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The nurse is caring for a group of patients with a variety of GI problems. Which factor can influence the occurence of both diarrhea and constipation?
A. increased metabolic rate
B. high solute tube feedings
C. side effects of medications
D. inability to perceive bowel cues
Side effects of medications
Rationale: medications, depending on their physiologic action, side effects, and toxic effects, can cause either constipation or diarrhea.
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A patient is admitted with a diagnosis of upper GI bleeding. The nurse should expect the color of this patients stool to be:
A. red
B. pink
C. black
D. brown
Black
Black (tarry) stool indicates upper GI bleeding. Enzymes acting on the blood turn it black. In addition, iron supplements, excessive intake of red meat, and dark green vegetables can cause black stools.
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Red colored stools indicates ____ GI bleeding.
lower
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When administering a small volume hypertonic enema to an adult, the nurse should:
A. insert the rectal tube 1 to 1.5 inches into the rectum
B. position the enema bottle 12 inches above the level of the patients anus
C. direct the rectal tube toward the vertebrae as it is inserted into the rectum
D. maintain the compression of the enema container until after withdrawing the tube
Maintain the compression of the enema container until after withdrawing the tube
rationale: this prevents suctioning back of the fluid that has just been instilled. Releasing compression on the bottle causes a vacuum at the tip of the nozzle that can injure mucous membranes.
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Before collecting a stool sample for occult blood, the nurse should:
A. plan to collect the first specimen of the day
B. secure a sterile specimen container
C. wash the patients perineal area
D. ask the patient to void
Ask the patient to void
Emptying the urinary bladder before attempting to have a bowel movement prevents accidental contamination of the specimen by urine.
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Which is a defining characteristic of the nursing diagnosis bowel incontinence?
A. frequent, soft stools
B. involuntary passage of stool
C. impaired rectal sphincter control
D. greenish-yellow color to the stool
- Involuntary passage of stool
- Rationale: An involuntary passage of stool is a major defining characteristic of the nursing diagnosis Bowel Incontinence, which is the state in which an individual experiences a change in usual bowel habits characterized by involuntary passage of stool.
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The nurse is collecting a bowel elimination history for a newly admitted patient with a medical diagnosis of possible bowel obstruction. Which question takes priority?
A. "do you use anything to help u move your bowels"
B. "when was the last time you moved your bowels"
C. "what color are your usual bowel movements"
D. "how often do you have a bowel movement"
- "When was the last time you moved your bowels"
- Rationale: a cardinal sign of bowel obstruction is the lack of a bowel movement (obstipation)
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A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. To best increase the bulk in fecal material, the nurse should recommend that the patient eat:
A. whole wheat bread
B. white rice
C. pasta
D. Kale
- Kale
- rationale: kale is an excellent source of dietary fiber.
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A patient is experiencing constipation. Which independent nursing action facilitates defecation of a hard stool?
A. applying a lubricant to the anus
B. encouraging a sitz bath after defecation
C. instilling warm mineral oil into the rectum
D. positioning cold compresses against the anus
Applying a lubricant to the anus
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A patient with flatulence is concerned about the production of unpleasant odors. The nurse should encourage the patient to avoid:
A. alcohol
B. raisins
C. Coffee
D. Eggs
- Eggs
- Rationale: eggs will produce odorous gas and should be avoided. In addition, the patient should be taught to avoid other odor- producing foods, such as asparagus, fish, garlic, green peppers, mustard, onions, radishes, and spicy foods
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A patient is admitted with lower GI tract bleeding. The nurse expects that the patient will have ________ (color) stool.
Bright red tinged
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The nurse determines that the teaching about a guaiac test of stool is understood when the patient states. "this test can detect the presence of ______."
hidden blood
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The nurse must collect a specimen for the presence of pinworms. Which action is most essential to ensure accuracy of the specimen?
- Perform the procedure the first thing in the morning before the first bowel movement
- Rationale: This ensures that there will be eggs available for collection at the perineal area. The adult pinworm (enterobius vermincularis) exits the anus at night to lay eggs. The celophae-tape (scotch tape) test is performed first thing in the morning before a bowel movement or bathing so these eggs are not disrupted or removed before obtaining a specimen for testing
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The nurse identifies that the patient understands the need to reestablish bowel flora after a week of diarrhea when the patient states, "im going to :
eat a container of yogurt every day for a few days."
Rationale: Yogurt is merely milk that is curdled by the addition of bacteria, specifically Lactobacillus bulgaricus and streptococcus thermophilus. Eating yogurt helps to restore bacterial balance of the resident flora of the intestine
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The nurse teaches a patient with a history of constipation that the excessive use of laxatives should be avoided primarily b/c it:
A. weakens the natural response to defecation
B. results in distention of the kidneys
C. causes abdominal discomfort
D. precipitates incontinence
- weakens the natural response to defecation
- Rationale: Laxatives cause a rapid transit time of intestinal contents. When used excessively, the bowels natural responses to fecal distention and rectal pressure weaken, resulting in chronic constipation.
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The nurse is assisting a patient with a bedpan. Which nursing action is most important?
A. position the pt slightly off the back edge of a regular bedpan
B. fold the top linen out of the way when putting pt on the bedpan
C. place the flat part of the rim of the fracture bedpan toward the patients feet
D. once on the bedpan raise the head of the bed so that the patient is in the fowlers position
- Once on the bedpan, raise the head of the bed so that the patient is in the fowlers position
- Rationale: Raising the patient to fowlers position assumes the familiar, usual position for having a bowel movement. The more vertical position utilizes gravity and hip flexion raises intra abdominal pressure, both of which maximize evacuation of feces.
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The nurse identifies that a patient has tarry stools. The nurse understands that tarry stools indicate:
Upper GI bleeding
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When the nurse uses a cone attached to a colostomy irrigation catheter it works by:
A. stopping the outflow of enema solution during the procedure.
B. dilating the stoma so that the enema tube can be inserted
C. facilitating the elimination of drainage from the colon
D. preventing prolapse of the bowel during peristalsis
- Stopping the outflow of enema solution during the procedure
- Rationale: The cone advances into the stoma until it effectively fills the opening, which prevents a reflux of solution while the irrigating solution is being instilled. In addition, it helps prevent accidental perforation of the bowel with the rectal catheter.
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Which is an appropriate goal for a patient with the nursing diagnosis Perceived constipation? The patient will:
- Have a bowel movement without the use of laxative
- Rationale: This is the most appropriate goal for a patient with the nursing diagnosis perceived constipation b/c a defining characteristic of this diagnosis is excessive use of laxatives to achieve a daily bowel movement.
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The nurse must administer a large volume tap water enema. Which mechanism associated with this type of enema increases peristalsis?
A. bowel distention
B. hypertonic action
C. irritating the bowel
D. absorption of fluid by stool
- Bowel distention
- Rationale: a large volume enema dilates the intestine by exerting pressure against the intestinal wall. This pressure stimulates peristalsis, which propels intestinal contents toward the anus.
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The nurse understands that a tape water enema is usually give to:
A. reduce abdominal gas
B. drain the urinary bladder
C. empty the bowel of stool
D. limit nausea and vomiting
- Empty the bowel of stool
- Rationale: a tap water enema puts fluid into the large intestine; the pressure of this volume causes the colon to empty of stool.
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A _______ helps to eliminate intestinal gas
harris drip (harris flush)
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Signs of a ________ include: fever, chills, urinary frequency, urgency, dysuria, hematuria, pain at the costovertebral angle, and elevated serum WBC.
UTI
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______ is a common mineral supplement, is available OTC medication and is often prescribed for the treatment of anemia. Has an astringent effect on the bowel and is notorious for causing constipation.
Iron
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__________ (particularly opioids)- narcotics, slow peristalsis and are associated with a high incidence of constipation
Pain medications
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Testing stool for occult blood
- use a clean, dry container
- take care that the sample is not contaminated by urine/ menstrual blood
- test 2 small stool samples from separate areas of the large sample
- spread each sample thinly, one at a time, onto the "windows" of the Hemoccult slide
- place the correct number and size of drops of developer solution into the "windows" of the opposite side of the hemoccult slide
- record a positive result if the slide windows turn blue
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Placing and removing a bedpan
- determine whether the patient will need to use a regular bedpan or a fracture pan
- don clean procedure gloves
- help the patient to achieve a position on the bedpan that will be most helpful in facilitating urinary or bowel elimination. Place the patient in semi-fowlers position whenever possible. Modify based on the pt's condition
- provide clean washcloths and towels for the pt to perform hygiene when elimination is complete. assist if the pt cannot perform these tasks independently
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Administering an enema
- determine the patients ability to retain the enema solution
- if the patient is immobile, have a bedpan or bedside commode available
- warm the solution
- lubricate the tip of the enema tubing generously
- insert the tubing only about 7.5 to 10 cm (3 to 4 inches) into the rectum
- hold the container at the correct height above the level of the hips
- instill the solution at a slow rate
- encourage the patient to take slow, deep breaths and hold the solution for 5-15 minutes depending on the type of enema
- assess the patient for cramping or inability to retain the solution
- document the results
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Removing stool digitally
- trim and file your fingernails if they are long. nails should not extend over the end of the fingertips
- obtain baseline vital signs and determine whether the patient has a history of cardiac problems or other contraindications
- determine whether procedure will be accompanied by suppository insertion or enema administration (will an oil rentetion enema be given first?
- use only one or two fingers and remove stool in small pieces
- allow the pt periods of rest, and monitor for signs of vagal nerve stimulation
- teach the patient lifestyle changes necessary to prevent stool retention
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Changing an ostomy appliance
- change the pouch every 3-5 days
- empty the old pouch prior to removing it, if possbile
- remove the wafer or pouch slowly and gently, pulling down from the top with one hang while holding counter-tension with the other
- assess the stoma and the peristomal skin area for abnormalities
- use a measuring guide to determine the size of the stoma
- trace the size of the opening onto the back of the wafer, and cut the wafer opening about 2-3 cm
- apply the new wafer with gentle pressure
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Irrigating a colostomy
- determine the patients normal bowel pattern before surgery
- use 500 to 1000 ml, preferably 1000 ml, of warm tap water, priming the tubing prior to irrigation
- position the pt in front of or on the toilet or bedside commode. if pt is immobile, place is left lying sims position, and use a bedpan
- remove the existing colostomy applicance. examine the stoma and periostomal skin
- place the irrigation sleeve over the stoma
- lubricate the cone at the end of the irrigation tubing. Through the top of the irrigation sleeve, gently insert the cone into the stoma
- open the clamp, and begin the irrigation
- when the irrigation is complete, clamp the top of the sleeve. allow approx. 30 minutes for evacuation
- remove the sleeve, and rinse, dry, and store it. Apply a new colostomy appliance
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