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