NCLEX

NCLEX Case Study: Nursing Care of the Patient With a Gastrointestinal Disorder

By March 18, 2018 No Comments

Gastrointestinal Disorder

Donna works in the gastrointestinal (GI) lab, in which many endoscopies (with contrast dye) and scope procedures are done.

Matching:

Match the names of the procedures in Column A with the interventions in Column B:

Procedures and Interventions

Procedures and Interventions

Jonathan comes to the clinic and receives preprocedure instructions for a colonoscopy.

Select all that apply:

Which factors does the nurse consider while giving Jonathan instructions for his endoscopic examination?
A. Age
B. Medications
C. Allergies
D. Transportation
E. Previous radiographic examinations
F. Language and cultural barriers

Multiple-choice:

When a new-graduate nurse asks about obtaining consent for the procedure, the nurse’s best response is:
A. “Since the physician has already obtained informed consent, we will get the patient to sign the consent.”
B. “Yes, we get consent when the patient comes for preprocedure instructions.”
C. “We need to wait until the physician is in the room to get the patient to sign the consent.”
D. “We usually wait until a family member is present before obtaining consent.”

One of Donna’s main nursing interventions for patients during their procedure is to position them correctly to reduce the incidence of complications.

Matching:

Match the tests in Column A with the correct positions in Column B (you may use positions more than once):

Match Tests

Match Tests

Multiple-choice:

After completing preprocedure teaching about the colonoscopy, the nurse knows that Jonathan requires further instruction when he states:
A. “I need to stop eating 8 hours before the test is scheduled.”
B. “I need to make sure that someone is with me to drive me home.”
C. “I will be able to resume my normal diet after the procedure.”
D. “I will only have to take a mild laxative the evening before the procedure.”

Fill in the blanks:

List the two tests that require bowel preparations, such as laxatives and GoLYTELY.
1._________________________________________________________________________
2._________________________________________________________________________

Select all that apply:

Jonathan is in the endoscopy room ready for his procedure. Identify the final safety checks that must be completed by the nurse:
A. Confirm the correct patient and procedure
B. Have resuscitative equipment available
C. Confirm that an oral airway has been inserted
D. Position the patient in the supine position with head of bed at 30°
E. Review the patient’s allergies before administering medications
F. Have suctioning equipment ready for use

During the procedure, Jonathan’s respiration rate is 18 breaths per minute, BP is 130/90 mmHg, and pulse is 88 beats per minute. Postprocedure, Donna takes his vital signs every 15 minutes to check for complications.

Matching:

Match the symptoms in Column A with the possible causes in Column B:

Match Symptoms

Match Symptoms

Jonathan’s colonoscopy is significant for large obstructive polyps; he needs reparative surgery and a temporary ostomy or opening from his GI tract to bypass the surgical repair. By the end of the week, he is admitted to the surgical unit following a colon resection with colostomy placement.

Multiple-choice:

After taking Jonathan to his new room, the post-anesthesia care unit (PACU) nurse hands off care to the nurse on the surgical unit. What would be most important for the PACU nurse to communicate?
A. Estimated blood loss during the procedure was 160 mL.
B. Vital signs were stable during the operative and recovery phases.
C. The patient vomited twice while in the PACU.
D. The patient’s family is on the way to the room.

Jonathan is upset about the surgery and does not like to “wear the bag.” He also com- plains about leakage from the bag and the nurse checks the seal, because the drainage can cause ulceration of the surrounding skin. Jonathan has a good support system; he has been married for 30 years and tomorrow he and his wife will participate in discharge teaching.The next day the nurse goes over the discharge-teaching list.

Matching:

Match the discharge topics in Column A with the appropriate teaching issues in Column B:

Match discharge topics teaching

Match discharge topics teaching

KEY POINTS:

Endoscopic Procedures

■ Endoscopic procedures allow direct visualization of the GI, respiratory, or urinary tracts.
■ Preprocedure instructions and postprocedure care are specific to the procedures being done.
■ Sedation is given to reduce anxiety and diminish the patient’s memory of the procedure, which can be uncomfortable.
■ Patients are NPO preprocedure to minimize vomiting and the risk of aspiration.
■ Lower GI procedures require a bowel prep in order to visualize the tract.
■ After the procedure, patients should be closely monitored for airway, breathing, circulation, and any signs of complications.
■ Beginning at the age of 50 years, a colonoscopy is recommended every 10 years to screen for colorectal cancer.

Colostomies

■ A colostomy is created as a temporary or permanent fecal diversion.
■ The stoma should be beefy red or pink in appearance; a dark-brown, black, or purplish color could be suggestive of compromised circulation.
■ The consistency of the stool output is related to the placement of the colostomy; stool is increasingly solid the closer to the sigmoid colon and rectum.
■ Ileostomies, which divert stool from the small bowel, produce more loose/liquid output than colostomies.
■ Appliances are usually changed every 5 to 7 days or when leaking.
■ Emptying the appliance when one quarter to one third full minimizes the chances of the bag pulling loose from the skin.
■ Patients can usually follow a regular diet, although avoiding foods that produce gas (dairy, corn), cause odor (fish, eggs), or are hard to digest (popcorn, seeds) is recommended.


Thomas, the nurse, is admitting Ranesha, who is well known to the GI inpatient unit because she often has ascites. Ranesha, although rehabilitated now, has a long history of alcoholism.

Multiple-choice:

When admitting Ranesha to the unit, what task can the nurse delegate to the unlicensed assistive per- sonnel (UAP)?
A. List her home medications
B. Measure her input and output (I&O)
C. Assess for edema
D. Measure her abdominal girth

On admission,Thomas assesses Ranesha’s respiratory status and finds that she is dyspneic with a peripheral pulse oximetry level of 88%.Thomas calls Ranesha’s PCP and sets up the procedure room for a paracentesis.

Multiple-choice:

One of the major complications that can occur postparacentesis is:
A. Polycythemia
B. Low white blood cells (WBCs)
C. Hypovolemia
D. Hypervolemia

Thomas assesses Ranesha and takes her weight; he measures her abdominal girth and has her void before the paracentesis is started.The paracentesis drains 1 L of fluid from Ranesha’s abdomen, which should decrease her weight by 1 kg (2.2 lb).

After the procedure, the PCP orders an electrolyte study.Thomas knows the normal lab values and compares them with Ranesha’s blood work.

Matching:

Match the lab tests in Column A with the normal values in Column B:

Match lab tests

Match lab tests

Thomas assesses Ranesha for the signs of hypovolemia.

TIP: Clinical manifestations of hypovolemia

■ Tachycardia
■ Hypotension
■ Pallor
■ Diaphoresis
■ Dizziness

Two other complications for which Thomas assesses Ranesha during the night include:

Bladder perforation

● Hematuria
● Oliguria
● Lower abdominal pain

Peritonitis

● Sharp abdominal pain
● Fever
● Vomiting
● Hypoactive bowel sounds

Ranesha does well after the procedure;Thomas notices a little leakage from the insertion site and places a sterile gauze on it. Ranesha reports feeling better because she finds it easier to breathe.

KEY POINTS:

Ascites

■ The exact cause of ascites is unknown, but it is believed that failure of the liver to metabolize aldosterone, sodium and water retention, and decreased albumin con- tribute to its development.
■ Clinical manifestations include increased abdominal girth, weight gain, swelling of the lower extremities, and dyspnea.
■ Management includes dietary restriction of sodium and diuretics; spironolactone (Aldactone) combined with furosemide (Lasix) has been found to be most effective.
■ A paracentesis is done to remove fluid that is causing the patient significant prob- lems, such as respiratory distress; this is only a temporary solution as ascites can rapidly recur.
■ After the procedure, the patient should be monitored for bleeding or excessive drainage from the puncture site, elevated temperature, change in mental status, and signs of hypovolemia or electrolyte shifts.


Thomas now turns his attention to his other patients on the unit. Another patient, Elin, had her call bell light on twice during this time and Jed, the nursing assistant, has responded but reports to Thomas that Elin is still uncomfortable with “severe indigestion.”Thomas reads her medical record and finds that this patient was admitted with gastroesophageal reflux disease (GERD).Thomas knows that GERD can cause esophageal spasms from inflammation.

Select all that apply:

Select all the nursing interventions that may help Elin’s pain.
A. Offer her a cup of tea
B. Position her flat
C. Administer an antacid
D. Position her on the right side
E. Provide additional pillows
F. Encourage her to remain upright after eating

Elin is scheduled for inpatient surgery the following day because her endoscopy showed Barrett’s esophagus from persistent GERD and she has an intolerance of medications. She is scheduled for a fundoplication, which repositions the fundus of the stomach to decrease the chance of reflux. Elin does well postoperatively but has complaints of constipation.

Select all that apply:

To decrease Elin’s problems with constipation, the nurse encourages her to:
A. Avoid frequent use of laxatives
B. Decreasefluids
C. Increase fiber in her diet
D. Decrease her level of physical activity
E. Minimize the use of opioids for pain control
F. Discuss any home remedies that have worked in the past

Select all that apply:

What breakfast would you encourage Elin to order?
A. Brancereal
B. Yogurt
C. Freshfruit
D. Whitetoast

KEY POINTS:

Gastroesophageal Reflux Disease

■ Excessive reflux may result from an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder.
■ Clinical manifestations include pyrosis (burning), dyspepsia (indigestion), regurgita- tion, dysphagia, and esophagitis.
■ A low-fat diet is recommended with avoidance of caffeine, tobacco, beer, milk, car- bonated beverages, and peppermint or spearmint.
■ Other management strategies include avoiding eating or drinking 2 hours before bedtime, elevating the head of the bed on 6- to 8-in. blocks, and maintaining a nor- mal body weight.
■ Medications that may be used include antacids, H2 receptor antagonists, proton pump inhibitors, and prokinetic agents.


Christian,a 32-year-old executive,was admitted yesterday for peptic ulcer disease (PUD). An esophagogastroduodenoscopy (EGD) in the clinic confirmed a gastric ulcer, and he is being worked up for Helicobacter pylori, a major causative agent of PUD.

Multiple-choice:

At change of shift report, a new nurse, who is unfamiliar with H. pylori, asks whether the patient should be in isolation. Her preceptor’s best response would be:
A. “If the patient starts vomiting, we should put him in contact isolation.”
B. “As long as he has started treatment with antibiotics, isolation is not necessary.”
C. “Standard precautions are all that are needed in this case.”
D. “By the end of our shift, I want you to be able to tell me all about H. pylori.”

Christian’s history includes a high-stress job and frequent headaches on the job. He takes NSAIDs frequently.Thus, his history is typical for a patient with PUD. He reports bloating, fullness, and nausea 30 to 60 minutes after meals. Christian is prescribed medication and lifestyle changes and will be discharged and monitored.

Multiple-choice:

During discharge teaching, the nurse sees that Christian understands his instructions when he states:
A. “I will eat large meals three times a day.”
B. “I will find a relaxation technique such as yoga.”
C. “I can still drink all the iced tea that I want.”
D. “I can have a few glasses of wine with dinner.”

Christian is prescribed four medications to start before his return visit to the GI clinic in 2 weeks.

Matching:

Match the medications in Column A with the indications in Column B:

Match Medications

Match Medications

Three months later, Christian is seen in the ED for severe gastric pain, a rigid abdomen, and hyperactive bowel sounds with rebound tenderness. A perforation is suspected and he is taken to the operating room. A gastrojejunostomy (Billroth II procedure) is done to remove the lower portion of the ulcerated stomach.

Select all that apply:

What are some important postoperative nursing interventions for Christian?
A. Keep supine postoperatively
B. Monitor bowel sounds
C. Turn, cough, and breathe deeply
D. Monitor input and output (I&O)
E. Teach about dumping syndrome
F. Encourage liquids with meals

KEY POINTS:

Peptic Ulcer Disease

■ Peptic ulcers can occur in the esophagus, stomach, or duodenum, although a duo- denal ulcer is most common.
■ Research has shown that peptic ulcers result from infection with H. pylori, a Gram-negative bacteria acquired through ingestion of food and water.
■ Clinical manifestations include a dull, aching pain or burning in the midepigastric or back area, pyrosis (heartburn), vomiting, and bleeding.
■ Duodenal ulcers cause pain hours after a meal, frequently wake a person up at night, and are relieved by eating.
■ Gastric ulcers are often aggravated by the ingestion of food, so pain may occur 1⁄2 to 1 hour after eating a meal.
■ The goal of treatment is to eradicate H. pylori and manage gastric acidity.
■ Management includes lifestyle changes and pharmacologic therapy; surgical options
are a last resort.
■ Complications include hemorrhage, perforation and/or penetration, and pyloric obstruction.
Gastric Surgery
■ Following gastric surgery, patients must be monitored closely to ensure that they receive optimal nutrition.
■ Dumping syndrome commonly occurs following a gastric surgery in which only a small gastric remnant is connected to the jejunum through a large opening; symp- toms can be managed through various strategies.
■ Vitamin and mineral deficiencies also occur, especially vitamin B12, as intrinsic fac- tor is lost with significant gastric surgeries.
■ Patients require extensive education about their diet after gastric surgery.


Christian understands his discharge instructions, and adjusts well after returning home. He later returns to the GI clinic for his 2-week checkup. Donna is the RN assessing patients. Just as Donna ushers him into the room, her certified nursing assistant (CNA) comes in and asks her to come quickly to the waiting room.There, Simon, age 21 years, is doubled over with right-lower-quadrant pain and severe rebound tenderness over McBurney’s point.

Hot spot:

Place a mark on McBurney’s point.

McBurney’s point.

McBurney’s point.

Donna asks the administrative manager to call the transport ambulance and have Simon taken immediately to the ED for a suspected ruptured appendix. She phones ahead to notify the ED staff of the direct admission and her assessment. Donna also draws Simon’s blood to expedite the admission process, because it all goes to the same lab through a pneumatic tube system.

Select all that apply:

Identify the priority interventions for the patient admitted with acute appendicitis:
A. Prepare the patient for surgery
B. Maintain NPO (nothing orally) status
C. Administer an enema preoperatively
D. Insert an intravenous (IV) catheter and begin IV fluids
E. Notify the surgeon if the pain becomes more diffuse
F. Insert a nasogastric (NG) tube

Multiple-choice:

What other assessment is important to rule out peritonitis as a complication of a ruptured appendix?
A. Blood pressure (BP)
B. Pulse
C. Respiration
D. Temperature

Simon is taken from the ED to surgery, and an appendectomy is done. He is admitted to the GI inpatient unit for the night.

On the following day, Simon is being prepared for discharge. He has a postoperative appointment for the clinic, but he suddenly starts vomiting.Thomas, the nurse, notifies the physician, who orders the placement of an NG tube.

Hot spot:

Trace on the diagram how you should measure a nasogastric (NG) tube:

Measure a nasogastric (NG) tube

Measure a nasogastric (NG) tube

Multiple-choice:

What is considered the most accurate method for verifying placement of the nasogastric (NG) tube?
A. Aspiration of stomach contents
B. Bolus of air and listen for the gurgle as injected
C. Check the pH of aspirated contents
D. X-rayverification

Thomas attached the NG tube to suction to remove any further gastric contents.The orders are to keep Simon NPO for at least 24 hours before discontinuing the tube and providing fluids orally.

KEY POINTS:

Appendicitis

■ When the appendix is kinked or occluded, inflammation occurs; rupture usually occurs within 24 hours of the onset of pain.
■ Pain may begin in the periumbilical area and then localizes to the right lower quadrant; pain that changes and becomes more diffuse may indicate rupture.
■ Although appendicitis is uncommon in the elderly, it carries a higher risk of perforation because the classic signs and symptoms are often absent.
■ Treatment is immediate surgery.
■ The major complication is perforation with possible resultant peritonitis.


Ed was recently diagnosed with Crohn’s disease.Throughout high school, it was thought that he had irritable bowel syndrome (IBS), which affects 20% of Americans.When Ed was admitted, diverticulitis was also ruled out because there was no acute inflammation on colonoscopy.The test revealed intermittent inflammation throughout the bowel with a classic cobblestone appearance to the tissue. Ed is on corticosteroids to decrease the current inflammatory episode.

Matching:

Indicate whether each characteristic in Column B is associated with Crohn’s disease or ulcerative colitis,
as mentioned in Column A:

Crohn's disease or ulcerative colitis

Crohn’s disease or ulcerative colitis

Ed is taught dietary control for his Crohn’s disease and discharged with a return appointment to the GI clinic.

Select all that apply:

Select the types of foods recommended for patients with Crohn’s disease.
A. Highcalorie
B. Lowcalorie
C. Highprotein
D. Highfiber
E. Highfat
F. Lowfat

KEY POINTS:

Inflammatory Bowel Disease

■ Although Crohn’s disease and ulcerative colitis differ in some of their characteristics and clinical manifestations, the management for both is quite similar.
■ The cause of inflammatory bowel disease (IBD) is unknown, but it is thought to be triggered by environmental agents; NSAIDs have been found to exacerbate IBD.
■ Crohn’s disease usually occurs in the ileum or ascending colon, ulcerations are dis- continuous giving a “cobblestone” appearance, bleeding is uncommon, and diarrhea is less severe than with ulcerative colitis.
■ Ulcerative colitis spreads diffusely in the rectum and descending colon, bleeding is much more common, and diarrhea is often severe.
■ Treatment focuses on reducing inflammation, suppressing the immune response, resting the bowel, preventing complications, and improving quality of life.
■ A low-residue, high-protein, high-calorie diet with supplemental vitamins is recom- mended.
■ Several medications are used such as corticosteroids and immunomodulators.
■ Surgery is indicated when other measures have failed to relieve the symptoms of IBD and quality of life is poor.


Polly is examined by Donna, the nurse working at the clinic. Polly came to the clinic because she had an attack (not her first)—which she describes as right-upper-quadrant (RUQ) pain after dinner. Polly is 3 months postpartum with her sixth child. An RUQ ultrasound finds the gallbladder to be edematous with several stones present.

Multiple-choice:

After being diagnosed with cholelithiasis, Polly has many questions. Donna provides education on her disease process, but it is evident that Polly needs further instruction when she states:
A. “These painful attacks are often precipitated by a fatty meal.”
B. “If the pain does not resolve, it could indicate that the stone is obstructed.”
C. “I won’t have to be in the hospital long if I am able to have a laparoscopic cholecystectomy.”
D. “If I can withstand the painful episodes, eventually the stones will dissolve.”

Polly is counseled on dietary management. She would like to avoid a cholecystectomy if possible because of child-care issues.

Select all that apply:

Select the foods that would be appropriate for Polly.
A. Beans
B. Eggs
C. Ice cream
D. Chicken
E. Apple
F. Bacon

Polly returns to the ED with pain 2 weeks later and is admitted for an open cholecystectomy. After surgery,she has a Penrose drain at the surgical site. This allows fluid to drain into the dressing on the abdomen.

Fill in the blanks:

Two other kinds of drainage tubes used postoperatively are described. Fill in the names.
1. It is a tube with a bulb at the end that is compressed to produce gentle suction at the surgical site.
__________________________________________________________________________________________________
2. It is a tube with a spring-activated device that is compressed to produce gentle suction at the surgical site.
__________________________________________________________________________________________________

KEY POINTS:

Gallbladder Disease

■ Cholecystitis can exist without stones, but 90% of the people with acute cholecysti- tis also have cholelithiasis (stones).
■ Risk factors include obesity, females, rapid weight loss or frequent changes in weight, estrogen therapy, and family history.
■ There are two major types of stones; one is comprised primarily of pigment and the second cholesterol.
■ Symptoms are related to the gallbladder disease itself or obstruction of the bile passages.
■ Ursodeoxycholic acid (UDCA) has been used to successfully dissolve small cholesterol based stones.
■ Laparoscopic cholecystectomies have decreased the surgical risks, length of hospital stay, and recovery period.


Erik, another patient in the clinic, visits frequently, sometimes more than once in a single week. He too has a history of alcoholism. He complains of epigastric pain that radiates to his back and left shoulder. It normally starts after eating, and he experiences nausea and vomiting. Donna assesses him, and finds that he is slightly jaundiced; she also notes two other unusual signs, discolorations, on Erik.

Hot spot:

Place the marks where you would find the discoloration of Turner’s sign and Cullen’s sign.

Turner’s sign and Cullen’s sign

Turner’s sign and Cullen’s sign

Donna draws labs on Erik and finds the following:
■ Decreased serum calcium and magnesium
■ Elevated serum bilirubin and liver enzymes
■ Elevated WBCs

Erik is admitted to the GI unit and an NG tube is inserted. He is given total parenteral nutrition (TPN), analgesics, and anticholinergics. Other types of tubes may also be used for long-term feedings.

Matching:

Match the names of the tubes in Column A with the identifying information in Column B:

Match Tubes

Match Tubes


Malcolm, age 44 years, is also a regular visitor in the clinic. He is a reformed drug abuser with hepatitis C and is now trying to decrease the effects of the hepatitis.

Matching:

Match the types of hepatitis in Column A with the transmission and risk factors in Column B:

Match Types of Hepatitis

Match Types of Hepatitis

Malcolm’s liver enzymes are elevated. His alanine aminotransferase (ALT) is above 20 (normal is 8–20 units/L) and the aspartate aminotransferase (AST) is 60 (normal is 5–40 units/L).His alkaline phosphatase (ALP) is also elevated (normal is 42–128 units/L).

He is admitted to the inpatient GI unit for a liver biopsy, bed rest, and nutritional coun- seling.All the patients who are admitted to the GI inpatient unit are followed closely in the clinic after they are discharged.

Multiple-choice:

In preparing to send Malcolm for a liver biopsy, the nurse prioritizes:
A. Make him NPO (nothing orally) after midnight
B. Start intravenous (IV) fluids before the procedure
C. Check for the results of coagulation tests
D. Obtain a consent for a blood transfusion

KEY POINTS:

Hepatitis

■ Hepatitis is a systemic viral infection that causes inflammation and necrosis of liver cells.
■ HAV and HEV are very similar.
■ HBV, HCV, and HDV carry a high risk for chronic liver disease.
■ Vaccinations are available for HAV and HBV.
■ The focus is on prevention.

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