Gastrointestinal System Disorders Q 291 - Gyan Darpan : Learning Portal
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Monday 11 April 2022

Gastrointestinal System Disorders Q 291

Five days after undergoing surgery, a client develops a small bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
    A. Imbalanced nutrition: Less than body requirements
    B. Acute pain
    C. Deficient fluid volume
    D. Excess fluid volume

Correct Answer: C. Deficient fluid volume

Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the intravascular spaces. Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses (diaphoresis). Measure urine specific gravity; observe for oliguria. This provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

Option A: If the obstruction isn’t resolved immediately, the client may experience an imbalanced nutritional status (less than body requirements); however, deficient fluid volume takes priority. Avoid or limit foods that might cause or exacerbate abdominal cramping, flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, orange juice). Individual tolerance varies, depending on the stage of disease and area of bowel affected.
Option B: The client may also experience pain, but that nursing diagnosis is also of lower priority than deficient fluid volume. Encourage the patient to assume a position of comfort (knees flexed). This reduces abdominal tension and promotes a sense of control.
Option D: Note possible conditions or processes that may lead to deficits such as fluid loss, limited intake, fluid shifts, environmental factors to assess causative and precipitating factors. Fluid loss may be an effect of diarrhea or vomiting).

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