Complaint of diarrhea accompanied by abdominal pain

119 views 10:40 am 0 Comments June 12, 2023

Mrs. Z is a 34-year-old female who come in with a complaint of diarrhea accompanied by abdominal pain.  Onset of the symptom was about 4 days ago.  She reports thinking she is running a fever but has not taken her temperature.  She concerned that she is starting to feel weak.

When asked how about the characteristics and the number of bowel movements a day, she reports increased number of BMs over the last few months.  In the last few days she reports averaging about 10 small volume watery stools with varying amounts of blood daily.

She denies recent travel and reportedly has not been on any antibiotics in the past few weeks.

In reviewing her record, you notice that her health history is positive for history of ulcerative colitis.  She has not been on any medications for this over the last few years as she had not been symptomatic.

Mrs. Z is on an oral contraceptive.  She takes slippery elm capsules and has for the last several years.  She reports that she has been taking 2 to 3 doses of Benefiber prebiotic fiber for the last couple days.

Objective data:

BP 116/70 sitting, 100/66 standing; P 92; Temp 100.1

Abdomen – active bowel sounds all 4 quadrants, mild tenderness with palpation

Otherwise her exam is unremarkable for pertinent positives or negatives.

Labs – WBC 14,000; Hgb 11.9; Hct 35.7; Sodium 133; Potassium 3.3

Instructions:

Please prepare and submit a paper 3-4 pages [total] in length (not including APA formatted title and references pages) answering the questions below. Please support your position with examples.

· What pharmacologic therapy would you prescribe for Mrs. Z?

· How will you evaluate the effectiveness of this therapy?

· What patient education would you provide for Mrs. Z relative to the pharmacologic agent you prescribed?

· Are there any pharmacogenetic considerations related to what you prescribed for the patient?

· Are there any alternative therapies or over-the-counter agents that might be of value to Mrs. Z?

· What, if any, lifestyle changes would you recommend?

Inflammatory bowel disease (IBD) can

affect structures or segments along the

gastrointestinal tract. The term includes both

acute and chronic disorders.

Acute and chronic IBD can result in nutritional

deficits, altered bowel elimination, infection,

pain, and fluid or electrolyte imbalances. The

nurse needs to be knowledgeable about acute

and chronic IBD in order to collaborate with the

client and the interprofessional team in treating

and managing these disorders.

ACUTE IN FLAMMATOR Y BOWEL DISEASE

Appendicitis

Inflammation of the appendix

●● Caused by an obstruction of the lumen or opening of

the appendix.

●● Fecaliths, or hard pieces of stool, can be the initial cause

of the obstruction.

●● Adolescents and young adults are at increased risk.

●● Refer to the NURSING CARE OF CHILDREN REVIEW MODULE,

CHAPTER 23: GASTROINTESTINAL STRUCTURAL AND

INFLAMMATORY DISORDERS.

Peritonitis

Inflammation of the peritoneum results from infection

of the peritoneum due to puncture (surgery or trauma),

rupture of part of the gastrointestinal tract (diverticulitis,

peptic ulcer disease, appendicitis, bowel obstruction), or

infection from continuous ambulatory peritoneal dialysis.

Gastroenteritis

Inflammation of the stomach and small intestine

●● Triggered by infection (either bacterial or viral).

●● Vomiting and frequent, watery stools place the client at

increased risk for fluid and electrolyte imbalance and

impaired nutrition.

CHRONIC IN FLAMMATOR Y

BOWEL DISEASE

Ulcerative colitis and Crohn’s disease are characterized by

frequent stools, cramping abdominal pain, exacerbations,

and remissions.

Ulcerative colitis

Edema and inflammation primarily in the rectum and

rectosigmoid colon

●● In severe cases, it can involve the entire length of the

colon. Mucosa and submucosa become hyperemic

(increase in blood flow), and the colon will become

edematous and reddened. It can lead to abscess formation.

●● Edema and thickened bowel mucosa can cause partial

bowel obstruction. Intestinal mucosal cell changes

can lead to colon cancer or insufficient production of

intrinsic factor, resulting in insufficient absorption of

vitamin B12 (pernicious anemia).

●● Classified as either mild, moderate, severe, and fulminant.

Crohn’s disease

Inflammation and ulceration of the gastrointestinal tract,

often at the distal ileum

●● All bowel layers can become involved; lesions are

sporadic. Fistulas are common.

●● Can involve the entire GI tract from the mouth to the anus.

●● Malabsorption and malnutrition can develop when

the jejunum and ileum become involved. Requires

supplemental vitamins and minerals, possibly including

vitamin B12 injections.

Diverticulitis

Diverticulitis is inflammation and infection of the bowel

mucosa caused by bacteria, food, or fecal matter trapped

in one or more diverticula (pouch‑like herniations in

the intestinal wall). Diverticulitis is not to be confused

with diverticulosis, which is the presence of many small

diverticula in the colon without inflammation.

●● Not all clients who have diverticulosis

develop diverticulitis.

●● Diverticula can perforate and cause peritonitis, and/or

severe bleeding.

ASSESSMENT

Etiology of ulcerative colitis and Crohn’s disease is

unknown but possibly due to a combination of genetic,

environmental, and immunological causes.

RIS K FACTORS

Genetics: Ulcerative colitis and Crohn’s disease

Culture: Caucasians (ulcerative colitis), Jewish heritage

(ulcerative colitis and Crohn’s disease), and African

Americans (diverticular disease)

Sex and age: The incidence of ulcerative colitis peaks at

adolescence to young adulthood (more often in females)

and older adulthood (more often in males). Crohn’s disease

usually develops in adolescents and young adults, but can

occur at any age. Diverticulitis occurs more often in older

adults and affects males more frequently than females.

Tobacco use: Crohn’s disease

EXPECTE D FINDINGS

Ulcerative colitis

●● Abdominal pain/cramping: often left‑lower quadrant pain

●● Anorexia and weight loss

PHYSICAL ASSESSMENT FINDINGS

●● Fever

●● Diarrhea: up to 15 to 20 liquid stools/day

●● Stools containing mucus, blood, or pus

●● Abdominal distention, tenderness, and/or firmness

upon palpation

●● High‑pitched bowel sounds

●● Rectal bleeding

Crohn’s disease

●● Abdominal pain/cramping: often right‑lower quadrant pain

●● Anorexia and weight loss

PHYSICAL ASSESSMENT FINDINGS

●● Fever

●● Diarrhea: five loose stools/day with mucus or pus

●● Abdominal distention, tenderness and/or firmness

upon palpation

●● High‑pitched bowel sounds

●● Steatorrhea

Diverticulitis

●● Acute onset of abdominal pain often in left‑lower quadrant

●● Nausea and vomiting

PHYSICAL ASSESSMENT FINDINGS

●● Fever

●● Chills

●● Tachycardia

●● Abdominal distention

LA BORATOR Y TESTS

Ulcerative colitis

Hematocrit and hemoglobin: Decreased

Erythrocyte sedimentation rate (ESR): Increased

WBC: Increased

C‑reactive protein: Increased

Albumin: Decreased

Stool for occult blood: Can be positive

K+, Na, Mg, Ca, and Cl: Decreased

Crohn’s disease

Hematocrit and hemoglobin: Decreased

ESR: Increased

WBC: Increased

C‑reactive protein: Increased

Albumin: Decreased

Folic acid and B12: Decreased

Anti‑glycan antibodies: Increased

Stool for occult blood: Can be positive

Urinalysis: WBC

K+, Mg, and Ca: Decreased

Diverticulitis

Hematocrit and hemoglobin: Decreased

ESR: Increased

WBC: Increased

Stool for occult blood: Can be positive

DIAGNOSTIC PROCE DURES

Magnetic resonance enterography: Used with all IBD

CLIENT EDUCATION: Maintain NPO for 4 to 6 hr prior to

the exam. You might be asked to drink a contrast medium

prior to the test.

Ulcerative colitis

Sigmoidoscopy or colonoscopy: Can diagnose

ulcerative colitis

Barium enema: Helpful to distinguish ulcerative colitis

from other disease processes

CT scan or MRI: Can identify the presence of abscesses

Stool examination: For the presence of parasites

or microbes

Crohn’s disease

Endoscopy

●● Newer diagnostic tools used, such as video

capsule endoscopy

●● Proctosigmoidoscopy: Performed to identify

inflamed tissue

●● Colonoscopy and sigmoidoscopy: A lighted, flexible

scope inserted into the rectum to visualize the rectum

and large intestine

Abdominal ultrasound, x‑ray, and CT scan: CT scans can

show bowel thickening.

Barium enema: Barium is inserted into the rectum as a

contrast medium for x‑rays. This allows for the rectum

and large intestine to be visualized, and is used to

diagnose ulcerative colitis. A barium enema can show the

presence of diverticulosis and is contraindicated in the

presence of diverticulitis due to the risk of perforation.

NURSING ACTIONS: Monitor postprocedure for

manifestations of bowel perforations (rectal bleeding, firm

abdomen, tachycardia, hypotension).

FINDINGS

●● Small intestine ulcerations and narrowing is consistent

with Crohn’s disease.

●● Ulcerations and inflammation of the sigmoid colon and

rectum is significant for ulcerative colitis.

CLIENT EDUCATION

●● Remain NPO as required, and perform bowel preparation.

●● There can be possible abdominal discomfort and

cramping during the barium enema.

PATIENT‑CENTERED CARE

NURSING CARE

Ulcerative colitis and Crohn’s disease

●● The client should receive instructions regarding the

usual course of the disease process.

●● The client should receive instructions regarding

medication therapy and vitamin supplements.

●● Monitor by colonoscopy due to the increased risk of

colon cancer.

●● Assist the client in identifying foods that

trigger manifestations.

●● Monitor for electrolyte imbalance, especially potassium.

Diarrhea can cause a loss of fluids and electrolytes.

●● Monitor I&O, and assess for dehydration.

●● Educate the client to eat high-protein, high-calorie,

low-fiber foods.