INTESTINAL AND RECTAL DISORDERS

Question 1

Risk factors for IBS

Answer 1

PSYCHOLOGICAL STRESS:
(Anxiety, Stress, Depression)
IRRITATING FOODS
(milk, yeast products, eggs, wheat, red meat)
hereditary
high-fat diet
alcohol and smoking use
women

Question 2

CLINICAL MANIFESTATIONS FOR IBS
Assessment: recognize cues

Answer 2

-Changed Alteration in bowel patterns
(IBS-D, IBS-C or IBS-M)
D-diarrhea C-constipation M-mixed U-unsubtyped

-Pain, Bloating, Abdominal distention accompanies change in bowel motility

Question 3

IBS

Patient Teaching/learning needs ?
Interventions: take action

(5/8 Important ones)

Answer 3

*Diet: *Increase Fiber –> reduce diarrhea
Metamucil (psyllium) - bulk-forming fiber laxative
-Probiotics –>restores gut flora
-Adequate fluid intake
*Encourage relaxation techniques –> reduce stress
AVOID ALCOHOL AND SMOKING
-Medication management

Question 4

Medication tx for IBS-D

Answer 4

-Loperamide (Imodium)

antidiarrheal (fecal urgency control)→ slows intestinal motility and affects water and electrolyte movement through the bowel

-Bile Acid Sequestrants (Cholestyramine)
-Alosetron (lotronex)[5HT antagonist] –>
ONLY for women with severe IBS-D that don’t respond adequately to conventional therapy

ATB for IBS-D (Rifaxamin)

Question 5

Medication tx for IBS-C

Answer 5

-Alosetron (Lotronex) → selective 5HT antagonist (selective serotonin antagonist) [slows colonic motility];
monitor for ischemic colitis, tx for severe constipation

Ischemic colitis → reduced blood flow to the colon resulting in pain and damage → SEVERE CONSTIPATION → If adverse reactions occur you need to stop right away

-Osmotic laxatives (PEG)
-Cl-channel activator (lubiprostone)
-Guanylate cyclase agonist (linaclotide)

Question 6

Diagnostic testing to r/o IBS

Answer 6

CBC or C-reactive protein

Question 7

Sac-like herniation of the lining of the bowel?

Answer 7

Diverticulum

Question 8

Difference between
Diverticulosis and Diverticulitis?

Answer 8

Diverticulosis → is the diverticula w/o inflammation → benign condition usually ASYMPTOMATIC

Diverticulitis → sac becomes inflamed and infected d/t food or feces getting stuck in sac and creating irritation/infection

Question 9

Clinical Manifestation for Diverticular Disease

Answer 9

-Pain is the most common symptom – helps to identify location of inflammation/infection; Reports of pain to LLQ → r/o diverticulosis/diverticulitis in sigmoid colon

-Chronic Constipation preceding diverticulosis (w/o inflammation → ASYMPTOMATIC but may include
bowel irregularities, nausea, anorexia,
bloating, and abdominal distention.

Question 10

Nursing Intervention for constipation

Answer 10

↑ fluids,
↑ soft fiber
-bulk-forming laxative: Psyllium
-exercise
-high fiber/low fat diet

No stimulants laxatives: (bisacodyl, senna) or mineral oil
routinely
No nuts, corn, popcorn/seeds (tomatoes, cucumber, squash, berries) [will get stuck and form diverculosis]

Question 11

S/S ACUTE DIVERCULITIS

Answer 11

mild or severe pain in LLQ
nausea, vomiting, fever, chills, and leukocytosis (elevated WBC)

Question 12

ACUTE DIVERCULITIS DIET AND TX (OUTPATIENT)

Answer 12

clear liquids until inflammation subsides
→ high-fiber, low-fat diet
(Prepared cereals or soft-cooked vegetables =
↑ Bulk of stool and facilitates peristalsis= defecating)

PO Antibiotics 7-10 days

If PO is not tolerated and excessive vomiting and nausea then hospitalization may be needed

Question 13

ACUTE DIVERCULITIS TX in HOSPITAL

Answer 13

• NPO, Rest, IV fluids, NG tube suctioning (same tx for acute gastritis; but no ATB-> Antacids, H2B, PPIs instead)
• IV antibiotics (UNASYN or TIMENTIN)

Question 14

COMPLICATIONS OF ACUTE DIVERCULITIS

Answer 14

Complications:
*Perforation,
hemorrhage,
*peritonitis,
obstruction,
*fistula (colovesical)
abscess

Question 15

What is Inflammatory Bowel Disease (IBD) ?

Answer 15

Group of chronic disorders that involve chronic inflammation of your digestive tract.
*Onset peaks between ages 15 and 25 years
*Autoimmune disease: *mild-severe acute exacerbations that occur at unpredictable lifetime intervals with *periods of remission [Dx in childhood]

Types of IBD include: *Ulcerative colitis and *Crohn’s disease → long-lasting inflammation and sores (ulcers) in the innermost lining of your large intestine (colon) and rectum

Question 16

CLINICAL MANIFESTATIONS FOR IBD
(CROHN’S)

Answer 16

CROHN’s Disease/Regional enteritis (or usually ascending colon)

-Inflammation of any segment of the GI tract →
mouth to anus (will jump sections); unable to surgically cure
*most common in ileum;
-diarrhea less severe;
*steatorrhea (increase fat in feces)
*severe weight loss (d/t decreased absorption),
-abdominal pain,
-fatigue

Question 17

CLINICAL MANIFESTATIONS FOR IBD
(ULCERATIVE COLITIS)

Answer 17

-Inflammation and ulceration of the
*colon (descending colon) and *rectum(100%),
bleeding & diarrhea with mucus
*pus are severe (10- 20 stools/day);
*dehydration;
-“cured” by colectomy

Question 18

COMPLICATIONS OF IBD (4)

(NEED TO KNOW)

Answer 18

hemorrhage,
bowel perforation,
peritonitis,
fistula (between bowel & bladder)

Question 19

NURSING INTERVENTIONS FOR IBD (6)

Answer 19

-Assess & treat pain or discomfort,
*anticholinergic medications b4 meals,
[Anticholinergic medication → ↓ parasympathetic stimulation → ↓GI]
-analgesics (ASA), positioning, diversional activities, and
prevention of fatigue
*Encourage bed rest to reduce peristalsis during exacerbation
-Fluid deficit,
*I&O, *daily weight →monitor for dehydration/fluid loss→ IV FLUIDS
-encourage oral intake,
-measures to decrease diarrhea
-Reduce anxiety (talk calmly, listen, pt. education)
*CONTACT PRECAUTION- C.dif via Antibiotics

Question 20

NUTRITIONAL DIET FOR IBD (

Answer 20

OPTIMAL Nutrition:
*↑ Protein
*↑ calorie and nutrients
*↓ residue (fruits)
*AVOID HIGH fiber diet

*Parental Nutrition (PN) may be needed

*AVOID HIGH fiber diet
*AVOID gas forming, and milk products
AVOID alcohol & smoking

Question 21

THINGS TO AVOID IN IBD (6)

Answer 21

*AVOID HIGH fiber diet
*AVOID gas forming
*AVOID dairy
*AVOID alcohol
AVOID smoking and caffeine(↑ motility & secretion)

Question 22

What is a Total colectomy with ileostomy?

Answer 22

removes all your large intestine (colon) and an ileostomy (a type of stoma in the ileum) is then formed using the end of your small intestine → the stoma is an opening in your abdomen, which is surgically created.
It diverts feces into a bag attached to the opening → *RLQ 2 cm below waist

Question 23

Post-op care for Ileostomy

Answer 23

Accurate record of I&O d/t loss of large volume (continuous liquid drainage), →NG suction, rectal packing removal in 1 wk → monitor stoma

*Skin and stoma care:
*1” pink to bright red, shiny (beef fresh looking)→
-fecal drainage (continuous liquids form) begin in 24-48 hrs→ empty q 4-6hrs, change bags 5-10
days -disposable, odor-proof pouch→ don’t irrigate
-Empty when ½ - 1/3 full to prevent pulling and leaks

*Diet and fluid intake: low-residue diet x 6-8 wks,
*Avoid hard-to-digest food- (i.e: corn, nuts, fruit seeds)
*obstruction risk (diverticulum)

Question 24

What is a Continent ileostomy (Kock pouch)

Answer 24

Surgeon removes your colon and rectum and creates an internal reservoir from your small intestine (Use distal ileum (30 cm)) to create a reservoir with a nipple valve
→ no need for external bag use → nipple valve is used to remove feces by catheter

Also used as treatment for bladder cancer when bladder is removed and ueter is connected to small intestine to make a reservoir

Irrigation helps train your body Irrigate with 10 -20 mL of warm NS → instill water gently → allow to drain via gravity using catheter

Question 24

What is the most commonly used surgical
procedure for ulcerative colitis ?

Answer 24

ileal pouch-anal anastomosis (IPAA)
AKA J-POUCH

surgical procedure used to restore gastrointestinal continuity after surgical removal of the colon and rectum. … Also called a J pouch or an internal pouch, the procedure involves the creation of a pouch of small intestine to recreate the removed rectum

(removing diseased colon and rectum) /*temporary diverting loop ileostomy (x 3mo) to allow healing
*voluntary defecation is maintained
*Perianal skin care due to leakage of fecal content
- use of skin barrier (Vaseline) after each bowel movement

Question 25

RISK FACTORS FOR CRC
Colorectal Cancer

Answer 25

*Diet: ↑ fat diet, ↓ fiber diet
Lifestyle factors: Obesity; Physical inactivity; Heavy Alcohol; smoking
*Family history:
*FAP (Familial adenomatous polyposis),
*colon cancer
*Previous colorectal polyps
*IBD
*Age >45

Question 26

CLINICAL MANIFESTATION OF CRC
Colorectal Cancer

Answer 26

*change in bowel habits
*Iron- deficiency anemia (d/t bleeding/menstruation)
→CHECK CBC/MCV; give IRON/VIT.B12
-blood in stool (occult,tarry, bleeding)
-tenesmus [feeling like you still need to make a BM]
-symptoms of obstruction
-pain, either abdominal or rectal;
-feeling of incomplete evacuation;
-Change in stool caliber
-occult bleeding

Question 27

SCREENINGS FOR CRC

Answer 27

*Importance of screening procedures
-Fecal occult blood test (FOBT)
-Fecal immunochemical test (FIT) -positive result indicates abnormal bleeding in the lower digestive tract
-Flexible sigmoidoscopy every 5 years
-Colonoscopy every 10 years
-Double-contrast barium enema study every 5 years

Question 28

TREATMENT FOR CRC

Answer 28

Treatment depends on the stage of the disease
-Adjuvant –radiation/chemotherapy
-Surgical intervention→
→colostomy

Question 29

NURSING INTERVENTIONS FOR
Patient With Cancer of the Colon or Rectum

Answer 29

*Preparing the patient for surgery/Emotional support : Consult a wound, ostomy, and continence nurse specialist- Select the ostomy site; Provide follow-
up care and teaching
*Providing postoperative care: Sterile dressing changes, care of drains, and
patient and caregiver teaching about the stoma * -Maintaining optimal nutrition/Providing wound care: Wound should be examined
regularly; Record bleeding, excessive drainage, and odor Monitoring and managing complications (Table 47-6) * *Removing and applying the colostomy appliance/ *Irrigating the colostomy
*Supporting a positive body image
*Discussing sexuality issues
-Promoting home and community-based care

Question 30

WHY DO WE IRRIGATE THE COLOSTOMY ?

Answer 30

*Irrigating the colostomy: to regulate the passage of fecal materials
*done at a regular time

*Irrigating reservoir contain 500 -1500 ml lukewarm tap water
*Hang it 18 in (45-50 cm) above the stoma (shoulder height) (TOO HIGH= FAST; TOO LOW = VERY SLOW)
*Insert cath 3-4 “
*Perform irrigation *1 hr after a meal
*Charcoal filters—deodorize and release flatus