NURS 4 Exam 1 IBD
Exudate phase
Serous/ serosanguinous exudate= from surgery Clear exudate= somebody that has allergies Purulent exudate= somebody that has an infection
Sigmoidoscopy
the endoscopic examination of the interior of the rectum, sigmoid colon, and possibly a portion of the descending colon
The most common site of inflammation for Crohn's disease
the most common site is the ileum -But it can be anywhere in the GI tract from the mouth to the rectum -The anatomy and physiology should help us to identify
Ulcerative colitis clinical manifestations
-Bloody mucus diarrhea -liquid/ semi formed stools -Nocturnal diarrhea -LLQ cramping -Anemia -Hypovolemia -Malnutrition
Crohn's disease pathophysiology/ etiology
-Chronic inflammation of the GI mucosa occurring anywhere from mouth to anus -Lesions have cobblestone appearance -Peak onset is between 15-30 years old -Crohn's disease is chronic and it affects any area in the GI tract and what is very annoying with Crohn's is that its a patchy type of manifestation of a disease process -so it can be at beginning of the intestine, somewhere in the colon, somewhere in the stomach, ■ so it's just a patchy disease ● Crohn's disease has a cobblestone appearance
Barium enema
-If the disease process happens anywhere in the GI tract then you can think that there might be a barium swallow as well ■ The patient needs to drink that contrast and then they will take pictures and with that you want to make sure the person is very well hydrated so that they can get rid of the barium or else they will have an infection. The patient already has a fragile GI tract so you don't really want that.
Iron test for IBD
-Is part of the nutrients because of the patient doesn't have any iron they may not be able to produce sufficient red blood cells and with ulcerative colitis they have a tendency to bleed
How does toxic megacolon occur in UC
-Obstruction perforation -Toxic megacolon does not happen very often. -In the picture, the toxic megacolon occurs because of C.DIFF ■ When the colon is inflamed and enlarges, paralysis occurs and nothing is able to move which makes things worse and the lining of the colon worse and there's perforation but it's not a very common complication
How does strictures occur in UC
-Obstruction, perforation -So the fibrous tissue does not have as much elasticity as the epithelial cells and so if we constantly aggress it; patients are more likely to develop a perforation -If the strictures becomes narrower and narrower then you will have an obstruction ■ It is like you have a hose that water keeps on backing up into and if you keep it long enough with time the hose there will be holes and there will be water squirting from different areas
How does colonic dilation occur in UC
-Perforation -This can happen from the inflammation and if the colon dilates then it can perforate and that will lead to rupture. When rupture happens then the content of the colon spreads into the stomach. ■ when there is perforation of the contents of the colon, it will spread into the abdominal cavity (peritoneum) and then the patient will have an infection and the patient become septic
How does perforation/ ruptured bowel occur in UC
-Septic shock -Death -This can happen from the inflammation and if the colon dilates then it can perforate and that will lead to rupture. When rupture happens then the content of the colon spreads into the stomach.
Surgical indications for IBD
-Sometimes when patients have surgery because they need to have a resection for instance a colectomy -They have to remove the diseased part of the intestine to minimize complications ■ One of the complications is cancer ● If it is becoming chronic then they are going to remove that particular area and so depending on the extent of the surgery they may have to allow the patient to rest for six weeks and you still have to make sure that the patient is fed during those six weeks and the TPN will be started and that's where your patient will go home with a PICC (peripheral central line).
Crohn's disease complications
-Strictures -Fistulas -Peritonitis -Thromboembolism -Arthritis -Ankylosing spondylitis -Osteoporosis -Liver disease -Skin lesions
How do we treat the inflammation rt to IBD
-Sulfasalazine (Azulfidine) -It's an oral medication that coats the GI tract -It inhibits prostaglandin and is related to inflammation (aspirin like) -You want to make sure the patient is taking it with fluids and you want to monitor for nausea and vomiting -The major side effect of this medication is that it will deplete folic acid and so you want them to take additional folic acid when they are on that particular drug This is the main drug
Albumin test for IBD
-The reason why is for malnutrition -This test is a long term test because it gives you the idea of nutritional status for the last 20 days ■ so that would be a good indication of their malnutrition
CBC for IBD
-To look at the blood panels and for electrolytes Anemia investigation -Because the patient is bleeding we should look at the hemoglobin and hematocrit -The patient is having diarrhea lets monitor their potassium, sodium ■ BUN and creatinine will give us ideas about the level of dehydration that is occurring and if there is renal involvement as well
Prealbumin for IBD
-When a person is having bowel surgery, you have to allow the intestines to heal ■ So then the patient might have to be on TPN ● You also might have manage their weight gain and their nutrition you need that lab that will help you to know the efficiency of a treatment and that's prealbumin -It changes in just a couple days as opposed to albumin that takes a while -So if you're going to monitor the patient's nutrition prealbumin would be important
Where is a colostomy located?
will be located on the lower left quadrant
A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps
A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease
The nurse explains to the patient with Crohn disease that the tube feedings allow for: a. rapid absorption in the upper GI tract. b. decompression of the stomach. c. reduction of diarrheic episodes. d. a permanent nutritional support.
A The tube feedings allow for rapid absorption of the nutrients in the upper GI tract. The tubefeedings are not permanent and will be followed by oral intake of a low-residue, high-protein, high-calorie diet
Crohn's disease clinical manifestations
Abdominal pain Diarrhea (liquid to semi formed stools) Malnutrition Occult blood in stool Fever -perforation, pt may become sick bc of perforation which can cause a fever. Weight loss Fatigue
Fulminant colitis
An acute form of ulcerative colitis that involves the entire colon; manifestations include severe bloody diarrhea, acute abdominal pain, and fever. -This phase is when you can have toxic megacolon
The nurse is caring for a patient who has been diagnosed with Crohn disease. When providing education concerning dietary recommendations, which statement indicates that the nurse'steaching has been successful? a. "I should try to eat as much fiber daily as I can." b. "Reducing dietary fat and fiber will be helpful in managing my condition." c. "I should not have lactose-containing products." d. "Eating a larger breakfast and smaller lunch and dinner portions is recommended."
B The recommended diet in Crohn disease consists of low-fat, low-fiber foods that are high inprotein and calories. Small frequent feedings are best. Lactose avoidance helps some patients
A 24-year-old woman with Crohns disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.
B. Fistulas between the bowel and bladder occur in Crohns disease and can lead to UTI. Teaching for UTIprevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.
Vascular phase
Vasodilation occurs As a result you get hyperpermeability so things are coming out from the vascular space
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
C Feedback:Bloody stool is far more common in cases of UC than in Crohns. Rectal involvement is nearly 100% incases of UC (versus 20% in Crohns) and patients with UC typically experience severe diarrhea. UC isalso characterized by a pattern of remissions and exacerbations, while Crohns often has a moreprolonged and variable course.
A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night
C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease.A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease.
13. After the nurse has provided patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD), which diet choice by the patient indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup
C. During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.
The nurse is teaching the family of an 8-year-old client with inflammatory bowel disease on the administration of prednisone ( corticosteroids) at home. At which time should the nurse instruct the parents to provide the medication to the client? A) 1 hour before meals B) At bedtime C) With meals D) Between meals
C. Corticosteroid can cause GI upset, should take it with meals
Ostomy care for IBD
Characteristic of a stoma Color, Edema, Bleeding, Healing What would be expected immediately post op? ■ Originally when it is out of surgery it will be edematous but if it is bleeding notify HCP ● But it should be raised just like in the picture. You should see the intestine
Assessments for ulcerative colitis
Characteristics of the stools Frequency of the stools -frequency should be assessed because the purpose of the colon is to reabsorb water and electrolytes ■ But because we have an inflamed colon you have to think if it is going to be reabsorb water ● But we will anticipate a problem with the reabsorption of water Left lower quadrant pain We have the descending colon to the left, transverse is right across the abdomen the Ascending colon to the right ■ So if the person has a disease processes that starts in the rectum goes up then we would expect that they will have pain in the left -Dehydration -Urine output -Electrolytes -Blood pressure Blood pressure will tank -Skin turgor -VS Heart rate will increase if there is dehydration because it compensate for the low cardiac output
What's the difference between the diarrhea in Crohn's vs the diarrhea that is present in UC
Crohn's Disease: There is no blood Ulcerative Colitis -Can have liquid/ semi formed stools with blood -Diarrhea can imbalance electrolytes because the colon is not able to reabsorb ■ So you want to know your primary electrolyte when they are having diarrhea ● POTASSIUM is the main ELECTROLYTE TO LOOK OUT FOR
TPN for IBD
Do not forget about their nutritional status ● They may need to be on TPN to allow the bowel to rest and recover or they may need to have enteral nutrition. Enteral nutrition like your Ensure that has additional nutritional values to help them to recover
ESR for IBD
Elevation with ESR will indicate nonspecific inflammation
What kind of vitamin deficiencies to expect with IBD
Folate (Folate Acid) B12 Vitamin A Vitamin C Vitamin D
IBD diet
High calorie High vitamin High protein Low residue Lactose free
Frequent causes of diarrhea
High fiber Dairy products Processed Foods
Ostomy for IBD
When a patient has an ostomy, they will have a rosebud on their abdomen ● Nurses need to assess that particular site. It needs to be beefy red instead of pale or darkish because some necrosis may be occurring so notify HCP. If it is bleeding there might be an issue ■ So teaching the client to assess the site and making sure that the color is even and nice.
Fistula associated with Crohn's disease
With Crohn's Disease there is a tendency to develop fistula A fistula is creating an opening between two cavities basically is just creating a tunnel and that can be really serious if it happens between the bladder and the intestines and you will see that that type of person will develop frequent UTIs
Does ulcerative colitis have bloody stools
Yes
Nutrition monitoring for IBD
You want to monitor the patient's hematocrit and hemoglobin and if you part of the team you are probably going to be some prealbumin test and some weight tests to make sure that the patient is progressing in their nutritional status
The nurse is concerned that a client with potential hepatic failure is at risk for developing ascites. Which assessment finding would indicate this development?A) Increased abdominal girth B) Gallbladder pain C) Yellow-tinged skin D) Bleeding and bruising easily
a
The nurse provides teaching on the diagnosis Risk for Deficient Fluid Volume to a client with ulcerative colitis. Which client statement indicates understanding of this information? A) "I will drink more than 1 liter of fluid each day." B) "I will continue to use a moisturizer on my skin." C) "I should report dry patches of skin immediately to my doctor." D) "If I have two liquid stools in any day, I will report this to my health care provider."
a
Mild ulcerative colitis is defined as
fewer than 4 stools per day
Diet for IBD
high calories & protein, low fiber during acute stage, high fiber when stable. low residue diet, frequent smaller meals, multivitamin, iron supplements, food diary, NPO & TPN to rest the bowel during acute exacerbation...!!!! ACUTE = NPO
A home health nurse is evaluating a client who had a colostomy placed 6 weeks ago for the treatment of ulcerative colitis. Which assessment will cause the nurse to conclude that teaching goals for this client have been met? A) A colostomy pouch that is clean and dry B) Vital signs that reveal a normal temperature C) A stoma that is pink and intact D) The client experiences pain with certain types of food.
c
Major side effect with sulfasalazine
it will deplete folic acid and so you want them to take additional folic acid when they are on that particular drug
Occult blood test
test used to detect hidden blood in the feces
Colonoscopy
the direct visual examination of the inner surface of the entire colon from the rectum to the cecum
Nursing diagnoses for IBD
-Acute pain (increased peristalsis) -Risk for imbalanced electrolytes (dehydration) -Imbalanced nutrition -Ineffective coping rt depression -Fatigue rt anemia -Activity intolerance -Impaired skin integrity rt diarrhea
What does fulminant colitis lead to?
Leads to anemia, possibly due to the impacted intake of nutrients.
Does Crohn's disease have blood stools?
No
What electrolyte should we be concerned with UC
POTASSIUM is the main ELECTROLYTE TO LOOK OUT FOR -The heart is very sensitive to potassium -Low potassium is common with diarrhea
Pathophysiology of Ulcerative Colitis
-Area of chronic inflammation of the mucosa and submucosa in the colon and rectum Crypts of Lieberkuhn -Peak incidence between 15 to 30 years of age -Begins in the rectum and progresses proximally -Something to keep in mind is that when there is inflammation those villi that are in the colon are not efficient and part of the problem is that at the very bottom there in the crypts -Called the Crypts (of Lieberkuhn) they produce mucus and so they are not efficient and so therefore that's why we have the inflammatory process
Clinical manifestations of UC
- Bloody mucus diarrhea - Nocturnal diarrhea - Mild <4 stools per day - Severe 6-10 liquid stools per day - LLQ cramping - Relief with defecation - Anemia, hypovolemia, Malnutrition - Fatigue, anorexia - Systemic manifestation · Arthritis · Uveitis · Sclerosing · Cholangitis · Thromboembolic event o With UC, the symptoms will have more systemic manifestations due to multiple factors impacting nutritional status
Classification of severity
- Mild: less than 4 stools a day - Moderate: 4-6 stools a day - Severe more than 6 stools a day
Clinical manifestations of Crohn's disease
- Persistent diarrhea · Liquid to semi-formed - R abdominal pain/ tenderness · Relief with defecation § Malnutrition, weight loss, fatigue, anemia
Reparative phase
-You will have the tissue repaired -The tissue when it repairs it can create scar tissue depending on what it is and that scar tissue is not as efficient as the original tissue it can be very fibrous so that's where you have strictures because of the constant chronic inflammation then you'll have that scar tissue that develops then the lumen of the intestine narrows and so strictures (narrowing) due to the inflammatory process happens.
Corticosteroids for IBD
-prednisone or Methyl prednisone or hydrocortisone - Corticosteroids for acute episodes ● But!!!!! When they have flare-ups; and if their medications are not working then we may need to add corticosteroids to control the inflammation and you are going to start them on a high dose and then taper it and that's very important for you to educate the patient on. ● ANOTHER SIDE EFFECT IS: their blood-sugar can go up. So their HCP will have to change their blood-sugar management if they are diabetic. Corticosteroids may make you want to eat more THEY ARE ALSO IMMUNOSUPPRESSED so you do not want sick people to be around them
Diagnostic tests for IBD
-sigmoidoscopy, colonoscopy -barium swallow -stool examination and culture -CBC to detect anemia -SED rate for inflammation -C-reactive protein -serum albumin(low due to malabsorption issues) -liver function tests(elevated bc malnutrition) -serum levels of vitamins(low bc malabsorption) -plasma viscosity/serum protein*** -fluid and electrolyte levels
While conducting a home visit with a client who hada partial resection of the ileum for Crohn's disease4 weeks previously, a nurse becomes concernedwhen the client says: 1. "My stools float and seem to have fat in them." 2. "I have gained 5 pounds since I left the hospital." 3. "I am still avoiding milk products." 4. "I only have two formed stools per day."
1 Bile salts are absorbed in the terminal ileum. Disease in this area or Resection of the ileum can result in poor fat absorption and loss of fat in the stool. Weight gain is a positive sign after small bowel resection forCrohn's disease, as are formed stools. Many clients with Crohn's disease develop lactose intolerance and therefore should avoid milk products
complications of ulcerative colitis
1. Hemorrhage (Hypovolemic shock) 2. Strictures 3. Colonic Dilation 4. Perforation/ Rupture Bowel 5. Toxic Megacolon
Problems to be anticipated if someone is having a lot stools
1. Impaired skin integrity- The anus becomes raw 2. Disturbed sleep pattern because of the nocturnal diarrhea 3. Impaired healing because you are not able to sleep -The purpose of sleep is to allow the body to sleep and recover! 4. Imbalanced nutrition -Because nothing is staying in the system 5. Social problems because if a teenager has to go to the bathroom 6 times a day (body image problems) -Having to use the restroom during class
Three phases of inflammation
1. Vascular phase 2. Exudate phase 3. Reparative phase
Which assessment data indicate that the client recovering from an open cholecystectomy requires pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing
2. Clients having abdominal pain frequently have shallow respirations. When assessing clients for pain, the nurse should discuss pain medication with any client who has shallow respirations.
A client is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. What finding is the nurse most likely to find in the client's history? 1) Renal calculi 2) Renal trauma 3) Recent sore throat 4) Family history of acute glomerulonephritis
3) Recent sore throat. RATIONALE: Typically, acute glomerulonephritis occurs 2 to 3 weeks after a strep throat infection. The Most Common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body. Renal calculi and renal trauma aren't known to cause acute glomerulonephritis. A family history isn't associated with the development of acute glomerulonephritis.
Severe ulcerative colitis is defined as
6- 10 liquids stools per day
A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds
A Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias.This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. Theother two findings are abnormal and also warrant intervention, but the potassium level takes priority
Chronic colitis
Persistent inflammation of the colon
Healing promotion for IBD
Physical and emotional rest ■ Of course you want to promote healing so balance of physical and emotional rest ● Allow the person to communicate
The nurse determines that a client is at risk for contracting hepatitis B because of intravenous drug use. What should the nurse teach to reduce the client's risk for this health problem? A) Avoid contaminated food and water. B) Avoid sharing needles. C) Avoid alcohol consumption. D) Wash hands frequently, as the disease is transmitted via the fecal-oral route.
B
The nurse is caring for a client with cirrhosis of the liver. Which information in the client's health history supports this diagnosis? A) Smokes two packs of cigarettes per day. B) Drinks a six-pack of beer each evening. C) Eats salads for lunch every day. D) Plays on an adult softball team several times a week
B
The nurse will plan to teach a patient with Crohns disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.
D Crohns disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must beadministered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not causemegaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.
Immunosuppressive agents for IBD
Imuran and Sandimmune The treatment can take up to six months when they are on immunosuppressants ■ These are drugs that are not going to be used by themselves ● They are used when the patient is not responding to regular medical regiment so we need to use some big guns to take care of the inflammation -You want them to avoid people that are likely to infect them
The most common site of inflammation for UC
Inflammation of colon -It starts near the rectum and goes up - but it's primarily in the colon
Where will someone with UC experience cramping?
LLQ
Where is an ileostomy located?
RLQ
Immune response modifiers for
Remicade, Humira These medications take care of the necrotic factor and inhibit inflammation in Crohn's Disease
Colectomy for IBD
Sometimes with colectomy they need to remove the whole colon because it is so diseased. And with that they have to create an ostomy ● An ostomy is an opening so that the stool can pass through The small intestine is going to be brought up to the skin So they can eliminate stool through the skin ■ So if there is an ileostomy; The opening will be at the right upper quadrant. The characteristics of the stool would be liquid because the colon reabsorbs fluid and if you remove the colon. Then fluid will not be reabsorbed.
What is the difference between Crohn's disease and UC from an anatomy standpoint?
The most common site for ulcerative colitis is the colon Inflammation of colon -It starts near the rectum and goes up - but it's primarily in the colon Crohn's Disease affects the most common site is the ileum -it can be anywhere in the GI tract from the mouth to the rectum -The anatomy and physiology should help us to identify
Liver function test
There is some kind of sclerosis that happens along the vessels to the bile and so that can obstruct the outlet of bile ● inflammation of the bile ducts in the liver. This inflammation, which affects patients with Crohn's Disease, leads to scarring of the bile ducts and eventually the liver, preventing bile from flowing normally
How does hypovolemic shock occur in UC
They are not able to take in as fast as the fluid is coming out ● you will see a decrease in blood pressure ● elevated heart rate ● And if it is not addressed then the patient can also develop acute renal failure or multiple organ failure related to the hypovolemia then there can be death
Loperamide for IBD
This is for diarrhea. If they have too many episodes of diarrhea you can give them Loperamide and that will slow down the motility of the GI tract. ■ However if they are in a fulminant phase/ acute phase you do not want to give them this medication because they can develop toxic megacolon.
Which is a risk for developing cancer, UC or Crohn's?
Ulcerative colitis
An 18-year-old client with complications related to ulcerative colitis is scheduled for an ileostomy. The client is concerned about the effect of the procedure on his social life and asks the nurse what to expect related to bowel function and care after surgery. What should the nurse respond about the client's concerns?Select all that apply. A) "The stoma will require that you wear a collection device all the time." B) "The drainage tends to be liquid but certain foods can cause it to be paste-like." C) "The drainage will gradually become semi-solid and formed." D) "After the stoma heals, you can irrigate your bowel so you won't have to wear a pouch." E) "You will be able to have some control over your bowel movements
a, b
A client is being scheduled for diagnostic tests to determine the presence of ulcerative colitis. For which diagnostic tests should the nurse plan to provide teaching?Select all that apply. A) Barium enema B) Intravenous pyelogram C) Colonoscopy D) Upper endoscopy E) Barium swallow
a, c, e- IV pyelogram: kidney disorders- upper endoscopy: esophagus and stomach disorder
A nurse is receiving a client from the Emergency Department diagnosed with an acute exacerbation of ulcerative colitis (UC). The nurse anticipates the client may present with which clinical characteristics?Select all that apply. A) 5-30 diarrhea stools per day with blood and mucus B) Steady right lower quadrant or periumbilical pain C) Cramping in left lower quadrant; relieved by defecation D) Tenderness and mass noted in right lower quadrantE) Fever, malaise, fatigue
a,c,e