A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse’s priority?
A.
Assess fluid intake every 24 hr.
B.
Ambulate three times a day.
C.
Assist with deep breathing and coughing.
D.
Monitor the incision site for findings of infection.
The correct answer and Explanation is :
The correct answer is C. Assist with deep breathing and coughing.
Explanation:
In the immediate postoperative period, especially after abdominal surgery, maintaining respiratory function is a critical priority. The risk of respiratory complications, such as atelectasis and pneumonia, increases after surgery due to factors like anesthesia, pain, and immobility. Assisting the client with deep breathing and coughing helps to promote lung expansion and clear secretions from the airways.
1. Importance of Deep Breathing and Coughing:
After abdominal surgery, patients often experience pain and may be hesitant to take deep breaths or cough, which can lead to decreased lung volumes. This can result in the accumulation of secretions and impaired gas exchange. Encouraging deep breathing helps to prevent atelectasis by keeping the alveoli open, improving oxygenation and reducing the risk of respiratory infections.
2. Role of Pain Management:
Effective pain management is crucial to facilitate deep breathing and coughing. Nurses should assess the patient’s pain levels and provide appropriate analgesics to ensure that the patient can engage in these activities without significant discomfort.
3. Monitoring for Complications:
While monitoring the incision site for signs of infection (Option D) and assessing fluid intake (Option A) are also important, they do not take precedence over the immediate need to maintain respiratory function. Infection may develop later, and fluid intake will be monitored periodically, but ensuring that the patient is breathing effectively is vital in the first 24 hours post-surgery.
4. Ambulation:
Though ambulation (Option B) is beneficial for promoting overall recovery and preventing complications, it is typically not initiated until the patient is stable and able to mobilize safely. The priority should be on respiratory exercises before moving on to physical activity.
In summary, assisting with deep breathing and coughing is essential for preventing respiratory complications and is therefore the nurse’s priority action in this scenario.