chapter 37 bowel

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1. a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

2. c. If the patient complains of severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur.

3. a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Jensen, 2011)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

4. b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate (Augmentin), laxatives, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

5. c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer’s instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.

6. d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

7. a. Preparation for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day 2 of the test, or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a short period of time. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests.

8. c. When a patient complains of dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the physician. The vagal nerve may have been stimulated.

9. d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

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10. a, c, e, f. The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.

11. d. For a bowel-training program to be effective, the patient must have ample time for evacuation (usually 20–30 minutes). Fluid intake is increased to 2,500 to 3,000 mL, food high in bulk is recommended as part of the program, and a daily enema is not administered in a bowel-training program. A cathartic suppository may be used 30 minutes before the patient’s usual defecation time to stimulate peristalsis.

12. a. An ileostomy may cause disturbed body image due to the invasive nature of the procedure and the presence of the stoma. Constipation does not normally occur with an ileostomy because the drainage is liquid. Growth and development are not generally affected by the formation of an ileostomy. Excess fluid volume is unlikely to occur because the drainage is liquid and probably continual.

13. b. If irrigation solution is not flowing, the nurse should first check the clamp on the tubing to make sure the tubing is open. Next, the nurse should gently manipulate the cone in the stoma and check for a blockage of stool. If there is a blockage, the nurse should remove the cone from the stoma, clean the area, and gently reinsert. Alternately, the nurse could assist the patient to a side-lying or sitting position in bed, place a waterproof pad under the irrigation sleeve, and place the drainage end of the sleeve in a bedpan.

14. c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the physician. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

15. a. Although all the choices are laxatives that would soften the stool and make it easier to expel, a stool softener, such as Colace, is the one recommended for a patient who must avoid straining. In this case, it would help to prevent disturbing the stitches in the perineum.

(Taylor 1392-1393)

Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

1. A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next?

Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants.

Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen.

Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort.

Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

2. A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation?

Elevate the head of the bed 30 degrees and reposition the rectal tube.

Place the patient in a supine position and modify the amount of solution.

Lower the solution container and check the temperature and flow rate.

Remove the rectal tube and notify the primary care provider.

3. A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply.

A patient diagnosed with peritonitis

A patient who is on prolonged bedrest

A patient who has diarrhea

A patient who has gastroenteritis

A patient who has an early bowel obstruction

A patient who has paralytic ileus caused by surgery

4. A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply.

A patient who is taking narcotics for pain

A patient who is taking laxatives

A patient who is taking diuretics

A patient who is dehydrated

A patient who is taking amoxicillin for an infection

A patient taking over-the-counter antacids

5. A patient has a fecal impaction. The nurse correctly administers an oil-retention enema by:

Administering a large volume of solution (500–1,000 mL)

Mixing milk and molasses in equal parts for an enema

Instructing the patient to retain the enema for at least 30 minutes

Administering the enema while the patient is sitting on the toilet

6. A nurse prepares to assist a patient with her newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.

“When you inspect the stoma, it should be dark purple-blue.”

“The size of the stoma will stabilize within 2 weeks.”

“Keep the skin around the stoma site clean and moist.”

“The stool from an ileostomy is normally liquid.”

“You should eat dark green vegetables to control the odor of the stool.”

“You may have a tendency to develop food blockages.”

7. A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?

Have the patient follow a clear liquid diet 24 to 48 hours before the test.

Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1.

Prepare the patient for the use of general anesthesia during the test.

Explain that barium contrast mixture will be given to drink before the test.

8. A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then she vomits. What should be the nurse’s next action?

Reassure the patient that this is a normal reaction to the procedure.

Stop the procedure, prepare to administer CPR, and notify the physician.

Stop the procedure, assess vital signs, and notify the physician.

Stop the procedure, wait five minutes, and then resume the procedure.

9. A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed?

c, b, d, a

d, c, a, b

a, b, d, c

b, a, d, c

10. A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply.

Draw up 30 mL of saline solution into the syringe.

Unclamp the suction tubing near the connection site to instill solution.

Place the tip of the syringe in the tube to gently insert saline solution.

Place syringe in the blue air vent of a Salem sump or double-lumen tube.

After instilling irrigant, hold the end of the NG tube over an irrigation tray.

Observe for return flow of NG drainage into an available container.

11. A nurse is teaching a patient with frequent constipation how to implement a bowel-training program. What is a recommended teaching point?

Using a diet that is low in bulk

Decreasing fluid intake to 1,000 mL

Administering an enema once a day to stimulate peristalsis

Allowing ample time for evacuation

12. A nurse caring for patients with bowel alterations formulates a nursing diagnosis for a patient with a new ileostomy. Which diagnosis is most appropriate?

Disturbed Body Image

Constipation

Delayed Growth and Development

Excess Fluid Volume

13. A nurse is irrigating the colostomy of a patient and is unable to get the irrigation solution to flow. What would be the nurse’s next action in this situation?

Assist the patient to a prone position on a waterproof pad and try again.

Check the clamp on the tubing to make sure that the tubing is open.

Quickly pull the cone from the stoma and check for bleeding.

Remove the equipment and call the primary care provider.

14. A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse’s first action in this situation?

Reassure the patient that this is a normal finding with a new ostomy.

Notify the primary care provider that the stoma is prolapsed.

Have the patient rest for 30 minutes to see if the prolapse resolves.

Remove the appliance and redo the procedure using a larger appliance.

15. A nurse is caring for a postpartum patient who has stitches in the perineum from an episotomy (surgically planned incision to prevent vaginal tears). Which medication would the nurse most likely administer to this patient?

A stool softener (Colace)

An osmotic laxative (Miralax)

A bulk-forming laxative (Metamucil)

An emollient laxative (mineral oil)

(Taylor 1391-1392)

Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.