Non-Inflammatory Bowel Disorders

Question 1

Non Inflammatory Bowel Disorders

Answer 1

• Can cause pain, changes in bowel pattern, bleeding, and malabsorption
• Group of disorders includes hemorrhoids, cancer, hernia, IBS, and intestinal obstruction
• A hernia that cannot be moved back into place w/ gentle palpation is considered irreducible and requires immediate surgical evaluation
  
  • In a hernia that is strangulated, blood supply is cut off to a portion of the bowel, increasing the risk for obstruction, necrosis, and perforation
  • Manifestations:
    
    • Abdominal distention
    • Tachycardia
    • Vomiting
    • Abdominal pain
    • Surgical intervention is necessary

Question 2

hemorrhoids

Answer 2

• Distended or edematous intestinal veins resulting from inc intra-abdominal pressure
  
  • Straining, obesity, prolonged sitting or standing, constipation, weight lifting
  • Pregnancy inc risk of hemorrhoids

Question 3

bowel herniation vs/ incisional hernias

Answer 3

• Bowel herniation: displacement of the bowel thru a weakness of the abdominal muscle into other areas of the abdominal cavity
• Incisional hernias: occur as a postsurgical complication due to inadequate healing of the incisional site from malnutrition, infection, or obesity

Question 4

hernia: risk factors

Answer 4

• Male sex: indirect inguinal hernia can be large and descend into scrotum
• Advanced age: direct hernia
• Inc intra-abdominal pressure due to pregnancy or obesity: femoral, adult acquired umbilical hernia
• Genetics: congenital umbilical hernia

Question 5

hernia: expected findings

Answer 5

Protrusion or lump at involved site: groin area, umbilicus, healed incision

Question 6

hernias: nursing actions

Answer 6

• If hernia does not require surgery, instruct client to wear a truss pad w/ hernia belt during waking hours to prevent the abdominal contents from bulging into hernia sac
• Inspect skin under pad daily

Question 7

hernia: post op education

Answer 7

• Instruct client to avoid inc intra-abdominal pressure for 2-3 weeks
  
  • Avoid coughing, straining, and lifting objects greater than 10 lbs
• Apply ice as prescribed
• Inspect and report redness/swelling at incisional site
• Prevent constipation by inc fiber and fluids
• Rest for several days and return to work when surgeon OKs it: usually 1-2 weeks post op

Question 8

IBS

Answer 8

• Disorder of the GI system that causes changes in bowel function–>chronic diarrhea, constipation, bloating, and/or abdominal pain
  
  • Etiology of IBS is uncertain, but it is thought that environmental, immunological, genetic, hormonal and stress influence the development and course of dz
    
    • Food intolerances worsen the manifestations
• Environmental factors: dairy projects, caffeinated beverages, infectious agents
• Immunological factors: cytokine genes (pro-inflammatory interleukins), TNF alpha
• Stress related factors: anxiety, depression

Question 9

IBS: health promotion and dz prevention

Answer 9

• Avoid trigger foods: dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspartame
• Avoid alcohol and caffeinated beverages
  
  • Avoid foods with fructose and sorbitol
• Consume 2-3 L of fluid per day from food and fluids
• Inc fiber to 30-40 g/day

Question 10

IBS: risk factors

Answer 10

• Female sex
• stress
• Eating large meals w/ a large amount of fat
• Caffeine intake
• Alcohol intake

Question 11

IBS: expected findings

Answer 11

• Cramping pain in abdomen
• Abdominal pain: left lower quadrant–>due to changes in bowel pattern and consistency
• Nausea w/ meals or passing stools
• Anorexia
• Abdominal bloating
• Belching
• Diarrhea: diarrhea predominant IBS
• Constipation: constipation predominant IBS
• Hyperactive or hypoactive bowel sounds

Question 12

IBS: lab tests

Answer 12

CBC, serum albumin, and ESR, and occult stools: typically all w/in expected reference range

Question 13

IBS diagnosis

Answer 13

• difficult to diagnose
• Based on presence of specific tests
• Including abdominal pain, accompanied by changes in bowel patterns, abdominal distention, feeling that defecation is not complete, and presence of mucus w/ stools
• Other criteria can include recurrent abdominal pain for 3 days during a month in the past 3 mos and 2 or more of the following
  
  • Improvement when the client moves his or her bowels
  • Onset when there is a change in frequency of stools
  • Onset when there is a change in appearance of stools

Question 14

IBS: hydrogen breath test

Answer 14

• Client is asked to exhale into a hydrogen analyzer before and after ingesting test sugar
  
  • Positive test: indicates excess hydrogen in the bloodstream from bacterial overgrowth or malabsorption
• Client edu:
  
  • Instruct client to remain NPO at least 12 hr prior to test, except for sips of water

Question 15

IBS: nursing care

Answer 15

• Reduce stress
• Limit intake of irritating agents: gas forming foods, caffeine, alcohol
• Encourage diet high in fiber and fluids
• Instruct client to keep a food diary to record intake and bowel patterns to adjust diet to prevent exacerbations

Question 16

diarrhea predominant IBS (IBS-D): meds

Answer 16

• loperamide
• psyllium
• alosetron
• Nursing Considerations:
  
  • Contraindications:
    
    • Hx of bowel obstruction
    • Crohn’s dz
    • UC
    • Impaired intestinal obstruction
    • Thrombophlebitis
• Client Edu:
  
  • Manifestations should resolve in 1-4 weeks
    
    • d/c after 4 weeks if manifestations persist
  • avoid concurrent use of psychoactive drugs and antihistamines
  • Report constipation, fever, inc abdominal pain, fatigue, dark urine, bloody urine, or rectal bleeding immediately b/c alosetron can cause ischemic colitis
    
    • d/c if these manifestations

Question 17

loperamide

Answer 17

• Dec peristalsis and inc bulk
• Can cause drowsiness
• d/c if no response after 48 hr

Question 18

psyllium

Answer 18

• Bulk forming laxative
• d/c for abdominal cramping, rectal bleeding, and vomiting
• Monitor for electrolyte imbalance

Question 19

alosetron

Answer 19

• An IBS selective medication that selectively blocks 5-HT3 receptors that innervate the viscera
  
  • Expected result: inc firmness in stools and dec urgency and frequency of defecation
• Indicated for IBS-d in women that has lasted more than 6 mos and is resistant to conventional mgmt
  
  • Use w/ caution in women and only as a last resort

Question 20

constipation predominant IBS (IBS-C): meds

Answer 20

• lubiprostone
• linaclotide

Question 21

lubiprostone

Answer 21

• an IBS specific medication that inc fluid secretion in the intestine to promote intestinal motility
  
  • Indicated for IBS-C in women
• Nursing Considerations:
  
  • Contraindicated: clients who have known or possible bowel obstruction
  • Not effective for men w/ IBS
• Client edu:
  
  • Take w/ food and water

Question 22

linaclotide

Answer 22

• Inc fluid and motility in the intestine
• Can relieve pain and cramps
• Client edu:
  
  • Instruct the client to take daily about 30 min before breakfast

Question 23

intestinal obstruction: mechanical vs. non-mechanical

Answer 23

• Mechanical obstruction: occurs when the bowel is blocked by something outside or inside the intestines
  
  • Ie. adhesions, tumors, hernias, fecal impactions, strictures due to Crohn’s dz, and diverticulitis
  • Complete mechanical obstructions should be addressed surgically
• Non-mechanical obstruction: caused by diminished peristalsis w/in the bowel (paralytic ileus)
  
  • Can occur post op due to the handling of the intestines during surgery
• Tx: focuses on fluid and electrolyte balance, decompressing the bowel, and relief/removal of obstruction

Question 24

mechanical obstructions: risk factors

Answer 24

• Encirclement or compression of intestines by adhesions, tumors, fibrosis (endometriosis), or strictures (Crohn’s dz, radiation)
  
  • Post surgical adhesions are often the cause of small bowel obstructions
  • Carcinomas are often the cause of large intestine obstructions
• Older adults: diverticulitis, fecal impaction, and tumors are common causes of obstruction
  
  • Bowel regimens can be effective in preventing impactions
• Hernia: bowel becomes trapped in weakened area of abdominal wall
• Volvulus (twisting) or intussusception (telescoping) of bowel segments

Question 25

non mechanical obstruction: risk factors

Answer 25

• Results from dec peristalsis secondary to the following
  
  • Neurogenic disorders: manipulation of the bowel during major surgery and spinal frx
  • Vascular disorders: vascular insufficiency and mesenteric emboli
  • Electrolyte imbalances: hypokalemia
  • Inflammatory responses: peritonitis or sepsis
• Manifestations of nonmechanical obstructions: diffuse, constant pain; significant abdominal distention; frequent vomiting

Question 26

small bowel and large intestine obstructions: expected findings

Answer 26

• Obstipation: inability to pass a stool and/or flatus for more than 8 hr despite feeling the urge to defecate
• Abdominal distention
• High pitched bowel sounds above site of obstruction (borborygmi) with hypoactive bowel sounds below, or overall hypoactive
  
  • Absent bowel sounds later in process

Question 27

small bowel obstructions: expected findings

Answer 27

• Severe fluid and electrolyte imbalance
• Metabolic alkalosis
• Visible peristaltic waves (possible)
• Epigastric or upper abdominal distention
• Abdominal pain, discomfort
• Profuse, sudden projective vomiting w/ fecal odor

Question 28

large intestine obstructions: expected findings

Answer 28

• Minor fluid and electrolyte imbalance
• Metabolic acidosis (possible)
• Significant lower abdominal distention
• Intermittent abdominal cramping
• Infrequent vomiting
• Diarrhea or ribbon like stools around an impaction

Question 29

intestinal obstructions: lab tests

Answer 29

• Inc Hgb, BUN, creatinine, and Hct–>indicate dehydration
• Inc serum amylase and WBC count–>can occur w/ strangulating obstructions
• ABGs indicate metabolic imbalance, depending on obstruction type
• Chemistry profiles reveal dec sodium, chloride, potassium

Question 30

intestinal obstruction: diagnostic procedures

Answer 30

• X-ray: flat plate and upright abdominal x-rays evaluate the presence of free air and gas patterns
• Endoscopy determines cause of obstruction
• CT scan determine cause and exact location of obstruction

Question 31

non mechanical obstruction: nursing care

Answer 31

• NPO w/ bowel rest
• Assess bowel sounds
• Provide oral hygiene
• Administer IV fluids and electrolytes: potassium
• Manage pain: once diagnosis identified
• Encourage ambulation
• Place in semi fowler’s

Question 32

mechanical obstruction: nursing care

Answer 32

• Prepare for surgery and provide preop care
• w/hold intake until peristalsis resumes

Question 33

intestinal obstructions: meds

Answer 33

• Prokinetics: promote gastric motility (octreotide) in paralytic ileus or partial obstruction
• Broad spectrum abx: esp with suspected bowel strangulation

Question 34

intestinal obstruction: NG tube w/ a vent

Answer 34

• (to prevent damage to the stomach mucosa during continuous suctioning)
  
  • Inserted to decompress the bowel
• Nursing actions:
  
  • Maintain intermittent suction as prescribed
  • Assess NG tube patency and placement
  • Irrigate Q4
  • Monitor and assess gastric output
  • Monitor nasal area for skin breakdown
  • Provide oral hygiene Q2
  • Monitor V/S, skin integrity, weight, I&O

Question 35

intestinal obstruction: surgical interventions

Answer 35

• Varies based on cause of obstruction
• Can include lysis of adhesions, colon resection, colostomy creation (temporary or permanent), embolectomy, thrombectomy, resection of gangrenous tissue, or complete colectomy
• Exploratory laparotomy:
  
  • Determine cause of obstruction and rectify if possible
  • Nursing Actions:
    
    • Ensure client understands type of procedure: open or laparoscopic
    • Monitor for hemodynamic instability
    • Administer IV fluid replacement
    • Monitor bowel sounds
    • Maintain NG tube patency and measure output
    • Clamp NG tube as prescribed to assess the client’s tolerance prior to removal
    • Advance diet as tolerated
      
      • Begin w/ clear liquids
      • Clamp tube after eating for 1-2 hour
    • Instruct client to report intolerance of intake following NG tube removal: n/v, inc distention

Question 36

intestinal obstruction: list complications

Answer 36

• dehydration
• electrolyte imbalance
• metabolic alkalosis
• metabolic acidosis

Question 37

intestinal obstruction: dehydration as a complication

Answer 37

• (small bowel obstruction):
• Cause: persistent vomiting
• Nursing actions:
  
  • Assess hydration thru evaluation of Hct, BUN, orthostatic V/S, skin turgor/mucous membranes, urine output, and SG
    
    • Notify provider of fluid imbalance
  • Administer IV fluids

Question 38

intestinal obstruction: electrolyte imbalance as a complication

Answer 38

• small bowel obstruction
• Cause: persistent vomiting
• Nursing Actions:
  
  • Monitor electrolytes (esp K)
  • Notify HCP of electrolyte imbalance
  • Administer IV fluids

Question 39

intestinal obstruction: metabolic alkalosis as a complication

Answer 39

• small intestinal obstruction
• Cause: persistent vomiting, leading to loss of gastric hydrochloride
• Nursing Actions:
  
  • Monitor for hypoventilation (confusion, hypercarbia) which is a compensatory action by the lungs
  • Obtain ABGs
  • Notify provider if labs are unexpected
  • Replace fluids and electrolytes
  • Provide oral hygiene to alleviate inc thirst response
    
    • Thirst response: dec in older adult
    • Provide oral hygiene routinely to ensure maintenance of moist mucous membranes

Question 40

intestinal obstruction: metabolic acidosis

Answer 40

• large bowel obstruction
• Cause: lower level obstruction
• Nursing Actions:
  
  • Monitor for deep, rapid respirations (compensatory action by the lungs), confusion, hypoTN, flushed skin
  • Obtain ABGs
  • Notify if unexpected lab findings