Nurse’s Best Action
The nurse’s best action when a burn patient has absent bowel sounds in all four abdominal quadrants 12 hours after the burn is to assess the patient’s abdomen thoroughly. This includes assessing the patient’s vital signs, abdominal pain, distention, tenderness, and rebound tenderness. The nurse should also listen to the patient’s bowel sounds in all four abdominal quadrants.
Why are Absent Bowel Sounds a Concern in Burn Patients?
Absent bowel sounds are a concern in burn patients because they may indicate paralytic ileus. Paralytic ileus is a condition in which the peristaltic movements of the intestines are slowed or stopped. Paralytic ileus can be caused by a number of factors, including:
- Pain: Burn injuries can be very painful, and pain can inhibit peristaltic movements.
- Inflammation: Burn injuries can cause inflammation throughout the body, including in the intestines. Inflammation can also inhibit peristaltic movements.
- Electrolyte imbalances: Burn injuries can lead to electrolyte imbalances, such as hypokalemia (low potassium) and hypomagnesemia (low magnesium). Electrolyte imbalances can also disrupt peristaltic movements.
Nursing Interventions for Paralytic Ileus in Burn Patients
The nursing interventions for paralytic ileus in burn patients are focused on preventing and managing complications. Nursing interventions include:
- Monitoring the patient’s vital signs and abdominal assessment: Nurses should monitor the patient’s vital signs and abdominal assessment closely for any signs of deterioration. This is important because paralytic ileus can lead to complications such as abdominal distention, vomiting, and constipation.
- Providing pain management: Nurses should provide pain management to the patient to help reduce pain and improve peristaltic movements. Pain management may include medications, non-pharmacological interventions, or a combination of both.
- Replacing electrolytes: Nurses should replace electrolytes, such as potassium and magnesium, as needed. Electrolyte replacement can help to improve peristaltic movements.
- Providing nutritional support: Nurses should provide nutritional support to the patient to help prevent malnutrition and promote healing. Nutritional support may include enteral nutrition (feeding through a tube) or parenteral nutrition (feeding through an IV).
The nurse’s best action when a burn patient has absent bowel sounds in all four abdominal quadrants 12 hours after the burn is to assess the patient’s abdomen thoroughly and monitor the patient’s vital signs and abdominal assessment closely. The nurse should also provide pain management, replace electrolytes, and provide nutritional support.