Chapter 47: Management of Patients With Intestinal and Rectal Disorders

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? • Watery with blood and mucus • Hard and black or tarry • Dry and streaked with blood • Loose with visible fatty streaks

Ans: A Feedback: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in patients who have ulcerative colitis.

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

Ans: B, D Feedback: Patients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which of the following? • White blood cell level • Creatinine level • Hemoglobin level • Potassium level

Ans: D Feedback: In elderly patients, it is important to monitor the patients serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels.

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer? • Development of new hemorrhoids • Abdominal bloating and flank pain • Unexplained weight gain • Change in bowel habits

Ans: D Feedback: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.

A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize? • Ineffective Tissue Perfusion Related to Bowel Ischemia • Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption • Anxiety Related to Bowel Obstruction and Subsequent Hospitalization • Impaired Skin Integrity Related to Bowel Obstruction

Ans: A Feedback: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.

A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal? A. Patient will accurately identify foods that trigger symptoms. B. Patient will demonstrate appropriate care of his ileostomy. C. Patient will demonstrate appropriate use of standard infection control precautions. D. Patient will adhere to recommended guidelines for mobility and activity.

Ans: A Feedback: A major focus of nursing care for the patient with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the patient than managing physical activity.

A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug? • Acyclovir (Zovirax) • Doxycycline (Vibramycin) • Penicillin (penicillin • Metronidazole (Flagyl)

Ans: A Feedback: Acyclovir (Zovirax) is often given to patients with viral anorectal infections. Doxycycline (Vibramycin) and penicillin (penicillin G) are drugs of choice for bacterial infections. Metronidazole (Flagyl) is used for other infections with a bacterial etiology; it is ineffective against viruses.

A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. What pharmacologic intervention should the nurse recommend to the patient for ongoing use? • Mineral oil enemas • Bisacodyl (Dulcolax) • Senna (Senokot) • Psyllium hydrophilic mucilloid (Metamucil)

Ans: D Feedback: Psyllium hydrophilic mucilloid (Metamucil) is a bulk-forming laxative that is safe for ongoing use. None of the other listed laxatives should be used on an ongoing basis because of the risk of dependence.

A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? • Insertion of a nasogastric tube • Insertion of a central venous catheter • Administration of a mineral oil enema • Administration of a glycerin suppository and an oral laxative

Ans: A Feedback: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.

A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the patients care knows that treatment will be chosen based on what risk? • Risk for infection • Risk for bowel incontinence • Risk for constipation • Risk for impaired tissue perfusion

Ans: A Feedback: Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do not contribute to bowel incontinence, constipation, or impaired tissue perfusion.

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? • High levels of alcohol consumption • History of bowel obstruction • History of diverticulitis • Longstanding psychosocial stress

Ans: A Feedback: Risk factors include high alcohol intake; cigarette smoking; and high-fact, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer.

The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen? • Anticholinergic medications 30 minutes before a meal • Antiemetics on a PRN basis • Vitamin B12 injections to prevent pernicious anemia • Beta adrenergic blockers to reduce bowel motility

Ans: A Feedback: The nurse administers anticholinergic medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease.

A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply. A. Acute Pain Related to Increased Peristalsis and GI Inflammation B. Activity Intolerance Related to Generalized Weakness C. Bowel Incontinence Related to Increased Intestinal Peristalsis D. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E. Impaired Urinary Elimination Related to GI Pressure on the Bladder

Ans: A, B, D Feedback: Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is not directly influenced.

The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? • Recurrent constipation coupled with weight loss • Foul-smelling diarrhea that contains fat • Fever accompanied by a rigid, tender abdomen • Bloody bowel movements accompanied by fecal incontinence

Ans: B Feedback: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foulsmelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize? • Close monitoring of temperature • Frequent abdominal auscultation • Assessment of hemoglobin, hematocrit, and red blood cell levels • Palpation of peripheral pulses and leg girth

Ans: B Feedback: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse.

A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale? • To treat any undiagnosed infections • To reduce intestinal bacteria levels • To reduce bowel motility • To reduce abdominal distention postoperatively

Ans: B Feedback: Antibiotics such a kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Keflex) are administered orally the day before surgery to reduce intestinal bacterial. Preoperative antibiotics are not given to treat undiagnosed infections, reduce motility, or prevent abdominal distention.

A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the patient to conduct online research into colostomies. B. Engage the patient in the care of the ostomy to the extent that the patient is willing. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

Ans: B Feedback: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image, since the benefits are likely already known. Online research is not likely to enhance the patients body image and some ostomies are permanent.

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? • Apply antibiotic ointment as ordered after cleaning the stoma. • Apply a skin barrier to the peristomal skin prior to applying the pouch. • Dispose of the clamp with each bag change. • Cleanse the area surrounding the stoma with alcohol or chlorhexidine

Ans: B Feedback: Guidelines for changing an ileostomy appliance are as follows. Skin should be washed with soap and water, and dried. A skin barrier should be applied to the peristomal skin prior to applying the pouch. Clamps are supplied one per box and should be reused with each bag change. Topical antibiotics are not utilized, but an antifungal spray or powder may be used.

During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? • Regular application of an OTC antibiotic ointment • Increased fluid and fiber intake • Daily use of OTC glycerin suppositories • Use of an NSAID to reduce inflammation

Ans: B Feedback: 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 that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.

A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids? • A 45-year-old teacher who stands for 6 hours per day • A pregnant woman at 28 weeks gestation • A 37-year-old construction worker who does heavy lifting • A 60-year-old professional who is under stress

Ans: B Feedback: Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.

A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses priority action? • Facilitate a referral to the wound-ostomy-continence (WOC) nurse. • Report signs and symptoms of obstruction to the physician. • Encourage the patient to mobilize in order to enhance motility. • Contact the physician and obtain a swab of the stoma for culture.

Ans: B Feedback: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem.

A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points? • Limit your fluid intake temporarily so you dont get diarrhea. • Avoid taking the drug on a long-term basis. • Make sure to take a multivitamin with each dose. • Take this on an empty stomach to ensure maximum effect.

Ans: B Feedback: Laxatives should not be taken on an ongoing basis in order to reduce the risk of dependence. Fluid should be increased, not limited, and there is no need to take each dose with a multivitamin. Senna does not need to be taken on an empty stomach.

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? • Spinach • Tofu • Multigrain bagel • Blueberries

Ans: B Feedback: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, lowresidue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.

A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. What discharge education topics should the nurse address with this patient? • The appropriate use of antibiotics to prevent postoperative infection • The correct procedure for taking a sitz bath • The need to eat a low-residue, low-fat diet for the next 2 weeks • The correct technique for keeping the perianal region clean without the use of water

Ans: B Feedback: Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat diet is not necessary and water is used to keep the region clean. Postoperative antibiotics are not normally prescribed.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the patient to take stool softener daily. B. Assess the patients food and fluid intake. C. Assess the patients surgical history. D. Encourage the patient to take fiber supplements.

Ans: B Feedback: The nurse should follow the nursing process and perform an assessment prior to interventions. The patients food and fluid intake is more likely to affect bowel function than surgery.

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake B. Risk for Infection Related to Possible Rupture of Appendix C. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake D. Chronic Pain Related to Appendicitis

Ans: B Feedback: The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.

A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response? A. Administer a Fleet enema as ordered and remain with the patient. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the patient supine and insert an NG tube. D. Page the primary care provider and report that the patient may be obstructed.

Ans: B Feedback: The patients change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.

A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity.

Ans: C Feedback: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.

A patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patients health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The patient should be assured that these are a normal, age-related physiologic change. C. The patients polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

Ans: C Feedback: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.

A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? • Annual screening colonoscopies • Adherence to recommended immunization schedules • Regular blood pressure monitoring • Frequent screening for osteoporosis

Ans: D Feedback: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring.

An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention? • Keep a food diary to determine the foods that exacerbate the patients symptoms. • Provide the patient with a bland, low-residue diet. • Toilet the patient on a frequent, scheduled basis. • Liaise with the primary care provider to obtain an order for loperamide.

Ans: C Feedback: Because the patients fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this patients health problem.

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

Ans: C Feedback: Bloody stool is far more common in cases of UC than in Crohns. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohns) and patients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohns often has a more prolonged and variable course.

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge? • The familys ability to take care of the patients special diet needs • The familys ability to monitor the patients changing health status • The familys ability to provide emotional support • The familys ability to manage the patients medication regimen

Ans: C Feedback: Emotional support from the family is key to the patients coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patients health status. It is highly beneficial if the family is willing and able to accommodate the patients dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.

A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function? • Use glycerin suppositories on a regular basis. • Limit physical activity in order to promote bowel peristalsis. • Consume high-residue, high-fiber foods. • Resist the urge to defecate until the urge becomes intense.

Ans: C Feedback: Goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.

A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurses most appropriate response to this observation? • Ensure that the patient knows that he or she will be responsible for care after discharge. • Reassure the patient that many people are fearful after the creation of an ostomy. • Acknowledge the patients reluctance and initiate discussion of the factors underlying it. • Arrange for the patient to be seen by a social worker or spiritual advisor.

Ans: C Feedback: If the patient is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the patient and explore the factors that underlie it. It is presumptive to assume that the patients behavior is motivated by fear. Assessment must precede referrals and emphasizing the patients responsibilities may or may not motivate the patient.

A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions? • Aim to eventually empty the pouch every 90 minutes. • Avoid emptying the pouch until it is visibly full. • Insert the catheter approximately 5 cm into the pouch. • Aspirate the contents of the pouch using a 60 mL piston syringe.

Ans: C Feedback: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes? • Preventing infection • Maintaining skin and tissue integrity • Preventing nausea and vomiting • Maintaining fluid and electrolyte balance

Ans: D Feedback: All of the listed focuses of care are important for the patient with a small bowel obstruction. However, the patients risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.

A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate? • Reassure the patient that the procedure is relatively low risk and that patients are usually successful in adjusting to an ostomy. • Provide the patient with educational materials that match the patients learning style. • Encourage the patient to write down these concerns and questions to bring forward to the surgeon. • Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomycontinence (WOC) nurse.

Ans: D Feedback: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for patients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the patients psychosocial and learning needs. Reassurance does not address the patients questions, and education may or may not alleviate anxiety.

Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy? • Risk for Unstable Blood Glucose Due to Changes in Digestion and Absorption • Unilateral Neglect Related to Decreased Physical Mobility • Risk for Excess Fluid Volume Related to Dietary Changes and Changes In Absorption • Ineffective Sexuality Patterns Related to Changes in Self-Concept

Ans: D Feedback: The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the physiologic changes that result from colorectal surgery.

A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient? • Administering bowel stimulants as ordered • Administering bulk-forming laxatives as ordered • Performing deep palpation as ordered to promote peristalsis • Preparing the patient for surgical bowel resection

Ans: D Feedback: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.