Which of the following is the best response by the nurse regarding paralytic ileus after abdominal surgery?

AIIMS Rishikesh NO - 2019

Medical Surgical Nursing

Easy

Appeared in: AIIMS Rishikesh NO - 2019

Explanation

Paralytic ileus is a common postoperative complication characterized by the temporary cessation of intestinal peristalsis (movement).
The most definitive clinical sign is the absence of bowel sounds upon auscultation of the abdomen, which indicates a lack of gastrointestinal (GIT) motility.
A nurse must listen for up to 5 minutes in each abdominal quadrant before concluding that bowel sounds are truly absent.

Option A: These are loud, 'growling' sounds (borborygmi) that indicate increased GI motility, which is the opposite of what occurs in paralytic ileus.
Option C: While abdominal distention and increased girth can result from the accumulation of gas and fluid in paralytic ileus, it is a symptom and not the most specific diagnostic sign. The absence of bowel sounds is more definitive.
Option D: Normal bowel sounds (soft gurgles occurring 5-35 times per minute) indicate healthy peristalsis, which is absent in paralytic ileus.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Assessment and signs of paralytic ileus post-abdominal surgery in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Nurses must perform regular abdominal assessments (inspection, auscultation, palpation, measuring girth) in postoperative patients to detect paralytic ileus early.
Early detection and intervention, such as maintaining NPO (nothing by mouth) status and inserting a nasogastric (NG) tube for decompression, are crucial to prevent complications like aspiration, bowel ischemia, and electrolyte imbalances.
What if? If a postoperative patient has hypoactive (infrequent, quiet) bowel sounds and is passing some flatus, this may indicate a resolving ileus. The nurse would encourage ambulation and continue to monitor closely rather than immediately escalating for aggressive intervention.

How to Approach the Question

First, identify the core concept from the stem: 'paralytic ileus' after 'abdominal surgery'.
Recall the pathophysiology of paralytic ileus: 'paralysis' or cessation of intestinal movement (peristalsis).
Analyze the question's requirement: the 'best response' or most characteristic sign a nurse would find.
Evaluate each option based on the pathophysiology. 'Hyperactive' and 'normal' sounds contradict the concept of paralysis.
Compare the remaining options. 'Increased abdominal girth' is a possible symptom, but 'absence of bowel sound' is the direct auscultatory finding that confirms the lack of motility.
Conclude that the absence of bowel sounds is the most definitive and primary sign among the choices.

Concept Tested & Keywords

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