A 2-year-old toddler is admitted with a diagnosis of Hirschsprung's disease and is scheduled for a pull-through procedure. Which nursing intervention is most important in the immediate postoperative period?
1Encourage early oral feeding to promote bowel function
2Position the infant in high Fowler's position to prevent aspiration
3Apply rectal thermometer for accurate temperature monitoring
4Monitor for signs of anastomotic leak and peritonitis✓ 정답
해설
Monitoring for anastomotic leak and peritonitis is critical postoperatively due to high complication risks. Other interventions like positioning and avoiding rectal thermometers are important but secondary to complication monitoring.
Clinical Judgment
This question evaluates the nurse's core role of preventing and early detecting postoperative complications. The pull-through procedure for Hirschsprung's disease is a surgery that removes the aganglionic segment of the bowel and pulls the healthy bowel down to connect it to the anus. The most serious early complication is peritonitis due to an anastomotic leak. If intestinal contents spill into the abdominal cavity, it can rapidly progress to severe infection and sepsis, requiring immediate intervention. Therefore, the nurse's highest priority intervention is to continuously monitor for signs of this life-threatening complication.
Memory Tip:
Leak Lookout! Post Pull-through.
A mnemonic to remember signs of anastomotic leak: Fever, Abdominal distension, Tachycardia, Emesis, Reduced bowel sounds (FATER).
KR vs US
In both Korea and the US, monitoring for postoperative complications is a top priority. The difference is that in the US NGN exam, questions asking for the "most important" or "priority" are very common, and life-threatening issues (e.g., anastomotic leak) always take precedence over other interventions like nutrition or positioning. The Korean exam is similar, but the NGN more explicitly assesses this Clinical Judgment and prioritization process.
임상 시나리오
Clinical Practice Guide
Key nursing care after pull-through surgery for Hirschsprung disease:
1. Monitor for signs of infection and leakage: Frequently assess vital signs (especially fever, tachycardia), abdominal status (distension, tenderness, bowel sounds), characteristics/amount/odor of drainage, and surgical site condition.
2. Maintain NPO (nothing by mouth): Stop oral feeding until bowel sounds return and a doctor's order is given. Provide fluids and electrolytes through intravenous fluid therapy.
3. No rectal manipulation: Absolutely prohibit the use of rectal thermometers, enemas, or suppositories as they can damage the anastomosis site.
4. Pain management: Reduce unnecessary stress and pain by administering effective analgesics as prescribed.
Caution
This is a common trap point in SATA (Select All That Apply) questions. For the question "Which nursing interventions are correct after pull-through surgery?", "Encourage early oral feeding" and "Use a rectal thermometer" are incorrect answers that can never be correct. Be sure to remember this.
핵심 개념
Hirschsprung's disease — Hirschsprung disease. Congenital intestinal aganglionosis. A condition where a portion of the large intestine is congenitally missing ganglion cells, causing that segment of the bowel to remain unrelaxed and continuously contracted, leading to severe constipation and intestinal obstruction.
Pull-through procedure — Penetration technique. Standard surgical procedure for Hirschsprung's disease. After removing the aganglionic segment of the intestine, the healthy intestine is pulled down toward the anus (pull through) and directly anastomosed. There are several techniques, including Swenson, Soave, and Duhamel.
Anastomotic leak — Anastomotic leak. A serious complication where the suture line between two bowel segments connected during surgery is not secure, causing intestinal contents to leak out. It is a major cause of peritonitis and sepsis.
Peritonitis — Peritonitis. Inflammation of the peritoneum (the thin membrane lining the abdominal cavity and covering the organs). Bacterial infection (e.g., from intestinal perforation or anastomotic leak) is the most common cause, presenting with symptoms such as acute abdominal pain, fever, and abdominal rigidity.
Postoperative nursing intervention — Postoperative nursing interventions. Systematic activities performed by nurses to promote patient recovery and prevent and manage complications after surgery. Includes monitoring, comfort enhancement, medication administration, and education.