Intro To Nursing Exam 3 Flashcards
1
Q
volume imbalances
A
- disturbances of the amount of fluid in the extracellular compartment
2
Q
osmoality imbalances
A
- disturbances in the concentration of body fluids
3
Q
hypernatremia
A
- water deficit
- hypertonic
- loss of relatively more water than salt or gain of more salt than water
4
Q
hyponatremia
A
- water excess
- hypotonic
- arises from gain of more water than salt or loss of more salt than water
5
Q
clinical dehydration
A
- extracellular volume deficit and hypernatrema combined
- ECV is too low and the body fluids are too concentrated
6
Q
Nursing Management of fluid volume deficit
A
- measure all fluids that enter and leave the body
- check electrolytes, CBC, and urine-specific gravity
- assess for hypertension and weak pulses
- assess respiratory system and tissue perfusion
- check orientation, vision, hearing, relfexes, and muscle strength
- check for weight changes
- check for skin break down and good oral care
7
Q
hypokalemia symptoms
A
- diarrhea, repeated vomiting
- use of potassium wasting diuretics
8
Q
hyperkalemia symptoms
A
- decreased urine output
9
Q
hypocalcemia symptoms
A
- acute pancreatitis, neuromuscular excitability
10
Q
hypercalcemia symptoms
A
- commonly found in cancer patients
11
Q
hypomagnesemia
A
- increases neuromuscular excitability
12
Q
hypermagnesemia
A
- ESRD, neuromuscular excitability, lethargy, decreased deep tendon reflexes
13
Q
pH
A
- reported degree of acidity
14
Q
acid buffers
A
- are pairs of chemicals that work together to maintain normal pH of body fluids
15
Q
respiratory acidosis
A
- arises from aveolar hypoventilation
- lungs unable to excrete enough CO2
- excess carbonic acid in the blood decreases pH
16
Q
respiratory alkalosis
A
- arises from hyperventilation
- lungs excrete too much CO2
- deficit of carbonic acid in the blood increases pH
17
Q
metabolic acidosis
A
- arises from increase in the metabolic acid or decrease in base (bicarbinate)
- kidneys unable to excrete enough metabolic acids which accumulate in the blood
- results in decreased level of conciousness
18
Q
metabolic alkalosis
A
- arises from direct increase in base (bicarbonate) or decrease in metabolic acid
- results in increased blood bicarbonate
19
Q
causes of alkalosis
A
- loss of gastric juices
- potassium wasting diuretics
- overuse of antiacids
- hyperventiliation
20
Q
nursing process assessment
A
- nursing history, medical history, daily weights, fluid intake and output, labratory studies
21
Q
nursing history
A
- age
- environment
- dietary intake
- lifestyle (alcohol intake, etc)
- medications
22
Q
medical history
A
- recent surgery
- gastrointestinal output
- acute illness or trauma
- respiratory disorders
- burns
- trauma
- chronic illness
- cancer
- heart failure
- oliguric renal disease
23
Q
daily weights
A
- indicator of fluid status
- use same conditions
24
Q
fluid intake and output
A
- 24 hours I&O (compare intake versus output
- intake includes all liquids eaten, drank, or through IV
- output is urine, diarrhea, vomitus, gastric suction, wound drainage
25
Q
isotonic solution
A
- have the same effective osmoality as body fluids
26
Q
hypotonic solution
A
- have an effective osmoality less than bosy fluids, thus decreasing osmoality by diluting body fluid and moving water into cells
27
Q
hypertonic solution
A
- have an effective osmoality greater than body fluids
28
Q
IV equipment
A
- vascular access devices, tourniquets, clean gloves, dressings, IV fluid contains, various types of tubing, electronic fluid devices, infusion pumps
29
Q
initiating IV therapy
A
- changing intravenous fluid containers, tubings, and dressings
- assissting patient with self-care activities
- complications: fluid overload, infiltration, extravasation, phlebitis, local infection, bleeding at the infusion sight, bruising
30
Q
blood component therapy
A
- IV administration of whole blood or blood component
31
Q
blood types
A
- O positive, O negative, A positive, A negative, B positive, B negative, AB positive, AB negative
32
Q
Blood groups
A
A, B, AB, O
33
Q
Autologous blood transfusion
A
- designates the reinfusion of blood or blood components to the same individual from whom they were taken
34
Q
pure food and drug act
A
- medication free from impurities
35
Q
FDA
A
- rigorous testing on potential products
36
Q
medwatch program 1993
A
- HCP report when harm done
37
Q
ISMP
A
- help health care practitioners understand medication error from a systems perspective, collect reports of errors, and disseminate recommendations to help prevent similar occurrences
38
Q
drug
A
- any substance that alters physiologic function with the potential of affecting health
39
Q
medication
A
- a substance used in the diagnosis, treatment, cure, relief, or prevention of health alteration
- regulated by the FDA
40
Q
drug administration purposes
A
- diagnostic, prophylaxis, therapeutic
41
Q
drug diagnostic purpose
A
- assessment of liver function
- diagnosis of myasthenia gravis
42
Q
drug prophylaxis purpose
A
- heparin to prevent thrombosis
- antibiotics to prevent infection
43
Q
drug therapeutic purpose
A
- replacement of fluids or vitamins
- supportive purposes (to enable other treatments such as anesthesia)
- palliation of pain and sure
44
Q
chemical drug names
A
- various chemical compounds
45
Q
generic drug names
A
- manufacturer who develops, helps to recognize class
46
Q
trade names
A
- first manufacturer of drug
47
Q
classfication of drugs
A
- based on its desired effect on the body system
48
Q
medication forms
A
- solid, liquid, topical, parenteral, sterile for body cavity instillation
49
Q
medication actions therapeutic effect
A
- expected and predicted response on body system
50
Q
side effects
A
- unintended and nontherapeutic effects which can range from tolerable to harmful and sometimes irreversible damage or death
51
Q
idiosyncratic reactions
A
- opposite or different response than expected such as hyperactivity with Benadryl
52
Q
synergistic effect
A
- 2 drugs cause greater body response when given together (positive or negative)
53
Q
allergic reaction
A
- sensitized immune response, unpredicted, simple itching, hives, rash, rhinitis
54
Q
anaphylactic allergic reaction
A
- amergency ABC problems, treatment for bronchospasm, wheezing, edema
55
Q
skin rash
A
- small, raised vesicles that are usually reddened
- often distributed over entire body
56
Q
pruritus
A
- itching of the skin with or without rasha
57
Q
angioedema
A
- edema due to increased permeability of blood capillaries
58
Q
rhinits
A
- inflammation of mucous membrances lining nose
- causes swelling and clear, watery discharge
59
Q
pharmacokinetics
A
- how medications enter and exit the body
- are absorbed and distributed
- reach their site of action
- alter body processess and are metabolized
60
Q
absorption pharmacokinetics
A
- passage of medication molecules into the blood from the site of administration
- factors that influence: route of admin, ability of medication to dissolve, blood flow to site of admin, body surface area, lipid solubility
61
Q
distribution pharmacokinetics
A
- occurs after absorption within the body to tissues, organs, and specific sites of action
- depends on physical and chemical properties of medication, physiology of the person taking it, circulation, membrane permeability, protein binding
62
Q
metabolism pharmacokinetics
A
- medications are metabolized into a less-potent or an inactive form
- biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals
- most biotransformation occurs in the lover
- kidneys, blood, intestines, and lungs play a role
63
Q
excretion pharmacokinetics
A
- medications exit the body through kidney (urine), liver (bile), bowel (stool), lungs (gases), exocrine glands (lipid, soluable meds)
- chemical makeup of medication determines the organ of excretion
64
Q
first pass effect
A
- phenomenon of drug metabolism at a specific location in the body which leads to a reduction in the concentration of the active drug before it reaches the site of action or systemic circulation
65
Q
therapeutic range
A
- constant blood level between MEC and toxicity
66
Q
MEC
A
- want of a constant blood level
67
Q
peak
A
- considered the maximal therapeutic level, mex serum dose, time varies
68
Q
trough/level
A
- the lowest therapeutic level
- can be measured by a lab draw just prior to the next scheduled dose
69
Q
onset
A
- body response to medication
70
Q
duration
A
- therapeutic range of medication
71
Q
biological half-life
A
- the time it takes for excretion to lower the blood concentration of a drug to decrease by 50%
- determines how often medication is given
72
Q
plateau
A
- occurs when a medication blood serum concentration reaches therapeutic effect and remains there
73
Q
time-critical medications
A
- 30 minutes before or after scheduled time
- non-time critical (within 1 hour of time due)
74
Q
patient teaching
A
- nurse tells how patient when and how to take medications
75
Q
essential parts of drug order
A
- full name of patient and file
- date and time order is written
- name and dosage of drug
- route of drug admin
- rfrequency of drug admin
- signature and stamp of health care provider
- if over the phone must RBAV - read back and verify
76
Q
medication rights
A
- patient, medication, dose, time, route, documentation
77
Q
standing or routine medication admin
A
- administered until the dosage is changed or another medication is prescribed
78
Q
single medication
A
- given one time only for a specific reason
79
Q
now medication
A
- when a medication is needed right away but not STAT
80
Q
prn medication
A
- medication given when the patient requires it
81
Q
STAT medication
A
- given immediately in an emergency
82
Q
prescription medication
A
- medicatio to be taken outside of the hospital
83
Q
assessment for medication
A
- always assess patient after giving medications that affect RR, HR, BP, LOC, blood sugar, and pain
84
Q
onset times for medication
A
- IV: 3-5 min
- IM: 3-20min
- SC: 3-20min
- PO: 30-45min
85
Q
medication reconciliation
A
- goal is to develop, update, coordinate, and comminucate accurate client medication information during transitions of care
86
Q
polypharmacy
A
- increase risk of adverse reactions and interactions
- 5 or more meds on a nonhospitalized client
- meds with same actions or chemical class
- risk of drug-drug or drug-food interactions
- taking herbal or nutritional supplements
- OTC meds
- multiple pharmacies or providers
87
Q
routes of administration
A
- oral, sublingual, buccal, inhalation, parenteral, intravenous, intramuscular, intradermal, subcutaneous, topical
88
Q
topical medication admin
A
- medications applied to the skin and mucous membranes generally have local effects
- applied to skin
- rectal
- vaginal
- otic
- optic
- nasal
89
Q
oral administration
A
- easiest and most desirable route
- empty stomach (1 hr before or 2 hr after)
- risk of drug-drug interaction is higher
- do not crush sustained release or enteric coated medications
90
Q
sublingual administration
A
- administer to patient sitting
- dissolves under tongue
- don’t swallow drug, eat, or smoke until after absorbed
91
Q
inhalation medication administration
A
- spray, mist, or powder
- pressurized metered dose inhalers (pMDIs)
- breath actuated metered dose inhalers (BAIs)
- release depends on strength of patient’s breath
- dry powder inhalers (DPIs)
- produce local effects such as bronchodilation
- some medications create serious systemic side effects such as tachycardia
92
Q
topical medication administration
A
- use gloves
- use sterile technique if open wound
- clean skin wound
- follow med instructions
93
Q
eye instillation medication
A
- artificial tears, vasoconstriction
- avoid touching cornea, very sensitive, pain fibers
- avoid eyelids with droppers and tubes
- pull down conjuctival sac and press lacrimal duct
94
Q
intraocular instillation
A
- disk resembles a contact lense and stays for a week
95
Q
ear instillation
A
- room temperature to prevent vertigo, dizziness, nausea
- use sterile solutions in case of ruptured ear drum
- never occlude the ear canal
- do not force medication into occluded ear canal
96
Q
vaginal instillation
A
-assess for drainage
- gloves, aseptic technique
- suppositories, foam, jellies, or cream
- may require applicator
97
Q
rectal instillation
A
- rectal suppositories are thinner and more bullet-shaped than vaginal
- rounded end prevents anal trauma
- use water soluable lubricant for insertion
- local effects (promotes defecation)
- systemic effects (reduces nausea)
98
Q
parenteral
A
- injection into body tissues
- invasive procedure that requires aspetic technique
- nurse checks against MAR 3 times
- risk of infection
- effects develop rapidly, depending on the rate of medication absorption
99
Q
preparing injection from ampule
A
- snap ampule neck
- aspirate medication to filter any glass fragments
- replace filter needle with needle sizr
- administer injection
100
Q
insulin injection
A
- administered by subcutaneous injection and occasionally IV because the GI tract breaks down and destroys oral form of insulin
- timing of insulin attempts to mimic normal pattern of release of insulin from pancreas before meals and at bedtime
- rotate injection sites to avoid lipodystrophy
101
Q
lipodystrophy
A
- loss of fat cells, can be a lump or small dent in skin from repeated injections, interferes with insulin absorption
102
Q
angles for injection
A
- IM 90
- Subcu 45 (1in) or 90 (2in) (depending how much you pinch)
- ID 15
103
Q
subcutaneous injection sites
A
- the outer posterior aspect of
the upper arms, the abdomen from below the costal margins to the iliac
crests, and the anterior aspects of the thighs - abdomen is reccomended for heparin
- absorption is quickest in the
abdomen, followed by arms, thighs, and buttocks - alternative sites scapular areas of upper back and upper ventral/dorsal gluteal areas
104
Q
LMWHeparin/Lovenox
A
- when injecting, use right or left side of abdomen 2 inches from umbilicus, and pinch injection site
- inject slowly at a 90 degree angle
- do not expel air bubble before giving medication
- leave in place 10 seconds after admin and hold pressure at site
105
Q
intramuscular sites
A
- ventrogluteal, vastus lateralis, deltoid
106
Q
intramuscular injection
A
- muscle is less senstive to irritating and viscous medications
- aspirate 5-10 seconds to assess for blood vessel (don’t do this on vaccinations)
107
Q
ventrogluteal injection
A
- involves the gluteus medius
- situated deep and away from major nerves and blood vessels
- preferred sited for adults, children, and older infants
108
Q
vastus lateralis injection
A
- often used for infants less than 7 months and for thin patients who don’t walk
109
Q
deltoid injection
A
- easily accessible
- potential for injury is present because the axillary, radial, brachial, and ulnar nerves along with brachial artery lie along this site
110
Q
z track method IM injection
A
- pull on overlying skin during IM injection to move tissue laterally in order to prevent tracking
- one hand holds skin 1 to 1.5 inches laterally or downward and other hand injects 1 mL per 10 seconds
- keep needle inserted for 10 seconds and don’t released skin until you withdrawl the needle
- minimizes skin irritation by sealing the medication in the muscle tissue
- protects subcutaneous tissues from irritating parenteral fluids which results in less discomfort and fewer lesions (used for irritating medications: iron, etc)
111
Q
intradermal injections
A
- used for skin testing (TB, allergies)
- slow absorption to avoid anaphylaxis
- use a tuberculin or small hypodermic syringe for skin teating (27, 25 guage)
- angle is 5-15 degrees bevel up
- sites should be hairless, light pigmentation, and free of lesions
112
Q
large volume infusions
A
- safest and easiest method of IV admin
- large volumes are used
- common: NS, D5W, lactated Ringer’s (vitamins and potassium chloride can be added)
- if infused too fast, patient at risk for overdose
- use standard dosases, standard procedures for ordering/preparing/administering
113
Q
intravenous injection
A
- can be mixtures within large volume of IV fluid, bolus, or piggyback
- administer fast acting medication
- establish constant therapeutic blood levels
- less irritating method for highly alkaline medications
- for fluid and electrolyte replacement
- always check compatibility of drugs administered together
114
Q
bolus injection
A
- small volume of medication through an existing IV infusion line that is continuous or intermittent venous access
- heparin or saline lock
- check for appropraite time of admin to avoid adverse effects
115
Q
piggyback infusion
A
- infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line
- use small amounts of compatible fluids
- use volume control admin sets, piggyback sets, and mini infusers
- proximal and distal on an IV are in relation to the person receiving IVF
115
Q
volume controlled infusion
A
- reduces the risk of rapid-dose infusion by IV push
- allows for administration of medications that are stable for a limited amount of time
- allows control of IV fluid intake
115
Q
intermittent venous access (saline lock)
A
- cost sacings resulting from the omission of continuous IV therapy
- effectiveness of nurse’s time enhanved by eliminating constant monitering of flow rates
- increased mobility, safety, and comfort for the patient
- before admin, assess IV site, flush to check flow, pull back for blood flow, flush often, cover saline lock with antimicrobial cap
- IV is changed every 72-96 hours (every 24 hours if using intermittenly)
116
Q
phlebitis
A
- inflammation in the walls of a vein
- treatment is to stop IVF, remove IV, elevate extremity, and apply warm compress 3-4 times daily, restart IV in another site, obtain culture at previous site
117
Q
thrombophlebitis
A
- blood clot formation at the site of inflammation
- treatment is to stop IVF, remove IV, elevate extremity, and apply warm compress 3-4 times daily, restart IV in another site, obtain culture at previous site
118
Q
cellulitis
A
- bacterial infection at the site of the IV
- has similar symptoms and treatment of phlebitis but is more severe
- treatment also includes antibiotics, antipyretic, analgesics if needed
119
Q
renal system
A
- filters arterial blood via renal arteries
- kidneys lie within retroperitoneal space behind the peritoneum
- nephrons drain into renal pyramids which drain into renal pelvis, urine flows from renal pelvis into ureters, peristalsis causes urine to drain into bladder
120
Q
nephrons
A
- functional unit of the kidney
- filter blood and remove waste products from blood
- contain cluster of capillaries called glomerulus
121
Q
glomerulus
A
- filters water, electrolytes, glucose, amino acids, urea, uric acid, and creatine
- large proteins and blood cells should not be filtered and indicate injury to nephrons
- a cluster of capillaries in each nephron
- filtrate and return 99% of plasma components back into vasculature
122
Q
endocrine function of the kidney
A
- BP control
- erythropoietin
- synthesis of vitamin D
123
Q
renin
A
- causes vasoconstriction when released from juxtaglomerular cells
- play a role in BP control in kidneys
- RAAS system
124
Q
prostaglandin E2 and prostacyclin
A
- secretion causes vasodilation
- play a role in BP control in kidneys
125
Q
erythropoietin
A
- stimulates RBC production and maturation in the bone marrow
126
Q
PTH
A
- regulate calcium and phosphate levels
127
Q
bladder
A
- bladder wall stretching of the detrusor muscle sends sensory message to sacral spinal cord of the need to micturate/void/urinate
- bladder contracts during urination and urinary sphincters relax during urination
- contraction of bladder closes off ureter openings and opens urethral sphincters
128
Q
internal sphincter
A
- at the top of the urethra
- made up of smooth muscle under involuntary control by brain
129
Q
external sphincter
A
- at the end of urethra
- skeletal muscle under voluntary control
130
Q
factors influencing urination
A
- growth and development, sociocultural factors, psychiological factors, personal habits, fluid intake and output, surgical procedures, medications, diagnostic examinations, muscle tone
131
Q
conditions of the lower urinary tract
A
- urethral narrowing, altered innervation of bladder, weakened pelvic or perineal muscles (females - pregnancy related)
132
Q
diabetes mellitus/neuromuscular disease affect on elimination
A
- decrease bladder tone, reduce sensation of fullness, or inability to control bladder
133
Q
benign prostatic hyperplasia
A
- enlarged prostate (obstruction)
- can cause urinary retention, incontinence
134
Q
urinary retention problem
A
- unable to fully empty bladder (often from BPH)
135
Q
post-void residual (PVR)
A
- bladder scan to measure urine left in bladder after voiding
136
Q
urinary tract infection
A
- upper (kidneys) or lower (bladder, urethra)
- symptoms: dysruria, hematuria, cystis: urgency, frequnecy, incontinence, foul odor, fever, chills, flank pain, delerium in older adults
137
Q
urinary stress incontinence
A
- coughing, sneezing, laughing, physical activity causes leakage
138
Q
urinary urge incontinence
A
- a strong need or urge to urinate causing leakage
139
Q
urinary reflex incontinence
A
- urine leakage due to nerve damage-
140
Q
urinary overflow incontinence
A
- incomplete bladder emptying, causing bladder to overfill when full, leads to leakage
141
Q
urinary functional incontinence
A
- physical inability to reach the toliet in time
142
Q
nocturia
A
- voiding at night
143
Q
urgency
A
- sudden strong desire to void
144
Q
dysuria
A
- painful or difficult voiding
145
Q
urinary hesitancy
A
- delay in initiating voiding
146
Q
neurogenic bladder
A
- nerve pathway not intact, doesn’t sense fullness, or control sphincters
147
Q
hematuria
A
- blood in the urine
148
Q
polyuria (diuresis)
A
- production of abnormally large amounts of urine
149
Q
polydipsia
A
- extreme thirst
- associated with polyuria
150
Q
anuria
A
- absense of urine production
151
Q
oliguria
A
- decreased urine output
- may signal impeding renal failure
- less than 30 mL an hour is a cause for concern
152
Q
skin and mucous membrane assessment
A
- pink, warm, dry, intact, smooth, look for breakdown suggesting incontinence or poor hygiene, turgor (no tenting)
153
Q
kidneys assessment
A
- place hand on posterior flank and other hand on abdomen and gently squeeze
154
Q
bladder assessment
A
- if full, felt above symphis pubic (bladder scan: ultrasound)
155
Q
urethral meatus assessment
A
- pink, small slit-like opening
- observe redness, lesions
156
Q
urinalysis (UA)
A
- pH, protein, glucose, ketones, blood, specifc gravity, WBC, bacteria
- specific gravity 1.005-1.030 (low: diluted, high: dehydrated)
157
Q
culture and sensitivty urine testing
A
- cleanse and mid-catch
- to indentify infective agents and appropriate antibiotics
158
Q
ultrasound
A
- need full bladder
- scan also after voiding to check for residual urine before catheterization
159
Q
xray Intravenous pyelogram
A
- use contrast dye
- assess for allergies including shellfish and iodine
- usually NPO and requires bowel prep to clean out and be able to see urinary tract, abnormalities, calculi, tumors, cysts
- encourage fluids after
- delayed reaction is possible
- facial flushing normal with dye
160
Q
computerized tomography (CT) of abdomen and pelvis
A
- cross-sectional images to assess for tumors or obstruction
161
Q
cystoscopy
A
- invasive endoscopy of bladder with lighted tube
- may be NPO
- blood in urine after test for 1-2 days
162
Q
end stage renal disease
A
- irreversible damage
- initially uremic syndrome
- peritoneal dialysis
- hemodialysis
- organ transplantation
163
Q
uremic syndrome
A
- BUM and creatine (nitrogenic wastes) not filtered out
- fluid and electrolyte imbalance
- nausea and vomiting
- coma, convulsions, H/A
164
Q
peritoneal dialysis
A
- surgically inserted abdominal catheter into peritoneal cavity allows sterile electrolyte solution to be instilled and absorb waste products and excess fluids through osmosis, diffusion, and ultrafiltration
- warm fluid instilled, fluid dwells approx 4 hours, drains, and refills
- around 4 exchanges per day or overngiht cycling - sterile procedure
165
Q
hemodialysis
A
- artificial kidney circulates blood as elecrolyte fluid bathes it and removes waste and excess fluid by osmosis, diffusion, and ultrafiltration
- blood is removed and returned to circulation through gore-tex graft, arteriorenous fistula, or hemodialysis catheter
- usually 3 times a week, 4 hour treatments
- risk for infection, fluid overload (may need fluid restriction), electrolyte imbalances
166
Q
organ transplantation
A
- from living or cadaver donor with compatible blood and tissue type
- immunosuppresants for life to prevent rejection of donor kidney
167
Q
urinary diversion
A
- diversion of urine to an external source
- used if bladder is removed, injury to bladder, chronic UTI
- one or both ureters is connected to abdominal wall opening (stoma) or tube into renal pelvis
168
Q
nephrostomy
A
- urinary diversion via a tube into the kidney
169
Q
ureterostomy
A
- urinary diversion where ureters use piece of bowel with stoma
170
Q
suprapubic catheter
A
- a surgically created connection between the urinary bladder and the skin to drain urine from the bladder in individuals with obstruction or normal urinary flow
171
Q
crede method
A
- restorative care technique
- manual compression of bladder to help with emptying
172
Q
closed drainage systems
A
- free drainage by gravity
- urine flow should not be obstructed
173
Q
securement device
A
- females to inner thigh
- for males, insert catheter at 90 degree angle to straigten urethra and ease insertion, insert until bifurcation to ensure balloon is not inflating prostatic urethra, secure to upper thigh or lower abdomen
174
Q
catheter care
A
- every 8 hours or as needed
- sterile technique for insertion
175
Q
coude catheter
A
- curvature at end to maneuver through enlarged prostate
- requires special training for insertion
176
Q
purewick catheter for women
A
- gauze with suction tube connected to suction canister
- change every 8-12 hours
177
Q
GI tract
A
- hollow muscular organs lined with mucous membranes
- absorb fluid and nutrients, break down food, regulate fluid and electrolytes, make and store feces
178
Q
mouth
A
- mechanical (chews) and chemical (saliva)
179
Q
esophagus
A
- guarded by e. sphincter that prevents food reflux and air entrance
180
Q
peristalsis
A
- moves food
- cardiac sphincter at the end of esophagus and stomach entrance which stops stomach reflux
181
Q
stomach
A
- storage
- mix with digestive juices (HCl, mucus, pepsin, instrinsic factor) into chyme
- mucus protects stomach from acid
182
Q
small intestine
A
- duodenum (11 in), jejunum (8 ft), ileum (12 ft)
- most of digestion, tranfer of nutrients, water, fats, vitamins, minerals, and electrolytes into blood
- plant fiber not digested but travels to LI with water, Na, and Cl
183
Q
large intestine
A
- ascending, transverse, descending, sigmoid, rectum
- absorption, secretion, elimination
184
Q
ileocecal valve
A
- prevents between reflux between small and large intestines
185
Q
anus
A
- contains internal and external sphincters
- involuntary and voluntary control
- sensory nerves
186
Q
valsalva maneuver
A
- bearing down, contracting abdominal muscles to exert pressure with forcedexpiration against a closed airway
187
Q
impaction
A
- unrelieved constipation and unable to expel the hardened feces in rectum
- debilitated, confused, unconscious, dehydrated, weak/unaware,
- can see oozing of liquid stool, feces leaks from above impaction, anorexia
188
Q
hemmorrhoids
A
- veins in rectum dilated from straining pressure (internal or external)
- painful
- thrombosed (purple, hard - need surgery)
- increased pressure over time - constipation, pregnancy, CHF, chronic liver disease
- use ice pack, warm sitz bath, topical medications, surgery
189
Q
incontinence
A
- the inability to control passage of feces, gas, or urine from anus/urethra
- risk for skin breakdown
190
Q
flatulence
A
- gas accumulation within intestinal lumen
- mouth: belching
- anus: flatus
- abd fullness, pain, cramping, esp if slower peristalsis
- ambulation helps
191
Q
diarrhea
A
- faster peristalsis
increase in stool number - liquid, unformed stool
- can be caused by bacteria, virus, parsites, emotional distress, tube feedings, GI disorders
192
Q
hemoccult stool
A
- small smaple (FOBT: fecal occult blood test) guaiac - 3 samples
- no NSAIDS within 7 days of testing
- avoid vitamin C, fruits, fruit juices for 3 days
- don’t eat red meat 3 days within testing
- positive results require flexible sigmoidoscopy or colonoscopy
193
Q
endoscopy
A
- lighted fiberoptic tube to visualize esophagus, stomach, and small instestine (upper GI tract)
- can remove polyps for biopsy
- anesthetic to throat, some clear liquids are oaky
- NPO before and until gag reflex returns
194
Q
colonoscopy
A
- NPO
- bowel prep: tube in to visualize LI/colon
- remoce polyps for biopsy or find source of bleeding
195
Q
upper GI series (barium swallow) x ray
A
- NPO
- drinks barium-opque contract solution, clear liquids and laxative day before
- shows pharynx, esophagus, stomach
196
Q
lower GI series (barium enema) xray
A
- NPO
- barium into anal opening
- shows large intestine
197
Q
amylase and lipase
A
- serum blood tests for hepatitis, pancreatitis
- most accurate results after fasting
198
Q
abdominal xray
A
- obstruction or abnormality
- no prep
199
Q
colorectal transit study
A
- how food moves through the colon
- swallos capsule with radiopaque markers
- x ray on the 5th day
200
Q
CT scan
A
- cross-sectional views
- oral and IV sedation contract dye
- NPO 4-6 hours before (depends on if oral contract is used)
201
Q
MRI
A
- magnet and radio waves to see inside the body
- NPO 4-6 hours before
- no metal objects in patient
202
Q
acute care implementation
A
- safety and comfort
- privacy and modesty
- abdominal tightening exercises 4 times a day
- ambulation, activity to stimulate peristalsis
- low residue foods for diarrhea (white rice, potatoes, bread, bananas, cooked cereals - BRAT diet)
- skin: no rinse spray, barrier cream, assess skin around wafers of ostomies
203
Q
laxatives
A
- bulk forming, stool softeners
204
Q
suppositories
A
- may act more quickly than oral meds
- goal is soft, brown stool without pain or difficulty
205
Q
antidiarrheal agents
A
- slow motility and reabsorb fluid
206
Q
nasogastric tube
A
- measured before placement - from tip of nose to ear lobe to xyphoid process
- water-soluable lubricant used for insertion
207
Q
ostomies
A
- temporary or permanent opening (stoma) surgically created in abdominal wall to allow passage of fecal matter
208
Q
stoma
A
- should be pink or red, never purple or black
209
Q
colostomy
A
- piece of large intestine
- more formed stool from colon
210
Q
ileastomy
A
- piece of small intestine
- more liquid, diarrhea like stool from small instesting
- increase fluids (drink 8 oz for emptying of bag)
- avoid indigestible fiber (popcorn, pinapple, corn, chinese cabbage, raw mushrooms) - may be eaten in small amounts and must drink fluids with them
211
Q
fecal management system purpose
A
- to divert and contain liquid stool within a closed drainage system in order to minimize risk of exposure to moisture
- prevent skin breakdown, incontinence associated dermatitis
- protect surgical wounds and pressure ulcers from fecel contamination
212
Q
fecal management system nursing alert
A
- physician order required
- physician performs digital rectal exam
- must not remain for 29> days
- nothing inserted into anal canal while in use
213
Q
fecal management system constradictions for use
A
- pediatric patients, inadequate rectal tone, lower large bowel surgery within year, reactal/anal injury or disease, severe rectal or anal structures or stenosis, anal tumors, severe hemorrhoids, rectal mucosal impairment, fecal impaction, rectal trauma, paralysis, system atnicoagulation therapy
214
Q
enema
A
- instillation of fluid into rectum and sigmoid colon
- breaks up rectal mass, stretches rectal wall, initiates defecation reflex
215
Q
cleansing enema
A
- remove stool - bowel prep
- height of fluid bag for enema determines depth of cleaning
- types: hypotonic/tap water, soapsuds, normal saline, low volume hypertonic, oil-retention, medicated
216
Q
hypotonic (tap water) enema
A
- stimualtes bowel movements
- risk of water toxicity
217
Q
soapsuds enema
A
- irritant (soap) promotes bowel peristalsis
218
Q
normal saline enema
A
- safest due to equal osmotic pressure
- volume stimulates peristalsis
219
Q
low-volume hypertonic enema
A
- commercially prepared
- used for clients who can’t tolerate high-volume enemas
220
Q
oil-retention enema
A
lubricates rectum and colon for easier stool passage
221
Q
medicated enema
A
- such as with antibiotics to dwell in for 1-3 hours
222
Q
enema postioning
A
- sims (left side with right leg flexed
- lubricate tip of the tube
- insert tube 3-4 inches (adult) 2-3 inches (child)
- hold tube 12-18 inches above anus as fluid instills
