Standardized Procedure for Irritable Bowel Syndrome

This document provides information about the standardized procedure for treating Irritable Bowel Syndrome (IBS). It discusses the purpose, development and review process, scope and setting, educational qualifications, supervision and evaluation, consultations, patient records, and more. The document also includes details about the definition, epidemiology, causes, symptoms, diagnostic tests, and management of IBS.

Running head: STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
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1STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
Irritable bowel syndrome (IBS) is a well-known disorder which primarily affect the
large intestine. Abdominal pain, cramping, constipation, diarrhea, gas and bloating are some
of the common symptoms associated with IBS (Chey, Kurlander & Eswaran, 2015). It can be
a chronic disease which needs to be clinically managed or the patient suffers for a long term.
Standardized procedure can be performed to treat the patients suffering from chronic IBS. A
registered nurse has the authority to perform standardized procedure function under the
conditions mentioned in the standardized procedure of the health care system. The healthcare
system needs to ensure that the nurse provides genuine evidence about the educational
qualification, required training and experience to perform the task. Standardized procedures
are authorized in the Nursing Practice Act (NPA) section 2725. These procedures are
developed in a collaborative way where health administration, nurses and other medical
professionals are involved. As nurses are the primary care givers in the interdisciplinary
collaboration their responsibility is also significantly higher to perform the functions of
standardized procedures. The standardized procedures are developed after critical assessment
and evaluation. It ensures more frequent positive patient related outcomes as the treatment is
more precise and based on evidence.
General Policy: Standardized Procedure for Nurses to treat Irritable bowel syndrome
1. Purpose
Board of Registered Nursing (BRN) collaborating with Allied Health Professions division
under the Board of Medical Quality Assurance publicised eleven points for the standardized
procedure guidelines. So establishing a standardized procedure to treat IBS in acquiescence
with the BRN guidelines where the nurses can perform their task without instantaneous
supervision from a doctor is the primary purpose.

2STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
2. Development and Review
 Standardized procedures are planned and developed by the collaboration of all the
stakeholders of a health organization. An interdisciplinary committee is established
consisting of administrative representatives, doctors, registered nurses and nurse
practitioners.
 The standardized procedures will be reviewed in regular intervals.
 The standardized procedures will be the evaluated by the interdisciplinary committee.
 After evaluation by the interdisciplinary committee final procedures will be signed
with date on the approval sheets.
 After the signature on the approval sheet and the final agreement all the standardized
procedures will be religiously maintained by the physicians and the nurses. The
collaboration among all the stakeholders in the organization will be maintained while
the standardized procedure is going on. The approval sheets will be kept in file as a
record of the nurse practitioners (NP) who are performing the tasks in the procedure.
 The physicians and the NPs working under their supervision will abide by the
agreements made in the approval sheets. They will be followed upon hire and any
changes required will be in accordance with the agreement made in the approval
sheet.
3. Scope and Setting of the NP
 Nurse practitioners performs tasks which are mentioned in the standardized
procedures. Those are decided based on their area of specialization, previous
experience and credibility of performing a specific task. The tasks include assessment,
treatment and management of IBS, evaluation of the physical condition and
promotions related to physical wellbeing.

3STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
 Nurse practitioners have the authority for practicing the approved standardized
procedures in the outpatient clinic of the organization. They also maintain the diet,
physical therapy, specific diagnostic procedures and care required to treat IBS.
4. Educational qualifications of the NP
 It is mandatory that the NP has a valid registration or RN license.
 Certification as an NP by the Board of Registered Nursing (BRN) is also crucial.
 Board certification from Nurses Credentialing Centre is also necessary.
 Current health care provider card, nurse practitioner furnishing number, DEA
registration number is required.
 The NP should be credentialed by the medical staff of an organization.
 The NP will be under the supervision of a physician who will observe, authorize and
document about the competency of the NP.
 The competency validation is mandatory for an NP after hire and annually.
 The checklist for competency validation prepared by the physician will be managed
and maintained by the medical staff office.
 Prepared checklist should be evaluated, assessed and updated if required on a yearly
basis.
5. Supervision and Evaluation
 The nurse practitioner has the authority to perform the standardized procedures without
any instantaneous supervision or intervention of the physician. The physician will only
intervene if that is specified in the standardized procedures guidelines.
 The physician will supervise maximum four nurses at the same time. The physician
will conduct a weekly review of the cases of all the nurses under his supervision.
Minimum ten percent of all the cases should be reviewed for all the nurses. The cases

4STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
are selected on a random basis. The results of the reviews will be documented in the
EMR within thirty days.
6. Consultations in the standardized procedures
Consultation from the physician is quintessential in the specific diagnosis of the
approved and planned standardized procedure. Collaboration with all the stakeholders
of the hospital organization is key to maintain the standardized procedure.
7. Patient Records
The nurse practitioners will maintain the documentation related to the patient
health using health informatics system like electronic medical record (EMR) and
electronic health record (EHR). Documents of all the patients will be done abiding by
the guidelines of standardized procedures. Uses of data warehouses, NHIN, PHIN and
Regional Health Information Organization (RHIO) is key to gather clinical
information about the patient.
Protocol
Definition
Irritable bowel syndrome (IBS) is a well-known disorder where persistent abdominal
pain, infection in the large intestine, constipation or diarrhoea or both occurs due to
depression, stress and anxiety. It is a chronic and recurring disorder which can sustain
throughout life if not treated well (Lee & Park, 2014). It has a long term detrimental physical
and mental effects on the adult patients and especially in older individuals.
Epidemiology
 The range of prevalence is from 3% to 20% in adults. Most of the researchers suggest
that the range is between 10 to 15%.

5STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
 Women have higher ratio of developing IBS then men. The ratio is 2:1 in favour of
women (Canavan, West & Card, 2014).
 IBS symptoms are higher in people younger than 45 years old.
 Later in life the older people also have higher chances to suffer from detrimental
effects of IBS.
Causes
 Acute gastroenteritis infection can trigger IBS.
 Psychological stress in adulthood and mental abuse in the childhood can cause IBS.
 Bacterial growth in small intestine is higher in the IBS affected patients.
 Gut micro biota (dysbacteriosis) can cause IBS (Lee & Lee, 2014).
 Protozoans like Blastocystis hominis can cause IBS symptoms.
 Vitamin D deficiency can cause IBS.
History
 Family history of ovarian and bowel cancer.
 Sudden weight loss.
 Irregularities in the bowel habit persisting for minimum 6 weeks.
 Bleeding from the rectum.
 Change in bowel habit in an individual more than 60 years old.
 Celiac related irregularities (Sainsbury, Sanders & Ford, 2013).
Symptoms
 Frequent diarrhoea.
 Abdominal pain.
 Constipation.
 Irregular bowel habit.

6STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
 Abdominal bloating.
 Incomplete evacuation of bowel.
 Fibromyalgia.
 Headache and pain the back.
 Fatigue syndrome and fibromyalgia.
 Gastro oesophageal irregularities.
 Depression.
 Anxiety.
 Nausea
 Sexual dysfunction and loss of carnal desire (Saha, 2014).
Diagnostic tests
To confirm the diagnosis of IBS following tests are necessary:
 Plasma viscosity or erythrocyte sedimentation rate test.
 Blood count.
 C reactive protein test (Soares, 2014).
 Coeliac disease related antibody testing.
For people who did not meet the IBS diagnostic criteria these tests are necessary.
Some of the common tests to diagnose IBS are:
 Sigmoidoscopy (rigid or flexible).
 Ultrasonography.
 Thyroid test.
 Faecal ova and parasite culture and microscopy.
 Hydrogen breathing test to confirm lactose intolerance and bacterial growth.
 Colonoscopy.

7STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
 Faecal occult blood test.
 Barium enema imaging test.
If the symptoms suggest ovarian cancer anaemia, rectal and abdominal masses,
inflammations should be checked in a patient and pelvic examination should be conducted.
The disorders like inflammatory bowel disease, colon cancer, thyroid and malabsorption of
lactose had similar probabilities at pretest with IBS (Melmed et al., 2013). So proper
diagnosis of IBS is very crucial for timely clinical interventions.
Management
Pattern of diet and lifestyle play an important role in triggering the symptoms and
deteriorate the condition in an IBS affected adult patient. So self-help is a critical strategy in
controlling IBS. Information should be provided about lifestyle pattern, dietary habit,
physical activities and medication to control IBS related symptoms.
 To control diarrhoea antimotility drugs like atropine and morphine can be used. Laxatives
such as methylcellulose and Metamucil can be applied to treat acute constipation (Ford et
al., 2014).
 Patients with IBS generally have higher fibre quantity in the diet which worsens their
condition. So evaluating the fibre intake per day and removing excess fibre from daily
diet is important. Generally it is reduced to 12 gram per day from 18 gram per day (Rao,
Yu & Fedewa, 2015).
 Patients affected with IBS should be restricted from having insoluble fibre. Quantity of
soluble fibre should increase in their diet like oats and ispaghula powder (Hookway et al.,
2015).
 Laxative and antimotility drugs dosage should be decided based on dose titration in
accordance to stool consistency.

8STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
 Tricyclic antidepressants can be used to treat abdominal pain. If laxative, antispasmodics
and loperamide has not worked on the patient effectively then tricyclic antidepressants
can be used.
 The treatment should start at 5 to 10 mg taken just one time at night. The effect should be
reviewed regularly and based on that the dosage can go up. Though the dosage should not
exceed 30 mg (Peyrin-Biroulet et al., 2015).
 If the tricyclic antidepressant application fails then reuptake inhibitor called serotonin can
be used in low dosage.
 Bifidobacterium infantis can be used as a probiotic to treat IBS patients (Didari et al.,
2015).
 Gluten free diet should be used while treating IBS affected patient (Vazquez–Roque et
al., 2013).
 Lower FODMAP diet can be used to treat symptoms of IBS. FODMAP stands for
Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (De Roest et
al., 2013).
 Hypnotherapy, cognitive behaviour therapy and psychological therapy can be used to
decrease abdominal pain and other IBS syndromes. This psychological interventions can
improve the quality of life (Laird et al., 2016). This should be applied to patients who are
suffering from more than 12 months and the primary medicines have not responded well.
 Patients should be advised to use probiotics for at least one month instead of acupuncture,
reflexology and aloe Vera as they do not have any impact in reducing IBS symptoms in
the patients (Cammarota et al., 2014).
 The diet of the patients should be assessed and evaluated critically from the collected
data of the patient lifestyle and dietary pattern (Hayes, Fraher & Quigley, 2014). Advice

9STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
from an experienced dietician should be followed to avoid foods detrimental for IBS. The
dietician should prepare an exclusion diet chart for the patients (Gibson et al., 2015).
 A positive diagnosis and sensible use of investigations to confirm IBS can eliminate
irrelevant investigations. Proper investigation and diagnosis can result in relief from the
symptoms. Better dietary review can reduce the unnecessary amount of fibre from the diet
giving positive patient related outcomes.
 A patient should be informed about the aspects of self-help and self-management of IBS.
It inflicts higher level of confidence in patients so better diagnosis occurs. It results in
positive clinical outcome for the IBS affected patient as the confidence of the clinician
also goes up.
 History and the symptoms must be examined carefully to diagnose IBS positively.
Positive diagnosis of the disease can eliminate the possibilities of other serious disorders
and precise clinical intervention in time. This not only improve the clinical efficiency of
the practitioner but also increases positive patient related outcome related to IBS (Williet,
Sandborn & Peyrin–Biroulet, 2014).
Development and Approval of the Standardized Procedure
This standardized procedure was planned, developed and approved by the Interdisciplinary
Committee (IDC) of the organization. Committee and will be reviewed and approved every
year or more frequently if required.
Revision Date_____________ Review Date______________
This standardized procedure was approved by the following:
Nursing _________________________________________ Date _________
Medicine _______________________________________ Date _________

10STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
Pharmacy ______________________________________ Date _________
Administration ________________________________ Date _________
The standardized procedure will be reviewed on yearly basis.
RNs authorized to perform the procedure
1. ______________________________________________ Date _________
2.______________________________________________ Date _________
The positive diagnosis of IBS is crucial for cost effective management and fast,
precise clinical intervention. Importance of self-help of the patient is also important for
treating patients affected with IBS. It ensures patient empowerment in the standardized
procedure for irritable bowel syndrome. This results in more confident patients which boosts
the moral of the healthcare providers like the NP. The nurse practitioners and the clinicians
should always follow the approved guidelines for standardized procedure. The health
professionals specially the nurse practitioners who are the primary care providers should
always abide by the guidelines as implementation of those guidelines ensures positive clinical
results. New concepts like psychotherapy, reducing fibre in daily intake and diet regulation
should be part of the standardized therapy which give new direction in IBS treatment. Proper
implementation of the approved guidelines for standardized procedures will result in more
efficient and precise treatment of the IBS affected patients with all the stakeholders
maintaining the guidelines and working in collaboration as proposed in the guidelines.

11STANDARDIZED PROCEDURE FOR IRRITABLE BOWEL SYNDROME
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