sensation of needing to urinate may temporarily decrease from operative trauma in the
region near the bladder. The fear of pain may cause the patient to feel tense and have
(1) If the patient does not have a catheter, and has not voided within eight
hours after return to the nursing unit, report this event to the supervisor.
(2) Palpate the patient's bladder for distention and assess the patient's
response. The area over the bladder may feel rounder and slightly cooler than the rest of
the abdomen. The patient may tell you that he feels a sense of fullness and urgency.
Assist the patient to void.
Assist the patient to the bathroom or provide privacy.
Position the patient comfortably on the bedpan or offer the urinal.
(4) Measure and record urine output. If the first urine voided following surgery
is less than 30 cc, notify the supervisor.
(5) If there is blood or other abnormal content in the urine, or the patient
complains of pain when voiding, report this to the supervisor.
(6) Follow nursing unit standing operating procedures (SOP) for infection
control, when caring for the patient with a Foley catheter.
d. Gastrointestinal System. Inactivity and altered fluid and food intake during the
perioperative period alter gastrointestinal activities. Nausea and vomiting may result from
an accumulation of stomach contents before peristalsis returns or from manipulation of
organs during the surgical procedure if the patient had abdominal surgery.
Report to the supervisor if the patient complains of abdominal distention.
Ask the patient if he has passed gas since returning from surgery.
(3) Auscultate for bowel sounds. Report your assessment to the supervisor,
and document in nursing notes.
(4) Assess abdominal distention, especially if bowel sounds are not audible or
are high-pitched, indicating an absence of peristalsis.
Provide a privacy so that the patient will feel comfortable expelling gas.
Encourage food and fluid intake when the patient in no longer NPO.