nur 211 fundamentals – final exam study guide set 2
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Fundamentals – Final Exam Study Guide
For all systems/categories remember we Cramping
utilize the nursing process. Bloating
Dehydration
Assessing – collecting, validating, and Fever
communicating, patient data Bloody stools
Frequent urge to evacuate bowels
Diagnosing – analyzing patient data to
Teachings of how to keep regular bowel
identify the patients strength and patterns
problems
Eat more fiber
Planning – specifying patient outcomes Drink more
and related nursing interventions Do not rely on laxatives
Reduce stress
Implementing/intervention – carrying out Do not ignore urge to go
the plan of care
Purpose for colonoscopy
Evaluating – measuring extent to which
patient achieved outcomes Visual examination of the rectum,
colon, and distal small bowel using a
Head to toe Assessment long, flexible, fiber-optic-lighted scope
Preparation – Informed consent is
signed, clear liquid diet (24-48hrs
Inspect, palpation, percuss, auscultation
before test), 2-day bowel prep using
strong cathartic and Dulcolax on day 1
Abdomen – and enema on day of the test or 1-day
bowel prep using ingestion of a gallon
Inspect-observe contour, any masses, scars, of bowel cleanser such as GoLytely,
distention sedation given before the test
Aftercare – Patient may experience
Auscultation – listen for bowel sounds in all flatulence or gas pains because air was
quadrants used to distend the intestines for better
visibility, usual diet resumed once
Note frequency and character, patient recovers, check vital signs,
audible clicks, and flatus observe for signs of bowel perforation,
rectal bleeding, abdominal pain, and
Describe bowl sounds as hypoactive, distention, fever, malaise
hyperactive, absent or infrequent
Nurse diagnoses and teachings with
colostomies and GI complications
Percussion and palpitations-professional
Keep patient as free of odors as
GI possible; empty appliance frequently
Inspect the patients stoma regularly
Side effects of diarrhea/findings expected Note the size, should stabilize within 7-
8 weeks
Nausea Measure patient fluid intake output
Abdominal pain
, Fundamentals – Final Exam Study Guide
If no bowel sounds movement after required), rather than the toilet, because the
surgery within a week and nauseated, water in the toilet bowl may affect the analysis
notify HCP and document results.
Potential for disturbed body image
Do not place toilet tissue in the bedpan or
GI complications specimen container because contents in the
paper may influence laboratory results.
Constipation
Perforated bowel Notify the nurse when the specimen is
Fecal impact available, so that it may be collected and
Bowel obstruction transported to the laboratory as required
Diarrhea
Radiation enteritis If antibiotic or antifungal therapy has already
begun, identify the specific medication in the
Ways to decrease constipation laboratory request
Exercise Foods that may cause a false-positive result
Drink fluids include red meat, animal liver and kidneys,
Include fruits, vegetable and fiber in salmon, tuna, mackerel and sardines, tomatoes,
diet cauliflower, horseradish, turnips, melon,
bananas, and soybeans.
Constipating factors/causes
Certain medications, such as a salicylate intake
Not enough water or fiber of more than 325 mg daily, steroids, and iron
Eating lots of dairy preparations, also may lead to false-positive
Resisting urge to poop readings
Not being active
Stress The ingestion of vitamin C can produce false-
Narcotics negative results even if bleeding is present.
Antidepressants
Iron pills Occult blood test: color matters!
Over use of laxatives
Red- fresh blood= lower GI
Constipation is often a chronic problem, Black – old blood= upper GI
diarrhea and fecal incontinence may result from
physiologic or lifestyle changes Respiratory
Stool specimen teaching s/s of hypoxia
Utilize disposable gloves and label correctly Dyspnea
Hypertension
Void first, because the laboratory study may be Tachypnea
inaccurate if the stool contains urine Pallor
Cyanosis
Defecate into the required container, such as Anxiety
clean or sterile bedpan or the bedside Restlessness
commode (depending on the specimen Confusion
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