NLE Gastrointestinal Nursing — Lower GI & Bowel DisordersRevision Notes

Exam tips

• Remember the mnemonic CRUST for Crohn's: Cobblestoning, Right lower quadrant (ileum), Universal (mouth to anus), Skip lesions, Transmural. For UC: CURE — Continuous, Ulcerative/bloody, Rectal start, Excised (colectomy cures it).
• If an NLE item mentions skip lesions or transmural involvement — answer is Crohn's. If it mentions continuous mucosal involvement or bloody diarrhea — answer is UC.
• Toxic megacolon question will describe distension + fever + tachycardia in a UC patient — the priority action is NOTIFY THE PHYSICIAN and prepare for surgery.
• Diet question during IBD flare: select LOW-residue, HIGH-protein, HIGH-calorie options.
• Fistula as a complication = Crohn's disease (transmural depth allows fistula formation).

Key points

• IBD is a chronic, relapsing inflammatory condition of the GI tract — cause is unknown (idiopathic) but involves an abnormal immune response.
• Two main types: Crohn's Disease (CD) and Ulcerative Colitis (UC) — they are frequently compared in NLE items.
• Crohn's Disease: affects ANYWHERE from mouth to anus (most common at terminal ileum); pattern is SKIP lesions (patchy, non-continuous); depth is TRANSMURAL (full-thickness wall involvement); complications include fistulas, strictures, and malabsorption; surgery is NOT curative (disease recurs).
• Ulcerative Colitis: affects COLON and RECTUM ONLY; pattern is CONTINUOUS starting from the rectum; depth is MUCOSAL/SUBMUCOSAL only; classic manifestation is frequent bloody mucoid diarrhea (10–20 episodes/day); risk of toxic megacolon and colorectal cancer is HIGHER than Crohn's; TOTAL COLECTOMY IS CURATIVE.
• Both cause diarrhea, abdominal pain, weight loss, fatigue, fever, and anemia.
• Crohn's specifically causes malabsorption of fat, Vitamin B12, and folate (due to terminal ileum involvement), perianal disease, and fistula formation.
• UC specifically causes bloody diarrhea, tenesmus (painful urge to defecate), and risk of toxic megacolon.
• Key diagnostic tools: colonoscopy with biopsy (central), CT/MRI enterography (for Crohn's fistulas), CRP/ESR (disease activity markers), and fecal calprotectin (marks intestinal inflammation).
• Toxic megacolon (UC complication): abdominal distension, fever, tachycardia, and absent/decreased bowel sounds — this is a SURGICAL EMERGENCY. Report immediately.
• Diet during flares: LOW-residue, HIGH-protein, HIGH-calorie; bowel rest with TPN in severe cases; avoid high-fiber foods, dairy (if lactose-intolerant), caffeine, cold and spicy foods.
• Monitor for hypokalemia and dehydration — chronic diarrhea depletes potassium and fluid volume.

Definitions

Common mistakes

• Confusing which disease has bloody diarrhea — UC causes frequent BLOODY mucoid diarrhea; Crohn's has softer, semi-liquid stools that are LESS bloody.
• Stating that surgery cures Crohn's disease — it does NOT. Only UC is curable by total colectomy.
• Forgetting that the colorectal cancer risk is HIGHER in UC than in Crohn's.
• Mixing up which disease causes fistulas — it is Crohn's (transmural), not UC.
• Neglecting to assess for toxic megacolon in UC patients — this is a life-threatening emergency.
• Giving high-fiber foods during a flare — fiber should be RESTRICTED during acute exacerbations to rest the bowel.

Exam tips

• Sulfasalazine key 3: Food + Fluids + Folic Acid. Plus: orange urine is NORMAL. Sulfa ALLERGY caution.
• Biologics (infliximab, adalimumab): the priority BEFORE starting = screen for TB and Hepatitis B.
• Corticosteroid question about stopping: always select the option that says 'taper gradually' — never abrupt discontinuation.
• Immunomodulators (azathioprine): monitor CBC (bone marrow suppression) and LFTs (hepatotoxicity).

Key points

• Aminosalicylates (5-ASA): Sulfasalazine 2–4 g/day and mesalamine are FIRST-LINE for mild-to-moderate UC.
• Sulfasalazine key nursing points: (1) take WITH FOOD and PLENTY OF FLUIDS, (2) supplement FOLIC ACID (sulfasalazine impairs folate absorption), (3) urine turns ORANGE-YELLOW (normal, reassure patient), (4) contains a SULFA component — assess for sulfa allergy before administration.
• Corticosteroids (prednisone, IV hydrocortisone): used for ACUTE FLARES only — short-term use due to Cushingoid effects, hyperglycemia, bone loss, and immunosuppression. NEVER STOP ABRUPTLY — must be tapered gradually to prevent adrenal crisis.
• Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate): steroid-sparing agents for maintenance. Monitor CBC and liver function tests — risk of BONE MARROW SUPPRESSION (leukopenia, thrombocytopenia) and hepatotoxicity.
• Biologics (infliximab, adalimumab — anti-TNF agents): used for moderate-to-severe IBD. CRITICAL: SCREEN FOR LATENT TB (Mantoux/TST) AND HEPATITIS B BEFORE STARTING. Watch for infusion reactions and opportunistic infections.
• Antidiarrheals (loperamide): use with CAUTION in IBD — avoid in active bloody diarrhea or suspected toxic megacolon (risk of precipitating megacolon).

Definitions

Common mistakes

• Forgetting to supplement folic acid with sulfasalazine — this is a critical nursing education point.
• Alarming the patient about orange urine from sulfasalazine — it is NORMAL and must be explained to prevent non-compliance.
• Stopping prednisone suddenly — always taper. NLE may test this as a medication error scenario.
• Starting biologics without TB and Hepatitis B screening — this is a major patient safety issue and NLE priority.
• Failing to monitor CBC with azathioprine or 6-MP — bone marrow suppression requires regular blood count monitoring.

Exam tips

• Key IBS identifier: pain RELIEVED by defecation + NO blood + NO weight loss + NO nocturnal symptoms = IBS (functional).
• Red flags (blood, weight loss, nocturnal pain, fever) = NOT IBS — suspect organic disease (IBD, colorectal cancer).
• Fecal calprotectin: NORMAL in IBS, ELEVATED in IBD — this differentiates the two.
• If NLE asks about IBS management: diet modification + stress management + symptom-specific drugs (not steroids or antibiotics).

Key points

• IBS is a FUNCTIONAL disorder — there is NO structural lesion, NO inflammation, and NO organic pathology found on testing.
• Mechanism: altered GI motility and visceral hypersensitivity (the gut is overly sensitive to normal stimuli).
• Classic presentation: chronic ABDOMINAL PAIN that is RELIEVED BY DEFECATION, bloating, and altered bowel habits.
• Three subtypes: IBS-D (diarrhea-predominant), IBS-C (constipation-predominant), and IBS-M (mixed).
• RED FLAGS that rule OUT IBS and point to organic disease: blood in stool, unexplained weight loss, nocturnal symptoms, fever, and elevated inflammatory markers (CRP, ESR). These require further investigation.
• Fecal calprotectin is NORMAL in IBS (vs. elevated in IBD) — key differentiating lab.
• Management: dietary modification (identify trigger foods, FODMAPs restriction — fermentable carbohydrates that worsen symptoms), increase fiber for IBS-C, stress management techniques, regular meals, and exercise.
• Pharmacologic options: antispasmodics (hyoscine) for cramping, loperamide for IBS-D, laxatives or lubiprostone for IBS-C.
• Psychosocial nursing care is important — IBS has a strong mind-gut connection (stress, anxiety, and depression worsen IBS).

Definitions

Common mistakes

• Diagnosing IBS when red flag symptoms are present — blood in stool, weight loss, or nocturnal symptoms require further investigation, not an IBS diagnosis.
• Overlooking the psychosocial dimension of IBS — stress management and counseling are KEY parts of the care plan.
• Using loperamide (antimotility) in IBS with diarrhea accompanied by fever or blood — this is dangerous (risk of toxic megacolon).
• Confusing IBS with IBD — IBS has NO inflammation and NO structural lesion; IBD has documented inflammation.

Exam tips

• Diverticulitis = LLQ pain + fever + leukocytosis. Appendicitis = RLQ pain + fever + rebound tenderness at McBurney's point.
• Diagnostic test of choice in acute diverticulitis = CT SCAN (NOT colonoscopy — risk of perforation).
• Diet rule: HIGH-fiber when WELL (prevention). LOW-fiber/clear liquids during ACUTE attack. Then BACK to high-fiber after recovery.
• Antibiotics in acute diverticulitis: metronidazole (anaerobes) + ciprofloxacin (gram-negative aerobes) — covers the polymicrobial colonic flora.

Key points

• Diverticulosis: outpouchings (diverticula) of the colonic mucosa, most commonly in the SIGMOID COLON. Caused by LOW-FIBER DIET and chronic constipation creating high intraluminal pressure that forces the mucosa to herniate through weak points in the bowel wall.
• Diverticulosis is often ASYMPTOMATIC — discovered incidentally. Management: HIGH-FIBER diet and adequate fluid intake to prevent progression.
• Diverticulitis: INFLAMMATION/INFECTION of a diverticulum. Presents with LEFT LOWER QUADRANT (LLQ) pain, fever, leukocytosis, nausea, and altered bowel habits.
• Diagnostics: CT SCAN of the abdomen/pelvis is the PREFERRED test in acute diverticulitis. AVOID colonoscopy and barium enema during acute inflammation — risk of PERFORATION.
• Acute management: NPO or clear liquids, IV fluids, and antibiotics (commonly metronidazole + ciprofloxacin) for infection control.
• Diet education: HIGH-FIBER diet and adequate fluids are for PREVENTION (when well). During an ACUTE ATTACK: LOW-fiber or liquid diet to rest the bowel, then advance to high-fiber after recovery.
• Complications to monitor: perforation, abscess, peritonitis, intestinal obstruction, and fistula formation.
• Surgical intervention (partial colectomy) is needed for complications or recurrent severe diverticulitis.

Definitions

Common mistakes

• Confusing LLQ pain (diverticulitis) with RLQ pain (appendicitis) — location is the key differentiator.
• Performing or recommending colonoscopy or barium enema during ACUTE diverticulitis — this risks perforation.
• Teaching high-fiber diet DURING an acute flare — during the acute attack, the diet is LOW-fiber or clear liquids; HIGH-fiber is for PREVENTION when the patient is well.
• Forgetting to teach adequate fluid intake alongside high-fiber — fiber without fluids worsens constipation.

Exam tips

• The three NEVERS of appendicitis: NO HEAT, NO LAXATIVES, NO ENEMAS — these are the most commonly tested safety rules in NLE.
• Pain migrates from periumbilical → RLQ = appendicitis. Pain at McBurney's point + rebound tenderness = classic presentation.
• Sudden pain relief = RUPTURE (not improvement). Immediately assess for peritonitis (rigid abdomen, absent bowel sounds, rising fever).
• Best position: SEMI-FOWLER'S (also localizes infection to the pelvis after rupture, preventing upward spread).
• After appendectomy: monitor for wound infection, peritonitis, and ileus.

Key points

• Appendicitis is the MOST COMMON cause of acute abdomen requiring emergency surgery. It is caused by obstruction of the appendiceal lumen (most commonly by a fecalith or lymphoid hyperplasia) → inflammation → bacterial overgrowth → ischemia → potential PERFORATION → PERITONITIS.
• Classic pain pattern: periumbilical pain that MIGRATES TO THE RIGHT LOWER QUADRANT (RLQ), localizing at McBURNEY'S POINT (midway between the umbilicus and the right anterior superior iliac spine).
• Key assessment findings: rebound tenderness (Blumberg's sign), involuntary guarding, low-grade fever (38–38.5°C), anorexia, nausea, vomiting, and mild leukocytosis (WBC 10,000–18,000/mm³).
• Special signs: Rovsing's sign (LLQ palpation causes RLQ pain), psoas sign (pain on right hip extension — retrocecal appendix), obturator sign (pain on internal rotation of right hip — pelvic appendix).
• DANGER SIGN: Sudden RELIEF OF PAIN followed by increasing rigidity and diffuse pain = RUPTURED APPENDIX with peritonitis. This is a SURGICAL EMERGENCY.
• ABSOLUTE PRIORITY SAFETY RULES for Appendicitis (high-yield NLE):
• (1) NEVER apply HEAT to the abdomen — increases blood flow and risk of rupture.
• (2) NEVER give LAXATIVES or ENEMAS — increases peristalsis and risk of perforation.
• (3) NEVER give opioid analgesics that MASK SYMPTOMS until the patient has been evaluated (per facility policy).
• (4) Keep patient NPO for surgery.
• (5) Position patient in SEMI-FOWLER'S or right side-lying with knees flexed — reduces tension on inflamed tissue.
• Cold packs may be used for comfort (COLD is acceptable; HEAT is NOT).
• Definitive treatment: APPENDECTOMY (laparoscopic or open).
• Post-rupture care: IV broad-spectrum antibiotics, monitoring for peritonitis (rigid board-like abdomen, absent bowel sounds, high fever).

Definitions

Common mistakes

• Applying a heating pad to relieve abdominal pain in a patient with suspected appendicitis — NEVER apply heat; use cold packs only.
• Administering laxatives or enemas for constipation in a patient with RLQ pain and fever — this can cause PERFORATION.
• Missing the 'sudden relief of pain' as a sign of rupture — this is a critical assessment finding; pain relief + rigidity = ruptured appendix.
• Positioning the patient in a supine flat position — correct position is SEMI-FOWLER'S or right side-lying with knees flexed.
• Delaying notification of the surgeon when rupture is suspected.

Exam tips

• Small bowel obstruction key triad: VOMITING early + HIGH-PITCHED bowel sounds + MINIMAL distension + METABOLIC ALKALOSIS.
• Large bowel obstruction key triad: DISTENSION (marked) + OBSTIPATION + LATE vomiting + METABOLIC ACIDOSIS.
• Priority interventions: NPO → NGT on low intermittent suction → IV fluids → strict I&O.
• NGT placement is confirmed by: aspirating gastric contents, testing pH (should be ≤5.5 — acidic), and X-ray confirmation. NEVER start suction without confirming placement.
• Strangulation warning signs = FEVER + TACHYCARDIA + CONSTANT (not colicky) pain = call the surgeon NOW.

Key points

• Intestinal obstruction is a blockage that prevents normal movement of intestinal contents — can be MECHANICAL or FUNCTIONAL (paralytic ileus).
• Mechanical obstruction causes: adhesions (MOST COMMON cause), hernias, tumors, volvulus (twisting of the bowel), and intussusception (telescoping of bowel into itself).
• Functional/Paralytic ileus causes: post-operative state (most common), peritonitis, electrolyte imbalances (hypokalemia), and medications (opioids, anticholinergics).
• SMALL BOWEL OBSTRUCTION manifestations: early profuse VOMITING (bilious, then feculent), severe CRAMPING PAIN, high-pitched borborygmi initially then ABSENT bowel sounds, MINIMAL distension, rapid DEHYDRATION, and METABOLIC ALKALOSIS (loss of HCl from vomiting).
• LARGE BOWEL OBSTRUCTION manifestations: gradual onset, MARKED DISTENSION (most prominent symptom), OBSTIPATION (complete absence of stool and gas), LESS vomiting (occurs late), and METABOLIC ACIDOSIS.
• Key acid-base distinction: Small bowel = METABOLIC ALKALOSIS (lose gastric acid HCl). Large bowel = METABOLIC ACIDOSIS.
• Priority nursing interventions: NPO immediately, insert NASOGASTRIC TUBE (NGT) for GI decompression on LOW INTERMITTENT SUCTION, IV fluids and electrolyte replacement, STRICT I&O monitoring.
• Monitor for STRANGULATION (blood supply to bowel is compromised): fever, tachycardia, rising intensity of pain, abdominal rigidity = SURGICAL EMERGENCY (bowel necrosis).
• Post-operative monitoring: return of bowel sounds, passing of flatus (first sign of GI motility returning), and tolerating oral intake.

Definitions

Common mistakes

• Confusing the acid-base disturbance: SMALL bowel obstruction = ALKALOSIS (vomiting loses HCl). LARGE bowel obstruction = ACIDOSIS. This is frequently tested.
• Not inserting the NGT early enough — decompression is a priority to prevent aspiration and relieve pressure.
• Missing signs of strangulation — fever + tachycardia + worsening pain in an obstruction patient = urgent surgical consultation.
• Giving oral fluids or food to a patient with suspected intestinal obstruction — always NPO.
• Confusing paralytic ileus with mechanical obstruction — ileus has NO mechanical blockage; it is a failure of peristalsis.

Exam tips

• Peritonitis classic triad: RIGID BOARD-LIKE abdomen + ABSENT bowel sounds + HIGH FEVER with TACHYCARDIA.
• Best position: SEMI-FOWLER'S (45°) — localizes pus to pelvis, away from the diaphragm and vital structures.
• Priority nursing actions in order: NPO → NGT → IV fluids → IV antibiotics → prepare for emergency surgery.
• Peritonitis after appendicitis = ruptured appendix. The sign: sudden pain RELIEF followed by diffuse rigidity and rising fever.

Key points

• Peritonitis is inflammation of the peritoneum — most commonly caused by bacterial contamination from a perforated viscus (ruptured appendix, perforated peptic ulcer, perforated diverticulum, or strangulated bowel).
• It is a LIFE-THREATENING EMERGENCY with rapid progression to septic shock if untreated.
• Classic signs: RIGID 'board-like' abdomen (involuntary guarding), DIFFUSE severe abdominal pain with rebound tenderness, ABSENT bowel sounds (paralytic ileus), fever (often high), tachycardia, and rapid deterioration to septic shock.
• Priority nursing interventions:
• (1) NPO immediately
• (2) NGT for GI decompression
• (3) Aggressive IV fluid resuscitation (to combat septic shock)
• (4) Broad-spectrum IV antibiotics (to cover gram-negative and anaerobic organisms)
• (5) URGENT surgical source control (exploratory laparotomy to repair the perforation and lavage the peritoneal cavity)
• Position: SEMI-FOWLER'S (30–45°) — localizes infected fluid to the pelvis (away from the diaphragm), reduces pressure on abdominal muscles, and eases breathing.
• NANDA nursing diagnosis priorities: Acute Pain, Risk for Infection/Sepsis, Deficient Fluid Volume, Impaired Gas Exchange.
• Monitor vital signs closely — fever, tachycardia, falling blood pressure, and decreasing urine output indicate septic shock progression.

Definitions

Common mistakes

• Positioning the patient flat — the correct position for peritonitis is SEMI-FOWLER'S to localize infection and ease breathing.
• Delaying fluid resuscitation — septic shock develops rapidly; aggressive IV fluids are a priority.
• Giving oral fluids or pain medications that mask assessment findings before surgical evaluation.
• Missing the transition from localized pain (appendicitis) to diffuse pain (peritonitis) — this signals spread of infection.

Exam tips

• Internal = ABOVE dentate line = PAINLESS BLEEDING. External = BELOW dentate line = PAINFUL.
• Conservative management priority: sitz baths + stool softeners + high-fiber diet. These 3 go together.
• Post-hemorrhoidectomy: warn patient first bowel movement will be painful; continue stool softeners; monitor for urinary retention.
• Bright red blood per rectum in NLE questions = always consider hemorrhoids first, but rule out colorectal cancer (especially if associated with weight loss or change in bowel habits).

Key points

• Hemorrhoids are dilated (varicosed) veins in the rectoanal region caused by increased intravascular pressure — risk factors include chronic straining, constipation, prolonged sitting, obesity, and pregnancy.
• INTERNAL hemorrhoids: located ABOVE the dentate line — PAINLESS (no somatic nerve fibers above this line); manifest as BRIGHT RED RECTAL BLEEDING during or after defecation; may prolapse.
• EXTERNAL hemorrhoids: located BELOW the dentate line — PAINFUL because this area has somatic innervation; palpable, may thrombose causing intense localized pain.
• Grading of internal hemorrhoids (I–IV): Grade I (no prolapse), II (prolapse with straining but self-reduces), III (requires manual reduction), IV (cannot be reduced — permanently prolapsed).
• Conservative management: HIGH-FIBER diet and increased fluid intake (soften stools), STOOL SOFTENERS (docusate sodium), SITZ BATHS (10–15 minutes, 3–4x/day — warm water soothes and promotes healing), topical anesthetics (lidocaine), and witch hazel compresses.
• Procedures for persistent hemorrhoids: rubber-band ligation (most common), sclerotherapy, infrared coagulation, and hemorrhoidectomy (surgical removal).
• Post-hemorrhoidectomy nursing care: sitz baths for comfort and hygiene, stool softeners (to prevent hard stools that traumatize the surgical site), high-fiber diet, monitor for urinary retention (common complication), and educate that the FIRST BOWEL MOVEMENT POST-OP IS PAINFUL — reassure patient and ensure stool softeners are taken.
• Monitor for post-hemorrhoidectomy bleeding — small amounts of blood-tinged discharge are normal; excessive bright red bleeding requires immediate reporting.

Definitions

Common mistakes

• Confusing internal (painless bleeding) with external (painful) hemorrhoids — location relative to the dentate line determines pain sensation.
• Forgetting to include sitz baths as the PRIMARY non-pharmacological intervention — this is frequently the correct NLE answer.
• Not warning patients about the painful first bowel movement after hemorrhoidectomy — anticipatory guidance is part of nursing education.
• Overlooking urinary retention as a common post-hemorrhoidectomy complication — monitor urine output carefully.

Exam tips

• Normal stoma = PINK or RED and MOIST. Abnormal = DARK/DUSKY/BLACK = ISCHEMIA → CALL THE PHYSICIAN NOW.
• Ileostomy output = LIQUID + ENZYME-RICH → TWO priorities: skin protection + hydration/electrolyte monitoring.
• Empty pouch at 1/3 to 1/2 full — not when completely full.
• Appliance opening = SLIGHTLY LARGER (1–2 mm) than stoma — not too large (skin breakdown) not too small (stoma trauma).
• NANDA priority for ostomy patient: Disturbed Body Image + Risk for Impaired Skin Integrity.
• Colostomy irrigation applies only to SIGMOID or DESCENDING colostomy — not ileostomy.

Key points

• An ostomy diverts the elimination of stool through a surgically created opening (stoma) in the abdominal wall.
• COLOSTOMY: diversion of the colon — output is more FORMED and less frequent the more DISTAL the stoma (sigmoid/descending colostomy output is the most solid; ascending colostomy output is more liquid).
• ILEOSTOMY: diversion of the ileum — output is LIQUID and CONTINUOUS because it bypasses the water-absorbing colon. The output is rich in digestive ENZYMES — high risk of severe PERISTOMAL SKIN BREAKDOWN.
• Normal stoma characteristics: PINK or RED in color, MOIST, and raised or flush with the skin surface. A healthy stoma looks like moist oral mucosa.
• EMERGENCY FINDING: DARK, DUSKY, or BLACK stoma = ISCHEMIA — report to the physician IMMEDIATELY.
• Pouch management: empty the pouch when it is ONE-THIRD TO ONE-HALF FULL (prevents the weight of contents from loosening the seal).
• Appliance fit: the opening of the appliance should be only SLIGHTLY LARGER than the stoma (1–2 mm) — too large = skin exposure to stool; too small = stoma trauma.
• Ileostomy-specific concerns: (1) HIGH RISK of DEHYDRATION and electrolyte imbalance (especially hyponatremia and hypokalemia) — teach patient to increase fluid and salt intake; (2) SKIN PROTECTION is paramount — peristomal skin must be assessed and protected at every pouch change; (3) ILEOSTOMY BLOCKAGE — high-fiber or high-cellulose foods (mushrooms, coconut, raw vegetables) can cause blockage.
• Colostomy irrigation (for sigmoid/descending colostomy only): can help regulate bowel movements — done at the same time daily to establish a pattern.
• Odor-producing foods: fish, eggs, garlic, onions, cabbage — patients can limit these for social comfort. Yogurt and cranberry juice may reduce odor.
• Gas-producing foods: beans, broccoli, carbonated drinks, beer — patients may limit these as tolerated.
• Body image is a CRITICAL nursing concern — patients need emotional support, education, and referral to an enterostomal therapy nurse (ET nurse) and ostomy support groups.
• NANDA nursing diagnoses: Disturbed Body Image, Risk for Impaired Skin Integrity, Deficient Knowledge, Risk for Fluid Volume Deficit (ileostomy).

Definitions

Common mistakes

• Failing to recognize a dark/dusky/black stoma as an emergency — this indicates ischemia and requires IMMEDIATE physician notification.
• Emptying the pouch too late (when more than half full) — the weight of contents can loosen the seal, causing leakage and skin breakdown.
• Cutting the appliance opening too large — this exposes peristomal skin to stool, causing breakdown.
• Not teaching ileostomy patients to increase fluid and electrolyte intake — dehydration is a real risk due to continuous liquid output.
• Neglecting body image concerns — emotional support and education are core nursing responsibilities for ostomy patients.
• Teaching ileostomy patients to eat high-fiber foods immediately post-op — this can cause blockage.

Exam tips

• Diarrhea acid-base = METABOLIC ACIDOSIS (loses bicarbonate in stool). Vomiting = METABOLIC ALKALOSIS (loses HCl).
• First-line for diarrhea = ORS (fluid and electrolyte replacement) — not loperamide.
• Avoid loperamide in BLOODY or FEBRILE diarrhea — risk of toxic megacolon or prolonged infection.
• First-line for constipation = fiber and fluids. If laxatives are needed = BULK-FORMING (psyllium) first, then osmotic, then stimulant (short-term).
• In Philippine community health settings (BHS, RHU), ORS preparation teaching is a core public health nursing competency.

Key points

• CONSTIPATION: infrequent (less than 3x per week), hard, dry, difficult-to-pass stools. Causes: low fiber/fluid intake, physical inactivity, opioid medications, ignoring defecation urge, and neurological conditions.
• Constipation management hierarchy: (1) Increase DIETARY FIBER (25–38 g/day) and FLUIDS (at least 2L/day); (2) MOBILIZATION and exercise; (3) Regular TOILETING ROUTINE (using gastrocolic reflex after meals); (4) Bulk-forming agents (psyllium — Metamucil) first-line laxative; (5) Osmotic laxatives (lactulose, polyethylene glycol); (6) Stimulant laxatives (senna, bisacodyl) — short-term only.
• NEVER encourage chronic stimulant laxative use — leads to LAXATIVE DEPENDENCE and impaired bowel motility.
• DIARRHEA: frequent, loose, watery stools. Metabolic consequence: METABOLIC ACIDOSIS (loss of bicarbonate in stool) + DEHYDRATION + HYPOKALEMIA.
• Diarrhea priority intervention: FLUID AND ELECTROLYTE REPLACEMENT — oral rehydration solution (ORS) is FIRST-LINE (WHO-recommended, accessible in Philippine healthcare settings including BHS and RHU level).
• In infectious diarrhea with blood or fever: AVOID loperamide (antimotility agents) — can precipitate toxic megacolon or prolong the infectious state by preventing elimination of pathogens.
• Protect PERIANAL SKIN in patients with diarrhea — frequent liquid stool causes skin breakdown, especially in elderly and immobile patients.
• NANDA diagnoses for diarrhea: Diarrhea, Deficient Fluid Volume, Risk for Electrolyte Imbalance, Impaired Skin Integrity (perianal).

Definitions

Common mistakes

• Recommending stimulant laxatives as first-line for constipation — bulk-forming agents (psyllium) are first-line.
• Giving loperamide (Imodium) to a patient with bloody diarrhea and fever — contraindicated in infectious/inflammatory diarrhea.
• Not replacing potassium in diarrhea — hypokalemia is a consistent complication of prolonged diarrhea.
• Overlooking perianal skin integrity in diarrhea patients — breakdown is painful and increases infection risk.
• Confusing the acid-base disturbance of diarrhea (ACIDOSIS — loss of bicarbonate) with that of vomiting (ALKALOSIS — loss of hydrochloric acid).

Exam tips

• Left-sided colon cancer = OBSTRUCTION symptoms (thin stools, constipation). Right-sided = ANEMIA and vague symptoms (no visible blood).
• Gold standard for colorectal cancer diagnosis = COLONOSCOPY with biopsy.
• IBD → increased colorectal cancer risk → surveillance colonoscopy every 1–2 years after 8–10 years of extensive UC.
• Change in bowel habits + rectal bleeding + weight loss = RED FLAGS = suspect colorectal cancer = refer for colonoscopy.

Key points

• Risk factors: long-standing IBD (especially UC ≥8–10 years), low-fiber/high-red meat and processed meat diet, family history of colorectal cancer or FAP (familial adenomatous polyposis), male gender, age >50, and sedentary lifestyle.
• Warning signs (CAUTION-modified for colorectal): CHANGE in bowel habits (alternating diarrhea/constipation), RECTAL BLEEDING or blood in stool, UNEXPLAINED iron-deficiency anemia, significant WEIGHT LOSS, and SENSE OF INCOMPLETE EVACUATION (tenesmus).
• Location matters: LEFT-SIDED and RECTAL tumors present earlier with obstructive symptoms (constipation, thin ribbon-like stools, visible rectal bleeding); RIGHT-SIDED tumors present LATER with vague symptoms, anemia (occult blood loss), and weight loss.
• Definitive screening and diagnostic test: COLONOSCOPY with biopsy.
• Nurses must reinforce colorectal cancer screening: colonoscopy starting at age 45–50 for average-risk individuals; earlier and more frequent surveillance for IBD patients and those with family history.
• IBD surveillance colonoscopies are recommended every 1–2 years after 8–10 years of disease in patients with extensive UC — to detect dysplasia before malignancy develops.

Definitions

Common mistakes

• Assuming rectal bleeding always means hemorrhoids — colorectal cancer must be ruled out, especially with associated weight loss or change in bowel habits.
• Not recognizing iron-deficiency anemia as a sign of right-sided colorectal cancer — anemia from chronic occult blood loss is a subtle presentation.
• Forgetting that IBD patients (especially UC) need earlier and more frequent colonoscopy surveillance.