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All notes for test 4 - EXAMINATION PREPRATION NOTE FOR RESPIRATION DIGESTION
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All notes for test 4 - EXAMINATION PREPRATION NOTE FOR RESPIRATION DIGESTION
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Universal Hospital Orientation Post Test Nassau Suffolk Coordinating Council of Nursing Education and Practice
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lOMoARcPSD|13111427All notes for test 4 - EXAMINATION
PREPRATION NOTE FOR RESPIRATION
DIGESTION
nursing (Harvard University)
,
, lOMoARcPSD|13111427
MED SURG STUDY GUIDE: CH. 43-47, 20-24
NURSING CARE OF THE PATIENT WITH GI DYSFUNCTION
ORGANS OF THE DIGESTIVE SYSTEM
QUADRANTS OF ABD
Epigastric region is where the stomach is.
Hypogastric or suprapubic region is where the
bladder is located.
The digestive system starts at the mouth all the way down to your rear end where you get rid of your waste products. The GI tract
is 30 ft long. The majority of the distance is in the small intestine. Doing the absorption of the fluid, absorption of the nutrience,
and pushing on the waste products getting ready to expel them. The three big jobs of GI system—digestive (breakdown starts with
mouth), absorption, elimination of waste products.
ASSESSMENT OF GI SYSTEM
• Health History
o Pain, dyspepsia (indigestion), gas, N/V, diarrhea, constipation, fecal incontinence, jaundice, past health, family,
and social hx
• Physical Exam
o Oral Cavity
▪ Lips, Gums, Tongue
▪ What clues would these give me? Moisture (hydration—if dry, they may be dehydrated), lips cracked
goes along with dehydration, nutrient deficiencies. Missing teeth (effecting ability to chew and what
kind
of diet they need to be on).
o Abdomen
▪ Inspection, Auscultation, Palpation, Percussion (Always go in this order, percussion and palpation may
alter sounds)
◆ Inspection—contour—flat, round, distended, protrusion; any bulges
◆ Auscultation—listening to bowel sounds; active, hyper, or hypoactive.
◆ Palpitation—light palpation noting any tenderness; feeling for masses or bulges, is it soft. If
firm or board like abdomen stands out because there is excessive rigidity for a reason.
◆ Percussion—not done frequently; assesses the size and density of abdominal organs and to
detect the presence of air-filled, fluid-filled, or solid masses.
o Rectal
▪ Inspection of skin for breakdown or external hemorrhoids. Anything affecting them stooling.
ORAL/ESOPHAGEAL DISORDERS (pg.1266-1267)
• Lips
o Actinic Cheilitis: dry cracking of the lips where upper and lower lips come together.
o Herpes Simplex 1: cold sore/canker sore caused by the herpes virus and once you have it your carrier and you
will always have it. Stressful situations or something immunosuppressive it causes it to flare up. Aggravating and
painful for a 4 to 5 days and then it will go away.
• Mouth
o Leukoplakia: discoloration of inside of cheeks (whitish or whitish gray patch); precursor for oral cancer.
Primarily seen in patients who use nicotine products especially dip.
o Candidiasis: oral thrush; caused by yeast. When someone develops this its b/c they have been taking
antibiotics for something else. Kills off bad pathogen but also kills off good pathogen. Gives an opportunity for
the yeast to grow. Immunosuppressive; people going through high dose chemotherapy are at risk for thrush.
They use an antifungal on a daily basis to prevent it from occurring.
o Karposi’s sarcoma: oral cancer strongly related to HIV/AIDS. When they get the severe
immunosuppression going on, they don’t have the T cells to fight things off and things start flaring up.
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