusception, volvulus, and paralytic ileus.

Definition of Irritable Bowel Syndrome?

Chronic functional disorder characterized by recurrent abdominal pain associated with 2 of 3 1. Pain improves with defecation 2. Change in stool frequency 3. Change in appearance of stool

Ulcerative Colitis:

Chronic inflammation and mucosal ulceration of the rectum, descending colon. Dx Findings: shortening of the colon, abnormal inflamed mucosa, friable mucosa with pseudopolyps or ulcers in descending colon.

indeterminate colitis

IBD patients have characteristics of both disorders and cannot be definitively diagnosed with either

Definition of small intestinal obstruction

Intestinal contents, fluid, and gas accumulate proximal (closer) to the obstruction. this causes abdominal distention and retention of fluid = decreased absorption and increased gastric secretion. Result: - decrease in venous and arteriolar capillary pressure. -third-spacing of fluids, electrolytes, and proteins. - increase in intestinal lumen

Adhesions

Loops of intestine become adherent to areas that heal slowly or scar after abdominal surgery; occurs most commonly in small intestine Result: After surgery, adhesions produce a kinking of an intestinal loop.

Hernia

Protrusion of intestine through a weakened area in the abdominal muscle wall Result: Intestinal flow may be completely obstructed. Blood flow to the area may be obstructed as well.

Signs and symptoms of Crohn's disease:

RLQ Pain unrelieved by defecation Diarrhea (5-6 per day) Abdominal pain/spasms abdominal cramping; especially after meals Weight loss due to pain after eating secondary anemia fever fat in the stools oral ulcers steatorrhea (fat in poop)

discuss assessment and Dx of IBS

Rome IV criteria: - Abdominal pain related to defecation; - Abdominal pain associated with a change in frequency of stool; - Abdominal pain associated with a change in form/appearance of stool. These symptoms occur once daily during the last three months. --> tell pt to record quality and quantity of stool --> increased C-reactive protein and fecal calprotectin --> negative serologic test

Where to most obstruction occur?

SMALL INTESTINE (if obstruction is in large intestine is happens on sigmoid colon)

Definition of intestinal obstruction

When blockage prevents normal flora of intestinal contents through the intestinal tract

Crohn's disease (regional enteritis):

a chronic autoimmune inflammation disorder that causes thickening, deep penetrating granulomas. This disease process is usually found in the ileum or ascending colon. Dx findings: skip lesions, narrowing of the colon, thickening of the bowel wall, mesenteric edema, fistulas. - albumin and protein levels will be decreased (malnutrition)

What is inflammatory bowel disease

a group of chronic disorders: Crohn's disease and ulcerative colitis that result in inflammation or ulceration (or both) of the bowel.

what is the function of the colon?

absorption of water and vitamins. neutralizes the end products

Definition of Large bowel obstruction

accumulations of intestinal contents, fluids, and gar proximal to the obstruction.

Describe pathophysiology of Ulcerative Colitis:

affects superficial mucosa do the colon and is characterized by multiple ulcerations that cause inflammation squamous shedding that causes bleeding

gastroesophageal reflux disease (GERD)

back flow of duodenal contents into esophagus that causes mucosal injury to the esophagus.

What is the priority intervention for a pt with an SBO

maintaining fluid and electrolyte balance.

Give an example of a functional obstruction:

muscular dystrophy, DM, parkinson's, surgery, amyloidosis

signs and symptoms of large bowel obstruction

slow symptom development - stool shape changes - blood in stool (iron deficiency) - weakness - wt loss -abdominal distention -loops of bowel can be seen through abd wall