Chapter 24: Nursing Management: Patients With Intestinal and Rectal Disorders

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." Explanation: 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.

A nurse is teaching an older adult 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." Explanation: 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.

A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?

A change in bowel habits Explanation: Although abdominal distention and blood in the stool (frank or occult) may be present, the chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Abdominal pain is a late sign.

A community health nurse is performing a home visit to a 53-year-old patient who requires twice-weekly wound care on her foot. The patient mentions that she is currently having hemorrhoids, a problem that she has not previously experienced. What treatment measure should the nurse recommend to this patient?

A high-fiber diet with increased fruit intake Explanation: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment necessary to promote the passage of soft, bulky stools to prevent straining. It is unnecessary to avoid showering, and antibiotics are not an effective treatment.

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition?

Anal fissure Explanation: Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?

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

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

The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?

Borborygmus Explanation: Borborygmus is the intestinal rumbling caused by the movement of gas through the intestines that accompanies diarrhea. Tenesmus refers to ineffectual straining at stool. Azotorrhea refers to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.

A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?

Chronic constipation with sporadic bouts of diarrhea Explanation: Most clients with irritable bowel syndrome (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 caring for a patient who is postoperative day 3 following bowel resection and the creation of a colostomy. While changing the dressing, the nurse notes the stoma is dusky in color. How should the nurse interpret this assessment finding?

Circulation to the stoma is compromised. Explanation: Postoperative complications following colon resection may include hemorrhage, infection, and anastomosis. A healthy viable stoma should be pink. This does not indicate that the patient's oxygen saturation is low or that the stoma is blocked.

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. Explanation: 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.

A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see?

Constipation Explanation: Orthostatic hypertension and other conditions associated with persistently high intra-abdominal pressure (such as pregnancy) can lead to hemorrhoids. The passing of hard stools, not diarrhea, can aggravate hemorrhoids. Diverticulosis has no relationship to hemorrhoids. Rectal bleeding is a symptom of hemorrhoids, not a predisposing condition.

The nurse is caring for a 77-year-old patient diagnosed with Crohn's disease. What would be especially important to monitor this patient for?

Dehydration Explanation: Elderly patients can become dehydrated quickly and develop low potassium levels (i.e., hypokalemia) as a result of diarrhea. The nurse observes for clinical manifestations of muscle weakness, dysrhythmias, or decreased peristaltic motility that may lead to paralytic ileus. All options would be important to monitor, but especially important is monitoring for dehydration.

What information should the nurse include in the teaching plan for a client being treated for diverticulosis?

Drink at least 8 to 10 large glasses of fluid every day Explanation: The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client 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, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.

An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?

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

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?

Increasing fluid intake to prevent dehydration Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

Which is the most prominent sign of inflammatory bowel disease?

Intermittent pain and diarrhea Explanation: 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.

The nurse is aware that many of the diseases of the lower gastrointestinal tract can be identified by the characteristics of the patient's stool. What would voluminous, greasy stools suggest?

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

As part of the management of constipation, the client is instructed to take 30 mL of mineral oil orally. How does mineral oil facilitate bowel evacuation?

Lubricates and softens fecal matter Explanation: Mineral oil is used to soften impacted stool in the management of constipation. It coats the surface of stool and intestine with a lubricant film to allow passage of stool through the intestine. Mineral oil also improves water retention of stool, thereby softening stool and facilitating bowel evacuation. Mineral oil does not work by irritating nerve endings in the intestinal mucosa. Saline cathartics, such as magnesium sulfate and citrate, increase the volume of intestinal content, thus stimulating evacuation.

Which of the following is considered a bulk-forming laxative?

Metamucil Explanation: Metamucil is a bulk-forming laxative. Milk of Magnesia is classified as a saline agent. Mineral oil is a lubricant. Dulcolax is a stimulant.

A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?

Nausea and vomiting Explanation: Nausea and vomiting are symptoms of a small bowel obstruction. Decrease in urine production and mucosal edema are not symptoms of a bowel obstruction. The patient may defecate mucus, but this is not accompanied by stool.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. Explanation: A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

The nurse is caring for a client with diarrhea. For which finding will the nurse suspect the diarrhea is caused by pancreatic insufficiency?

Oil droplets on the toilet water Explanation: Symptoms of diarrhea depend upon the cause and the severity of the diarrhea. Oil droplets on the toilet water may be suggestive of pancreatic insufficiency. Nocturnal diarrhea is associated with diabetic neuropathy. Voluminous greasy stools are associated with malabsorption. Blood, mucus, and pus in the stool is associated with inflammatory enteritis or colitis.

A 16-year-old girl presents at the emergency department complaining of right lower quadrant pain and is diagnosed with appendicitis. When assessing this patient, what signs or symptoms should the nurse expect to find?

Rebound tenderness, McBurney's sign, low-grade fever Explanation: Rebound tenderness, McBurney's sign (pain midway between umbilicus and right iliac crest), and a low-grade fever are all signs of appendicitis. Other clinical findings include a rigid abdomen, a preference to lie still with right leg flexed, right lower quadrant pain, muscle guarding, periumbilical pain, anorexia, nausea, and vomiting. The other findings are not signs of appendicitis. A patient with appendicitis would not have Levine's sign, Chvostek's sign (tetany), or Trousseau's sign (tetany).

When the nurse interviews a client with internal hemorrhoids, what would the nurse expect the client to report?

Rectal bleeding Explanation: Internal hemorrhoids often cause bleeding but are usually not painful. Severe pain is associated with external hemorrhoids, due to the inflammation and edema caused by thrombosis. Pus is associated with an anorectal abscess or anal fistula. While straining against hard stools due to constipation is one potential cause of hemorrhoids, there are many other causes including chronic diarrhea, pregnancy, prolonged sitting, and others.

Which of the following is the most common symptom of a polyp?

Rectal bleeding Explanation: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.

The nursing educator is teaching a group of nurses about constipation and the elderly. What recommendation for this population should a nurse can make about treating chronic constipation?

Take a stool softener, such as docusate sodium (Colace), daily. Explanation: 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 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.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?

The client exhibits signs of adequate GI perfusion. Explanation: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

A client reports taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?

They can be habit forming and will require increasing doses to be effective. Explanation: The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.

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

Usual pattern of elimination Explanation: Constipation has many possible causes and assessing the client'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 client's current medications, diet, and activity levels.

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a:

fissure. Explanation: 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. Hemorrhoids are dilated veins outside or inside the anal sphincter. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus.

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for:

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

The nurse is caring for an older adult client with enteritis who reports frequent diarrhea. Which assessment finding should the nurse anticipate?

metabolic acidosis Explanation: Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis. Diarrhea leads to hypokalemia. Elevated neutrophils are associated with infection and not frequent diarrhea. Rovsing sign is associated with appendicitis.

Which client requires immediate nursing intervention? The client who:

presents with a rigid, board-like abdomen. Explanation: 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 periumbilical 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 ribbonlike stools.

The nurse is caring for a client with a mechanical intestinal obstruction who is at risk for perforation. For which finding(s) should the nurse monitor the client? Select all that apply.

sudden, sustained abdominal pain abdominal distention fever Abdominal distention, fever, and sudden, sustained abdominal pain are the symptoms of perforation in a client with intestinal obstruction. High-pitched bowel sounds above the obstructed area are consistent with a mechanical obstruction, not a perforation. The client may also experience severe intermittent cramping during a mechanical obstruction.

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:

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