NUR 2571 Gastrointestinal - exam 1 note
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Appendicitis (S/S) - AnswerGeneralized abdominal pain that progressively worsens.
Nausea and vomiting
Localized RLQ pain (McBurney's Point)**
Rebound tenderness.
Dysphagia (Assessment) - AnswerDifficulty swallowing liquids or solids.
Recurrent pulmonary infections. (Related to aspiration)
Coughing after eating or drinking.
Dysphagia (Diagnostics) - AnswerBarium swallow test or an endoscopic evaluation.
Swallow studies are preformed by occupational therapy, NOT the nurse.
The nurse can do a swallow screening and request a consult with OT for further evaluation.
Dysphagia (Nursing Interventions) - AnswerProvide the patient with thickened fluids and foods.
- Do not provide a patient on thickened fluids with a straw!
Keep the patients head of bed at 30-45 degrees to prevent aspiration
A patient admitted with appendicitis is scheduled for an appendectomy tomorrow. As the nurse you are
evaluating the patients pain, the patient states their pain suddenly went away. What does this indicate?
- AnswerSudden relief of pain indicates that the appendix has ruptured.
This is a medical emergency that will require the patient to go in for emergency surgery.
, A ruptured appendix places the patient at a high risk for developing septicemia.
The nurse is admitting a child with a diagnosis of "Rule out appendicitis" The nurse assesses this client
for which manifestations? (SATA)
a. Generalized abdominal pain
b. Pain localizing in the right lower quadrant
c. Fatty stools
d. Elevated white blood cell count - AnswerAnswer: A, B, D; Pain related to appendicitis begins as
generalized abdominal pain, however as it progresses it intensifies and becomes more localized in the
right lower quadrant. Fatty stools are not a clinical manifestation of appendicitis. During appendicitis,
WBCs can elevated to 15,000 - 20,000.
Appendicitis (Patho) - AnswerInfection of the appendix causes inflammation and blockage, possibly
leading to rupture.
Appendicitis (Treatment & Interventions) - AnswerSurgical removal of the appendix.
Place the patient in semi-fowlers position on their right side to prevent spread of infection.
Apply cold packs for discomfort.
Do not administer laxatives.
True/False
Heat therapy is a beneficial way of managing pain in a patient with appendicitis. - AnswerFALSE
Heat stimulates vasodialation and allows for the spread of infection. COLD is the only therapy that
should be utilized.
Ulcerative Colitis - AnswerChronic inflammation of the colon.
Characterized by remissions and exacerbation.
Inflammation develops into abscesses that penetrate mucosa.
Ulcerative Colitis (S/S) - Answer10 or more liquid stools every day
Abdominal pain
.
Appendicitis (S/S) - AnswerGeneralized abdominal pain that progressively worsens.
Nausea and vomiting
Localized RLQ pain (McBurney's Point)**
Rebound tenderness.
Dysphagia (Assessment) - AnswerDifficulty swallowing liquids or solids.
Recurrent pulmonary infections. (Related to aspiration)
Coughing after eating or drinking.
Dysphagia (Diagnostics) - AnswerBarium swallow test or an endoscopic evaluation.
Swallow studies are preformed by occupational therapy, NOT the nurse.
The nurse can do a swallow screening and request a consult with OT for further evaluation.
Dysphagia (Nursing Interventions) - AnswerProvide the patient with thickened fluids and foods.
- Do not provide a patient on thickened fluids with a straw!
Keep the patients head of bed at 30-45 degrees to prevent aspiration
A patient admitted with appendicitis is scheduled for an appendectomy tomorrow. As the nurse you are
evaluating the patients pain, the patient states their pain suddenly went away. What does this indicate?
- AnswerSudden relief of pain indicates that the appendix has ruptured.
This is a medical emergency that will require the patient to go in for emergency surgery.
, A ruptured appendix places the patient at a high risk for developing septicemia.
The nurse is admitting a child with a diagnosis of "Rule out appendicitis" The nurse assesses this client
for which manifestations? (SATA)
a. Generalized abdominal pain
b. Pain localizing in the right lower quadrant
c. Fatty stools
d. Elevated white blood cell count - AnswerAnswer: A, B, D; Pain related to appendicitis begins as
generalized abdominal pain, however as it progresses it intensifies and becomes more localized in the
right lower quadrant. Fatty stools are not a clinical manifestation of appendicitis. During appendicitis,
WBCs can elevated to 15,000 - 20,000.
Appendicitis (Patho) - AnswerInfection of the appendix causes inflammation and blockage, possibly
leading to rupture.
Appendicitis (Treatment & Interventions) - AnswerSurgical removal of the appendix.
Place the patient in semi-fowlers position on their right side to prevent spread of infection.
Apply cold packs for discomfort.
Do not administer laxatives.
True/False
Heat therapy is a beneficial way of managing pain in a patient with appendicitis. - AnswerFALSE
Heat stimulates vasodialation and allows for the spread of infection. COLD is the only therapy that
should be utilized.
Ulcerative Colitis - AnswerChronic inflammation of the colon.
Characterized by remissions and exacerbation.
Inflammation develops into abscesses that penetrate mucosa.
Ulcerative Colitis (S/S) - Answer10 or more liquid stools every day
Abdominal pain
