Ch 48 Intestinal & Rectal Disorders

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct to identify the cause of constipation? Choose the correct option.

Review the client's usual pattern of elimination. Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.

A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?

Lack of free water intake A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation. Poor fluid intake is the most likely cause.

The nurse is monitoring a patient's postoperative course after an appendectomy. The nurse's assessment reveals that the patient has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse's report to the physician is that the patient has signs/symptoms of which of the following complications?

Peritonitis The nurse should report to the physician that the patient has signs/symptoms of peritonitis. Signs/symptoms of a pelvic abscess include anorexia, chills, fever, diaphoresis, and diarrhea. Signs/symptoms of an ileus include absent bowel sounds, nausea, and abdominal distention. Signs/symptoms of hemorrhage include tachycardia, hypotension, anxiety, and bleeding.

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?

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

A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?

The consistency of stool and comfort when passing stool In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination. People differ greatly in their bowel habits and normal bowel patterns range from three bowel movements per day to three bowel movements per week. It is important for the stool to be soft to pass without pain. The client may not be able to fully evacuate with a bowel movement; it may take time.

A 43-year-old man is seen in the office where you work with complaints of severe pain and bleeding while having a bowel movement. Upon inspection, his healthcare provider notes a linear tear in the anal canal tissue. While reviewing with him the medical management for his condition, he asks you to repeat the name of the condition. The nurse will most likely tell him that he has been diagnosed with a ________.

fissure An anal fissure (fissure in ano) is a linear tear in the anal canal tissue. An anal fistula (fistula in ano) is a tract that forms in the anal canal. The condition described is known as a fissure. Hemorrhoids are dilated veins outside or inside the anal sphincter. The condition described is known as a fissure. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus. The condition described is known as a fissure.

Which client requires immediate nursing intervention? The client who:

presents with a rigid, board-like abdomen. A rigid, board-like abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and peri-umbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbon-like stools.

A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:

Intestinal malabsorption. Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

Right lower quadrant The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium (Colace) daily. Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?

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

A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Select all that apply.

• Do not suppress the urge to defecate. • Drink at least 8 to 10 large glasses of fluid every day. Avoid constipation. Do not suppress the urge to defecate. Consume at least 2 L/day (within limits of the client's cardiac and renal reserve) and include foods that are soft but have increased fiber, such as prepared cereals or soft-cooked vegetables, to increase the bulk of the stool and facilitate peristalsis, thereby promoting defecation. Avoid the use of laxatives or enemas except when recommended by the physician. Exercise regularly if the current lifestyle is somewhat inactive.

Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution?

0.9% NS The administration of several liters of an isotonic solution is immediately prescribed. Hypovolemia occurs because massive amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space.

After assessing a client with peritonitis, the nurse most likely would document the client's bowel sounds as:

Absent. Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.

Mr. Munster, a client in the primary care office where you work, reports having increased incidence of constipation. You complete your assessment and discuss the potential causes with Mr. Munster. What can cause constipation? a) Insufficient fiber b) Emotional stress c) All options are correct. d) Inactivity

All options are correct. Constipation may result from insufficient dietary fiber and water, ignoring or resisting the urge to defecate, emotional stress, use of drugs that tend to slow intestinal motility, or inactivity. It may stem from several disorders, either in the GI tract or systemically.

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?

Borborygmus Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.

The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits The chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Excess gas, daily bowel movements, and abdominal cramping when having a bowel movement are not indicators of colon cancer.

Which of the following is the most common presenting symptom of colon cancer?

Change in bowel habits The most common presenting symptom is a change in bowel habits. Fatigue, anorexia, and weight loss may occur, but are not the most common presenting symptom.

A patient informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The patient states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?

Chronic constipation with sporadic bouts of diarrhea Most clients with IBS describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.

The nurse is conducting discharge teaching for a patient with diverticulosis. Which of the following should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily. The nurse should instruct a patient with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The patient should include unprocessed bran in the diet because it adds bulk and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, the patient should exercise regularly if his or her current lifestyle is somewhat inactive.

The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness?

Endoscopy with mucosal biopsy Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR.

Which of the following is the most prominent sign of inflammatory bowel disease?

Intermittent pain The most prominent symptom is intermittent pain that occurs with diarrhea but does not decrease after defecation. Abdominal distention, hyperactive bowel sounds, and increased peristalsis are not the most prominent signs.

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?

Low residue Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity Fecal incontinence can disrupt perineal skin integrity. Maintaining skin integrity is a priority, especially in the debilitated or older adult patient.

Vomiting results in which of the following acid-base imbalances?

Metabolic alkalosis 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.

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:

Peritonitis Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections.

When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?

Rectal bleeding Internal hemorrhoids cause bleeding but are less likely to cause pain, unless they protrude through the anus. External hemorrhoids may cause few symptoms, or they can produce pain, itching, and soreness of the anal area.

Effie Geitgey, a 93-year-old retired waitress, obsesses about the regularity of her bowel movements, which is a common complaint among the residents of the long-term care facility where you practice nursing. During one of your education sessions, you reinforce the medically acceptable definition of "regularity." What is the actual measurement of "regular"?

Stool consistency and client comfort are the proper measurements. Normal bowel patterns range from three bowel movements per day to three bowel movements per week. In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination.

Which of the following is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance. The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.

A patient diagnosed with colon cancer presents with the characteristic symptoms of a left-sided lesion. Which of the following symptoms are indicative of this disorder? Select all that apply.

• Narrowing stools • Constipation • Abdominal distention Melena and dull abdominal pain are associated with right-sided lesions. The other symptoms are found with left-sided lesions.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

"At first, the stoma may bleed slightly when touched." The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown. (less)

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." The client stating that he ate roast beef on rye bread indicates the need for a dietary consult because rye bread contains gluten, which must be eliminated from the client's diet. The client stating that he's followed the ordered medication regimen and diet doesn't suggest that the client needs a dietary consult; a treatment regimen consisting of medications to improve symptoms and dietary modification is necessary to treat celiac disease. The client stating that he hasn't traveled outside of the country doesn't suggest that dietary concerns exist. The client saying that he can't have oatmeal shows an understanding of the dietary restrictions necessary with celiac disease.

The nurse is assessing a patient for constipation. Which of the following is the first factor the nurse should review to identify the cause of constipation?

Usual pattern of elimination Constipation has many possible reasons and assessing the patient's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the patient's current medications, diet, and activity levels.

The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred?

Wound dehiscence has occurred. Any suggestion from the patient that an area of the abdomen is tender or painful or "feels as if something just gave way" must be reported. The sudden occurrence of serosanguineous wound drainage strongly suggests wound dehiscence

Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?

Diarrhea The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.

The nurse is reinforcing diet teaching for a patient s diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet?

High-fiber diet A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants, such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, and alcohol, should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

The nurse is admitting a patient with a diagnosis of diverticulitis and assesses that the patient has a board-like abdomen, no bowel sounds, and complains of severe abdominal pain. What is the nurse's first action?

Notify the physician. Abdominal pain, a rigid board-like abdomen, loss of bowel sounds, and signs and symptoms of shock occur with peritonitis. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections; thus, the nurse should notify the physician.

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation." The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.

The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?

Clamp the tubing and give the patient a rest period. When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.

The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation?

Dry skin thoroughly after washing The nurse should teach the patient without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, Kenalog spray, and nystatin powder are used when there is peristomal skin irritation and/or fungal infection.

A patient with an ileostomy should avoid which of the following?

Enteric-coated products Patients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and layered tablets. This is because these products may pass through without being absorbed. Preparations such as slow-K (potassium chloride) leave a "ghost" of the wax matrix coating, but that does not indicate the drug has been unabsorbed. It is not essential for the patient to avoid antacids and antibiotics if they have been prescribed.

The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?

Familial polyposis Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Being older than age 40 is a risk factor for colorectal cancer. A high-fat, high-protein, low-fiber diet is a risk factor for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.

Diet therapy for patients diagnosed with IBS include which of the following?

High-fiber diet A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, alcohol should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

Celiac sprue is an example of which category of malabsorption?

Mucosal disorders causing generalized malabsorption In addition to celiac sprue, regional enteritis and radiation enteritis are examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small bowel bacterial overgrowth, tropical sprue, and Whipple's disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection can result in development of malabsorption syndromes.

A client comes to the clinic complaining of not having a bowel movement in several days, abdominal cramping, and nausea. When the nurse puts the client on the stretcher, he vomits a large amount of fecal material. What should the first action by the nurse be?

Notify the physician. The physician should be notified immediately to examine the client because the client is exhibiting signs of an intestinal obstruction. Starting the IV and inserting a nasogastric tube would be interventions that the physician will order after seeing the client. The nurse does not insert intestinal tubes.

A client has noticed increased incidence of constipation since he broke his ankle and cannot complete his daily 3-mile walk. As his home care nurse, you complete your assessment and discuss the potential causes. During your client education session, what do you explain as the mechanical cause of his constipation?

Stool remaining in the large intestine too long Whenever stool remains stationary in the large intestine, moisture continues to be absorbed from the residue. Consequently, retention of stool, for any number of reasons, causes stool to become dry and hard. This would be caused by stool remaining in the large intestine too long.

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find:

severe abdominal pain with direct palpation or rebound tenderness. Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.