NUR303 Evolve Unit 4
When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement?
"I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching?
"If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency.
The nurse finds that a patient admitted to the hospital with cirrhosis of the liver is disoriented, lethargic, and drowsy and has abnormal reflexes. Based on the patient's signs and symptoms, the nurse understands that the patient is in grade ___ hepatic encephalopathy. Fill in the blank using a whole number.
2 R: Hepatic encephalopathy has grades 0 to 4 based on three factors: level of consciousness, intellectual function, and neurologic findings. Grade 2 is characterized by lethargy, drowsiness, and inappropriate behavior (level of consciousness); disorientation (intellectual function); and asterixis and abnormal reflexes (neurologic findings). Grade 1 is characterized by a short attention span, mild confusion, and depression. Grade 3 is characterized by loss of meaningful conversation, marked confusion, and incomprehensible speech. Grade 4 is characterized by a complete lack of intellectual function. Grade 0 is characterized by insomnia, sleep disturbances, and a subtle change in computational skills.
A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect?
Asterixis Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state.
The patient is scheduled for a q12h dose of lactulose 30 grams orally. Available is an oral solution containing 5 g/10 mL. How much solution should be poured into the medication cup to give the required dose?
60mL
A patient has been admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse. Laboratory results are significant for an alanine aminotransferase (ALT) of 198 IU/L and aspartate transaminase (AST) of 224 IU/L. Which diagnosis does the nurse attribute these findings to?
Alcohol abuse In the patient with alcohol abuse, liver disease could develop as a complication, increasing the liver function tests above the normal levels. The normal ALT range is 7 to 56 IU/L and the normal AST range is 5 to 40 IU/L. Diabetes would result in elevated blood sugar levels. Malnutrition would be evidenced by low protein levels. Osteomyelitis is an infection of the bone, which would result in an elevated white blood cell count.
A female patient with irritable bowel syndrome (IBS) and diarrhea is prescribed treatment. What medication will the nurse discuss with the patient?
Alosetron R: Alosetron is used to treat IBS with diarrhea in women. Linaclotide is used in the treatment of IBS with constipation in men and women. Lubiprostone is the medication used in the treatment IBS with constipation in women. Trimethobenzamide is used in the treatment of nausea and vomiting.
A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient?
Anemia Leukopenia Thrombocytopenia Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia, leukopenia, and thrombocytopenia are probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia is also due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Leukemia and polycythemia vera are not caused by cirrhosis.
The nurse suspects that a patient has hepatitis A. Which symptom will the patient most likely report that it developed first?
Anorexia The preicteric phase of hepatitis is usually marked by severe anorexia, malaise, and fever. Itching and jaundice appear later in the hepatitis disease process in a stage known as the icteric phase. Ascites may develop as a long-term effect of diffuse liver damage.
A male patient is being treated for irritable bowel syndrome (IBS) with constipation. About what medication used for treatment does the nurse educate the patient?
Linaclotide R: Linaclotide is used in men to treat IBS with constipation. Alosetron and loperamide are medications used in the treatment of diarrhea. Lubiprostone is used in the treatment of IBS with constipation in women.
A patient is newly diagnosed with irritable bowel syndrome (IBS). When educating the patient about the disorder, what should the nurse be sure to include about exacerbating the illness?
Anxiety Depression Posttraumatic Stress Disorder Psychologic stressors such anxiety, depression, and posttraumatic stress disorder may exacerbate IBS. Bloating and excessive flatulence are gastrointestinal symptoms of IBS, not physiologic stressors.
A patient with acute hepatitis B will be discharged tomorrow. The nurse should include which measures in the discharge teaching plan?
Avoid foods that are very hot or very cold. Be sure to allow for periods of rest during the day. Eat small meals frequently rather than three times a day. R: Several measures are important for ensuring that the patient with hepatitis receives adequate nutrition. The anorexia and distaste for food cause nutritional problems. Assess the patient's tolerance of specific foods and eating patterns. Small, frequent meals may be preferable to three large ones and also may help prevent nausea. Measures to stimulate the appetite, such as mouth care, antiemetics, and attractively served meals in pleasant surroundings, should be included in the nursing care plan. Drinking carbonated beverages and avoiding very hot or very cold foods may help alleviate anorexia. Rest is an important factor in promoting hepatocyte regeneration. Assess the patient's response to the rest and activity plan, and modify it accordingly. Adequate fluid intake (2500 to 3000 mL/day) is important. Restricting fluid intake and participating in exercise regimens are not appropriate measures. Patients with hepatitis need to avoid alcoholic beverages.
The nurse is caring for a patient with hepatitis C. What steps regarding nutrition can the nurse take to ensure that the patient gets the best nutrition possible?
Avoid very hot or very cold foods. Ensure that the patient drinks at least 2500-3000 mL of water every day. Ensure that the patient has a good breakfast and small or moderate dinner. R: Drinking very hot or very cold foods may cause anorexia; therefore, the patient should be encouraged to avoid hot and cold foods. The nurse should maintain adequate fluid intake of 2500 to 3000 mL/day to maintain hydration. The patient experiences less nausea in the mornings; therefore, the breakfast should be the most nutritious meal. Small, frequent meals may be preferable to three large ones and may also help prevent nausea. Liquids may not be able to meet the nutritional requirements of the patient due to nausea and vomiting. The patient may not be able to have raw foods due to nausea and anorexia.
What points should a nurse emphasize while teaching a patient ways to protect oneself from exposure to hepatitis B infection?
Use disposable needles and syringes. Avoid sharing toothbrushes and razors. Avoid unsafe sex with multiple partners, and always use condoms. Hepatitis B spreads through sexual contact and through blood. Sharing razors or toothbrushes with an infected person may introduce infection in another person's body. Similarly, a needle used by an infected person can spread the infection. Hepatitis B also spreads via sexual exposure with an infected person. Using a condom gives some protection against the spread of infection. Hepatitis B doesn't spread through water and food. Hepatitis B doesn't spread with general casual contact.
What nursing diagnostic statement would be assigned the highest priority in the plan of care for a patient who has ulcerative colitis?
Deficient fluid volume R: In ulcerative colitis, fluid is not absorbed from the distal large intestine because of ulceration, bleeding, and, later, scarring and narrowing of the lumen of the bowel. Fluid and electrolytes are also lost in the stool; therefore deficient fluid volume is the priority nursing diagnostic statement. Activity intolerance, impaired tissue integrity, and risk for impaired skin integrity are all possibilities related to ulcerative colitis, but they are not as high of a risk as deficient fluid volume.
A patient with a chronic hepatitis C virus (HCV) infection is admitted to the hospital. What are the factors that contribute to a high risk for development of cirrhosis of the liver in this patient?
Diabetes mellitus Alcohol consumption Elevated levels of cholesterol R: Hepatitis C virus (HCV) infection is more likely than hepatitis B virus (HBV) to become chronic. An infection with HCV can lead to development of cirrhosis of the liver. People with diabetes mellitus have a compromised immune function and are at risk of developing cirrhosis. Alcohol consumption may further deteriorate the liver function and lead to development of cirrhosis of the liver. Elevated cholesterol or triglycerides suppresses liver function and may lead to progression of HCV to cirrhosis. Smoking and a high-sodium diet have no effect on hepatitis C progression, because they do not affect liver function.
Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease?
Diarrhea R: Diarrhea is the most common clinical manifestation seen in both disorders. Vomiting is usually not related to either disorder. Hypocalcemia is seen only in ulcerative colitis. Rectal bleeding is not seen with Crohn's disease but is common and can be severe in ulcerative colitis.
What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections?
Dispose of the needles and syringes used on the patient carefully. Wear gloves while handling articles contaminated by urine or feces. Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle. R:Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis.
A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient?
Edema of the feet Blood in the stools or black stools Disorientation and lethargy R: Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Cirrhosis doesn't lead to pain in the chest with a cold sweat or difficulty in breathing.
A patient has just undergone a liver transplant and is now in the intensive care unit (ICU). What nursing interventions are appropriate for this patient to prevent respiratory complications?
Encourage the patient to cough Encourage the patient to take deep breaths. Consider repositioning the patient. The patient who has had a liver transplant requires highly skilled nursing care in an ICU or another specialized unit. To prevent respiratory complications, the patient should be encouraged to use measures such as coughing, deep breathing, and repositioning. Administering cough suppressants would be counterproductive to recovery. The patient can be ambulated later, when the condition is stable.
A patient with hepatitis A is in the acute phase. The nurse plans care while anticipating that the patient may be experiencing which symptoms?
Fatigue Pruritus Anorexia R: The acute phase of hepatitis usually lasts from one to four months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant, and smokers may have distaste for cigarettes. There is also a decreased sense of smell. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Pruritus (intense chronic itching) sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. Dizziness and visual disturbances are not symptoms of the acute phase of hepatitis A.
The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication?
Frequent nosebleeds and bruising The liver produces clotting factors. As cirrhosis becomes more advanced, the production of clotting factors is disrupted and thereby decreased, making the patient more susceptible to bleeding. Increasing frequency and severity of nosebleeds and bruising would indicate a deterioration in liver function. Urine retention, abnormal blood glucose, and constipation are not directly associated with advanced cirrhosis.
Assessment findings of a patient include asterixis, hyperventilation, fetor hepaticus, fatigue, a body temperature of 95° F, and continuous lip smacking. Which condition does the nurse suspect?
Hepatic encephalopathy Hepatic encephalopathy is a mental disorder that occurs due to acute or chronic liver injury. Hypothermia, grimacing reflexes (actions like lip smacking and lip puckering), fatigue, asterixis, hyperventilation, and fetor hepaticus are the clinical manifestations of hepatic encephalopathy. Hepatitis is an inflammatory condition of the liver, characterized by anorexia, nausea, vomiting, and fever. Liver cirrhosis is a liver disease manifested by symptoms ranging from portal hypertension to liver failure. Hepatorenal syndrome occurs in patients with decompensated liver cirrhosis and can lead to renal failure.
A patient reports vomiting, nausea, and joint pain. An IgM antibody test has been prescribed. The nurse suspects what diagnosis?
Hepatitis A Hepatitis A is associated with nausea, vomiting, weight loss, and joint pain. When an individual is infected with the hepatitis A virus, the body produces the hepatitis A antibody immunoglobulin M (IgM). Because the primary health care provider prescribes an IgM antibody test, the nurse suspects that the patient has hepatitis A infection. Hepatitis B is diagnosed by performing anti-HBc IgG and anti-HBe tests. Anti-HCV, HCV genotyping, and HCV RNA quantification are performed to rule out hepatitis C. Hepatitis D is confirmed by performing anti-HDV and HDV antigen tests.
Which hepatitis virus is transmitted parenterally from mother to fetus?
Hepatitis B The hepatitis B virus is transmitted parentally from mother to fetus. Studies show that most mother-to-child HBV transmission occurs during or shortly before delivery. The hepatitis A virus is transmitted through the fecal-oral route by consuming foods or drinks contaminated with the hepatitis A virus. The hepatitis C virus is transmitted by sharing contaminated needles. The hepatitis E virus is also transmitted by the fecal-oral route.
A patient presents with fatigue, nausea, vomiting, and yellowish-colored eyes. A serum bilirubin test and complete urine examination are prescribed. The test results reveal increased serum levels of both conjugated and unconjugated bilirubin and increased levels of bilirubin in the urine. The nurse suspects what diagnosis?
Hepatocellular jaundice R: Hepatocellular jaundice is associated with increased serum levels of both conjugated and unconjugated bilirubin and increased levels of urinary bilirubin. Fatigue, yellowing of the eyes, nausea, and vomiting are the clinical manifestations of hepatocellular jaundice. Urinary bilirubin levels are elevated in patients with acute hepatitis, but levels of serum bilirubin remain the same. Chronic hepatitis is associated with increased levels of serum alkaline aminotransferase (ALT) and aspartate aminotransferase (AST). In hemolytic jaundice, conjugated bilirubin levels are normal, urinary bilirubin levels are negative, and serum unconjugated bilirubin levels are elevated.
What are the clinical manifestations of chronic hepatitis?
Hepatomegaly Elevated liver enzymes Chronic hepatitis is manifested by hepatomegaly and elevated liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Bilirubinuria, nausea, vomiting, and decreased sense of taste are associated with acute hepatitis.
A patient suffering from ascites is admitted to the hospital. What are the factors that can lead to ascites development?
Hyperaldosteronism Portal hypertension Decreased serum colloidal oncotic pressure R: Hyperaldosteronism or increased secretion of aldosterone causes ascites. Portal hypertension causes an increase in resistance to blood flow in the liver leading to ascites. When there is decreased serum colloidal oncotic pressure, there is impairment of synthesis of albumin and loss of albumin in the peritoneal cavity. It leads to ascites. Diabetes is a metabolic syndrome and does not cause ascites. Increased flow of hepatic lymph, not decreased flow, leads to ascites.
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume R: Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priority. Impaired skin integrity, imbalanced nutrition, and excess fluid volume are all seen in patients with cirrhosis, but they are not priorities at this time.
An elderly woman reports weakness, abdominal pain, and bleeding from the vagina. When reviewing the patient's diagnostic test reports, the nurse notes anemia and an enlarged spleen. The nurse suspects that the patient has what condition?
Liver cirrhosis R: Liver cirrhosis is clinically manifested by skin lesions and enlarged spleen, resulting in hematologic changes such as thrombocytopenia, leucopenia, and anemia. It is associated with endocrine problems such as vaginal bleeding in elderly women and gynecomastia in males. Anorexia, dull and aching abdominal pain, progressive weight loss, and jaundice are the characteristics of pancreatic cancer. Acute liver failure is associated with jaundice, encephalopathy, and coagulation abnormalities. Acute pancreatitis is manifested by abdominal pain that radiates to the back; dyspnea, flushing, and cyanosis may accompany the pain.
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?
Milk thistle may affect liver enzymes and thus alter drug metabolism. R: Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
Patient A: Cirrhosis, standard interferon Patient B: Chronic Hepatitis C, Ribavirin Patient C: Chronic Hepatitis B, Telbivudine Patient D: Autoimmune hepatitis, Azathioprine The nurse reviews the medication records for a group of patients. The nurse should question the medication that has been prescribed for which patient?
Patient A R: Patients with cirrhosis have multiple complications such as portal hypertension, gastric and esophageal varices, peripheral edema, and ascites. Drugs such as nadolol, octreotide, and vasopressin are given to reduce the risk of bleeding and to stop bleeding. Standard interferon, which is effective in treating infections, has been prescribed for patient A. This medication should be questioned for patient A, because there is no indication that patient A has an infection. Patients with chronic hepatitis C are prescribed ribavirin, a guanosine analog, used to stop RNA replication. Telbivudine is a thymidine nucleoside analogue and is used to stop DNA replication, so it helps in the treatment of chronic hepatitis B. Azathioprine is an immunosuppressant used in treating autoimmune diseases.
A nurse is caring for a patient with cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination?
Small areas of bleeding into the skin Vascular lesions formed by small blood vessels Small dilated blood vessels with spiderlike branches R: Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.
A patient with cirrhosis of the liver is on furosemide. The nurse should monitor the patient for which findings to prevent complications of diuretic therapy?
Tachycardia Hypotension Muscle weakness Cardiac arrhythmias R: When a patient is on diuretic therapy, it is important to monitor fluid and electrolyte status. The patient should be monitored carefully for signs of hypokalemia, including tachycardia, hypotension, muscle weakness, and cardiac arrhythmias. Hypertension and lethargy are not complications of diuretic therapy.
A patient reports loss of appetite, nausea, and vomiting. Laboratory tests results reveal darkened urine and a positive hepatitis C antibody test. Which medication does the nurse anticipate will be prescribed?
Telaprevir R: Fatigue, loss of appetite, nausea, and vomiting are the clinical manifestations of hepatitis. A positive report for the HCV antibody confirms hepatitis C infection. Telaprevir is a protease inhibitor and is effective in the treatment of hepatitis C. Adefovir, tenofovir, and entecavir belong to the class of nucleoside and nucleotide analogs and are used in the treatment of hepatitis B infection.
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons?
There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. R: Ascites related to cirrhosis is caused by decreased colloid oncotic pressure from the lack of albumin due to the liver's inability to synthesize it and the portal hypertension that shifts protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism, which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not contribute directly to ascites.
While reviewing laboratory reports of a patient, the nurse finds ulcerative colitis. Which surgery does the nurse expect to be beneficial for this patient?
Total proctocolectomy with ileal pouch/anal anastomosis R: The most commonly used surgical procedure for ulcerative colitis is a total proctocolectomy with ileal pouch/anal anastomosis. In this procedure a diverting ileostomy is performed and an ileal pouch is created and anastomosed directly to the anus. After this surgery, the patient is able to control defecation at the anal sphincter. Sigmoid colostomy is recommended for a patient who has cancer in the rectosigmoidal area. Ascending colostomy is recommended for a patient who has a perforating diverticulum in the lower colon. Total proctocolectomy with permanent ileostomy involves the removal of the colon, rectum, and anus.
A patient with liver cancer is scheduled to receive radiofrequency ablation (RFA) therapy. The nurse knows that this treatment is appropriate for which of these?
Tumors that are less than 5 cm in size In RFA, a thin needle is inserted into the core of the tumor. The electrical energy is used to create heat in a specific location for a limited time. The end result is destruction of tumor cells. This procedure can be done percutaneously, laparoscopically, or through an open incision. RFA can be used to treat tumors that are less than 5 cm in size and for palliative purposes. RFA is not effective in tumors over 6 cm or metastatic cancer. Alcohol injection is used for tumors that are less than 3 cm in size.
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome?
Use smallest gauge needle possible when giving injections or drawing blood. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. Instruct patient to avoid aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) to prevent hemorrhage when varices are present. R: Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. Aspirin and NSAIDS should be avoided because they can increase bleeding in ruptured varices. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.
A patient with hepatitis A infection is being discharged from the hospital. What is the most important instruction that the nurse should include in the discharge teaching?
Wash hands carefully after bowel movements. The mode of transmission of hepatitis A infection is the fecal-oral route. Therefore, it is very important to maintain personal and environmental hygiene. The nurse should teach the patient and the family members about careful hand washing immediately after bowel movements and before eating to prevent outbreaks of hepatitis A viral infection. Not sharing toothbrushes and razors is a concern for the prevention of hepatitis B and C, because they are transferred through blood contact. There is no need to isolate the patient with hepatitis A unless he or she is incontinent or maintains poor personal hygiene. Acetaminophen may cause liver damage and should be avoided in hepatic viral infection.
A patient is diagnosed with irritable bowel syndrome (IBS). What food item should the nurse encourage the patient to avoid?
Wheat R: Fructans, galactans, lactose, and fructose contribute to the development of irritable bowel syndrome. Wheat is a source of fructans and may cause IBS. Fish is rich in omega-3 fatty acids. Milk is a good source of calcium. Pulses are rich in proteins.