Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 13 Perioperative Care^491


INTERPRETING TEST RESULTS



  • Electrolyte abnormality due to vomiting.

  • Abdominal flat and upright x-ray shows stool in constipation, gas-filled intes-
    tinal loops in paralytic ileus.


TREATMENT



  • Monitor abdomen for distention; listen for bowel sounds.

  • Assess for dehydration as a result of prolonged vomiting.

  • Restrict oral intake in paralytic ileus or if nausea and vomiting are present.

  • Nasogastric (NG) tube connected to suction to prevent vomiting in paralytic
    ileus.

  • Progress diet as tolerated once bowel sounds return and patient is passing
    flatus rectally.

  • Administer intravenous fluids.

  • Administer total parenteral nutrition.

  • Administer antiemetics as required.


NURSING DIAGNOSES



  • Risk for imbalanced nutrition: less than what body requires

  • Risk for imbalanced fluid volume

  • Risk for delayed surgical recovery

  • Risk for constipation

  • Altered bowel elimination


NURSING INTERVENTIONS



  • Ask patient about presence of nausea.

  • Monitor vital signs for changes.

  • Listen to bowel sounds; assess abdomen for distention.

  • Monitor intravenous site for signs of infiltration, pain, and redness.

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