A nurse is caring for a patient who underwent cardiac surgery 24 hours ago. The patient reports chest pain, shortness of breath, and has decreased urine output. On assessment, the nurse notes hypotension and tachycardia. What is the most appropriate initial nursing intervention?
1Administer a prescribed laxative to stimulate bowel movement
2Insert a nasogastric tube for gastric decompression✓ 정답
3Encourage the patient to drink plenty of fluids to promote peristalsis
4Position the patient in high Fowler's position and apply heat to the abdomen
해설
Nasogastric decompression is the initial intervention for postoperative ileus to relieve distention and prevent complications. Other options are inappropriate or less effective.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a suspected postoperative ileus in a cardiac surgery patient. Postoperative ileus is a temporary paralysis of intestinal motility, a common complication after major surgery, especially abdominal or cardiac procedures. The key is recognizing the cluster of symptoms: chest pain (can be referred pain from diaphragmatic irritation), shortness of breath (due to abdominal distention pushing up on the diaphragm), decreased urine output (indicating potential hypovolemia or decreased cardiac output), hypotension, and tachycardia. These vital sign changes signal a potential complication beyond simple constipation.
Answer Rationale: Key Point! The most appropriate initial intervention is Insert a nasogastric tube for gastric decompression. A nasogastric (NG) tube connected to low intermittent suction is the standard initial management for a symptomatic postoperative ileus. It decompresses the stomach and intestines by removing accumulated air and fluid, which:
1. Relieves abdominal distention and pressure.
2. Alleviates pain and shortness of breath.
3. Reduces the risk of vomiting and aspiration.
4. Allows the bowel to rest and recover its motility.
This intervention directly addresses the root cause of the patient's distressing symptoms and is a priority before other measures.
Distractor Analysis: Watch out for confusion! Option ①: Administering a laxative is contraindicated in a paralytic ileus. Laxatives stimulate peristalsis in a bowel that is paralyzed, which can lead to bowel perforation.
Option ③: Encouraging oral fluids is also contraindicated. The patient's gut is not moving, so fluids will simply accumulate, worsening distention, nausea, and the risk of vomiting/aspiration. IV fluids are the appropriate route for hydration in this scenario.
Option ④: While positioning in high Fowler's might ease respiratory effort, applying heat to the abdomen is not the initial priority and could be dangerous if the cause of pain is not yet fully diagnosed (e.g., ruling out ischemia or perforation). Decompression is the definitive action.
Related Concepts: This scenario highlights the importance of differentiating between simple constipation and a paralytic ileus. The presence of systemic signs (hypotension, tachycardia, decreased urine output) elevates the urgency. Nursing management focuses on decompression (NG tube), maintaining NPO (Nothing by Mouth) status, administering IV fluids, and monitoring for resolution of symptoms (return of bowel sounds, passage of flatus).
Concept Summary
Concept
Definition & Key Points
Postoperative Ileus
Temporary cessation of bowel motility after surgery. Presents with abdominal distention, nausea/vomiting, absence of bowel sounds, and failure to pass flatus/stool.
Nasogastric (NG) Decompression
Primary intervention for ileus. Relieves pressure, prevents aspiration, allows bowel rest. Connect to low intermittent suction.
NPO Status
Essential during ileus. No food or fluids by mouth until bowel function returns (active sounds, flatus).
Contraindicated Actions
Laxatives, enemas, or oral intake can cause harm (perforation, aspiration) in a paralytic state.
Side-by-Side Comparison!
Condition
Postoperative Ileus
Simple Constipation
Pathophysiology
Paralytic. Bowel motility is absent.
Mechanical. Stool is hard/dry, but peristalsis is present.
Bowel Sounds
Absent or markedly decreased.
Usually present, may be normal or hyperactive.
Systemic Symptoms
Common (e.g., nausea, vomiting, distention, hypotension, tachycardia).
Rare. Primarily local discomfort.
Initial Nursing Intervention
NG tube decompression, maintain NPO.
Increase fiber/fluids if allowed, ambulation, stool softeners.
Danger of Laxatives
High risk of perforation.
Often appropriate treatment.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Surgery, anesthesia, and opioid analgesics inhibit the parasympathetic nervous system, which stimulates peristalsis. This leads to a temporary functional obstruction.
Vagus Nerve (Cranial Nerve X): Key parasympathetic nerve for GI motility. Its inhibition contributes to ileus.
Diaphragmatic Irritation: Abdominal distention can push against the diaphragm, causing referred pain to the chest and shoulder, and impairing lung expansion (shortness of breath).
Opioid-Induced Ileus: A major side effect. Nurses must balance pain management with bowel regimen (e.g., scheduled stool softeners like docusate).
Memory Tips
ILEUS = I Let Everything Up Suction (Initial intervention is suction/NG tube).
NPO for Ileus, PO for Constipation: Remember the route for intake.
No Laxatives on a Lazy Bowel: A paralyzed (lazy) bowel cannot be forced to work with stimulants.
High-Frequency NCLEX Topics
NCLEX loves to test priority actions for postoperative complications. Ileus is a classic. Remember the sequence: Assess (vitals, abdomen, bowel sounds) → Identify the problem (ileus vs. other) → Intervene with the safest, most direct action (decompression) → Monitor outcomes. The presence of abnormal vital signs (hypotension/tachycardia) is a huge red flag that often points to the correct answer.
Watch Out for Question Variations!
Shift from Symptom to Intervention: Instead of "what is the initial intervention?", it could be "the nurse identifies which finding as a priority to report?" (Answer: Absent bowel sounds with abdominal distention and vomiting).
Shift to Medication: "Which medication should the nurse anticipate administering for a postoperative ileus?" (Trick question! The answer is often none for direct treatment of ileus; focus is on supportive care and possibly holding certain meds like opioids).
Shift to Patient Education: "The nurse is teaching a patient about signs of returning bowel function. Which statement by the patient indicates understanding?" (Correct: "I will tell you when I pass gas.").
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, 68, who had a coronary artery bypass graft (CABG) yesterday. He is on patient-controlled analgesia (PCA) with morphine. This morning, he states his abdomen feels "bloated and tight," he hasn't passed gas, and he's nauseated. His abdomen is distended and tympanic to percussion, and bowel sounds are absent in all four quadrants.
Nursing Intervention Strategy:
1. Assessment: Perform a focused abdominal assessment: inspect, auscultate (for at least 2 minutes per quadrant), palpate gently, percuss. Assess pain (location, character), nausea, and vital signs. Check the last bowel movement and flatus. Review intake/output records.
2. Action: Notify the surgeon or advanced practice provider of your findings. The likely order will be: "Insert NG tube to low intermittent suction, maintain NPO, IV fluids."
3. Implementation: Insert the NG tube, confirm placement (by X-ray is gold standard post-insertion), secure it, and connect to low intermittent suction. Provide frequent oral and nasal care. Maintain accurate intake/output, including NG output.
4. Monitoring & Evaluation: Monitor for return of bowel sounds, passage of flatus, decrease in abdominal distention, and reduction in NG output (which signals resolving ileus). Assess the patient's comfort and respiratory status.
Patient Safety and Precautions:
NG Tube Placement: Always verify placement after insertion and before each use (if for medication) per facility policy. Aspirate gastric contents and check pH (pH < 5.5 suggests gastric placement). A chest X-ray is definitive.
Aspiration Risk: Keep the head of bed elevated at least 30 degrees if possible.
Skin Integrity: Secure the NG tube to prevent pressure on the nares. Check the skin frequently.
Fluid & Electrolyte Balance: NG suction removes fluid and electrolytes (especially potassium and chloride). Monitor labs and replace as ordered.
Explain the procedure to the patient. Gather supplies (tube, lubricant, tape, suction canister, stethoscope).
Measure tube length (tip of nose to earlobe to xiphoid process).
Lubricate and insert gently through the nostril. Have the patient swallow sips of water (if not NPO) or dry swallow to advance the tube.
Secure the tube. Confirm placement (X-ray ordered).
Connect to ordered suction (usually low intermittent). Document the type of tube, insertion site, length at naris, and patient tolerance.
Medication Considerations: All oral medications are held while NPO and the NG tube is to suction. Some medications may be given IV or via the NG tube (if ordered) by clamping suction for 30 minutes after administration.
A Word from Your Senior Nurse
"In the real world, postoperative ileus is very common, but it can be scary for patients. They're already in pain and then they feel this awful pressure and can't breathe well. Your quick assessment and action with the NG tube provide immense relief. Remember, your assessment is key—don't just chart 'abdomen distended.' Chart the specifics: 'Abdomen firm, distended, tympanic to percussion in all quadrants. Bowel sounds absent for 2 minutes of auscultation.' This detailed communication helps the provider make the right call quickly. Connecting the dots between the surgery, the opioids, and the belly is what makes you a great nurse!"