11.12 Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder in which there is abdominal discomfort, along with a change in bowel patterns. There are three different subclasses of IBS: IBS-C, IBS-D, and IBS-M. In IBS-C, constipation is the predominant stool pattern. In IBS-D, diarrhea is the predominant stool pattern. With IBD-M, there is a mix of bowel movement types, alternating between diarrhea and constipation.

IBS is most common in women younger than 50 years old. Additionally, clients with anxiety, depression, or increased stress are more likely to experience IBS. Family history/genetics is a risk factor, and IBS is most common in clients from South America and least common in clients from Southeast Asia. Certain foods can also trigger IBS symptoms, such as dairy products; gas-producing foods such as cabbage and beans; carbonated beverages; and citrus fruits.

Pathophysiology

IBS is a functional disorder, meaning there are symptoms present but there is no correlating gastrointestinal disease. The cause of IBS is unknown, but there are many theories regarding the development of this disorder such as the following^[1],[2]:

• Alterations in intestinal muscle contractions, with increased muscle contractions causing diarrhea and decreased or weak contractions causing constipation.
• Inappropriate nervous system signaling in the GI tract.
• Alterations in the normal intestinal flora when compared to clients without IBS.
• Changes in the immune response of the gastrointestinal tract.
• Environmental factors such as significant stress early in life, antibiotic use, infections such as gastroenteritis, and the inability to tolerate certain foods.

Assessment

Physical Exam

Common signs and symptoms of IBS include the following^[3]:

• Abdominal pain
• A change in bowel habits such as diarrhea, constipation, or alternating diarrhea and constipation
• Abdominal distention or bloating
• Correlation of symptoms with intake of certain foods that are relieved by bowel movements

IBS can be diagnosed using the Rome IV criteria, as there is no specific diagnostic test for IBS. To be diagnosed with IBS, the client must experience at least two of the following symptoms for at least three days a month over a three-month time span^[4]:

• Abdominal pain that improves after having a bowel movement
• Alterations in stool frequency
• Alterations in the appearance of stool

Common Laboratory and Diagnostic Tests

There are no diagnostic tests for IBS. However, if other alarming symptoms are present, such as blood in stool or unexpected weight loss, blood tests such as a complete blood count or metabolic panel may be done to rule out other causative factors. If diarrhea is an associated symptom, stool tests may be ordered to rule out an infectious cause. A colonoscopy may also be ordered, especially if there is a family history of gastrointestinal cancer or IBD.^[5]

Nursing Problems and Diagnosis

Nursing priorities for those suffering from irritable bowel syndrome include managing symptoms, promoting good nutrition, and preventing dehydration.

Nursing diagnoses for clients with irritable bowel syndrome are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for those with irritable bowel syndrome are as follows^[6],[7]:

• Acute Pain r/t disease process
• Constipation r/t disease process
• Diarrhea r/t disease process
• Imbalanced Nutrition: Less than Body Requirements r/t increase in symptoms with food intake
• Risk for Fluid Volume Deficit r/t diarrhea

Outcome Identification

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes include the following:

• The client will rate their pain at three or less on a scale of zero to ten on a daily basis.
• The client will pass bowel movements without straining until their next scheduled appointment.
• The client will exhibit a formed stool that occurs at the client’s normal frequency until their next scheduled appointment.
• The client will maintain a weight within a healthy range that is appropriate for their height over the next six months.
• The client will exhibit blood pressure and heart rate within normal limits for age, moist mucous membranes, and urine output appropriate for age until their next scheduled appointment.

Interventions

Medical Interventions

The goal of IBS treatment is to control symptoms that are experienced by the client. This can be accomplished with lifestyle changes and the use of medications.^[8]

Lifestyle Changes

• Increased physical activity can decrease symptoms because it increases the amount of time it takes for food to move through the colon.
• Avoid foods that are poorly absorbed that increase symptoms such as wheat products, onions, dairy, and some fruits and vegetables.

Medications

• For clients with constipation as the predominant symptom, fiber supplements and/or laxatives may be prescribed.
• For clients with diarrhea as the predominant symptom, antidiarrheals and/or probiotics may be prescribed.
• Low doses of antidepressants such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) can be helpful for clients with severe symptoms.
• Alosetron has shown symptom improvement in women with IBS-D.
• Rifaximin, an antibiotic, has also reduced the occurrence of diarrhea and abdominal pain in those with IBS.

Nursing Interventions

When providing nursing care to a client diagnosed with IBS, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching^[9],[10]:

Nursing Assessments

• Assess the client’s daily intake of food to establish a baseline of their dietary status.
• Assess the client’s weight daily to monitor their progress towards weight-related goals.
• Assess the frequency, consistency, and amount of stool.
• Monitor electrolytes levels and replenish if necessary if diarrhea is present.
• Assess for signs of dehydration due to fluid loss: dry skin and mucous membranes, increased heart rate, low blood pressure, and decreased urine output.

Nursing Actions

• Administer IBS medications as prescribed by the provider to help manage symptoms.
• Encourage referral to gastroenterologist because they can individualize the client’s IBS treatment plan.
• Encourage referral to a dietician to help create a dietary plan that is client-specific.
• Encourage oral fluid intake/administer intravenous fluids to prevent/treat dehydration when diarrhea is present. Cold liquids should be avoided as they can increase gastrointestinal motility.

Client Teaching

• Avoid food triggers, such as gas-producing foods, gluten, and carbohydrates that contain lactose and fructose. A diet high in fiber and increased fluid intake should be encouraged if constipation is an issue.
• Use stress management strategies (such as deep breathing and meditation) to help decrease symptoms.
• Keep a food diary to help identify personal food triggers.

Evaluation

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.