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Continuing Education

By Diane Madsen, BSN, RN, Tamara Sebolt, BSN, RN, Laura Cullen, MA, RN,
Beverly Folkedahl, BSN, RN, COCN, CWCN, Toni Mueller, MSN, RN, CCRN,
Corinne Richardson, BSN, RN, and Marita Titler, PhD, RN, FAAN

Listening to
Bowel Sounds:
An Evidence-Based Practice Project
Nurses find that a traditional practice isn’t the best indicator
of returning gastrointestinal motility in patients who’ve
undergone abdominal surgery.

Overview: Nurses’ practice of listening to bowel sounds was first proposed in 1905
and continues today, largely unquestioned. The authors developed a project to
determine whether any compelling evidence exists for using this method to assess
for the return of gastrointestinal (GI) motility following abdominal surgery.
Literature on the subject was evaluated and an assessment of nursing practice was
conducted. Based on the literature review and the assessment, a nursing practice
guideline was developed, implemented, and evaluated. (Note that the nursing
practice guideline outlined in this article was evaluated for use with abdominal sur-
gery patients only and hasn’t been evaluated in and may not be appropriate for
other patient populations). The results were positive and indicate that clinical
parameters other than bowel sounds, such as the return of flatus and the first post-
operative bowel movement, are appropriate in assessing for the return of GI motil-
ity after abdominal surgery. Bowel sound assessment was discontinued and patient
outcomes were evaluated to make sure that the practice change had no adverse
effect on patients’ recovery.

Diane Madsen is a staff nurse; Tamara Sebolt is a nurse manager; Laura Cullen is an advanced practice nurse and evidence-based
practice coordinator; Beverly Folkedahl is an advanced practice nurse; Toni Mueller is associate director of perioperative nursing;
Corinne Richardson is a staff nurse; and Marita Titler is director of research, quality, and outcomes management, all in the
Department of Nursing at the University of Iowa Hospitals and Clinics, Iowa City. The project was supported by the Evidence-
Based Practice Staff Nurse Internship at the University of Iowa Hospitals and Clinics. The authors wish to thank Joseph J. Cullen,
MD, professor of surgery at the University of Iowa College of Medicine and chief of the surgical service at the Veterans Affairs
Medical Center, Iowa City, for his assistance. Contact author: laura-cullen@uiowa.edu. The authors of this article have no other
significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

40 AJN t December 2005 t Vol. 105, No. 12 http://www.nursingcenter.com


hat’s the best indication of returning • Does bowel sound assessment promote early

W gastrointestinal (GI) motility in


patients who’ve undergone abdomi-
nal surgery? A century ago, nurses
first began listening for bowel
sounds as a sign of such recovery. Since then, the
practice has persisted largely unquestioned and is
supported more by tradition than by evidence.
intervention, such as feeding, or recovery in
abdominal surgery patients?
Alteration in GI motility following abdominal
surgery was first documented with the introduction
of X-rays in the 1890s, and in 1905 (as reported by
Nachlas and colleagues) Cannon first proposed
auscultation of bowel sounds to determine whether
It has become apparent, as nursing practice has GI motility had returned after abdominal surgery.2
evolved, that this is the case with many nursing Nursing students are taught to listen for as long as
activities. In order to improve the quality of care, five minutes in each of the four quadrants of the
it’s vital that nurses question their current practices abdomen to determine whether bowel sounds are
to determine whether they’re based on evidence or present; nurses may therefore spend up to 20 min-
merely on tradition. utes per patient on one component of the nursing
The Iowa Model of Evidence-Based Practice to assessment.3-5 Given the imperative to improve
Promote Quality Care successfully promotes the patient outcomes and the pressure to use nursing
integration of evidence into practice.1 The model time more efficiently, it’s necessary to question the
outlines the implementation of an evidence-based validity of this traditional nursing practice.
practice project (see Figure 1, page 42). Identifying
a practice problem or new knowledge triggers the SYNTHESIS OF THE EVIDENCE
evidence-based practice process. Leaders in the Locating research evidence was a challenge.
health care facility and on the nursing unit then Literature searches were attempted with the help of
review the proposal to determine what priority it other nurses and librarians, but with few results.
should be given, and they assemble a team to carry The basic research in this area is old and in some
it out. cases wasn’t listed in Medline when this project
The team selects, reviews, critiques, and synthe- began. To find the literature, we used a “snowball”
sizes the evidence in the literature. If the research method6 (meaning that an initial information
evidence is sufficient, the team initiates change. If source referred us to other sources); in this case, a
the evidence is insufficient, the team reviews other surgical motility researcher shared his collection of
evidence or suggests more research. The team then articles and provided leads, resulting in a more
pilots and evaluates the practice change to deter- effective literature retrieval.
mine whether revisions are needed before integrat-
ing and applying the change in other clinically
appropriate areas. More evaluation and dissemina-
tion of results is essential to integrate the practice
into daily care.
There are no nursing interventions
This article describes the results of an evidence- associated with the presence or
based practice project that began when one of us
(DM), a staff nurse on a GI surgery unit, ques- absence of bowel sounds.
tioned the practice of listening to bowel sounds to
assess for gastric motility. We followed the Iowa
Model described above.
Published research on the correlation between
CLINICAL ISSUE bowel sounds and GI motility is sparse and dates to
Our evidence-based practice project began with the the 1960s. Recent research has focused on using
identification of a clinical problem, which we pacemakers or drugs to speed recovery, with incon-
framed in a series of questions that hadn’t been suf- sistent findings that aren’t clinically useful. We
ficiently addressed in the nursing literature: looked for studies that involved the return of GI
• Why do we listen to bowel sounds? motility after abdominal surgery as well as the use
• What evidence supports listening to bowel of assessment for bowel sounds in abdominal sur-
sounds? gery patients. Critique and synthesis of the evidence
• Are bowel sounds a valuable tool for determin- included primary findings from clinical research
ing the return of GI motility after abdominal sur- describing the pattern of returning GI motility, as
gery? well as secondary findings from research that

ajn@lww.com AJN t December 2005 t Vol. 105, No. 12 41


Figure 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care

Problem focused triggers Knowledge focused triggers


• risk management data • new research or other literture
• process improvement data • national agencies or organizational
• internal/external benchmarking data standards and guidelines
• financial data • philosophies of care
• identification of clinical problem • questions from institutional standards committee

Consider No Is this topic


other a priority for the
triggers organization?

Yes

Form a team

Assemble relevant research and related literature

Critique and synthesize research for use in practice

Is there
Yes a sufficient No
research
base?
Pilot the change in practice
• Select outcomes to be achieved
• Collect baseline data Base practice on other types of evidence: Conduct
• Design evidence-based • case reports research
practice (EBP) guideline(s) • expert opinion
• Implement EBP on pilot units • scientific principles
• Evaluate process and outcomes • theory
• Modify the practice guideline

Is change
Continue to evaluate quality No appropriate for Yes
Institute the change in practice
of care and new knowledge adoption in
practice?

Monitor and analyze structure,


process, and outcome data
Disseminate results • environment
• staff
• cost
• patient and family
= a decision point

Copyright University of Iowa Hospitals and Marita Titler. Reproduced with permission from Marita Titler, PhD, RN, FAAN; for permission to use or reproduce the
model, please contact Dr. Titler at marita-titler@uiowa.edu.

42 AJN t December 2005 t Vol. 105, No. 12 http://www.nursingcenter.com


addressed other questions. Several randomized,
Figure 2. Timing of Return of Postoperative GI Motility
controlled trials; 15 experimental studies; and three
systematic reviews were included in the evidence
synthesis (see Table 1, page 46). More evidence 4 – 24 hours
from available research, expert opinion, and case
studies report the practice of listening to bowel 2 – 4 days
sounds to determine motility only as a matter of
tradition. 3 – 7 days
The return of GI motility after abdominal sur-
gery follows a predictable pattern, beginning with
random electrical impulses, then random muscle
contractions, eventually becoming coordinated
myoelectrical activity, and then propulsion.7 The
return of GI motility begins in the small intestine; it
is then seen in the stomach and, finally, the colon
(first on the right side, then on the left).7-10 The tim-
ing of the return of postoperative GI motility varies
according to the surgical procedure11 and other clin-
ical variables, but motility is usually seen in the
small intestine in four to 24 hours, the stomach in
two to four days, and the colon in three to seven
days postoperatively (see Figure 2, at right).
Early postoperative bowel sounds probably don’t
represent the return of normal GI motility2, 12, 13;
rather, they most likely represent uncoordinated
early contraction in the small intestine.14-16
Therefore, auscultation of the abdomen during the
early recovery phase after abdominal surgery isn’t a
good assessment of the recovery of postoperative
motility.15
Preventing oral intake in the first days after
abdominal surgery has been standard practice
because of concern that complications such as anas-
tomotic leakage, dehiscence, wound disruption,
vomiting, and aspiration might arise,17, 18 but recent
research has questioned this tradition.19-21 Bufo and Motility is usually seen in the small intestine in four to 24 hours, the stomach in
colleagues speculate that the tradition of prohibit- two to four days, and the colon in three to seven days.
ing early feeding may be a holdover from a time
when now-outdated anesthetics that were associ-
ated with more nausea and vomiting were in use.22 toms of ileus, such as distension, feeling bloated,
Recent research suggests that early feeding is, in and cramps.17, 22-26, 31 In addition to monitoring for
fact, safe for patients, and bowel sounds do not returning GI motility, postoperative assessment
indicate feeding tolerance.17, 22-26 Patient outcomes of should include pain assessment and the monitoring
early feeding include tolerance of oral intake and of vital signs and intake and output.
improved patient comfort; early feeding may also Interviewing patients can help reveal some of the
reduce length of hospital stay and stimulate recov- important signs of returning GI motility. Instead of
ery of motility.17-19, 22 The recent work on early feed- approaching patients with a stethoscope in hand,
ing and other research on reducing the routine use nurses can ask how they feel and whether flatus,
of nasogastric tubes are additional contributions to bowel movements, and appetite have returned.
the growing body of evidence on recovery of post- There are additional benefits to this approach.
operative motility. Spending time with patients and listening to their
The primary markers for returning GI motility needs—as well as allowing more time to answer
after abdominal surgery are the return of flatus and questions—helps establish rapport and educate
bowel movement, indicating recovery of the patients on postoperative preventive management.
colon.27-30 Additional indications of recovery from
postoperative ileus are the patient’s ability to toler- CURRENT PRACTICE
ate oral intake without nausea or vomiting, the We created questionnaires for practitioners that
return of appetite, and an absence of other symp- were designed to identify their understanding of GI

ajn@lww.com AJN t December 2005 t Vol. 105, No. 12 43


Figure 3. Duration of Bowel Sound Assessment pain, distension, firmness, vomiting, and bowel
100
sounds (see Figure 4, page 45). The nurse experts
90 UIHC RN (n = 19) NP/WOCN (n = 54) also listed the clinical parameters they used to mon-
80 itor changes in the patient’s clinical condition and
that would prompt notification of the surgeon (see
70 Figure 5, page 45). Parameters listed most often
were vomiting, distension, pain, wound drainage,
60
Percent

and firmness.
50 The surgeon questionnaire included seven short-
answer items on the physiology of bowel recovery,
40
practice preferences, and key clinical parameters.
30 The physicians reported that the three most impor-
tant clinical parameters that indicate the return of GI
20 motility are return of flatus (89%), bowel movement
10 (44%), and appetite (44%). The majority of the sur-
geons (78%) reported that the monitoring of bowel
0 sounds by nurses is not helpful to them in patient
< 30 30–60 1 minute > 1 minute 5 minutes management. The five nursing assessments most val-
seconds seconds
ued by surgeons were the return of flatus (78%) and
Duration of Listening bowel movement (67%) (both of which are indica-
tors of recovery), and distension (44%), nausea
UIHC = University of Iowa Hospitals and clinics staff nurses; NP/WOCN = nurse practitioners (44%), and vomiting (44%) (all three of which are
with wound, ostomy, and continence certification.
negative indicators). Of interest are the differences
between nurses and surgeons in their rankings of
parameters indicating a need to notify surgeons.
motility and their current assessment practices after There are no nursing interventions associated
abdominal surgery (sample questionnaires are avail- with the presence or absence of bowel sounds.
able from the authors). We solicited nurse practi- Other assessments will reveal the absence of bowel
tioners (NPs) with wound, ostomy, and continence motility and suggest appropriate interventions. For
certification (n = 206) and selected nurse experts example, the nurse can ask the patient if he’s nause-
(who may not have had such certification) from our ated and, if so, treat the nausea. Similarly, the nurse
organization (n = 25). We also sent questionnaires may treat abdominal distension by inserting a naso-
on current practice to surgeons within our organiza- gastric tube. If distension is present in a patient who
tion (n = 15). Return of the survey was considered already has a nasogastric tube, the nurse should
an indication of consent to participate. Sixty-eight check the tube’s placement and patency.
NPs (33%) and 19 staff nurse experts (76%)
returned questionnaires. Of the 68 questionnaires CHANGING PRACTICE
from the NP group, only 54 (26%) were useable, Based on our review of the growing body of evi-
because several respondents indicated that their clin- dence in the literature and the questionnaire results
ical practice area didn’t include abdominal surgery. discussed here, we decided that a change in care
Nine (60%) of the 15 general surgeons responded. was needed. We instituted a practice change in our
The nursing questionnaires included six multiple organization, eliminating the practice of listening
choice questions, one item asking practitioners to for bowel sounds after abdominal surgery. Prior to
rank the importance of clinical parameters, and making the change, several things needed to hap-
two short answer items. The results showed that all pen. One step was to work with the nursing infor-
nurses who responded to the questionnaire contin- matics group to change the online documentation
ued to listen to bowel sounds following abdominal system to allow the documentation of useful assess-
surgery. Nearly 60% of NPs and 90% of the nurses ments rather than just listening for bowel sounds.
at our organization auscultate in four quadrants Next, we developed a program on the practice
every four to eight hours. Despite the fact that most change, to be led by two staff nurses who under-
nursing textbooks advise listening for up to five stood the evidence for not listening to bowel
minutes in each of the four quadrants to determine sounds, as well as the new documentation stan-
whether bowel sounds are present, the majority of dards and who led change on the surgical unit.
nurses actually listen for less time (see Figure 3, Prior to the staff education from nurse leaders,
above). Nurses monitor a number of other clinical we conducted a pretest to assess knowledge among
indicators of GI motility when caring for the surgical unit nurses. A poster displayed in the unit
patient who has undergone abdominal surgery. The report room reviewed the literature on the history
indicators most often ranked as important were and physiology of bowel sound assessment and the
44 AJN t December 2005 t Vol. 105, No. 12 http://www.nursingcenter.com
Figure 4. Nursing Assessment Parameters Identified as Most Important
100
90 UIHC RN (n = 19) NP/WOCN (n = 54)
80
70
60
Percent

50
40
30
20
10
0
Pain Distention Firmness Vomiting Bowel Nausea Flatus Cramping
sounds
Assessment Parameters
UIHC = University of Iowa Hospitals and Clinics staff nurses; NP/WOCN = nurse practitioners with wound, ostomy, and continence certification.

Figure 5. Clinical Parameters for Notification of Surgeon


100
90 UIHC RN (n = 19) NP/WOCN (n = 54)
80
70
60
Percent

50
40
30
20
10
0
Vomiting Distention Abdominal Wound Firmness Shoulder Nausea No bowel No flatus
pain drainage pain sounds
Clinical Parameters
UIHC = University of Iowa Hospitals and Clinics staff nurses; NP/WOCN = nurse practitioners with wound, ostomy, and continence certification.

return of GI motility, as well as results from the models and troubleshooters at the bedside. Another
questionnaires, which described the current prac- poster in the unit report room helped nurses use the
tice patterns and preferences among the NP, staff revised online documentation. Additional assess-
nurse, and surgeon groups. ment guides were placed at computers where nurses
Using evidence helped us promote acceptance of and other care providers document. Also, a pocket
the new protocol. Several nurses were selected to assessment guide was made available to each nurse
facilitate the change by training the trainers— to use when assessing patients. The guide included
working with small groups of nurses on the same 10 assessment items written on one side and, on the
shifts who would then educate other nurses. This reverse, questions to ask the patient. These tools
arrangement allowed questions to be answered as helped remind nurses to comprehensively docu-
nurses piloted the new guidelines and acted as role ment each of the relevant assessment parameters.

ajn@lww.com AJN t December 2005 t Vol. 105, No. 12 45


Table 1. Selected Studies Used in the Development of Guidelines for Nurse Monitoring of Patients
Subjects and Procedure Study Description and Relevant Findings
Benson MJ, et al. Gastroenterology 1994;106(4):924-36.
29 consecutive patients (23 patients Randomized, placebo-controlled, double-blind study
were in sample) undergoing intra- • Bowel sounds and flatus were compared as indicators of motility, but flatus was the primary clinical indicator;
abdominal surgery for sigmoid carci- both are insensitive and indirect indicators of motility.
noma; compared rectal cisapride with • Clinical resolution of ileus (passage of flatus) preceded the complete recovery of small bowel motility (bowel
placebo on proximal small bowel sounds occurred even earlier).
migrating myoelectric complex (MMC), • “Bowel sounds are thought to arise from the movement of an air–water interface in the upper gastrointestinal
monitored with manometer (GI) tract. Their return in the post-op state does not, judging from our data, correlate with the complete recov-
ery of proximal small bowel motility.” (Bowel sounds returning before motility may allow a change in treatment
or feeding.)[page 935]

Boghaert A, et al. Acta Anaesthesiol Belg 1987;38(3):195-9.


53 adult patients undergoing any type Randomized, double-blind trial
of surgery; monitored cisapride effect • Recovery of the left colon may take up to 7 days and coincides with the end of postoperative ileus.
on return of postoperative motility in • Bowel sounds may be present even though propulsive motility hasn’t yet returned.
patients with ileus • Passage of flatus, unlike the presence of bowel sounds, may be considered a direct indicator of colonic peri-
stalsis, the start of which marks the end of postoperative ileus.

Bohm B, et al. Arch Surg 1995;130(4):415-9.


12 canines underwent laparoscopic Prospective randomized, controlled study in the canine model
placement or conventional laparotomy • Postoperative motility, indicated by 1st bowel movement, returned faster after laparoscopic procedures than
for electrode placement. Myoelectric with “open” procedures.
activity was monitored during laparo- • Motility returned 1st to the small intestine, then to the stomach.
scopic right colectomy, conventional
right colectomy, or anesthesia alone;
measuring median time to return of nor-
mal myoelectrical activity

Bufo AJ, et al. Dis Colon Rectum 1994;37(12):1260-5.


38 consecutive patients (36 in sample) Nonrandomized prospective study
undergoing colorectal operations • 31 of 36 patients tolerated early feeding and had shorter mean length of hospital stay (5.7 days);
patients with traditional, conservative treatment had, on average, an 8-day stay; patients with ileus had
a 10.6-day stay.
• Most patients had return of flatus and bowel movement within 3 to 5 days (mean = 4.2 days).
• Neither bowel sounds nor flatus determined patients’ tolerance of oral intake or was a good indicator
of when to resume feeding.

Condon RE, et al. Am J Physiol 1995;269(3 Pt 1):G408-17.


48 patients undergoing elective major Experimental design with convenience sample
abdominal surgery (1984 to 1994) had • Ileus resolved 3.8 days postoperatively (range, 2 to 6 days) as indicated by flatus and bowel movement
colonic smooth muscle electrical activity (bowel sounds were not used as an indicator).
recorded • Right colon returned before left colon.
• Ileus recovery was also indicated by flatus, defecation, and the ability to consume solids without nausea or vomiting.
• Normal colonic activity was seen after the seventh postoperative day.

And finally, a resource manual helped orient new lar to assessing the conscious one. Regardless of the
nurses. The manual is updated periodically and patient’s level of awareness, the return of bowel
includes research articles, computer documentation sounds after abdominal surgery represents the
guides, survey results, and project evaluation data. return of uncoordinated contractions in the small
intestine, not propulsive contractions in the colon.
PROTOCOL LIMITATIONS The presence or absence of abdominal distension or
The practice protocol was implemented and evalu- firmness, vomiting, and bowel movements should
ated on a general surgery unit with abdominal surgery be assessed to determine the status of GI motility in
patients. The new protocol was limited to abdominal the unconscious patient. The signs that should trig-
surgery patients, because the research in the literature ger notification of the surgeon are nearly the same:
review did not include other surgical procedures or vomiting, abdominal distension or firmness, and
patient populations. The protocol may not be appro- increased wound drainage.
priate for medical patients, because their impaired Pain is an additional indicator to monitor in
motility would probably not follow the same pattern postoperative patients and may indicate impaired
seen with postoperative paralytic ileus, as described in recovery of GI motility. The use of epidural anal-
the abdominal surgery research literature. gesia has led to better pain management but
In the new protocol, assessing the unconscious requires pain assessment that’s tailored to the
patient for clinical indicators of GI motility is simi- patient’s condition.
46 AJN t December 2005 t Vol. 105, No. 12 http://www.nursingcenter.com
After Abdominal Surgery
Subjects and Procedure Study Description and Relevant Findings
Ducerf C, et al. Ann Surg 1992;215(3):237-43.
10 patients following cholecystectomy, Experimental design with convenience sample
underwent 4 days of monitoring by elec- • Defined normal postsurgical recovery as “absence of abnormal clinical signs and the presence of gas expul-
tromyographic recordings sion between 2nd and 3rd day after surgery.” [page 238]
• 3 hours after surgery, phase III of MMC was present in short duration and shorter intervals; duration of MMC
increased progressively from the 1st to the 4th postoperative day.
• A circadian pattern emerged on the 2nd day and became normal on the 4th postoperative days.

Graber JN, et al. Surgery 1982;92(1):87-92.


6 monkeys undergoing three surgical Experimental design, random order of procedure with each monkey serving as its own control
procedures • Subjects exhibited the following pattern of return of motility: antrum at 3.4 hours; small bowel at 6.5 hours;
right colon at 45 hours; sigmoid colon at 55 hours.
• Contractile activity may not be equivalent to coordinated gut propulsion.
• Colonic ileus lasted up to 48 hours, regardless of the degree of bowel handling.
• A delay in gastric emptying was seen as long as 48 hours after operation.
• Bowel movement occurred by 2nd postoperative day.
Hotokezaka M, et al. Dig Dis Sci 1996;41(5):864-9.
11 patients undergoing colon surgery; Prospective experimental design
recorded gastric myoelectric activity • Patients were given a clear liquid diet after passage of flatus or feces, followed by a regular diet when liquids
were tolerated 24 to 48 hours after surgery.
• There was no correlation between presence of gastric dysrhythmias and clinical recovery of gastrointestinal
function; rapid recovery of gastric myoelectrical activity did not correspond with clinical course of the patient
following surgery.
• The stomach recovered more slowly than the small intestine and more rapidly than the colon.

Huge A, et al. Dis Colon Rectum 2000;43(7):932-9.


19 patients undergoing left hemicolec- Experimental design with convenience sample
tomy, sigmoid resection, or primary • 18 of 19 patients had their 1st stool on postoperative day 3; 1 on postoperative day 4.
anastomosis; monitored postoperative • 7 of 19 patients had propagating contractile events on postoperative day 2 and 8 had them on postoperative day 3.
colonic tone barostat and manometry • There was no relationship between propagating contractions and flatus or 1st bowel movement. Bowel sounds
were present in 2/3 of patients on postoperative day 1 and in all by day 3. “Consequently, auscultation of
bowel sounds and recording of colonic motility did not correlate well. We suspect that the bowel sounds origi-
nated mainly in the small bowel, which has been shown to resume its motility before the colon.” [page 937]

Schippers E, et al. Dig Dis Sci 1991;36(5):621-6.


13 patients undergoing different surgical Prospective, convenience sample
procedures; measured mechanical activ- • Return of motility in small intestine did not coincide with clinical recovery from postoperative ileus.
ity in the jejunum and compared • 1st flatus occurred on 3rd postoperative day in cholecystectomy patients and on 4th day in those who under-
patients’ mechanical return of motility by went large bowel resection.
procedure and early feeding • Myoelectrical activity began on the day of the procedure in cholecystectomy patients (4.5 hours after proce-
dure) and later in those who underwent large bowel resection (56.4 hours after the procedure).
• Small intestine motility returned first and colon motility returned last.
• Feeding changed the interdigestive pattern in the small intestine within minutes of ingestion.
• Return of initial electrical and motor activity is not associated with clinical recovery from postoperative ileus (clinical
recovery was indicated by 1st flatus and 1st stool).

EVALUATION OF OUTCOMES Implementation process. We evaluated the imple-


The evaluation of evidence-based practice includes mentation process in two ways: at the time of the
three components: nursing knowledge, the process posttest, we asked the nurses to complete an addi-
of implementation, and patient outcomes. tional questionnaire on the implementation process
Nursing knowledge. The pretest and posttest to find out whether facilitation of the new guideline
instruments were identical 10-item questionnaires was adequate, and we also audited the nursing charts
that addressed those items of postoperative nursing to assess nurses’ compliance with the new guideline.
knowledge deemed most critical in the literature we The rate of response to the implementation process
reviewed. We surveyed only nurses working on the questionnaire was 42%. Eighty-five percent of RN
general surgery pilot unit. Sixty-three percent of the respondents agreed or strongly agreed (on a four-
preeducation group and 83% of the posteducation point Likert scale) that they felt prepared to imple-
group responded to the questionnaires. Respondents ment the practice change. All of the RNs agreed or
showed improvement after the educational poster strongly agreed that they felt knowledgeable enough
sessions: the pretest and posttest mean scores were to carry out the new guideline. The majority of
53% and 94% correct, respectively. One item on respondents (85%) agreed or strongly agreed that
the questionnaire accounted for all but one of the they were able to identify the postoperative signs of
wrong answers, indicating that the item probably returning gastrointestinal motility. In addition, 85%
should have been revised. of nurses reported using the guideline.

ajn@lww.com AJN t December 2005 t Vol. 105, No. 12 47


practice. We monitored patient outcomes to deter-
A New Practice Guideline mine whether discontinuing the monitoring of
bowel sounds was detrimental to patients. The
The following guideline on gastrointestinal (GI) assessment after
patient outcomes in the abdominal surgery popu-
abdominal surgery was developed as a result of the evidence-
lation that are most relevant to the return of GI
based practice project conducted by the authors.
motility are paralytic ileus, bowel obstruction, and
Policy early feeding. Comparing the preimplementation
After abdominal surgery, abdominal assessment is completed at and postimplementation patient groups revealed a
least every eight hours until the patient experiences first flatus and higher rate of paralytic ileus in the preimplementa-
first bowel movement, and then twice daily and as needed until tion group (13%) than in the postimplementation
discharge. group (4%). No bowel obstructions were docu-
mented in either of the two groups. We don’t
Procedure attribute the lower rate of paralytic ileus in the
1. Explain the procedure to the patient. postimplementation group to the introduction of
2. Interview the patient regarding the presence or absence of the new practice guideline; rather, the lower rate
the following subjective symptoms indicative of postoperative demonstrates that eliminating the monitoring of
ileus or return of GI motility: bowel sounds wasn’t detrimental to patients and
• abdominal pain, discomfort probably reflects other patient characteristics.
• flatus within the previous 8 hours Early feeding of abdominal surgery patients was
• bowel movement within the previous 12 to 24 hours, stool not evaluated, but that may be the next project for
• nausea, vomiting, or both the team.
• feeling bloated
• return of appetite, feeling hungry NURSING IMPLICATIONS
• abdominal cramps This evidence-based practice project has significant
• referred pain (for example, shoulder pain) implications for nursing. The first and most obvi-
3. Place the patient in the supine position for assessment, and ous implication concerns nurses’ time. Depending
ensure comfort (for example, raise the head of the bed slightly). on how closely a nurse follows the textbook recom-
4. Inspect the patient’s abdomen, including assessment of pres- mendations on assessing bowel sounds in postoper-
ence or absence of ative abdominal surgery patients—for up to five
• distention. minutes per quadrant—nurses could save as much
• drainage from the wound. as 20 minutes of nursing care time per patient and
5. Palpate the patient’s abdomen, if it’s distended, in a system- have time for more useful patient care activities.
atic fashion, taking care not to cause discomfort. Palpation This project also illuminated the importance of
includes assessment of presence or absence of questioning traditions. Staff nurses can improve the
• abdominal firmness. quality of care by identifying important practice
• abdominal tenderness. issues that can be addressed by examining the evi-
dence. Evidence may be scarce, but being persistent
and employing different strategies to locate it can be
effective. For example, overcoming a dearth of
available evidence may be possible by collaborating,
We evaluated nurses’ use of the new guideline by as we did, with a researcher who knows about the
auditing the charts of consecutive admissions before issue and can identify or provide relevant articles to
and after implementation, with a preimplementa- get the team started. As we learned from our expe-
tion group of 32 patients and a postimplementation rience, overcoming the initial difficulties and com-
group of 49. The results indicated that nurses pleting a project can be rewarding. Implementing
assessed for nausea, vomiting, and abdominal dis- evidence-based practice in our organization
tension before and after the new guideline was improved nursing knowledge, nursing process, and
implemented, and also assessed for flatus, bowel patient outcomes. t
movement, and appetite. Nurses documented
bowel movements before and after the new proto- REFERENCES
col was implemented as part of standard 1. Titler MG, et al. The Iowa Model of Evidence-Based
intake–output monitoring. But documentation of Practice to Promote Quality Care. Crit Care Nurs Clin
North Am 2001;13(4):497-509.
flatus (50% before implementation; 67% after 2. Nachlas MM, et al. Gastrointestinal motility studies as a
implementation) and appetite (3% before imple- guide to postoperative management. Ann Surg 1972;
mentation and 57% after implementation) both 175(4):510-22.
increased with use of the new practice protocol. 3. Interpreting abnormal abdominal sounds. Nursing 2000;
30(6):28.
Patient outcomes. Monitoring of patient out- 4. Kirton CA. Assessing bowel sounds. Nursing 1997;
comes is essential when evaluating evidence-based 27(3):64.

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5. Mehta M. Assessing the abdomen. Nursing 2003;33(5):54-5.
6. Greenhalgh T, et al. Diffusion of innovations in service
organizations: systematic review and recommendations. 3.5 HOURS
Milbank Q 2004;82(4):581-629. Continuing Education
7. Livingston EH, Passaro EP, Jr. Postoperative ileus. Dig Dis
EARN CE CREDIT ONLINE
Go to www.nursingcenter.com/CE/ajn and receive a certificate within minutes.
Sci 1990;35(1):121-32.
8. Graber JN, et al. Relationship of duration of postoperative
ileus to extent and site of operative dissection. Surgery
1982;92(1):87-92. GENERAL PURPOSE: To give registered professional nurses
9. Hotokezaka M, et al. Gastric myoelectric activity changes an opportunity to learn about an evidence-based prac-
following open abdominal surgery in humans. Dig Dis Sci tice project conducted to see whether any compelling
1996;41(5):864-9. evidence exists for listening to bowel sounds to assess
10. Schippers E, et al. Return of interdigestive motor complex for the return of gastrointestinal (GI) motility after
after abdominal surgery. End of postoperative ileus? Dig abdominal surgery.
Dis Sci 1991;36(5):621-6.
GENERAL PURPOSE: After reading this article and taking
11. Bohm B, et al. Postoperative intestinal motility following the test on the next page, you will be able to:
conventional and laparoscopic intestinal surgery. Arch Surg
1995;130(4):415-9. • describe the background information the authors
12. Boghaert A, et al. Placebo-controlled trial of cisapride in considered in designing their study.
postoperative ileus. Acta Anaesthesiol Belg 1987;38(3): • outline the methodology they used and the factors
195-9. considered in conducting their study.
13. Rothnie NG, et al. Early postoperative gastrointestinal • discuss the authors’ results and conclusions related
activity. Lancet 1963;2:64-7. to nursing practice guidelines for assessing the
14. Benson MJ, et al. Small bowel motility following major return of GI motility.
intra-abdominal surgery: the effects of opiates and rectal cis-
apride. Gastroenterology 1994;106(4):924-36. TEST INSTRUCTIONS
15. Huge A, et al. Postoperative colonic motility and tone in To take the test online, go to our secure Web site at
patients after colorectal surgery. Dis Colon Rectum www.nursingcenter.com/CE/ajn.
2000;43(7):932-9.
To use the form provided in this issue,
16. Morris IR, et al. Changes in small bowel myoelectrical
activity following laparotomy. Br J Surg 1983;70(9):547-8.
• record your answers in the test answer section of the
CE enrollment form between pages 48 and 49.
17. Behrns KE, et al. Prospective randomized trial of early initi-
ation and hospital discharge on a liquid diet following elec-
Each question has only one correct answer. You
tive intestinal surgery. J Gastrointest Surg 2000;4(2):217-21. may make copies of the form. Test code AJN2405.
18. Lewis SJ, et al. Early enteral feeding versus “nil by mouth”
• complete the registration information and course evalu-
after gastrointestinal surgery: systematic review and meta- ation. Mail the completed enrollment form and regis-
analysis of controlled trials. BMJ 2001;323(7316):773-6. tration fee of $22.75 to Lippincott Williams and
19. Fearon KC, Luff R. The nutritional management of surgical Wilkins CE Group, 2710 Yorktowne Blvd., Brick, NJ
patients: enhanced recovery after surgery. Proc Nutr Soc 08723, by December 31, 2007. You will receive
2003;62(4):807-11. your certificate in four to six weeks. For faster service,
20. Holte K, Kehlet H. Prevention of postoperative ileus. include a fax number and we will fax your certificate
Minerva Anestesiol 2002;68(4):152-6. within two business days of receiving your enrollment
21. Nygren J, et al. New developments facilitating nutritional form. You will receive your CE certificate of earned
intake after gastrointestinal surgery. Curr Opin Clin Nutr contact hours and an answer key to review your
Metab Care 2003;6(5):593-7. results. There is no minimum passing grade.
22. Bufo AJ, et al. Early postoperative feeding. Dis Colon
Rectum 1994;37(12):1260-5.
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• Send two or more tests in any nursing journal published
23. Feo CV, et al. Early oral feeding after colorectal resection:
a randomized controlled study. ANZ J Surg 2004;74(5):
by Lippincott Williams and Wilkins (LWW) together,
298-301. and deduct $0.95 from the price of each test.
24. Gocmen A, et al. Early post-operative feeding after cae-
• We also offer CE accounts for hospitals and other
sarean delivery. J Int Med Res 2002;30(5):506-11. health care facilities online at www.nursingcenter.
25. Mangesi L, Hofmeyr GJ. Early compared with delayed oral
com. Call (800) 787-8985 for details.
fluids and food after caesarean section. Cochrane Database PROVIDER ACCREDITATION
Syst Rev 2002(3):CD003516. This continuing nursing education (CNE) activity for 3.5
26. Seven H, et al. A randomized controlled trial of early oral contact hours is provided by LWW, which is accredited
feeding in laryngectomized patients. Laryngoscope as a provider of continuing nursing education by the
2003;113(6):1076-9.
American Nurses Credentialing Center’s Commission on
27. Bauer JJ, et al. Is routine postoperative nasogastric decom- Accreditation and by the American Association of
pression really necessary? Ann Surg 1985;201(2):233-6.
Critical-Care Nurses (AACN 00012278, CERP
28. Ducerf C, et al. Postoperative electromyographic profile in Category A). This activity is also provider approved by
human jejunum. Ann Surg 1992;215(3):237-43.
the California Board of Registered Nursing, provider
29. Thoren T, et al. Effects of epidural bupivacaine and epidural number CEP 11749 for 3.5 contact hours. LWW is also
morphine on bowel function and pain after hysterectomy.
Acta Anaesthesiol Scand 1989;33(2):181-5.
an approved provider of CNE in Alabama, Florida, and
Iowa, and holds the following provider numbers:
30. Tollesson PO, et al. A radiologic method for the study of
postoperative colonic motility in humans. Scand J
AL #ABNP0114, FL #FBN2454, IA #75. All of its home
Gastroenterol 1991;26(8):887-96. study activities are classified for Texas nursing continuing
31. Condon RE, et al. Human colonic smooth muscle electrical
education requirements as Type 1. Your certificate is valid
activity during and after recovery from postoperative ileus. in all states. This means that your certificate of earned
Am J Physiol 1995;269(3 Pt 1):G408-17. contact hours is valid no matter where you live.

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