Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?
A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.
Correct Answer: B. Document the finding as the only action.
Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. After the mid and late 1990s, the idea of staged food intake was advanced: a small amount of light fluid is started several hours after burn so as to not only supplement nutrition but stimulate GI peristalsis and improve GI blood supply. Once bowel sound resumes, the amount of food can be increased.
Option A: Post-burn GI dysfunction is caused by multiple factors, and therefore maintaining GI function is a systematic engineering project. The therapeutic strategy should not rely on a single treatment or a single drug.
Option C: It is suggested that small doses of dopamine should be administered to dilate the renal and GI vessels, and free oxygen radical clearing agents to attenuate ischemia/reperfusion injury in the process of resuscitation. These comprehensive resuscitation measures played an important role in protecting GI function, helping resume bowel sound earlier and digestive function.
Option D: In some patients in whom fluid resuscitation was not implemented effectively for various reasons, wound surface infection often caused severe injury to the GI function, or even toxic paralytic ileus palsy, greatly increasing toxin absorption and bacterial superinfection.
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