NUR 170 Exam 4 Copy- Galen College of Nursing
Exam 4 Review Unit 8 – Gastrointestinal Chapter 52 1. What is intrinsic factor? (1086) a. Smooth muscle
... [Show More] cells that line the stomach are responsible t o gastric motility. Parietal cells produce intrinsic factor, a substance that aids in the absorption of vitamin B12. Absence of this causes pernicious anemia. 2. Why is abdominal assessment done in the specific order: look, listen, feel? (1089) a. So that palpation and percussion do not increase intestinal activity and bowel sounds. 3. What should a nurse do if they observe a pulsating mass or hear a bruit during assessment? (1090) a. Priority Assessment i. If a bulging, pulsating mass is present during assessment of the abdomen, do not touch the area because the patient may have an abdominal aortic aneurism, a life-threatening problem. Notify the HCP of this problem immediately!! Peristaltic movements are rarely seen unless the patient is thin and has increased peristalsis. If these movements are observed, note the quadrant of origin and direction of peristaltic flow. Report this finding to the HCP because it may indicate an intestinal obstruction. b. If a bruit is heard over the aorta, that usually indicates the presence of an aneurysm. If this sound is heard, do not percuss or palpate the abdomen. Notify the HCP of your findings! 4. What important assessment has to be done after an EGD? (1093-1094) a. Visual examination of the esophagus, stomach and duodenum. b. Before the procedure: i. Remain NPO 6-8 hours before ii. Avoid taking anticoagulants, aspirin, or other NSAIDS for days before the test unless absolutely necessary. iii. Remove dentures c. During: i. HOB elevated ii. Nurse monitors respirations for rate and depth and the oxygen saturation level via pulse oximeter. If the patient’s respiratory rate is below 10 breaths per minute or the exhaled carbon dioxide level falls below 20%, the nurse typically uses a stimulus such as a sternal rub to encourage deeper and faster respirations. d. After the test: i. Check vitals (every 30 minutes) ii. Raise bed side rails iii. Pt. remains NPO until the gag reflex returns (30-60 minutes) iv. Pt. will need someone to drive them home. Instruct them not to drive for 12-18 hours v. Hoarse voice or sore throat is normal and may last for several days vi. Bruising around the eyes is common (resolves in a week) vii. Priority Assessment 2 1. The priority for care to promote safety after esophagogastroduodenoscopy is to prevent aspiration. Do not offer fluid of foods by mouth until you are sure the gag reflex is intact! Monitor for signs of perforation, such as pain, bleeding, or fever. 5. What post-procedure teaching is needed after a ERCP? (1094-1095) a. Includes visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and location of obstruction. b. After: i. Assess vitals every 15 minutes, until stable ii. Same teaching as EGD iii. Priority Assessment 1. Teach the patient and family to monitor for severe post procedure complications at home, including cholangitis (gallbladder inflammation), bleeding, perforation, sepsis, and pancreatitis. The patient has severe pain if any of these complications occur. Fever is present in sepsis. These problems do not occur immediately after the procedure; they may take several hours to 2 days to develop. [Show Less]