Inflammatory Bowel

A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch?

"I will empty my pouch when it is about one-third full." The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal. The client with an ileostomy must wear a pouch at all times to collect stool. The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time. A pouch can be worn for 3 to 7 days before being changed.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client:

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

Which diet would be most appropriate for the client with ulcerative colitis?

high-protein, low-residue Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

When establishing goals for a client who has had an abdominal perineal resection with a colostomy, which is a realistic outcome 4 weeks after the surgery? The client will:

verbalize any concerns about sexuality. The client should be encouraged to discuss any concerns about sexuality. The client will not need to maintain a high-carbohydrate or high-protein diet. Rather, the client will be encouraged to maintain a normal diet while avoiding any foods that cause odor and flatulence. The colostomy pouch does not need to be changed every day. The pouch can adhere to the skin for 3 to 7 days. Not every client irrigates his or her colostomy. For those who do, irrigation schedules vary according to the individual.

A client diagnosed with colon cancer has a colostomy. The nurse has completed discharge teaching. Which of the following statements would indicate that the client is in need of further teaching?

"I will have to adapt my daily routine around my colostomy changing schedule." The client with the colostomy can lead a normal life. The colostomy can be changed by the client without assistance. Sex, exercise, and swimming are all possible with the colostomy. The daily routine does not need to be altered just because the client has a colostomy.

A client who has ulcerative colitis is taking sulfasalazine to treat inflammation. Which instructions related to drug therapy should the nurse include in the client's teaching plan? Select all that apply.

Drink a full glass of water when taking the medication. Avoid exposure to direct sunlight. Report any bruising or bleeding. Sulfasalazine is a sulfonamide antibiotic. The nurse should instruct clients who are taking sulfasalazine to take it 1 hour before or 2 hours following a meal for adequate absorption. The medication should also be taken with a full glass of water to help prevent crystalluria and renal calculi. Photosensitivity can develop, so the client should avoid exposure to direct sunlight. Blood disorders, such as hemolytic anemia and aplastic anemia, may develop with prolonged use; clients should be instructed to report any unusual bruising or bleeding tendencies. Antacids can interfere with the absorption of the medication and should not be taken with the drug.

A nurse is caring for a client following gastric bypass surgery. At the six week appointment, the client reports symptoms of nausea, abdominal pain and cramping following meals and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply.

Eat small, frequent meals Reduce high concentrated sugars Refer client to a dietician Following gastric bypass surgery, many have symptoms of the dumping syndrome. Dumping syndrome occurs when food and gastric juices from the stomach move to the intestine in an uncontrollably fast manner leading to early and late symptoms. Early symptoms include the nausea and abdominal cramping. Late signs are related to the insulin surge and include symptoms of hypoglycemia. Eating small and frequent meals, reducing high concentrated sugars and following a dietician's guidelines all are helpful in reducing symptoms. Limiting sodium intake may be a good dietary practice but is not indicated in reducing causes of dumping syndrome. There are no guidelines when to ingest fluids other than liquids and solids should not be taken together.

A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply.

Monitor the vital signs for fever. Percuss the liver to note lack of dullness. Percuss the abdomen to note tympany. Auscultate bowel sounds to note frequency. Percussion will show resonance and tympany indicating paralytic ileus. Lack of liver dullness may indicate free air in the abdomen. The client with peritonitis will have fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases.

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

hypokalemia Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction?

Clients should experiment to find the diet that is best for them. It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.

A nurse is reviewing instructions for a low-residue diet with a client who has an acute exacerbation of colitis. To evaluate the client's understanding of the diet, the nurse asks the client to plan a menu. Which of the following food selections by the client indicates an understanding of a low-residue diet?

Lean roast beef, white rice, and tea with sugar A low-residue diet decreases the amount of fecal material in the lower intestinal tract. This is necessary in the acute phase of ulcerative colitis to prevent irritation of the colon. Orange juice contains cellulose, which is not absorbed and irritates the colon. Cream soup and milk contain lactose, which is irritating to the colon.

A client has early signs of oral cancer. To conduct a focused assessment, what should the nurse do? Select all that apply.

Monitor the client's height and weight. Determine presence of dysphagia. Inspect the mouth for infection and inflammation. The nurse is conducting a focused assessment of the client's mouth and ability to obtain nutrition. Therefore, the nurse focuses on inspecting the mouth for infection or inflammation, determining if the client has difficulty swallowing, and assuring nutrition by weighing the client and noting weight loss or gain. A sign of oral cancer is numbness of the tongue; losing a sense of taste is not an early sign of oral cancer. Urinary output, while important, is not a part of a focused assessment for this health problem. The client may have pain, and for a more general assessment, the nurse can inquire about use of pain medications

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first?

Provide parenteral rehydration therapy as prescribed. Initially, the extracellular fluid (ECF) volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which interventions should the nurse include? Select all that apply.

Tape all IV tubing connections securely. Monitor the IV infusion rate hourly. Weigh the client daily. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the IV fluid infusion rate hourly (even when using an IV fluid pump), and securely tape all IV tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the IV dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

A nurse is caring for a client with an ileostomy. The nurse understands the client is at risk for developing anemia for which reason?

The hemopoietic factor is absorbed only in the terminal ileum. Vitamin B12 (extrinsic factor) combines with intrinsic factor, a substance secreted by the parietal cells of the gastric mucosa, forming the hemopoietic factor. Hemopoietic factor is absorbed only in the ileum, from which it travels to bone marrow and stimulates erythropoiesis. The other choices are incorrect based on pathology of absorption.

As part of a routine screening for colorectal cancer, a client must undergo fecal occult blood testing. Which foods would the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period? Select all that apply.

Turnips Red meat Horseradish The client would avoid red meat, poultry, and fish as well as beets, broccoli, cauliflower, horseradish, mushrooms, and turnips. Such fruits as cantaloupe, melons, and grapefruit are also prohibited. Tomatoes and peas are acceptable. The client would be taught to maintain a high-fiber diet in order to promote colonic emptying time and fecal bulk, which aid in obtaining specimens.

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for:

bloody, diarrheal stools. Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome.

A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing:

difficulty coping It is not uncommon for clients with ulcerative colitis to become apprehensive and have difficulty coping with the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.

After a subtotal gastrectomy, the nurse is developing a plan with the client to assist the client to gain weight. To help the client meet nutritional goals at home, the nurse should:

encourage the client to eat smaller amounts more frequently. Because of the client's reduced stomach capacity, frequent small feedings are recommended. Early satiety can result, and large quantities of food are not well tolerated. Each client should progress at his or her own pace, gradually increasing the amount of food eaten. The goal is three meals daily if possible, but this can take 6 months or longer to achieve. Nausea can be episodic and can result from eating too fast or eating too much at one time. Eating less and eating more slowly, rather than not eating at all, can be a solution. Bland foods are recommended as starting foods because they are easily digested and are less irritating to the healing mucosa. Bland foods are not less nutritional.

A nurse on a medical surgical unit is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100° F (37.8° C). The nurse suspects that these are symptoms often associated with:

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer; the bloody stools will present first. A client with diverticulitis commonly states he/she has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

managing diarrhea Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client:

verbalizes the importance of small, frequent feedings. Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. A heating pad should not be applied to the intestine as it is inflamed. It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy.

The nurse is instructing a client who has had an ileostomy about the diet following surgery. The nurse should tell the client:

"Chew your food thoroughly." The client is instructed to chew food well to aid digestion and prevent obstruction. The client should maintain an adequate fluid intake. The client is usually placed on a regular diet but is encouraged to eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas, tomatoes) with caution; these foods may swell in the intestine and cause an obstruction. Eating six small meals a day is not necessary.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted. An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

A client with a diagnosis of severe ulcerative colitis is admitted to the hospital. The nurse would assess for which of the following?

Extreme muscle weakness and tachycardia Potassium functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. These symptoms develop in hypokalemia which results from severe diarrhea associated with colitis. Skin rash and diplopia are associated with calcium excess. Tetany and muscle spasms are incorrect because the client is experiencing diarrhea. Nausea and vomiting is not correct because it is not a common finding with severe colitis unless there was an indication of an obstruction.

What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.

Reduce fluids with meals, but take them between meals. Eat in a relaxing environment. Obtain adequate amounts of protein and fat in each meal. Dumping syndrome results in excessive, rapid emptying of gastric contents. The nurse should instruct the client to avoid dumping syndrome by eating small, frequent meals rather than three large meals, having a diet high in protein and fat and low in carbohydrates, reducing fluids with meals but taking them between meals, and relaxing when eating. The client should eat slowly and regularly and rest after meals.

A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply.

fluid and electrolyte imbalance respiratory distress Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure precipitating movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause:

hyperglycemia. Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. Although air embolism may occur during TPN administration, this problem results from faulty catheter placement, not overly rapid administration. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:

hypokalemia. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

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

increasing fluid intake to prevent dehydration. 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.

What knowledge should guide the nurse when caring for client with a new ileostomy?

Anticipate that emotional stress can increase intestinal peristalsis. Emotional stress of any kind can stimulate peristalsis and thereby increase the volume of drainage so irrigations are not indicated. The stoma may drain sooner or later than 72 hours. The ileum has less formed drainage and won't be controlled by irrigations, and bleeding may be observed initially.

A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of which of the following would be significant to this client's diagnosis?

Ulcerative colitis A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Crohn's disease does not have inflammatory symptoms, but rather more abdominal pain related. A family history of peptic ulcers is not a genetic risk factor as well as appendicitis.

Immediately after surgery to create an ileostomy, which goal has the highest priority?

maintaining fluid and electrolyte balance A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?

Acute pain A nurse must collaborate with a physician to achieve the best pain control for the client. A nurse may not give medications, such as analgesics and antibiotics, without a physician order, and she assesses the client's response to pain medications and provides feedback to the physician. The nurse may assist the client with nonpharmacologic activities for pain control. She may implement independent nursing interventions, such as performing assessments, providing appealing fluids, pacing nursing care to promote rest and minimize client fatigue, and providing small frequent meals to address Risk for imbalanced fluid volume, Activity intolerance, and Imbalanced nutrition.

A client with ulcerative colitis is to take sulfasalazine. Which instruction should the nurse provide for the client about taking this medication at home? Select all that apply.

Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day. Avoid activities that require alertness. Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP). Sulfasalazine may cause dizziness, and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the HCP immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200 to 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

passage of flatus and feces from the colostomy. A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Neither absence of stomach drainage nor absence of nausea and vomiting is a criterion for judging whether gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery.

The registered nurse (RN) is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a licensed practical/vocational nurse (LPN/VN) or a nursing assistant/unregistered healthcare worker (UHW)? Select all that apply.

Provide report for the oncoming shift Place a dry dressing over an abdominal incision Document intake and output in the electronic medical record The RN may delegate to the LPN/VN or nursing assistant the responsibilities of documentation of intake and output and dressing an abdominal wound. The LPN/VN may provide nursing report to the oncoming shift. The RN would administer carboplatin, a chemotherapeutic agent as this is out of the scope of practice of the LPN/VN. The RN would also complete any post-operative assessment such as bowel sounds and post-operative ambulation since the RN holds the responsibility of this nursing assignment. Review the management of care following a subtotal gastrectomy and delegation practices if you had difficulty answering this question.

The nurse is giving preoperative instructions to a client who will have a reversal of a colostomy. The nurse should prepare the client to expect which nursing actions during the immediate postoperative period? Select all that apply.

nasogastric (NG) tube attached to low intermittent suction calculation of intake and output every 8 hours administration of IV fluids After bowel surgery, an NG tube attached to low intermittent suction is used to remove gastric fluids. The amount of fluid from the NG tube suction is important because it contributes to the client's overall fluid and electrolyte balance. IV fluids are used to maintain hydration, and intake and output is measured to determine hydration status. Postoperative vital signs are assessed more frequently than every 6 hours. Bowel sounds will be auscultated to determine when they return. Measuring abdominal girth is not necessary following colostomy reversal.