Chapter 57: Care of Patients with Inflammatory Intestinal Disorders

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." Correct B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your health care provider before you attempt to have intercourse."

A simple change in positioning during intercourse may alleviate the client's apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client's concerns, but it focuses on the wrong issue; the client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address the client's concerns, but it similarly focuses on the wrong issue. Telling the client that he needs to get clearance from his health care provider is an evasive response that does not address the client's primary concern.

The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (Select all that apply.) A. Anorexia Correct B. Depression C. Drowsiness D. Frequent urination E. Headache Correct F. Vomiting Correct

Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that should be reported to the health care provider. Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

A client is scheduled for discharge after surgery for inflammatory bowel disease. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? A. Ability of the client and spouse to perform incision care and dressing changes Correct B. Effective coping mechanisms for the client and spouse after the surgical experience C. Knowledge about the client's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments

Assessing the client's and the spouse's ability to carry out incision care and dressing changes is essential for avoiding further development of the infectious process, as well as infection of the surgical incision itself. Assessing coping mechanisms and knowledge of the client's pain medication are important, but are not the priority. Understanding the importance of scheduled follow-up appointments is important, but is not the priority.

A client admitted with severe gastroenteritis has been started on an IV, but the client continues having excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? A. Balsalazide (Colazal) B. Loperamide (Imodium) Correct C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)

If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily. Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for clients with ulcerative colitis for long-term therapy. MOM is a laxative.

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." Correct D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

Lactose-containing foods are often poorly tolerated and should be reduced or eliminated from the diet of clients with UC. Carbonated beverages are GI stimulants that can cause discomfort and should be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms; nurses should never advise clients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in clients with UC.

A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced." Correct

Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation. Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the client's pain as the inflammation subsides, but this is not the purpose of the drug—it is not an analgesic.

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." Correct C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet or an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread Correct B. Chuck steak patty (6 ounces) C. Strawberries (1 cup) D. Tomato (1 medium)

Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat should be reduced in clients with diverticular disease. If the client wants to eat beef, it should be of a leaner cut. Foods containing seeds, such as strawberries, should be avoided. Tomatoes should be avoided unless the seeds are removed. The seeds may block diverticula in the client and present problems leading to diverticulitis.

A client diagnosed with ulcerative colitis is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? A. "Be aware of the symptoms of toxic megacolon that we discussed." Correct B. "If diarrhea increases, you should let your health care provider know." C. "Pregnancy should be avoided." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia. Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever Correct C. Epigastric cramping D. Hypotension with vomiting

Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of CD than of other acute inflammatory bowel disorders. Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Clients with CD experience about 20 loose, bloody stools daily. B. Clients with UC may experience hemorrhage. Correct C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

Hemorrhage is commonly experienced by clients with UC. Five to six stools daily is common with CD. The peak incidences of UC are between 15 to 25 and 55 to 65 years of age. Fistulas commonly occur as a complication of CD.

A client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the client whether family members could be trained in stoma care B. Has another client with a stoma who performs self-care talk with the client Correct C. Requests that the health care provider request antidepressants and a psychiatric consult D. Suggests that the health care provider request a home health consultation so stoma care can be performed by a home health nurse

Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her self-care. If at all possible, the client should perform stoma care so that he or she can be as independent as possible. Although the client may need medication for depression, the priority is to encourage the client to look at, touch, and begin caring for the stoma. A home health nurse can be a support, but cannot provide all of the care that the client will need.

A client has an anal fissure. Which intervention most effectively promotes perineal comfort for the client? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using hydrocortisone cream to relieve pain Correct

Witch hazel wipes may be effective in relieving the pain associated with anal fissures. Enemas should be avoided when an anal fissure is present. Cold packs should be applied to acute inflammation to diminish discomfort. Bulk-forming agents should be used to decrease pain associated with defecation.

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the client to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." Correct C. "Take an over-the-counter antidiarrheal medication." D. "Contact your provider for an antibiotic medication."

Clients should be taught to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

A client admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this client? A. Applying hydrocortisone cream B. Cleaning the area with soap and hot water C. Using sitz baths three times daily Correct D. Wearing absorbent cotton underwear

Clients with skin breakdown may use sitz baths for comfort 2 or 3 times daily. Barrier creams, not hydrocortisone creams, may be used. The skin should be cleaned gently with soap and warm water. Absorbent cotton underwear helps keep the skin dry, but is not a comfort measure.

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? A. Bacteria on the client's hands B. Ingestion of parasites in the water Correct C. Insufficient vaccinations D. Overcooked food

A main cause of gastroenteritis when traveling outside the country is ingestion of water that is infested with parasites. Bacteria on the client's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for a complete blood count and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Correct

Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be rapidly administered rectally, and blood draws and stool specimen collection should be implemented rapidly, but prevention and treatment of dehydration are the priorities for this client.

A client with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The client asks the nurse how this is helpful for improving symptoms. How does the nurse reply? A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." Correct B. "It provides key nutrients and extra calories to promote healing." C. "It is bland and reduces the secretion of gastric acids." D. "It does not contain caffeine or other GI tract stimulants."

For less severe exacerbations, an elemental or semi-elemental product such as Vivonex PLUS may be prescribed to induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest. Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol should be avoided, but this is not the reason for using Vivonex PLUS.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? A. Having a home health consultation for wound care Correct B. Requesting an antianxiety medication C. Requesting pain medication for the client's osteoarthritis D. Placing the client in a skilled nursing facility for rehabilitation

Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited. No indication suggests that the client is experiencing anxiety regarding postoperative care. Pain medication may be needed for the client's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the client can remain in his or her home with sufficient support services.

A certified Wound, Ostomy, and Continence Nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Call the health care provider if your stoma has a bluish or pale look." Correct C. "Notify the health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the health care provider must be notified immediately. It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the client will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A client who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Proper handwashing techniques to avoid cross-contamination of the client's wound C. The amount of pain medication that the client is allowed to take in each dose D. Written and oral instructions regarding symptoms to report to the health care provider Correct

It is most important to provide the client and case manager with both written and oral instructions on reportable symptoms to avoid the development of complications. Although instruction on proper handwashing and the client's medication regimen are important, they are not the highest priority. It will be the home health nurse's responsibility to bring supplies to the client's home.

A client is admitted with severe viral gastroenteritis caused by norovirus. The client asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? A. "You may have contracted it from an infected infant." B. "You may have consumed contaminated food or water." Correct C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne. Campylobacter can be transmitted by contact with infected infants or animals. Escherichia coli may be spread via animals and contaminated food, water, or fomites. HIV may be spread via the blood, but not norovirus. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? A. Instructing the client about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the client's medicine cabinet C. Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions Correct D. Teaching the client how to clean the perineal area after each loose stool

Obtaining the client's blood pressure and heart rate is included in the education of home health aides and other UAP. Client teaching and medication administration are complex skills that should be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A client with ulcerative colitis is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? A. Corticosteroid therapy will be stopped. B. Sulfasalazine (Azulfidine) will be stopped. C. Corticosteroid therapy will be tapered. Correct D. Sulfasalazine (Azulfidine) will be tapered.

Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in clients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the client's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A. A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place Correct

The ICU nurse is familiar with the care of a client with peritonitis, including monitoring for complications such as sepsis and kidney failure. The client with CD who has a draining enterocutaneous fistula, the client with UC who needs discharge teaching, and the client with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for clients with their respective disorders.

Which client does the charge nurse assign to an experienced LPN/LVN? A. A 28-year-old who requires teaching about how to catheterize a Kock ileostomy B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy Correct C. A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 D. A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin. Teaching about how to catheterize a Kock ileostomy, assessing the client with UC with a high white blood cell count, and monitoring the client with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." Correct B. "This is something that you will have to discuss with your health care provider." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal.

The RPC-IPAA has become the most effective alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months. Telling the client that he or she will have to discuss it with the health care provider evades the question; the nurse can give generalities to the client based on past practice and available data. The time that the client has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch should heal in 1 to 2 months, not 6 months; this estimate is not based on the expected outcome.

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? A. Pain when coughing B. States, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" Correct D. Temperature of 100.8° F (38.2° C).

The client feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence; the nurse should immediately assess the wound and notify the health care provider. Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8° F (38.2° C) all require further assessment or intervention, but are not as great a concern as the possibility of wound dehiscence for this client.

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's Correct D. Supine

The client is maintained in semi-Fowler's position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion. High-Fowler's position would be too high for the client postoperatively; it would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position would not enhance the client's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion; the client would be more likely to develop complications (wound drainage stasis and atelectasis) in this position.

A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." Correct B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

The client should avoid being around large crowds to prevent developing an infection. The client should not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client should not experience difficulty with wound healing while taking adalimumab. The client should not experience a decrease in blood pressure from taking this drug.

A client demonstrates the manifestations of diverticulitis with a suspected complication of peritonitis. What is the priority nursing intervention? A. Assessing the client for changes in vital signs B. Medicating the client for pain C. Monitoring for changes in the client's mentation D. Preparing the client for emergency surgery Correct

The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed. It is expected that the client will experience changes in vital signs as a result of the infectious process and accompanying pain. Although monitoring the client's vital signs is important, the client has an immediate need to go to surgery. Medicating the client for pain and determining whether the client is experiencing changes in mentation are important, but are not the highest priority.

The RN receives a change-of-shift report about four clients. Which client does the nurse assess first? A. A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F Correct C. A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

This client with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed. The client with UC who had six liquid stools, the client whose colostomy bag does not have any stool in it, and the client who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications. The client with possible appendicitis has a life-threatening emergency.