NEW YORK NURSE: January 2007
by Denise Côté-Arsenault, PhD, RNC, FNAP, Associate and Brody Professor, University of Rochester School of Nursing
Evidence-based practice is the new buzz-phrase in nursing practice, but what does it really mean at a practical level? To begin with, it means that nurses should be questioning every aspect of routine nursing care by asking, “What evidence is there that this assessment or intervention makes a positive difference in my care?” Asking this question is often difficult because we do things as a matter of course, assuming that someone must know that this works, or it wouldn’t be in the policy and procedure manual.
Listening to bowel sounds in the post-operative abdominal surgery patient is a case in point. Abdominal surgery is known to suppress gastrointestinal activity, but the causes are multi-faceted and poorly understood. Post surgical nursing care appropriately includes assessing the return of gastrointestinal (GI) function. What key assessments should be done and is there evidence to support them? Here is the scoop…
Nurses have traditionally been taught to assess the post-operative abdominal surgery patient by listening to bowel sounds in all four quadrants of the abdomen. It has been assumed that if bowel sounds are heard, the GI tract is moving, or peristalsis is taking place. If bowel sounds are absent after listening for five minutes, oral intake might be delayed or a paralytic ileus might be suspected.
However, when a group of nurses (Madsen et al., 2005) took a look at the research and expert evidence on this topic, utilized the Iowa Model of Evidence-Based Practice to review research and evidence on this topic, they were surprised to find nothing to support this practice.
There is no research evidence that corroborates the assumed association between bowel sounds and GI motility status.
The nurses developed a nursing practice guideline based on their review of the literature, which was then implemented and evaluated. Assessing bowel sounds does not lead to a specific nursing intervention, which is a clue that it is not useful. Most surgeons do not listen to bowel sounds and do not consider these assessments by nurses useful.
In addition, there is no evidence that not listening to bowel sounds is detrimental to post-operative abdominal surgery patients. Several clinical trials indicate that early oral hydration and nutrition are safe. Indeed, patients who are given early oral intake go home earlier than those who are on traditional regimes of delayed oral intake. The delay of oral intake to allow for healing and a return of GI motility appears to have been misguided practice – early oral intake provides nutrition that promotes healing and stimulates earlier GI functioning.
So what should be assessed? Nurses should certainly assess the GI system post surgery by noting: (1) the return of flatus, (2) the first bowel movement, (3) normal vital signs, (4) a lack of nausea/vomiting and the return of appetite, and (5) the absence of signs of ileus, such as distension, bloating, and cramps.
Early bowel sounds represent uncoordinated contractions in the small intestine, not propulsive contractions of the colon. In addition, gastrointestinal function returns to different areas at different times. The small intestine returns to normal function between 4 and 24 hours, the stomach in two to four days, and the large intestine in three to seven days. Not only is it impossible to accurately distinguish from where bowel sounds are coming; these sounds should have no effect on nursing care. Nurses should notify the surgeon of vomiting, distention, firmness, or an increase in wound drainage.
The take-home message: don’t listen for bowel sounds in your post-abdominal surgery patients. Use that precious time to ask them about flatus, bowel movements, and appetite, which are all signs that GI function is returning.
Evidence-based practice is critical for nurses and other healthcare providers. Projects should be shared and examined by others, so publishing this information is very helpful. Perhaps if all nurses share their own clinical questions and answers, we will improve our care more quickly. Our patients will be the beneficiaries and nurses can be confident that they are giving the best care possible.