Page 1286 - Saunders Comprehensive Review For NCLEX-RN

fistula formation (fever associated with pain),
hemorrhage (signs of shock), and complete intestinal
obstruction.
2. Monitor for signs of bowel perforation, which include
low blood pressure, rapid and weak pulse, distended
abdomen, and elevated temperature.
3. Monitor for signs of intestinal obstruction, which
include vomiting (may be fecal contents), pain,
constipation, and abdominal distention; provide
comfort measures.
4. Note that an early sign of intestinal obstruction is
increased peristaltic activity, which produces an
increase in bowel sounds; as the obstruction
progresses, hypoactive bowel sounds may be heard.
5. Prepare for radiation preoperatively to facilitate
surgical resection, and postoperatively to decrease the
risk of recurrence or to reduce pain, hemorrhage,
bowel obstruction, or metastasis.
E. Nonsurgical interventions
1. Preoperative radiation for local control and
postoperative radiation for palliation may be
prescribed.
2. Postoperative chemotherapy to control symptoms and
the spread of disease
F. Surgical interventions: Bowel resection, local lymph node
resection, and creation of a colostomy or ileostomy
G. Colostomy, ileostomy
1. Preoperative interventions
a. Consult with the enterostomal therapist
to assist in identifying optimal
placement of the ostomy.
b. Instruct the client in prescribed
preoperative diet; bowel preparation
(laxatives and enemas) may be
prescribed per surgeon preference.
c. Intestinal antiseptics and antibiotics
may be prescribed to decrease the
bacterial content of the colon and to
reduce the risk of infection from the
surgical procedure.
2. Postoperative: Colostomy

a. If a pouch system is not in place, apply
a petroleum jelly gauze over the stoma
to keep it moist, covered with a dry
sterile dressing; place a pouch system
on the stoma as soon as possible.
b. Monitor the pouch system for proper fit

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