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NUR211/NUR211 Final Exam Study Guide
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NUR211/NUR211 Final Exam Study Guide
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NUR211 Final Exam Study GuideFor all systems/categories remember we • Nausea
utilize the nursing process. • Abdominal pain
• Cramping
Assessing – collecting, validating, and • Bloating
communicating, patient data • Dehydration
• Fever
Diagnosing – analyzing patient data to • Bloody stools
identify the patients strength and • Frequent urge to evacuate bowels
problems
Teachings of how to keep regular bowel
Planning – specifying patient outcomes patterns
and related nursing interventions
• Eat more fiber
• Drink more
Implementing/intervention – carrying out
• Do not rely on laxatives
the plan of care
• Reduce stress
• Do not ignore urge to go
Evaluating – measuring extent to which
patient achieved outcomes
Purpose for colonoscopy
Head to toe Assessment • Visual examination of the rectum,
colon, and distal small bowel using a
Inspect, palpation, percuss, auscultation long, flexible, fiber-optic-lighted scope
• Preparation – Informed consent is
Abdomen – signed, clear liquid diet (24-48hrs
before test), 2-day bowel prep using
Inspect-observe contour, any masses, scars, strong cathartic and Dulcolax on day 1
distention and enema on day of the test or 1-day
bowel prep using ingestion of a gallon
Auscultation – listen for bowel sounds in all of bowel cleanser such as GoLytely,
quadrants sedation given before the test
• Aftercare – Patient may experience
Note frequency and character, flatulence or gas pains because air was
audible clicks, and flatus used to distend the intestines for better
visibility, usual diet resumed once
patient recovers, check vital signs,
Describe bowl sounds as hypoactive,
observe for signs of bowel perforation,
hyperactive, absent or infrequent rectal bleeding, abdominal pain, and
distention, fever, malaise
Percussion and palpitations-professional
Nurse diagnoses and teachings with
GI colostomies and GI complications
Side effects of diarrhea/findings expected • Keep patient as free of odors as
possible; empty appliance frequently
, • Inspect the patients stoma regularly Void first, because the laboratory study may be
• Note the size, should stabilize within 7-8 inaccurate if the stool contains urine
weeks
• Measure patient fluid intake output Defecate into the required container, such as
• If no bowel sounds movement after clean or sterile bedpan or the bedside
surgery within a week and nauseated, commode (depending on the specimen
notify HCP and document required), rather than the toilet, because the
• Potential for disturbed body image water in the toilet bowl may affect the analysis
results.
GI complications
Do not place toilet tissue in the bedpan or
• Constipation specimen container because contents in the
• Perforated bowel paper may influence laboratory results.
• Fecal impact
• Bowel obstruction Notify the nurse when the specimen is
available, so that it may be collected and
• Diarrhea
transported to the laboratory as required
• Radiation enteritis
If antibiotic or antifungal therapy has already
Ways to decrease constipation
begun, identify the specific medication in the
laboratory request
• Exercise
• Drink fluids
Foods that may cause a false-positive result
• Include fruits, vegetable and fiber in include red meat, animal liver and kidneys,
diet salmon, tuna, mackerel and sardines, tomatoes,
cauliflower, horseradish, turnips, melon,
Constipating factors/causes bananas, and soybeans.
• Not enough water or fiber Certain medications, such as a salicylate intake
• Eating lots of dairy of more than 325 mg daily, steroids, and iron
• Resisting urge to poop preparations, also may lead to false-positive
• Not being active readings
• Stress
• Narcotics The ingestion of vitamin C can produce false-
• Antidepressants negative results even if bleeding is present.
• Iron pills
• Over use of laxatives Occult blood test: color matters!
Constipation is often a chronic problem, Red- fresh blood= lower GI
diarrhea and fecal incontinence may result from
physiologic or lifestyle changes Black – old blood= upper GI
Stool specimen teaching Respiratory
Utilize disposable gloves and label correctly s/s of hypoxia
• Dyspnea
, • Hypertension Upper airways – nose, oral cavity, pharynx,
• Tachypnea larynx
• Pallor
• Cyanosis Forced vital capacity – Maximum amount of air,
• Anxiety that can be removed from the lungs during
• Restlessness forced expiration
• Confusion
• Drowsiness Peaked expiratory flow rate – refers to the point
of highest flow during forced expirations,
Cause = hypoventilation reflects changes in the size of pulmonary
airways, it is measured using a peak flow meter
Terminology for respiratory system
Measure of the fastest flow of exhaled air after
a maximal inspiration
Hypoxia-a state describing oxygen-deficient
tissue
Pulmonary ventilation – movement of air in and
Gas exchange – process of taking in oxygen and out of the lungs
releasing carbon dioxide
Perfusion – process by which oxygenated blood
passes through the body tissue
Alveoli (air sacs) – the primary units for the
exchange of oxygen and carbon dioxide in the
lungs Pulse oximetry – an assessment tool that
measures oxygen saturation of hemoglobin in
the capillary beds
Atelectasis – collapsed lung; incomplete
expansion of the alveoli
Respiration – inhalation and exhalation of air
BiPap: bi-level positive air pressure – change in
the air position while the patient breathes in Residual volume – amount of air remaining in
and out the lungs after a forced exhalation
Bronchiodialtor – a medication that expands the Spirometry – direct measurement of lung
opening of the passages into the lungs volume and capacity
Cpap (continuous positive airway pressure) – Surfactant – reduces surface tension between
pressurized air delivered into the lungs to keep moist membranes of alveoli, preventing their
them expand during exhalation collapse
Corticosteroids – reduces inflammation and Tidal volume – amount of air that moves in and
swelling in the respiratory tract out of the lungs during a normal breath
Expiration – breathing out (exhalation) Total lung capacity – the volume of air in the
lungs after a maximal inhalation
Inspiration – breathing in (inhalation)
Vital capacity – the total volume of air that can
Lower airway – trachea, bronchi, bronchioles, be exhaled after maximal inhalation
alveoli
Normal vitals
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