Chapter 43: Lower GI problems

Drug therapy: IBS Antidepressants

Low doses of tricyclic antidepressants seem to provide benefit Possibly work by decreasing peripheral nerve sensitivity

When is surgery indicated for IBD?

• Drainage of abdominal abscess • Failure to respond to conservative therapy • Fistulas • Inability to decrease corticosteroids • Intestinal obstruction • Massive hemorrhage • Perforation • Severe anorectal disease • Suspicion of carcinoma

Audience response question: D.B. must undergo surgical intervention. Which comment indicates that additional instruction about the care of his new ileostomy is needed?

"I should change the appliance daily to prevent odors." Rationale: The appliance is changed every 4 to 7 days unless leakage occurs. Flatus is expelled from the bag through a charcoal filter that helps control odor. Skin around the stoma should be washed with pain water or mild soap, rinsed with warm water, and dried thoroughly before the barrier is applied. When the appliance is changed, the skin should be assessed for irritation. Mild to moderate swelling of the stoma in the first 2 to 3 weeks after surgery is expected. Therefore, the size of the pouch opening that fits around the stoma needs to be adjusted to accommodate the stoma's changing size.

NCLEX review question When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching?

"I will be able to regulate when I have stools." Rationale: The ileostomy is in the ileum and drains liquid stool frequently, unlike the colostomy which has more formed stool the further distal the ostomy is in the colon. The ileostomy pouch is usually worn 4-7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

Practice NCLEX pretest question A 58-year-old woman is being discharged home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member?

A registered nurse with 6 months of experience on the surgical unit Rationale: The patient needs ostomy care directions/reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.

NCLEX review question The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate?

"The tube will help to drain the stomach contents and prevent further vomiting." Rationale: The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

NCLEX review question The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate?

"This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again." Rationale: Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

From discussion board: C Diff.

- 90% of those who get CDI have been on antbx (some even just one dose) - use of PPI increases risk of infection Those with healthy immune systems are low risk for development. Many health care workers carry C. dif but do not get the infection (being a carrier, but not getting sick is COLONIZATION) Improper hand washing by health care workers (HCWs) continues to be the #1 reason it is spread. Those at highest risk are the elderly. Infection usually occurs 2-3 days after exposure. Complications: colitis is the actual condition that is manifested by diarrhea and can lead to dehydration, electrolyte disturbances, hypoalbuminemia, toxic megacolon, bowel perforation, hypotension, renal failure, SIRS, sepsis, and death.

Tests and treatment of C. diff

- GDH (Glutamate dehydrogenase): Detects antigen for both toxic & non-toxic strains. Sensitive but not specific. - Rapid C-diff test If first test positive, follow up screening to test for toxins. - Cell cytotoxicity test - Toxigenic stool culture (sensitive, 2-3 days for results) treatment: - Vancomycin - Metronidazole - Surgery - Fecal transplant

NCLEX review question A patient who is given a bisacodyl (Dulcolax) suppository asks the nurse how long it will take to work. The nurse replies that the patient will probably need to use the bedpan or commode within which time frame after administration?

15-60 minutes Rationale: Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

NCLEX review question A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times?

8:00 AM, 12:00 PM, and 4:00 PM Rationale: A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

Practice NCLEX pretest question The nurse identifies that which patient is at highest risk for developing colon cancer?

A 32-year-old female with a 12-year history of ulcerative colitis Rationale: Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity (body mass index ≥ 30 kg/m2); family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, hereditary nonpolyposis colorectal cancer syndrome; red meat (=7 servings/week); cigarette use; and alcohol (=4 drinks/week).

Drug therapy: Constipation Bulk Forming methylcellulose (Citrucel) psyllium (Metamucil, Perdiem, Konsyl, Hydrocil, Fiberall)

Absorbs water; increases bulk, thereby stimulating peristalsis Action: Usually within 24 hr *Contraindicated in patients with abdominal pain, nausea, and vomiting and in patients suspected of having appendicitis, biliary tract obstruction, or acute hepatitis. Must be taken with fluids (≥8 oz); best choice for initial treatment of constipation.*

NCLEX review question A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient?

Administration of a cleansing enema Rationale: Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively, and an IV antibiotic may be used in the OR. A clear liquid diet will be used the day before surgery with the bowel cleansing.

Gerontologic consideration for IBD

Although IBD is considered a disease of teenagers and young adults, a second peak in occurrence is in the sixth decade

Drug therapy: IBS Selective chloride channel activator Lubiprostone (Amitiza) Linaclotide (Linzess)

Approved for the treatment of IBS-related constipation in women *linaclotide (Linzess) is approved for use in men and women* *Contraindicated in patients with history of mechanical GI obstruction*

Audience response question: After teaching D.B. about dietary modifications, you determine that teaching was effective when he chooses which menu?

Baked cod, baked sweet potato, and canned pears Rationale: Patients with inflammatory bowel disease require a high-calorie, high-vitamin, high-protein, low-residue, lactose-free (if lactase deficiency) diet. High-fat foods may trigger diarrhea. Cold foods and high-fiber foods may increase gastrointestinal transit.

NCLEX review question Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)?

Bloody, diarrhea stools Cramping abdominal pain Rationale: Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

Drug therapy: Constipation Saline and Osmotic Solutions Magnesium salts (magnesium citrate, Milk of Magnesia) Sodium phosphates (Fleet Enema, Phospho-soda) lactulose (Constulose) polyethylene glycol (MiraLAX, GoLYTELY, CoLyte)

Cause retention of fluid in intestinal lumen caused by osmotic effect Action: Within 15 min-3 hr Magnesium-containing products may cause *hypermagnesemia in patients with renal insufficiency*

NCLEX review question The nurse is preparing to administer a scheduled dose of docusate sodium (Colace) when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse?

Chart the dose as not given on the medical record and explain in the nursing progress notes. Rationale: Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

Collaborative care: Diverticulosis and Diverticulitis Collaborative therapy

Conservative Therapy • High-fiber diet • Dietary fiber supplements • Stool softeners • Anticholinergics • Bed rest • Clear liquid diet • Oral antibiotics • Mineral oil • Bulk laxatives • Weight reduction (if overweight) Acute Care: Diverticulitis • Antibiotic therapy • NPO status • IV fluids • Bed rest • NG suction • Surgery -Possible resection of involved colon for obstruction or hemorrhage -Possible temporary colostomy

Drug therapy: IBD Hematinics and vitamins oral ferrous sulfate or gluconate, iron dextran injection (Imferon), cobalamin, zinc, folate

Correct iron-deficiency anemia and promote healing

Drug therapy: IBD 5-Aminosalicylates (5-ASA) Systemic: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa), olsalazine (Dipentum), balsalazide (Colazal) Topical: 5-ASA enema (Rowasa), mesalamine suppositories (Canasa)

Decrease GI inflammation through direct contact with bowel mucosa

Drug therapy: IBD Antidiarrheals diphenoxylate with atropine (Lomotil) loperamide (Imodium)

Decrease GI motility

Drug therapy: IBD Corticosteroids Systemic: corticosteroids (prednisone, budesonide [Entocort]) (oral); hydrocortisone or methylprednisolone (IV for severe IBD) Topical: hydrocortisone suppository or foam (Cortifoam) or enema (Cortenema)

Decrease inflammation

Drug therapy: Antidiarrheal Drugs Donnagel-PG (combination of kaolin, pectin, and paregoric)

Decreases peristalsis and intestinal motility.

NCLEX review question The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse?

Delay the patient's signature on the consent and notify the physician about the conversation with the patient. Rationale: The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

Drug therapy: IBD Immunosuppressants azathioprine (Imuran), 6-mercaptopurine (6-MP), methotrexate, cyclosporine

Suppress immune response

Practice NCLEX pretest question The nurse is admitting a 68-year-old man with severe dehydration and frequent watery diarrhea. He just completed a 10-day outpatient course of antibiotic therapy for bacterial pneumonia. It is most important for the nurse to take which action?

Don gloves and gown before entering the patient's room. Rationale: Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

NCLEX review question When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?

Dried beans, All Bran (100%) cereal, and raspberries Rationale: A high fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

What are some complications of Crohn's disease?

Fat malabsorption and anemia occur because bile salts and cobalamin are absorbed exclusively in terminal ileum

NCLEX review question A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first?

Fecal impaction Rationale: Patients with limited mobility are at risk for fecal impactions due to constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

Practice NCLEX pretest question A 20-year-old man is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?

Firmly distended abdomen Rationale: Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

NCLEX review question The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture?

High-pitched and hyperactive above the area of obstruction Rationale: Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

NCLEX review question The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer?

History of colorectal polyps Rationale: A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

NCLEX review question What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy?

How to deep breathe and cough Rationale: Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively, but done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

NCLEX review question Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of

Impaired peristalsis Rationale: Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

Drug therapy: Constipation Stimulants cascara sagrada, senna (Senokot) phenolphthalein: sennosides (Ex-Lax), bisacodyl (Correctol, Feen-a-Mint, Dulcolax), docusate/ phenolphthalein (Doxidan)

Increase peristalsis by irritating colon wall and stimulating enteric nerves Action: Usually within 12 hr Cause melanosis coli (brown or black pigmentation of colon). Are most widely abused laxatives. *Should not be used in patients with impaction or obstipation.*

Drug therapy: Constipation Intestinal Secretagogue linaclotide (Linzess)

Increases fluid secretion and accelerates intestinal transit. Action: Usually within 24 hr Used in the treatment of idiopathic constipation and irritable bowel syndrome with constipation (men and women).

Drug therapy: Constipation Selective Chloride Channel Activator lubiprostone (Amitiza)

Increases intestinal fluid secretion and motility Action: Usually within 24 hr Used in the treatment of idiopathic constipation and irritable bowel syndrome with constipation (women only). *Contraindicated in patients with history of mechanical GI obstruction.*

NCLEX review question The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way?

Increases peristalsis by stimulating nerves in the colon wall Rationale: Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms. Fiber and bulk forming drugs increase bulk in the stool; water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

Drug therapy: IBD Biologic and targeted therapy (immunomodulators) infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi) natalizumab (Tysabri)

Inhibit the cytokine tumor necrosis factor (TNF) *TNF: involved in systemic inflammation and is one of the cytokines that make up the acute phase reaction* Prevent migration of leukocytes from bloodstream to inflamed tissue

What is IBS?

Irritable bowel syndrome: Common chronic functional disorder Characterized by intermittent abdominal pain or discomfort and stool pattern irregularities Symptoms may occur for years More frequent diagnosis in women *from lecture: - low FODMAP diet (fermentable olgo-di-monosaccharides and polyols), eat lots of fiber*

Drug therapy: Antidiarrheal Drugs octreotide acetate (Sandostatin)

Suppresses serotonin secretion, stimulates fluid absorption from GI tract, decreases intestinal motility.

IBD: ulcerative colitis and Crohn's Extraintestinal complications of IBD

Joints • Peripheral arthritis (colitic) • Ankylosing spondylitis • Sacroiliitis • Finger clubbing Skin • Erythema nodosum • Pyoderma gangrenosum • Mouth • Aphthous ulcers Eye • Conjunctivitis • Uveitis • Episcleritis Gallstones Kidney stones Liver disease: primary sclerosing cholangitis Osteoporosis Thromboembolism

Drug therapy: Constipation Stool Softeners and Lubricants Softeners: docusate (Colace, Surfak, Peri-Colace) Lubricants: mineral oil (Fleet's Oil Retention Enema, Kondremul Plain)

Lubricate intestinal tract and soften feces, making hard stools easier to pass; do not affect peristalsis Action: Softeners in 72 hr, lubricants in 8 hr *Can block absorption of fat-soluble vitamins such as vitamin K, which may increase risk of bleeding in patients on anticoagulants.*

Drug therapy: Antidiarrheal Drugs calcium polycarbophil (Mitrolan)

MOA: Bulk-forming agent that absorbs excessive fluid from diarrhea to form a gel. Used when intestinal mucosa cannot absorb fluid.

Drug therapy: Antidiarrheal Drugs bismuth subsalicylate (Pepto-Bismol)

MOA: Decreases secretions and has weak antibacterial activity. Used to prevent traveler's diarrhea.

Drug therapy: Antidiarrheal Drugs loperamide (Imodium, Pepto Diarrhea Control)

MOA: Inhibits peristalsis, delays transit, increases absorption of fluid from stools.

NCLEX review question The nurse would question the use of which cathartic agent in a patient with renal insufficiency?

Magnesium hydroxide (Milk of Magnesia) Rationale: Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

NCLEX review question The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation?

Maintain a high intake of fluid and fiber in the diet. Rationale: Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be reduced. Other medications may decrease constipation, but it is best to avoid laxatives. Eating several small meals per day and position do not facilitate bowel motility. Defecation is easiest when the person sits on the commode with the knees higher than the hips.

Manifestations of large and small bowel obstructions

Manifestation Small Intestine Large Intestine Onset: Small- Rapid Large- Gradual Vomiting: Small- Frequent and copious Large- Rare Pain: Small: Colicky, cramplike, intermittent pain Large: Low-grade, cramping abdominal pain Bowel movement: Small: Feces for a short time Large: Absolute constipation Abdominal distention Small: Greatly increased Large: Increased

Practice NCLEX pretest question After an abdominal hysterectomy, a 45-year-old woman complains of severe gas pains. Her abdomen is distended. It is most appropriate for the nurse to administer which prescribed medication?

Metoclopramide (Reglan) Rationale: Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide (Reglan) or alvimopan (Entereg) to stimulate peristalsis.

Stoma characteristics: Edema

Mild to moderate edema : Normal in the initial postoperative period. Trauma to the stoma. Moderate to severe edema: Obstruction of the stoma, allergic reaction to food, gastroenteritis.

NCLEX review question The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record?

No bowel movement for 3 days Rationale: MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. MOM would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

Drug therapy: Antidiarrheal Drugs diphenoxylate with atropine (Lomotil)

Opioid and anticholinergic. Decreases peristalsis and intestinal motility.

Drug therapy: Antidiarrheal Drugs paregoric (camphorated tincture of opium)

Opioid. Decreases peristalsis and intestinal motility.

Collaborative care: Peritonitis Collaborative therapy

Preoperative or Nonoperative • NPO status • IV fluid replacement • Antibiotic therapy • NG suction • Analgesics (e.g., morphine) • Oxygen PRN • Preparation for surgery to include the above and parenteral nutrition Postoperative • NPO status • NG tube to low-intermittent suction • Semi-Fowler's position • IV fluids with electrolyte replacement • Parenteral nutrition as needed • Antibiotic therapy • Blood transfusions as needed • Sedatives and opioids

Drug therapy: IBD Antimicrobials metronidazole (Flagyl) ciprofloxacin (Cipro) clarithromycin (Biaxin)

Prevent or treat secondary infection

NCLEX review question Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse?

Reposition the tube and check for placement. Rationale: The tube may be resting against the stomach wall. The first action by the nurse (since this is intestinal surgery and not gastric surgery) is to reposition the tube and check it again for placement. The physician does not need to be notified unless the tube function cannot be restored by the nurse. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

Stoma characteristics: Color

Rose to brick-red: Viable stoma mucosa Pale: May indicate anemia Blanching, dark red to purple: inadequate blood supply to the stoma or bowel.

Stoma characteristics: Bleeding

Small amount: Oozing from the stoma mucosa when touched is normal because of its high vascularity. Moderate to large amount: Could indicate lower gastrointestinal bleeding, coagulation factor deficiency, stomal varices secondary to portal hypertension.

Staging of colorectal cancer

Stage I grown beyond the mucosa into the submucosa, but no lymph nodes are involved. Stage II grown beyond the submucosa into the muscle but there is no lymph node involvement or metastasis. Stage III any tumor with lymph node involvement but no metastasis. Stage IV any tumor with lymph node involvement and metastasis.

NCLEX review question What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)?

Take each dose with a full glass of water or other liquid Rationale: Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

NCLEX review question The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site?

The patient must be able to see the site Rationale: In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag.

Bridge to NCLEX question What should a patient be taught after a hemorrhoidectomy?

Use prescribed pain medication before a bowel movement Rationale: After a hemorrhoidectomy, the patient usually dreads the first bowel movement and often resists the urge to defecate. Pain medication may be given before the bowel movement to reduce discomfort. The patient should avoid constipation and straining. A high-fiber diet can reduce constipation. A stool softener such as docusate (Colace) is usually ordered for the first few postoperative days. If the patient does not have a bowel movement within 2 to 3 days, an oil-retention enema is administered.

Drug therapy: IBS Synthetic opioid Loperamide (Imodium)

Used to treat incidences of diarrhea Decreases intestinal transit

Drug therapy: IBS Serotonergic antagonist Alosetron (Lotronex)

Used to treat severe pain and diarrhea Available only in a restricted access program for women who have not responded to other IBS therapies, because *serious side effects: severe constipation, ischemic colitis* d/c if constipation occurs

Bridge to NCLEX question The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is

a sigmoid colostomy Rationale: The more distal the ostomy is, the more the intestinal contents resemble feces eliminated from an intact colon and rectum. Output from a sigmoid colostomy resembles normally formed stool, and some patients are able to regulate emptying time so they do not need to wear a collection bag.

Bridge to NCLEX question When a 35-year-old female patient is admitted to the emergency department with acute abdominal pain, which possible diagnosis should you consider that may be the cause of her pain (select all that apply)?

a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding d. Irritable bowel syndrome e. Inflammatory bowel disease Rationale: All these conditions could cause acute abdominal pain.

Bridge to NCLEX question A nursing intervention that is most appropriate to decrease postoperative edema and pain after an inguinal herniorrhaphy is

applying a scrotal support with ice bag Rationale: Scrotal edema is a painful complication after an inguinal hernia repair. Scrotal support with application of an ice bag may help relieve pain and edema.

Bridge to NCLEX question A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that

follow-up colonoscopies will be needed to ensure that the cancer does not recur Rationale: Stage 1 colorectal cancer is treated with surgical removal of the tumor and reanastomosis, and so there is no ostomy. Chemotherapy is not recommended for stage I tumors. Follow-up colonoscopy is recommended because colorectal cancer can recur.

Bridge to NCLEX question The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to

increase fluid intake Rationale: Acute diarrhea resulting from infectious causes (e.g., virus) is usually self-limiting. The major concerns are transmission prevention, fluid and electrolyte replacement, and resolution of the diarrhea. Antidiarrheal agents are contraindicated in the treatment of infectious diarrhea because they potentially prolong exposure to the infectious organism. Antibiotics are rarely used to treat acute diarrhea. To prevent transmission of diarrhea caused by a virus, hands should be washed before and after contact with the patient and when body fluids of any kind are handled. Vomitus and stool should be flushed down the toilet, and contaminated clothing should be washed immediately with soap and hot water.

Bridge to NCLEX question In contrast to diverticulitis, the patient with diverticulosis

often has no symptoms Rationale: Many people with diverticulosis have no symptoms. Patients with diverticulitis have symptoms of inflammation. Diverticulitis can lead to obstruction or perforation.

Bridge to NCLEX question In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease

often recurs after surgery, whereas ulcerative colitis is curable with a colectomy Rationale: Ulcerative colitis affects only the colon and rectum; it can cause megacolon and rectal bleeding, but not nutrient malabsorption. Surgical removal of the colon and rectum cures it. Crohn's disease usually involves the ileum, where bile salts and vitamin cobalamin are absorbed. After surgical treatment, disease recurrence at the site is common.

Bridge to NCLEX question The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply)

persistent abdominal pain marked abdominal distention Rationale: With lower intestinal obstructions, abdominal distention is markedly increased and pain is persistent. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation, not diarrhea.

Bridge to NCLEX question Assessment findings suggestive of peritonitis include

rebound abdominal pain Rationale: With peritoneal irritation, the abdomen is hard, like a board, and the patient has severe abdominal pain that is worse with any sudden movement. The patient lies very still. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness

Bridge to NCLEX question The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu

scrambled eggs and sausage Rationale: Celiac disease is treated with lifelong avoidance of dietary gluten. Wheat, barley, oats, and rye products must be avoided. Although pure oats do not contain gluten, oat products can become contaminated with wheat, rye, and barley during the milling process. Gluten is also found in some medications and in many food additives, preservatives, and stabilizers.

Risk factors for colorectal cancer

• Family history of colorectal cancer (first-degree relative) • Personal history of inflammatory bowel disease • Personal history of colorectal cancer • Family or personal history of familial adenomatous polyposis (FAP) • Family or personal history of hereditary nonpolyposis colorectal cancer (HNPCC) syndrome • Obesity (body mass index≥30 kg/m2) • Red meat (≥7 servings/wk) • Cigarette smoking • Alcohol (≥4 drinks/wk) *African americans are highest risk, especially men*

Collaborative care: IBD Collaborative therapy

• High-calorie, high-vitamin, high-protein, low-residue, lactose-free (if lactase deficiency) diet • Drug therapy: - Aminosalicylates - Antimicrobials - Corticosteroids - Immunosuppressants - Biologic and targeted therapy (immunomodulator) • Elemental diet or parenteral nutrition • Physical and emotional rest • Referral for counseling or support group • Surgery

Collaborative care: IBD Diagnostics

• History and physical examination • CBC, erythrocyte sedimentation rate • Serum chemistries • Testing of stool for occult blood • Testing of stool for infection • Capsule endoscopy • Radiologic studies with barium contrast • Sigmoidoscopy and colonoscopy with biopsy

Collaborative care: Peritonitis Diagnostics

• History and physical examination • CBC, including WBC differential • Serum electrolytes • Abdominal x-ray • Abdominal paracentesis and cx of fluid • CT scan or ultrasound • Peritoneoscopy

Collaborative care: Colorectal Cancer Diagnostic

• History and physical examination • Digital rectal examination • Testing of stool for occult blood • Barium enema • Sigmoidoscopy • Colonoscopy • CBC • Liver function tests • CT scan of abdomen • MRI • Ultrasound • Carcinoembryonic antigen (CEA) test

Collaborative care: Diverticulosis and Diverticulitis Diagnostic

• History and physical examination • Testing of stool for occult blood • Barium enema • Sigmoidoscopy • Colonoscopy • CBC • Urinalysis • Blood culture • CT scan with oral contrast • Abdominal x-ray • Chest x-ray

Collaborative care: Colorectal Cancer Collaborative therapy

• Surgery -Right hemicolectomy -Left hemicolectomy -Abdominal-perineal resection -Laparoscopic colectomy • Chemotherapy • Targeted therapy • Radiation therapy

Foods to avoid in celiac disease

• Wheat • Barley • Oats • Rye • Flour (unless it says gluten-free flour, or is made purely from a nongluten source, such as rice flour) • Baked goods, including muffins, cookies, cakes, pies • Bread, including wheat bread, white bread,"potato" bread • Pasta, pizza, bagels