A nurse is caring for a 58-year-old female client who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian cancer 2 days ago. The client reports severe abdominal pain rated 8/10, nausea, and has not had a bowel movement since surgery. Which nursing intervention should the nurse implement first?
The client appears uncomfortable, frequently changes positions, and states "I feel like my stomach is going to explode." Bowel sounds are absent on auscultation, and the abdomen is distended and firm to palpation.
1Administer the prescribed opioid analgesic for pain management
2Insert a nasogastric tube to decompress the stomach
3Notify the physician immediately about the client's condition✓ 정답
4Encourage the client to ambulate to stimulate bowel function
해설
Severe pain, absent bowel sounds, and distension suggest paralytic ileus or obstruction, requiring immediate physician notification. Other interventions are secondary until medical evaluation.
Clinical Presentation and Pathophysiology The client’s report of severe abdominal pain (8/10), nausea, absent bowel sounds, and a distended, firm abdomen two days after extensive gynecological surgery strongly suggests postoperative ileus (POI). POI is a temporary impairment of gastrointestinal motility, a common complication following abdominal surgery. In this case, the absence of bowel sounds indicates a complete lack of peristalsis, and the client’s sensation that her "stomach is going to explode" reflects progressive abdominal distension from accumulating gas and fluid. This condition can lead to serious complications such as vomiting with risk of aspiration, fluid and electrolyte imbalances, and increased pressure on the surgical wound. The underlying pathophysiology involves a complex neurogenic and inflammatory response triggered by surgical manipulation of the bowel, which inhibits coordinated smooth muscle contraction [1,3].
Priority Intervention and Clinical Reasoning The nurse’s first action must be to notify the physician immediately (Option 3). This is a critical change in the client’s condition that requires urgent medical evaluation and orders. The assessment findings of a firm, distended abdomen with absent bowel sounds are hallmark signs of a paralytic ileus, which can mimic or precede a mechanical obstruction or perforation. Delaying notification could lead to clinical deterioration. While a nasogastric (NG) tube for decompression (Option 2) is often the definitive treatment for POI, this is an invasive procedure that requires a physician’s order. The nurse cannot independently insert an NG tube without a prescription. Administering an opioid analgesic (Option 1) is contraindicated as a first-line action because opioids slow gastrointestinal motility further, potentially worsening the ileus, even though the client is in significant pain. Encouraging ambulation (Option 4) is a helpful preventive and supportive measure for resolving mild POI, but it is not appropriate as the initial intervention for a client with a rigid, silent abdomen and severe distress, as it does not address the immediate risk of complications from severe distension [2,3].
Risk Factors and Evidence-Based Context This client possesses multiple risk factors that make POI a predictable, yet serious, postoperative event. A systematic review and meta-analysis confirms that the prevalence of POI is significant after major abdominal cancer surgeries [3]. Furthermore, research specifically on gynecological oncology patients identifies radical surgery for endometrial cancer as a primary treatment with a known association with postoperative paralytic ileus . The study on influencing factors for POI after radical endometrial cancer surgery found that a history of prior abdominal surgery is a significant risk factor . Although the client’s surgical history is not detailed here, the extensive nature of a total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian cancer involves significant peritoneal manipulation and dissection, directly contributing to the inflammatory cascade that causes POI [1,2]. The nurse’s recognition of these high-risk factors should heighten the index of suspicion for POI, making the constellation of symptoms an expected, but emergent, finding that requires prompt escalation. The goal of early notification is to facilitate rapid decompression and supportive care, as studies investigating therapies like medium-frequency pulsed electrotherapy aim to shorten the duration of this exact complication .
References (research sources)
[3]
Prevalence and risk factors for postoperative ileus in colorectal cancer patients: a systematic review and meta-analysis.Meta-analysis/systematic reviewGuo D, Peng S, An W, Yu J, Chu X. (2025) · DOI: 10.3389/fonc.2025.1742152
Clinical Practice Guide
Assessment of Postoperative Ileus
Key Findings: Absent bowel sounds, firm and distended abdomen, nausea, absence of flatus or stool, and patient report of severe pain or a sensation of "exploding."
Timing: Typically occurs within 24-72 hours after abdominal surgery.
Differentiation: Distinguish from mechanical obstruction (which may have high-pitched, hyperactive sounds early) by the complete absence of bowel sounds on auscultation.
Priority Nursing Actions
Immediate Notification: Report the critical assessment cluster (distension, absent sounds, pain) to the physician or advanced practice provider immediately to obtain urgent orders.
Withhold Oral Intake: Maintain NPO status to prevent further gastric distension and reduce aspiration risk.
Prepare for Orders: Anticipate orders for nasogastric tube insertion, IV fluid resuscitation, electrolyte monitoring, and possible imaging such as an abdominal x-ray or CT scan.
Safety Alert
Do not administer opioids or prokinetic agents without a provider order in suspected ileus. Opioids can further suppress peristalsis. Ambulation or early feeding protocols are contraindicated until peristalsis returns and a mechanical obstruction is ruled out.
Postoperative Ileus — A temporary impairment of gastrointestinal motility occurring after abdominal surgery, characterized by absent bowel sounds, abdominal distension, and nausea, caused by a neurogenic and inflammatory response to surgical manipulation.
Paralytic Ileus — A functional obstruction of the intestines due to cessation of peristalsis, presenting with a firm, distended abdomen and absent bowel sounds, which can lead to vomiting, aspiration, and fluid imbalances if not promptly managed.
Nasogastric Decompression — A procedure involving the insertion of a tube through the nose into the stomach to remove accumulated gas and fluid, often used to relieve distension in cases of ileus or obstruction, but requiring a physician's order.