Chapter 57: Care of Pts With Inflammatory Intestinal Disorders

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

B. Rationale: The likely cause of gastroenteritis when a patient travels outside the country is ingestion of water that is infested with parasites.Bacteria on the patient'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 patient with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary 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.

D. Rationale: The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for patients with gastroenteritis. Older patients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure.Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this patient.

Complications of celiac disease

cancer (non Hodgkins lymphoma) and nutritional deficits

Appendicitis

inflammation of the appendix evidenced by RLQ pain caused by an obstructed lumen that causes infection

Gastroenteritis

inflammation of the mucus membranes of the stomach and intestinal tract (secondary to a viral or bacterial infection)

Diverticulitis

inflammation or infection of the diverticula

Signs of uncomplicated diverticulosis

intermittent LLQ pain and constipation

Surgical treatment for UC

restorative or total proctolectomy

Surgical treatment of Crohn's disease

small bowel resection, ileocecal resection, dilate narrowed area to open things up

Labs to run for peritonitis

CBC, H&H, CMP (creatinine and BUN), blood cultures, and ABG

Treatment of anorectal abscess

incision and drainage

Symptoms of anal fistula

pruritus, duscharge, pain (worse with BM because of pressure)

Peritonitis

acute inflammation and infection of the peritoneum

Nonsurgical interventions for peritonitis

manage pain, check vitals frequently, and antibiotics

Celiac disease

chronic inflammation of the small intestine mucosa secondary to autoimmune disease, genetics, or environmental factors

A male patient 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." 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 primary health care provider before you attempt to have intercourse."

A.

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

A.

A patient diagnosed with ulcerative colitis (UC) 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 signs/symptoms of toxic megacolon that we discussed." B. "If diarrhea increases, you must let your primary health care provider know." C. "You must avoid pregnancy." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

A. Rationale: 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 patient with a history of osteoarthritis has a 10-inch (25.5 cm) incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the patient's care does the nurse make certain to discuss with the primary health care provider before the patient's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the patient's osteoarthritis D. Placing the patient in a skilled nursing facility for rehabilitation

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

Labs to run for Crohn's disease

CMP, CBC, folic acid, B12, albumin, CMP, and urinalysis

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

B.

A Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a patient 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 your primary health care provider if your stoma has a bluish or pale look." C. "Notify the primary health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

B. Rationale: If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary 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 patient will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A patient is admitted with severe viral gastroenteritis caused by norovirus. The patient 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." C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

B. Rationale: 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, not novovirus, can be transmitted by contact with infected infants or animals. Escherichia coli, not novovirus, may be spread via animals and contaminated food, water, or fomites. HIV, not novovirus, may be spread via the blood. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

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

B. Rationale: Patients with CD can have 5-6 soft, loose stools per day, but they are nonbloody. Five to six stools daily is common with CD, not 20 loose, bloody stools. The peak incidences of UC are between 30 and 40 years and again at 55 to 65 years of age, and not just 15 to 40 years of age. Fistulas commonly occur as a complication of CD.

A nurse is teaching a patient about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advice the patient? 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." 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."

B. Rationale: The nurse teaches the patient that the most effective way to manage diverticulitis is to consume 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 nor 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.

A patient 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 patient to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." C. "Take an over-the-counter antidiarrheal medication." D. "Contact your primary health care provider for an antibiotic medication."

B. Rationale: The nurse tells the patient 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 patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs/symptoms are most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees, constipation B. Chronic diarrhea, abdominal colicky pain, and fever C. Epigastric cramping & persistent rectal bleeding D. Hypotension with vomiting and headache

B. Rationale: These signs/symptoms are more specific to CD than any of the other acute inflammatory bowel disorders.Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a sign/symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

A patient 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 patient whether family members could be trained in stoma care B. Has another patient with a stoma who performs self-care talk with the patient C. Requests that the primary health care provider request antidepressants and a psychiatric consult D. Suggests that the primary health care provider request a home health consultation so stoma care can be performed by a home health nurse

B. Rationale: When a patient with a recently created ileostomy refuses to look at the stoma and wants the nurse to perform all required stoma care, the nurse has another patient with a stoma who performs self-care talk with the patient.If at all possible, the patient would perform stoma care so that he or she can be as independent as possible. Although the patient may need medication for depression, the priority is to encourage the patient 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 patient will need.

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

C. Rationale: An important comfort measure for a patient admitted with severe diarrhea experiencing skin breakdown is using sitz baths three times daily.Barrier creams, not hydrocortisone creams, may be used. The skin would be cleaned gently with soap and warm, not hot, water. Absorbent cotton underwear helps keep the skin dry but is not a comfort measure.

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

C. Rationale: The nurse expects that corticosteroid therapy will be tapered as the UC improves in the patient who was taking both sulfasalazine and corticosteroids. 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 patients. 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 patient's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient 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." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

C. Rationale: The nurse teaches the newly diagnosed patient with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet. Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC.

An obese patient is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the patient'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" D. Temperature of 100.8°F (38.2°C).

C. Rationale: The patient feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence. The nurse must immediately assess the wound and notify the primary 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 patient.

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

C. Rationale: The patient is maintained in this 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 patient postoperatively. It would place strain on the abdominal incision(s), and, if the patient was still drowsy from anesthesia, this position would not enhance the patient'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 patient would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position.

Labs to run for UC

CBC, c reactive protein, erythrocyte sedimentation rate, CMP, albumin, and stool sample

A patient who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The patient 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 patient's wound C. The amount of pain medication that the patient is allowed to take in each dose D. Written and oral instructions regarding signs/symptoms to report to the primary health care provider

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

A patient has an anal fissure. Which intervention most effectively promotes perineal comfort for the patient? 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

D. Rationale: The intervention that most effectively promotes perineal comfort in a patient with anal fissure is using hydrocortisone skin cream to relieve perineal pain.Enemas would be avoided when an anal fissure is present. Cold packs would be applied to acute inflammation to diminish discomfort. Bulk-forming agents would be used to decrease pain associated with defecation.

Sources of peritonitis infection

E. coli, strep, staph, pneumococcus, and gonococcus

Diverticulitis symptoms

LLQ pain, low grade fever, nausea, constipation, rectal bleeding, distention, rebound tenderness, and guarding

Symptoms of parasitic infection

abdominal tenderness, nausea, vomiting, diarrhea, fever, and bloody stools

Diagnostic tests for peritonitis

abdominal x-ray, CT, and ultrasound

Anal fistula

abnormal tract between the anal canal and external perianal skin, most often secondary to abscess

Treatment for parasitic infection

amebicide drugs, IV fluids for flush, and intestinal motility agents to get the bowel moving and get the parasite out

Symptoms of celiac disease

anorexia, diarrhea and/or constipation, steatorrhea, abdominal pain, bloating/distention significant with gluten foods

Interventions for diverticular disease

antimicrobials, pain control, avoid straining, NPO, low fiber diet, and surgery

Peritonitis is most often due to....

bacterial or chemical contamination of the peritoneal cavity

Enteroenteric fistula

between 2 sections of the intestine

Enterovesical fistula

between the bowel and bladder.

Enterocutaneous fistula

between the intestine and the external skin (seep intestinal contents outside the abdominal wall through the skin)

Enterovaginal fistula

between the intestine and the vagina (intestinal contents seeping out of the vagina)

Crohn's disease

chronic inflammation of primarily the small intestine but can also be the colon that can cause a thickened bowel wall

Ulcerative colitis

chronic inflammation of the large intestine that has periods of remission and exacerbation

Antidiarrheals with UC

control diarrhea, be careful they can cause megacolon

Glucosteroids for UC

decrease inflammation (only short tern)

Immunomodulators for UC

decreased immune response to reduce inflammation

Diverticulosis

diverticula in the wall of the intestine specifically

Surgical treatment for peritonitis

exploratory laparotomy, laparoscopy

History to gather for assessment of UC

family history, nutrition, bowel patterns, pain, tenderness, sudden urge to defecate, and weight loss

Steatorrhea

fatty stool

Ulcerations that develop with Crohn's disease can increase the risk for...

fistula development

Treatment for anal fistula

fistulotomy

Third spacing (complication of peritonitis)

fluid shifts from the extracellular into the abdominal cavity causing increased abdominal pressure

Treatment for celiac disease

gluten free diet and vitamin and mineral supplements

How can you prevent parasitic infections?

hand washing

Assessment for gastroenteritis

history of recent travel, dietary intake, abdominal assessment, signs and symptoms of fluid volume deficit

Intervention for gastroenteritis

hydration (IV or oral), antibiotics if indicated, and prevent transmission

When can appendicitis become life-threatening?

if not treated within 24-36 hours

Anorectal abscess

inflamed localized area of pus in the soft tissue of the rectum or anus, most often secondary to obstruction of the ducts of anorectal glands

Diagnostic tests for UC

magnetic resonance enterography (MRE), EGD, colonoscopy, CT, and barium enema

Nonsurgical management of Crohn's disease

medications similar to UC, diet management, fistula management

Nonsurgical treatment for UC

monitor skin integrity, daily weights, drug therapy, bowel rest, diet control, and holistic care

Parasitic infections occur due to

oral-fecal, oral-anal, or fecal exposure

Treatment of anal fissure

pain relief, stool softeners, bulk forming laxatives, sits baths, and surgery

Assessment for appendicitis

pain, abdominal assessment, look at McBurney's point and rebound tenderness, labs, CT scan, and ultrasound

Symptoms of anal fissure

pain, bloody stool, pruritus, urinary alterations, and dyspareunia

Signs and symptoms of Crohn's disease

pain, diarrhea, steatorrhea, bright red blood in stool (inflammation), and low grade fever

Signs and symptoms of peritonitis

pain, tenderness, abdominal distention, hypoactive or absent bowel sounds, fear, and anxiety

Parasitic infection

parasites that invade the GI tract

Causes of peritonitis

perforation, penetrating wound, bowel obstruction, genital tract infection, surgery, and peritoneal dialysis

Complications of appendicitis

peritonitis, sepsis, and septic shock

Assessment for parasitic infection

recent travel, diet, bowel patterns, fatigue, weight loss, never

Symptoms of anorectal abscess

rectal pain, swelling, redness, discharge, bleeding, pruritis, and fever

Aminosalicylates for UC

reduce inflammation of the intestinal lining

Diverticular disease

small bulging pouches that can form in the mucosal lining of the digestive system; occur in weakened areas of the intestinal wall

Anal fissure

tear of the anal lining due to straining, chronic anorectal disease, or trauma (insertion)

Complications of peritonitis

third spacing, hypovolemic shock, sepsis, septic shock, and respiratory insufficiency

Complications of diverticular disease

trapped food particles, abscesses, perforation, peritonitis, and GI bleed

Causes of ulcerative colitis

unknown, but possible genetic, immunologic, and/or environmental

Diagnostics for Crohn's disease

x-ray and MRE