The nurse observes that Joan’s abdomen is firm and distended. The nurse performs an abdominal assessment.
In what sequence should the nurse perform the abdominal assessment?
Inspection, Auscultation, Percussion, Palpation
Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.
Which assessment is most important for the nurse to perform?
Auscultate bowel sounds.
Based on subjective data by Joan (bloated and nauseated) and objective data by the nurse (abdomen firm and distended), the nurse’s first concern is that Joan may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds.
In assessing bowel sounds, it is most important for the nurse to perform which action?
Listen for up to 5 minutes when auscultating for bowel sounds.
Rationale: The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.
The nurse auscultates for Joan’s bowel sounds and hears faint gurgling sounds after 3 minutes.
How will the nurse record this finding?
Hypoactive bowel sounds.
Normally, bowel sounds are heard 5-35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive.
While the nurse is completing the assessment, Joan begins to cry and laments, “I just knew something would go wrong.”
How should the nurse respond?
“Tell me what is making you feel so upset?”
This open-ended statement encourages the client to express further concerns and fears.
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 client?
“It sounds as if you have had another experience that did not go well.”
The nurse’s response validates Joan’s feelings, which will encourage Joan to verbalize further.
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Joan responds, “I did everything my healthcare provider told me to do. The surgery must have failed. It was supposed to make my intestines work better!”
How should the nurse respond?
Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when desired surgical outcome is achieved.
Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis.
The nurse explains to Joan that she has developed constipation, probably as the result of a number of factors. Joan has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 ml.
The nurse explains risk factors that can contribute to constipation.
Which postoperative medication is most likely to contribute to constipation?
Morphine sulfate, an opioid analgesic.
The most common adverse effect of opioid analgesics is constipation.
What impact does this fluid intake have on Joan’s bowel patterns?
This inadequate fluid intake has contributed to her constipation.
An adult needs 1,400 to 2,000 ml of fluid daily to prevent hardening of the stool.
What other questions should the nurse ask Joan?
“How often do you get out of bed and walk?”
Immobility is a major risk factor for constipation.
The nurse revises Joan’s plan of care to include postoperative constipation.
Before establishing the diagnostic statement, the nurse needs to complete which task?
Determine which factor is causing the problem.
The cause of the problem should be determined since this is a component of the diagnostic statement.
The nurse determines that Joan’s inadequate fluid intake, decreased mobility, and opioid use are significant factors in the development of her constipation.
Which nursing diagnosis should the nurse include in Joan’s plan of care?
Constipation related to surgery and anesthesia.
This diagnostic statement uses the correct format and identifies both the problem and the etiology.
The nurse explains that the glycerin suppository will have a laxative effect.
How will the nurse explain to Joan the action of the laxative?
“Movement of the intestine will push the bowel contents out so you will have a bowel movement.”
Laxatives stimulate peristalsis so that the bowel contents can then be expelled.
The nurse explains to Joan that her healthcare provider has prescribed 2 medications: a one-time dose of glycerin (Fleets) rectal suppository and docusate sodium (Surfak) 100 mg PO daily.
The nurse administers the first dose of docusate sodium (Surfak).
This medication primarily alters which aspect of the client’s bowel movement?
Surfak is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.
Before administering the rectal suppository, it is most important for the nurse to perform which assessment?
Observe for the presence of rectal bleeding.
The administration of a rectal suppository is contraindicated in the presence of rectal bleeding, so this assessment is the most important.
When administering the rectal suppository, the nurse asks Joan to take several slow, deep breaths.
What is the rationale for this instruction?
Relax the anal sphincter and reduce discomfort.
Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.
The nurse documents the administration of the rectal suppository in the nurse’s notes.
Which notation is correct?
0900. One glycerin suppository administered per rectum for constipation, as prescribed.
This documentation correctly identifies the medication, the dose, the time, and the route of administration, as well as the reason for administering the medication.
Which statement provides the best documentation of the outcome from the suppository administration?
Client produced six 1/4 inch hard pellets of brown stool following suppository administration.
This documentation provides the most specific objective data related to the effectiveness of the suppository.
The next day, Joan has still not expelled additional feces.
To determine the presence of fecal impaction, the nurse prepares Joan for which prescribed procedure?
Digital rectal examination
Digital rectal examination is the procedure performed to assess for the presence of fecal impaction.
The UAP obtains sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy.
What action should the nurse implement?
Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed.
The task should not be delegated to the UAP because it is an invasive procedure that places the client at risk. The UAP can be assigned to assist the nurse with client positioning. Assisting in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use nonsterile gloves, which are less costly than sterile gloves, and lubricant for this procedure.
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.
Vagal nerve stimulation can cause a reflex slowing of the heart rate.
The nurse notifies the healthcare provider of the presence of a fecal impaction and receives a verbal prescription over the telephone for enema administration.
What action should the nurse take?
Administer the enema as prescribed and obtain the healthcare provider’s signature the next day.
A verbal prescription is legally permissible. The nurse should, however, take measures to ensure client safety because of verba; prescriptions can be a source of error.
When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the healthcare provider, who sounds angry and states, “Are you questioning my prescription?”
How should the nurse respond to the healthcare provider?
“I want to ensure that I transcribe this prescription correctly to avoid error.”
This assertive response teaches the healthcare provider the purpose of repeating back verbal prescriptions.
The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Joan begins to experience abdominal cramping.
What action(s) should the nurse take to relieve abdominal cramping?
Lower the enema bag.
Roll the clamp to stop enema until cramping subsides.
Lowering the enema bag will slow or stop the flow of fluid, which should reduce or stop the client’s abdominal cramping.
Rolling the clamp to stop the enema will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.
Joan has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Joan, the nurse receives a report from the UAP that another client is vomiting. The nurse tells Joan she will return as soon as she deals with the other client’s problem.
What task can the nurse delegate to the UAP?
Assist the client who vomited with mouth care and bathing after the nurse administers an antiemetic.
Hygiene and comfort care are both within the UAP’s scope of practice.
The nurse assesses the client who is vomiting and acts to alleviate this problem. She returns to Joan’s room. Joan is interested in the amount of fluid administered via the enema but does not understand “milliliters,” Joan received a total volume of 725 ml.
How will the nurse accurately explain the amount of fluid to Joan using household measurements?
The conversion factors needed are: 30 ml = 1 ounce, and 1 cup = 8 ounces. 725 ml/30 = 24 ounces/8 = 3 cups.
The nurse wants Joan to increase her daily oral fluid intake to 2 liters of fluid for the next few days.
The nurse advises Joan to drink a minimum of how many 8-ounce cups of fluid daily?
Eight to nine
One 8-ounce cup contains 240 ml (8 * 30 ml/ounce). Two liters = 2,000 ml. 2,000 ml/240 ml = 8.33 cups/day.
The remainder of Joan’s surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Joan eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity. She states that she really likes salads.
Which salad choice is best to promote bowel regularity?
Fresh fruit salad with apple and banana slices.
Fresh fruits are a good source of fiber, which is important for bowel regularity.
The nurse uses the hospital breakfast menu as a teaching tool.
Which breakfast selection by Joan indicates that she understands teaching about dietary measures to promote bowel regularity?
Oatmeal with raisins, and orange juice.
Whole-grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.
Joan expresses her thanks to the nurse and states she feels confident in her ability to manage her diet, fluid intake, and activity when she is discharged to ensure regular bowel patterns.