C.W.'s condition deteriorates; on the third day after admission she experiences intractable abdominal painand unrelenting nausea and vomiting
C.W. is taken to the operating room because of probable sBO and is readmitted to your unit from the postanesthesia care unit. during surgery, 38 inches of her small bowel were found to be severely stenosed with two areas of visible perforation. Much of the remaining bowel is severely inflamed and friable. A total of 5 feet of distal ileum and 2 feet of colon have been removed, and a temporary ileostomy was established. she has a Jackson-Pratt (JP) drain to bulb suction in her right lower quadrant (RLQ), and her wound was packed and left open. she has two peripheral IVs, a salem
sump nasogastric tube (NGT), and a Foley catheter. Her vital signs (Vs) are 112/72, 86, 24, 100.8° F (38.2° C)
(tympanic). You attach her NGT to low-continuous wall suction per the postoperative orders.
You begin a thorough postoperative assessment of C.W.'s abdomen.
What does your assessment include?
List the steps in the order in which the assessment should be completed.
• Observe the dressing for drainage. Look for abdominal distention or signs of inflammation. Is the
dressing intact, and does it contain drainage? Observe the color of the stoma, color and amount of
drainage in the pouch, whether the seal is intact around the stoma, and whether there is any skin
exposed around the stoma and the drainage bag. Is the JP sutured in place? Is the JP bulb connected to
the JP drain? If suction is applied, what are the appearance and amount of drainage from the JP drain?
• Auscultate for bowel sounds around the periphery of the wound dressing (be sure to clamp the NGT first).
• Lightly palpate the abdomen for any unusual tenderness or firmness, or distention. Do not palpate
firmly or near the incision. Omit percussion at this time.
• Look around and under C.W. for drainage and bleeding.
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