Quote from nursing student 19
I have another question. If you do chart absent bowel sounds, don't you have to chart what you did about it ? i.e ambulating if indicated, notify the doc, ... or do you just write continue to monitor.
I had a post op pt. this weekend and whenever I charted something my instructor was on my back asking me " what did I do about it"? So if the BS are absent what should you do?
Well, first off...your instructor is trying to lead you down the path of critical thinking, teaching you to think the problem through and come up with different interventions you may need to utilize..and realize that frequent monitoring is "doing something". (I'm guessing your instructor is also trying to teach you the need of follow-up assessments and to not just let things lay...both very important points to make.) I think the question about charting what you did about it is interesting..as nurses, we chart many things. And when we chart an assessment with what could be an abnormal finding, then of course we're going to need to chart interventions....which could apply in the limited scenario you've presented. However, what do you need to do if the finding is not only anticipated but normal? I'd say charting a thorough assessment and normal post-op care would be all that was needed. Let me explain.
In the scenario presented with absent bowel sounds in a post-operative patient, you're going to chart your assessment of the bowel sounds, you're going to chart the finding of an NG/OG and it's patency, what suction setting it's at, any drainage and it's assessment (color, amount, consistency, etc.) and then you're going to chart your re-assessment when it's next indicated. If your instructor were to ask you about your initial finding, ("what are you going to do about it?"), saying you'd do all these things would be an appropriate reply. Then, when you'd anticipate the bowel motility to return, and if you don't find it has, you are going to take your assessment and actions down a different path, which may include notifying the MD, checking the gastric tube for placement & patency, and possibly checking labs...would really depend upon the patient and the situation. The key is your nursing assessment
. Does that make sense? It's kind of a hard scenario to envision without more specific patient indicators, I hope I"m communicating accurately the general idea.
Post-operative care is really very involved, moreso depending upon the type of surgery the patient has and his/her comorbidities. You need to have a good handle on your patient's operative course and history to be able to do a good and thorough post-operative assessment. Even if your patient is taken to the PACU for their initial recovery (I work with open heart patients and we recover them in the ICU), you still need to have a grasp of the issues at hand.
I hope that answers your questions..if not, repost and I'll try to be more thorough in my reply. Good luck to you in your studies.