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FONDATION OF NURSING
exam 2 CHAP. 38
| Question | Answer |
|---|---|
| BOWEL ELIMINATION | IBS=LOOSE APPETITE constipation, diarrhea, or both. The symptoms may be brought on by diet, stress, depression, or anxiety. |
| Peristalsis PARASYMPATHATIC=LISTEN TO BOWEL SOUND | is under control of the nervous system.•Contractions occur every 3 to 12 minutes. LISTEN 12 MINS, B4 CHARTTING NO BOWEL SOUND. BETTER SAY DIMINISH BOWEL SOUND |
| STOMACH | is a hollow, J-shaped . stores food during eating, secretes digestive fluids, churns food to aid in digestion, and pushes the partially digested food, called chyme. The pyloric sphincter,regulates the size of the opening at the end of the stomach, MOVE c |
| SMALL INTESTINE | The small intestine is about 20 ft (6 m) long and about 1 in (2.2 cm) wide. digestion of food and absorption of nutrients into the bloodstream. |
| LARGE INSTESTINE (FECES IN STIMOID-EMPTY IN RECTUM-OUT ABNORMAL DISTENDED VEINS=HEMORROIDS) | ABSORP H20 -FORMATION & EXPULSION OF FECES BACTERION IN LG IN MAKE VIT K, B COMPLEX-VIT CHYME 1500ML IN LARGE.INTS TKE 800-1000ML DAILY LESS ABSORP=LOOSE STOOL STOOL REMAIN LONG IN L.INS=TOO MUCH H20 ABSORBED=STOOL DRY AND HARD |
| Developmental considerations DIETARY IMPACT | BREASTFED-LOOSE-NO ODOR-SOFT STOOL-GOLDEN BREASTMILK=GET NUTRIENT 4 DGSTN TODDLER-SICK COULD REGRESS= BACK ON TRACT AT HOME ELDER=PRONE TO CONSTIPATION-RECTAL RECEPTOR DECREASE RESPONSE TO STRETCHING=DONT FEEL HAVE STOOL=SIT THERE=DRY HARD |
| SLOWING OF GI MOTILITY W/ INCREASED STOMACH EMPTYING. ENCOURAGE FIBER 25-30 , H20 2,3000ML QD DECREASE MUSCLE TONE, WEAK OF INST. WALL W/ RISK OF DIVERTICULIS | NOT IGNORE URGE, REGULAR EXERCISE, PROVIDE EASY ACCESS TO RESTROOM-DISCOURAGE HEAVY ACTIVITIES AFTER EATING |
| FECAL NCONTINENCE? (involuntary or inappropriate passing of stool or flatus) | FECAL IMPACTATION? prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum |
| DAILY PATTERNS | FREQUENCY, TIMING, CONSIDERATIONS, POSITION AND PLACE. CHANGE IN THE ROUTINE =CONSTIPATION PRIVATE AFFAIRE IN COMFORT OF OWN BATHROOM |
| FOOD W/ LAXATIVE EFFECTS=prunes bran, chocolate, spicy foods, alcohol, coffee GAS=onions, cabbage, beans, cauliflower | TOLARATE FOOD BASED ON CULTURE. LACTOSE INTOLARANCELACK OF LACTASE ENZYME (GAS AND DIARRHEA) |
| CONSTIPATING FOOD=: processed cheese, lean meat, eggs, pasta, rice, white bread, iron and calcium supplemeNts | |
| ACTIVITY AND MUSCLE TONE | REGULAR EXERCISE IMPROVE GI MOTILITY AND MUSCLE TONE AND INACTIVTY DECREASE. PROLONG BEDREST, DECREASE MOTILITY=CONSTIPATION |
| LIFSTYLE | SOCIAL CULTURE INFLUENCES MAY RESULT IN A PERSON'S ACCEPTANCE OF BOWL ELIMTN AS A NORMAL LIFE PROCESS PREOCUPATION WITH BOWEL ELIMINATION FEELING THAT BOWEL ELIMNATION S A DIRTY PROCESS PROCESS OR RITUAL PRACTICES |
| MEDICATIONS? ALTER ELIMINATION PATTERNS NORMAL POO BROWN, BRIGH RED-LOW GI BLEED FROM RECTUM VEINS YELLOW-CELIAC DISEASE-BULKY GREASY-FOUL-SMELL | ANTIBIOTICS=STOOL LOOSE LIGHT, CLEAR=LIVER OR BOWEL DUCK IRON=DARK ; HIGH GI BLDG GREEN= FOOD POISONG , DYE, LEAFY, DIARRHEA YELLOW POO=MALASORPTION, EX FAT CYSTIC FIBROSIS BARRIUM CONSTRAST DX=NASTY, CHUNKY, WHITE, RESDISH(LET PT DRINK LOTS OF H20) |
| PARALYC ILIEUS | PATIENT TAKING PAIN MEDS(OPIOID) FOR WOUND=CONSTIPATION =COMPLET SHUT DOWN OF BOWEL(PERISTALISIS MOVEMENT) CARE PLAN ON OLDER PT RETURN FROM SURGERY ON CONSTIPATION OR RISK OF ... VASOVAGAL RESPONSE DUE 2 STRAINING WHILE POOPING |
| PHYSIOLOGICAL VARIABLES | STRESS COULD LEAD TO ANXIETY, DECREASE OR INCREASE GI MOTILITY. FIGHT-FLIGHT RESPONSE SHUNT BLOOD AWAY FROM GI, TO SKELETAL MUSCLE=SLOW GI MOTILITY CHRONICALLY WORRYING-HOLDING ON PROBGLEMS-NEGATIVE FEELING= FREQUENT CONSTIPATION |
| PATHOLOGIC CONDITIONS | DIESEASE CAN AFFECT ELIMINATION PATTERN |
| STOOL COLLECTION FECAL OCCULT-HIDDEN-BLOOD DO IT 3 TIMES ON 3 DIFFERENT STOOL(3 SAMPLES) | MEDICAL ASEPTIVE IS IMPERATIVE URINATE FIRST, DONT DROP TISSUE ON POO GET SAMPLE FROM INSIDE-HIDDEN BLOOD IN STOOL RUB SAMPLE ON CARD-CARD WIL CHANGE COLOR TO LET YOU KNOW IF THERE IS BLOOD SCREEN FOR IBS, GI BLEEDING, ULCER DISEASE |
| UPER GI BLEEDING ULCER due to a reaction between hemoglobin and gastric acid=BLACK | LOWER GI BLEEDING= from hemorrhoids or a polyp, may produce bright-red blood in the stool |
| PROMOTE REGULAR BOWEL MOVEMENT inactivity can lead to constipation, distention, and impaction. IDENTIFY PT THAT AT HIGHER RISK FOR CONSTIPATION'IMMOBILITY=ION=OPIOID | REGULAR PATTERN=TIME 1 QD W/O PAIN POSITIONNG=SQUAT ON TOILET BOWL PRIVACY=RESPECT PT NEEDS TO BE ALONE NUTRITION=FIBER LOTS OF H20 2,000 to 3,000 mL and high-fiber intake EXERCISE-MPROVE GI MOTILITY AND AIDS DEFECATION |
| BEDPAN | head of the bed elevated to as close to a sitting position as possible, at least 30 degrees, unless this is contraindicated |
| ABDOMINA SETTING | patient, lying in a supine position, tightens and holds the abdominal muscles FOR 6 seconds and then relaxes them. Repeat several times each waking hour. |
| THIGHT STRENGTHENING | thigh muscles are flexed and contracted by slowly bringing the knees up to the chest one at a time and then lowering them to the bed. Several times for each knee each waking hour. |
| DIARRHEA? | FOOD POISONING REFRIGERATE COLD FOOD ASAP WASH HAND SEPARATE CUTTING BOARDS(VEGETABLES+MEAT) NO WASHING MEAT |
| TREATMENT OF DIARRHEA | Remove the cause of diarrhea whenever possible (e.g., medication or food poisoning) FIBER+H2O Affects youngest (dehydration, lost of electrolyte, K =CARDIAC) &oldest more Answer call bells immediately. Give special care to the region around the anus |
| EMPTYING COLON | ENEMA=CLEANSING= RELIEVE CONSTIPATION QUICKLY CRAMPS=COLD SOLUTION W/ FAST FLOW RATE RETENSION= RETAINED FOR 15 /30MINS I.E OIL-RETENTION SIMS=TURN ON LEFT SIDE GI TRACT BOWLS |
| BOWEL INCONTINENCE=INABILITY TO CONTROL ANAL SPHINCTER=CHANGE IN RECTUM=AGE, NEUROLOGIC DISEASE AND CHILDBIRTH | DIGITAL =INSERTED LUBRICATED FINGER TO BREAK HARD MASS GENTLY. NAUSEA-VOMITG,DIZZY=VAGUS NERVE STIMULATED PT HAS LITTLE STOOL ON CLOTHES, NOT REAL POO, CHECK AND DO DIGITAL HBP HIGH, DIAPHORITIC =CONSTIPATED=DIGITAL REMOVAL. NO ODOR TO DO IT |
| BOWEL TRAINING PROGRAM= PPL WITH CONSTANT CONSTIPATION | MANIPULATE FACTORS W/IN PT CONTROL =FOOD, FLUID INTAKE INTAKE, EXERCISE=PRODUCE REGULAR SOFT BOWEL MOVEMENT AT REGULAR INTERVAL |
| NG TUBE=FEED PT, GASTIC SECRETIONS DECOMPRESS ABDOMEN- MAKE GI TRACT TO REST B4 SURGERY LAVAGE GI TRACT FROM POISON W/ SALINE DRAW NEEDED DOSE CLAMP SUCTION INSERT TIP IN PORT HOLD END NG TUBEOVE IRRIGATION TRAY OR EMESIS BASIN OBSERVE RETRN FLOW | ABUSING LAXATIVES=REBOUND CONSTIPATION STIMULATING MUSCLE TOO MUCH= WON'T FUNCTION ANYMORE I.E COLACE=STOOL SOFTNER |
| OSTOMY=OPENING FROM INSIDE ORGAN TO OUTSIDE STOMA=EXIT , OPENING OF OSTOMY=LIVE TSSUE=PINK PALE=ANEMIA SOULD EAT DARK GREEN=CHLOROPHYL=DEODORIZE FECES STOMA STICKING OU, WAIT 30MNS, AND CALL MD | ILEOSTOMY=FROM SMALL INTESTIN(DIGESTION AND ABSORBTION)=LIQUID PROLONGE EXPOSED=BREAKDOWN SKIN - COLOSTOMY=LARGE INTESTING=SOLID STOOL FIRST PLACE IMMATURE TAKE 6-8 WEEKS TO MATURE, SHRINK=NOT TOO THIGHT=SUFFOCATE TOO LOOSE=LEAK OUT SKIN=BREAKDOWN |
| INTAKE /OUTPUT AVOID ALCOHOL, ONIONS, EGGS=GAS HIGH IN FIBER, BEANS, (BANANA GOOD) | IPAA-ILEAL-POUCH-ANAL-ANASTOMOSIS=INCONTINENCE |
| SEQUENCE OF ABDOMINAL ASSESSMENT? | INSPECTION + AUSCULTATION DONE B4, TO AVOID DISRUPTING SOUND OF PERISTALISIS AND BOWEL MOTILITY PERCUSSION + PALPITATION DONE BY ADVANE PRACTICE PROFESSONAL |
| DECREASED O ABSENT BOWEL SOUNDS=LISTENED TO 5MINS ABSENCE MOTILITY=PERITONITIS,PARALYTIC ILEUS, PROLONGED IMMOBILITY | HYPERACTIVE BOWEL SOUNDS = INCREASED BOWEL MOTILITY=DIARRHEA, GASTROENRRITIS, EARLY BOWEL OBSTRUCTION |
| CONSTIPATION FOOD= PASTA, CHEESE, LEAN MEAT, EGGS LAXATIVES=FRUITS, VEGGY, CHOCOLATE,ALCOHOL AND COFFE GAS=ONION, CABBAGE, BEANS AND CAULIFLOWER |
Created by:
Seka_nurse
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