Nursing Assessment: GI System (Test 2) Flashcards
What is part of ingestion and propulsion of food?
Mouth, pharynx, esophagus
What is responsible for only digestion?
Mouth
What does the mouth consist of?
Teeth, saliva/enzymes, mucosal layers, esophagus, lower esophageal sphincter
What is responsible for both digestion and absorption?
Stomach
What does the stomach consist of?
Mucosal layers, hydrochloric acid, enzymes, pyloric sphincter
What is one of the side effects of chemo r/t GI system?
Sore mouth
What can you use to help mouth soreness?
Give them magic mouthwash, it has Lidocaine, Malox, etc. in it
Why are mucous membranes so important?
The entire GI system is lined with it and in order for the whole system to function we have to keep it healthy
What helps with peristalsis?
Stomach and small intestines
What is responsible for the absorption of nutrients?
Small intestine
What does the small intestine consist of?
Mucosal layers, duodenum, Jejunum, ileum, and villi
What is responsible for elimination?
Large intestine
What does the large intestine consist of?
Ascending colon, transverse colon, descending colon, rectum, anus
What else is part of the GI system besides mouth, stomach, small intestine, large intestine?
Liver, biliary tract, pancreas
What are general effects of aging on the GI system?
Muscles weaken, decreased function- effect on valves, sphincters, and wall of colon; decreased production and secretion of enzymes- effect on digestive process
What does the large intestine do besides elimination?
It absorbs water and is part of the immune system
What do you need to ask when you find out a patient has a colostomy?
Where it is, know that it affects self concept and image and body integrity, and ask how it affects them
How old should a child be before having nuts?
2, because of potential allergies
How old should a child be before they have dairy?
1
When assessing indigestion what should you ask?
What they have for lunch, how much they eat, do you ever have lunch without indigestion?, etc.
What can sclerosis be caused by?
Chemicals or overuse of alcohol
What parts of the GI system are affected by aging?
Mouth, esophagus, abdominal wall (all muscle basically), stomach (*ulcers), small intestines, liver, large intestine, anus, rectum
What is subjective data needed for assessment of GI system?
Important health info: past health history, meds, surgery or other treatments
Study the…
GFHP’s on younger and older adults about the GI system!!! :)
What is the objective data needed for assessment of GI system?
Physical exam: mouth, abdomen, rectum and anus
How long is the newborn “period?”
4 weeks old
To help keep infants to keep food down what should you assess?
How they feed their baby, like burping, etc.
How do you assess the abdomen?
First look, then listen, then start at RLQ because that’s where the colon starts
What are types of GI radiologic studies?
Upper GI Series (barium swallow), lower GI Series (barium enema), abdominal ultrasound, virtual colonoscopy
Are barium swallows and enemas common?
No
What is your job in preparing the patient for a barium swallow?
You need to teach them what’s going to happen
What is the most important follow up care for the barium swallow?
Increase fluids to get rid of barium and they may need a laxative because it becomes concrete eventually
What part of the barium swallow and enema is radioactive?
The barium
What is the purpose of the barium enema?
An effort to see the colon through the X-ray, the follow up is the same as swallow, esp. with laxative
What is the most popular diagnostic study of the GI system?
Endoscopy
What can the endoscope be used for?
EsophaGastroDuodenoscopy (EGD), sigmoidoscopy, colonoscopy
What does ERCP stand for?
Endoscopic retrograde cholangio-pancreatography
What does the ERCP look at?
Gallbladder and pancreas
What is the other type of endoscopy besides the endoscope and ERCP?
Capsule endoscopy
What is the capsule for the capsule endoscopy? What’s the nurse’s job?
A tiny camera is in it and the nurse’s job is to recover the camera
What is the prep for the EGD?
Maybe a few hours of NPO and help explain, they may put anesthesia on throat
How do you prevent elders from losing potassium?
Go lightly
The nurse observes that Mrs. Creighton's abdomen is firm and distended. WHat assessment is most important for the nurse to perform? A. Auscultate bowel sounds B. Measure abdominal girth C. Observe incisional staples D. Measure BP
A is correct. Her girth has nothing to do with anything at this point, staples aren’t main source of pain, and you’re probably already getting vitals
The nurse auscultates for Joan's bowel sounds and hears faint gurgling sounds after three minutes. How will the nurse record this finding? A. Hypoactive bowel sounds B. Normal bowel sounds C. Paralytic ileus D. Reduced peristalsis
A is correct.
In assessing bowel sounds, it is most important for the nurse to perform which action?
A. Ask the client what she had her last BM
B. Listen for up to 5 minutes when auscultating for bowel sounds
C. Perform a rectal exam
D. Place client in knee-chest position to expel excess gas prior to auscultation
B is correct.
While the nurse is completing the assessment, Joan begins to cry and laments, “I just knew something would go wrong.” What is the best response by the nurse?
A. This is a minor problem. We’ll have you better very soon.
B. You have to expect that problems will occur after surgery.
C. Tell me what is making you feel so upset.
D. Why are you letting this upset you?
C is correct.
Joan tells the nurse that she hates hospitals because she says “Nobody ever tells you what’s happening, and you end up with all these things going wrong.” Which response by the nurse will encourage continued verbalization by the patient?
A. All the nurses are very busy here, and they are doing the best job they can.
B. You should write down your questions so you can get some answers.
C. I will be happy to tell you everything that’s happening, so nothing else will go wrong.
D. It sounds as if you have had another experience that did not go well.
D is correct.
Joan responds, “I did everything my HCP told me to do. The surgery must have failed. It was supposed to make my intestines work better! How should the nurse respond?
A. Refer the client to the surgeon to answer any questions about the surgical outcome.
B. Advise the client that an incarcerated hernia is repaired to improve peristalsis so an error must have occurred during the surgery.
C. Offer the client emotional support as she copes with this adverse outcome of surgery.
D. Explain the the client the multiple factors that can decrease peristalsis postop, even when the desired surgical outcome is achieved.
D is correct. It is not C because it is a normal effect of surgery.
Read the rest…
Of the quizzes on PP!!! :)
What postop med is most likely to contribute to constipation?
Morphine sulfate, an opioid analgesic
While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?
Decreased pulse rate
Does a stool softener stimulate movement?
No
Should a stool softener cause abdominal cramping?
No because it is inserted rectally
What are hemorrhoids?
Blood vessels all stretch out because of pressure r/t pregnancy, varicose veins, strain
What are hemorrhoids like?
Just like varicose veins in the rectum
Do you need sterile gloves for a rectal examination?
No, just gloves to protect you
What do we use D5O IVs for?
To bring diabetic’s sugar up and it pulls potassium out of the circulating system
When does the gut form in the neonate?
???
When can we detect GI activity of the embryo?
???
Is everything in the same spot of a child as an adult?
???
When would you try to assess the pediatric abdomen?
???
When is swallowing voluntary?
6 weeks
How much saliva do infants have?
Minimal
How does the stomach lie in infant’s abdomen?
Stomach lies transversely and is horizontal
Infants and children…
Have less stomach capacity
What are gastric secretions like in an infant compared to older children and adults?
Less acidic
How is hydrochloric acid concentration until school age?
Low concentration
Human milk has properties that…?
Partially compensate for decreased digestive function and optimize nutrition
What can milk or formula do to gastric secretions?
Increase alkalinity of them
What part of the stomach in a baby is different? How does that affect them?
Cardiac sphincter is relaxed at birth, allowing mild, occasional regurgitation of stomach contents
What does a baby’s diarrhea look like?
A little solid with a water ring around it
What are infants at risk for?
High risk for dehydration
Common illnesses for babies?
Ears or upper respiratory infections
Why is giving a baby a bottle when their ears are hurting and laying them to sleep a bad idea?
The milk may migrate to the Eustachian tubes and make the infection worse
What is hydrocephalus?
Spinal fluid gets caught in the head
How long is head circumference measured for? Why?
Until 18 months to 2 years for hydrocephalus
What “arrest” type is more common in babies?
Respiratory more than cardiac
What to know about peristaltic waves in infants?
They may reverse and cause regurgitation and vomiting
Is peristalsis faster or slower for infants compared to adults?
Tends to be faster, with food remaining in the stomach for a shorter period
What conditions can increase the rate of propulsion and peristalsis?
Fever and diarrhea
What enzymes do infants have a deficiency of?
Amylase, lipase, and trypsin
When are sufficient quantities of enzymes present to aid digestion?
Not until 4 to 6 months
What kind of function is immature in the first year?
Liver function
What are things to assess for a pediatric’s GI tract?
History, vomiting episodes?, diarrhea?, daily weights, vital signs, intake and output, skin integrity, urine specific gravity, episodes of apnea or respiratory distress?, pain?, bowel sounds, abdominal circumference, calorie count, electrolyte status, hydration status
If an infant has vomiting episodes, what should you know about them?
Amount, color, and consistency of emesis
If an infant is having diarrhea, what should you know about it?
Frequency, amount, color, and consistency of stools
What should you do with an infant’s daily weights?
Plot progress on growth chart
When taking an infant’s vital signs, what should you add on top of normal vitals?
Quality of respirations
When assessing skin integrity of infants, what areas are really important?
Perianal and rectal areas
What diagnostic tests may be used for infants?
CBC, erythrocyte sedimentation rate, electrolytes, liver enzymes, absorption tests, stool reducing substances, pH, fat, trypsin, occult blood, stool culture, ova and parasites, upper GI tract, colonoscopy, small bowel follow through, barium enema, gastric emptying, pH probe
Are those diagnostic tests for infants listed common?
Not unless there are indicators they are sick
What is a standard tests for infants?
PKU for Phenylketonuria
What is PKU?
Excretions of ketones, etc., that say baby can’t digest protein
What is testing/treatment for PKU?
They test for it by taking blood out of feet, and they can just manage it
