Gastro Flashcards
Diverticula
are saccular dilations or outpouchings of the mucosa that develop in the colon.
Diverticulitis
is the inflammation of the diverticula resulting in perforation into the peritoneum.
Clinically, diverticular disease convers a spectrum from:
asymptomatic, uncomplicated diverticulosis to diverticulitis with complications such as perforation, abscess, fistula, and bleeding.
Do you always get “itis”?
- Diverticula are common, most people never develop the diverticulitis.
Where are they found?
- Can occur anywhere in the Gi tract, but are most commonly found in the left (descending, sigmoid) colon.
Symptoms
- Pain (usually lower left descending colon)
- Nausea/vomiting
- Fever
- Tenderness
- Constipation (less commonly diarrhea)
Assessment/diagnostic
- Hx and physical exam
- Testing of stool for occult blood
- Barium enema
- Sigmoidoscopy
- Colonoscopy
- CBC
- Urinalysis
- Blood culture
- CT scan with oral contrast
- Abdominal x-ray
- Chest xray
Teaching
- High fiber diet
- Dietary fiber supplements
- Stool softeners
- Anticholinergics
- Bed rest
- Clear liquid diet
- Oral antibiotics
- Mineral oil
- Bulk lacatives
- Weight reduction
Treatment
Antibiotics
- goal of treatment is to let the colon rest and the inflammation subside.
- clear liquid diet
- acute care- NG suction and IV fluid
- surgery is reserved for patients with complications such as an abscess or obstruction that cannot be managed medically.
Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply.
- Bran cereal.
- Broccoli.
- Tomato juice.
- Navy beans.
- Cheese.
1, 2, 4.
Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
- Elevated red blood cell count.
- Decreased platelet count.
- Elevated white blood cell count.
- Elevated serum blood urea nitrogen concentration.
- Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.
The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema:
- Can perforate an intestinal abscess.
- Would greatly increase the client’s pain.
- Is of minimal diagnostic value in diverticulitis.
- Is too lengthy a procedure for the client to tolerate.
- Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client’s pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine.
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- Using enemas to relieve constipation.
- Decreasing fluid intake to increase the formed consistency of the stool.
- Eating a high-fiber diet when symptomatic with diverticulitis.
- Refraining from straining and lifting activities.
- Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.
After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. 1. “With careful attention to my diet, my diverticulosis can be cured.”
- “Using a cathartic laxative weekly is okay to control bowel movements.”
- “I should follow a diet that’s high in fiber.”
- “It is important for me to drink at least 2,000 mL of fluid every day.”
- “I should exercise regularly.”
3, 4, 5.
Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/ day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.
A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he:
- Passes stool without cramping.
- Does not have diarrhea any longer.
- Is not as anxious as he was.
- Does not expel gas like he used to.
- Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas formation.
A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
- Percuss the abdomen to note resonance and tympany. 2. Percuss the liver to note lack of dullness.
- Monitor the vital signs for fever, tachypnea, and bradycardia.
- Assess presence of polyphagia and polydipsia.
- Auscultate bowel sounds to note frequency.
1, 2, 5.
Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.
Inflammatory bowel disease (IBD)
Chronic inflammation of the GI tract. It is characterized by periods of remission interspersed with periods of exacerbation. The exact cause is unknown, and there is no cure.
IBD is classified as either Crohn’s disease or ulcerative colitis
Location of ulcerative colitis and crohns
Ulcerative colitis- colon
crohn’s- mouth to anus
** both are autoimmune**
Environmental factors that cause IBD
- diet
- hygiene
- stress
- smoking
- NSAID use ( influence microbial system)
Where in the world is IBD most prevalent?
Industrialized regions
Genetic factors that cause IBD
- white
- Jewish decedent
- familial genome- but if not exposed to trigger agent it can remain dormant.
Canned elemental food
High protein, low fiber, calorie rich supplement for ulcerative colitis
Why do you have bloody diarrhea in ulcerative colitis
The lining of the colon sloughs off and causes bloody diarrhea
Signs/symptoms of UC
Anemia skin breakdown fever diarrhea boody stools, weight loss, abdominal pain, fatigue
Five major classes of medications used to treat IBD
aminosalicylates antimicrobial corticosteroids immunosuppressants biologic and targeted therpy
Describe Crohn cells
cobblestone cells in large colon, no parastalsis and an have blockage
** steroids are last resort**
The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply.
- A client with Crohn’s disease who is receiving total parenteral nutrition (TPN).
- A client who underwent inguinal hernia repair surgery 3 hours ago.
- A client with an intestinal obstruction who needs a Cantor tube inserted.
- A client with diverticulitis who needs teaching about his take-home medications.
- A client who is experiencing an exacerbation of his ulcerative colitis.
2, 5.
The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis?
- A demanding and stressful job.
- Changing to a modified vegetarian diet.
- Beginning a weight-training program.
- Walking 2 miles every day.
- Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.
A client who is experiencing an exacerbation of ulcerative colitis is receiving I.V. fluids that are to be infused at 125 mL/ hour. The I.V. tubing delivers 15 gtt/ mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? ________________________ gtt/ minute.
31 gtt/ minute
To administer I.V. fluids at 125 mL/ hour using tubing that has a drip factor of 15 gtt/ mL, the nurse should use the following formula: 125 mL/ 60 minutes × 15 gtt/ 1 mL = 31 gtt/ minute.
When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply.
- Assessing the client’s bowel sounds.
- Providing skin care following bowel movements.
- Evaluating the client’s response to antidiarrheal medications.
- Maintaining intake and output records.
- Obtaining the client’s weight.
2, 4, 5.
The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.
Which goal for the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?
- Promoting self-care and independence.
- Managing diarrhea.
- Maintaining adequate nutrition.
- Promoting rest and comfort.
- 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
The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has:
- Conserved energy.
- Reduced intestinal peristalsis.
- Obtained needed rest.
- Minimized stress.
- Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.
A client’s ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications?
- Heart failure.
- Deep vein thrombosis.
- Hypokalemia.
- Hypocalcemia.
- 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.
A client who has ulcerative colitis says to the nurse, “I can’t take this anymore! I’m constantly in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with this.” Based on these comments, an appropriate nursing diagnosis for this client would be:
- Impaired physical mobility related to fatigue.
- Disturbed thought processes related to pain.
- Social isolation related to chronic fatigue.
- Ineffective coping related to chronic abdominal pain.
- It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about 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.
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?
- “Ulcerative colitis can be cured by the use of steroids.”
- “Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”
- “Long-term use of steroids will prolong periods of remission.”
- . “The side effects of steroids outweigh their benefits to clients with ulcerative colitis.”
- 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.
A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs?
- Continuous enteral feedings.
- Following a high-calorie, high-protein diet.
- Total parenteral nutrition (TPN).
- Eating six small meals a day.
- Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client’s nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client’s symptoms.
A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions 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- 1,500 mL per day.
- Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider.
- Stop taking the medication if the urine turns orange-yellow.
- Avoid activities that require alertness.
- If dose is missed, skip and continue with the next dose.
1, 2, 4.
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 health care provider immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200- 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.
The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication?
- Avoid taking it with food.
- Take the total dose at bedtime.
- Take it with a full glass (240 mL) of water.
- Stop taking it if urine turns orange-yellow.
- Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.
The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? ________________________ tablets.
4 tablets
To administer 2 g sulfasalazine (Azulfidine), the nurse will need to administer 4 tablets.
A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following nursing interventions will be most helpful to the client?
- Review her current coping mechanisms and develop alternatives, if needed.
- Suggest a less stressful career in which she would still use her education and experience.
- Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases.
- Prepare family members for the fact that she will have to work part-time.
- A client with ulcerative colitis need not curtail career goals. Self-care is the cornerstone of long-term management, and learning to cope with and modify stressors will enable the client to live with the disease. Giving up a desired career could discourage and even depress the client. Placing the responsibility for minimizing stressors at work in the hands of others leads to a feeling of loss of control and decreases the sense of responsibility needed for sound self-care. Working part-time rather than full-time is unnecessary.
