Question

After four hours under your care, the patient develops a fever of 99.9F and is difficult to arouse. You were able to get a doctor’s order for an IV of LR to run at 50ml/hr. Urine output is improving and the Foley is draining 40ml/hr. Lung sounds unchanged and pulse ox is 92%. RR 14 and BP 110/60, HR 90. O2 at 2L NC intact. The colostomy is not functioning and there are no bowel sounds. Incision site clean and dry. Jackson Pratt intact draining a small amount of fluid. You assessed her abdominal pain at an 8/10 and administered 2mg morphine sulfate IVP 30 minutes ago. What is the next nursing action?

Answer 1

COLOSTOMY – It is a surgical procedure which brings down the portion of the large intestine through the abdominal wall to carry feces out of the body. STROMA – Its meaning opening, or mouth. It is an artificial opening that allows faeces, or urine either from the intestine or from the urinary tract to pass.

ILEUS – It is a post complication of surgery that is characterized by loss of forward flow of intestinal content. It is often accompanied by abdominal cramps, constipation, vomiting, electrolyte imbalance and dehydration

NURSING INTERVENTION

1. Monitor for respiratory and circulatory status carefully and frequently during morphine therapy, especially when drug therapy initiated. When a patient is being converted to morphine because respiratory depression and severe hypotension can develop. (life threatening depression can occur even when morphine is taken as prescribed and is not misused or abused).

2. Monitor the abdominal distension or tenderness

3. If colostomy is not working after the surgery of 4-6 hours and having pain, cramps or nausea then intestine could be obstructed (abdominal adhesion- there are bands of fibrous tissue form between the abdominal tissue and organ). Inform doctor about it, watch for a sign of swelling of the stone and adjust the opening of the wafer as needed until the swelling goes down. Assessment of colostomy drainage. Auscultate the vowel sound (ileus) is recommended before starting any oral diet and fluid.

4. Assessment of Jackson Pratt drain, if drainage is less than 30 ml in 24 hours. this may mean you can remove drain.

5. Assessment for increase pain, redness and swelling around the drainage. (possible signs of infection)

IT ANY DOUBT POST A QUESTION