Research for Practice

Return of Bowel Sounds Indicating An End of Postoperative Ileus: Is it Time to Cease this Long-Standing Nursing Tradition?
Robert L. Massey

phenomenon commonly known as postoperative ileus (POI) occurs almost universally among the millions of patients worldwide who undergo abdominal surgery. POI is a form of gastrointestinal (GI) dysmotility causing a build-up of gas and fluid within the GI tract lasting 3-5 days after abdominal surgery (Maron & Fry, 2008; Massey, 2010; Person & Wexner, 2006). Historically, nurses and physicians have been trained to ascultate daily for at least 5 minutes in each of the four abdominal quadrants (20 minutes total) for the return of bowel sounds after abdominal surgery (Madsen et al., 2005). Over time, this has evolved as an indicator of the resolution of POI. However, the efficacy of auscultation for return of bowel sounds as an indicator for the resolution of POI has been questioned through evidence-based inquiry. Using the Iowa Model of EvidenceBased Practice (Titler et al., 2001), Madsen and colleagues (2005) explored the evidence and actual clinical practice to determine if auscultation of the abdomen for the return of bowel sounds was a reliable indicator of the return of GI motility and thus an end to POI in patients recovering from abdominal surgery. Determination of the primary endpoint indicator for an end to POI (return of bowel sounds, first flatus and/or bowel movement after surgery, tolerating a diet) remains controversial (Delaney et al., 2010; Huge

Evidence and rationale supporting return of bowel sounds as an unreliable indicator of the end of postoperative ileus after abdominal surgery are provided.

Introduction A loss of gastrointestinal motility, commonly known as postoperative ileus (POI), occurs after abdominal surgery. Since the 1900s, nurses and other clinicians have been taught to listen for return of bowel sounds to indicate the end of POI. Evidence-based nursing literature has challenged this long-standing traditional nursing practice. Purpose The purpose of this study was to provide evidence from a randomized clinical trial and rationale supporting evidence-based inquiry concerning return of bowel sounds as an unreliable indicator of the end of POI after abdominal surgery. Method Time (days) of return of bowel sounds after abdominal surgery was compared to the time (days) of first postoperative flatus, an indicator of the end of POI, in 66 patients recovering from abdominal surgery randomized to receive standard care compared to those who received standard care plus a rocking chair intervention. Findings Pearsons correlation between time to first flatus and return of bowel sounds for combined groups was not significant (r=0.231, p=0.062, p<0.05) indicating that time to return of bowel sounds and time to first flatus were not associated. Conclusions The results of this study provide support to evidence-based inquiry that questions the relevance of traditional nursing practice activities such as listening to bowel sounds as an indicator of the end of POI.

Robert L. Massey, PhD, RN, NEA-BC, is Assistant Professor and Director, Clinical Nursing, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

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et al., 2000; Person & Wexner, 2006; Prasad & Matthews, 1999; Stewart & Waxman, 2007; Thomas, Ptak, Giddings, Moore, & Oppermann, 1990; Waldhausen, Shaffrey, Skenderis, Jones, & Schirmer, 1990). Previous research has questioned the reliability of return of bowel sounds as an indicator for the end of POI, supporting Madsen and colleagues (2005) evidence-based inquiry versus multiple indicators (first flatus and/or bowel movement) for the end of POI (Huge et al., 2000; Waldhausen & Schirmer, 1990). However, previous research did not compare return of bowel sounds to a specific indicator, such as first postoperative flatus, for the end of POI. Therefore, design of the randomized trial of rocking chair therapy included measuring the date and time of return of bowel sounds as the primary indicator for the end of POI, date and time of passage of first postoperative flatus, and determining if there was an association. In this article the results of the study are reported and rationale is presented for why return of bowel sounds is probably not an indicator for return of POI.

use; however, more research is required to validate their contributions (Kehlet, 2008; Maron & Fry, 2008). The duration of POI is in part related to the degree of surgical trauma and appears to be most severe following extensive surgeries of the colon, especially those requiring reanastomosis (Huge et al., 2000; Kehlet, 2008; Maron & Fry, 2008; Person & Wexner, 2006). POI, one of the most significant side effects of abdominal surgery, can last 3-5 days and result in an average hospital stay of 7-8 days. It adds billions of dollars to health care costs annually (Miedema & Johnson, 2003; Person & Wexner, 2006). Patients often describe the period immediately after surgery, until the resolution of POI, as the most uncomfortable part of their abdominal surgery recovery experience (Massey, 2010; Moore, Shannon, Richard, & Vacca, 1995; Thomas et al., 1990).

Literature Review
Review of the literature for this article included MEDLINE, SCOPUS, and CINHAL searches plus a snowball method due to alterations in bowel motility being first identified in the 1890s and Cannon proposing auscultation for return of bowel sounds in 1905 (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Nachlas, Younis, Roda, & Wityk, 1972). Nursing research regarding correlations between auscultation of bowel sounds and resolution of POI are limited although there have been case studies reported in the literature (Kirton, 1997; Mehta, 2003); therefore, the reliance on the surgical literature. Clinical standards for determining the prevention, treatment, and end of POI continue to be as confounding as the multiple combinations of contributing factors that cause it (Huge et al., 2000; Kehlet, 2008; Maron & Fry, 2008; Person & Wexner, 2006). Current clinical practice protocols include daily auscultation of the patients abdomen for the return of bowel sounds plus monitoring the patient for the passage of flatus, a phenomenon traditionally called surgeons music (Prasad &

Background
Postoperative ileus occurs universally after abdominal surgery (open and laparoscopic), resulting in absent or delayed gastrointestinal motility that causes gas and fluid retention within the GI tract (Delaney, 2004; Kehlet, 2008; Maron & Fry, 2008; Person & Wexner, 2006; Stewart & Waxman, 2007). Patients experience a symptom cluster that includes nausea, vomiting, abdominal distention, diet intolerance, pain, and is generally a self-resolving phenomenon complicating a full and timely recovery of the postabdominal surgery patient (Delaney et al., 2010; Massey, 2010). Abdominal incisions, manipulation of the bowel, and extensive dissection required to remove abdominal lesions initiate a surgical-induced stress response believed to be the primary cause of POI (Desborough, 2000; Person & Wexner, 2006). Other causes may include inflammation, hormonal effects, and opioid

Matthews, 1999, p. 489) and/or passage of stool. Postoperative return of bowel function within the GI tract varies by location. The return of function appears to occur first in the small intestine within 24 hours after surgery, the stomach in 24-48 hours, and the colon within 3-5 days (Huge et al., 2000; Stewart & Waxman, 2007; Waldhausen & Schirmer, 1990; Waldhausen et al., 1990) Waldhausen and colleagues (1990) first indicated the passage of flatus usually preceded the first bowel movement, and the two events generally occur with 24 hours of each other. The first bowel movements after abdominal surgery are liquid in nature, a phenomenon supporting POIs link to a build-up of gas and fluid within the bowel rather than the hard, dry stool common with constipation. Evidence supports the use of passage of first flatus after surgery as the indicator to define the return of GI motility (Madsen et al., 2005; Maron & Fry, 2008; Massey, 2010; Person & Wexner, 2006; Prasad & Matthews, 1999; Waldhausen et al., 1990). Other parameters may include absence of a symptom cluster that includes abdominal distention, nausea, vomiting, pain, and the inability to tolerate a diet until the resolution of POI (Delaney, 2004; Delaney et al., 2010; Madsen et al., 2005; Maron & Fry, 2008; Person & Wexner, 2006). More studies are required to determine the reliability and validity of passage of first postoperative flatus and absence of abdominal distention, nausea vomiting, and tolerance of diet to indicate a return of GI motility or the end of POI.

Bowel Sounds
Findings from seminal studies involving electrode implantation during laparotomy supported suspicions that bowel function may never cease fully during or after abdominal surgery and created further doubt regarding the reliability of using presence of bowel sounds as an indicator of POI resolution (Huge et al., 2000; Waldhausen & Schirmer, 1990; Waldhausen et al., 1990). Past research also has failed to find any positive correlations between bowel sounds and actual propulsive bowel

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TABLE 1. Time to Return of Bowel Sounds
Mean Time to Bowel Sounds (Days) Day 1 Day 1 Day 2 Day 3 Rocking Non-Rocking

such as reduced pulmonary complications, deep vein thrombosis, and other negative physiological changes associated with bed rest.
p

n
1 25 8

% 2.9 75.3 23.5

n
1 22 9

% 3.1 68.8 28.1

Rocking Chair Intervention

A rocking motion delivered using a rocking chair is a relatively new nursing-derived noninvasive procedure believed to reduce the duration and effects of POI. Findings of three nursing studies demonstrated efficacy of rocking chair motion in reducing POI duration in patients after abdominal surgery and cesarean section (Massey, 2010; Moore et al., 1995; Thomas et al., 1990). Rocking motion has also been used by nurses to calm infants and symptoms of dementia in older adults (Bonadonna, 1981; Houston, 1993; Vrugt & Pederson, 1973). The gentle rhythmic rocking chair motion is thought to modulate the surgical stress response through vestibular nerve stimulation of the reticular activating system, thus mitigating the effects of POI. The rationale for this study was to evaluate the efficacy of rocking chair motion on the duration of POI in patients recovering from abdominal surgery. A secondary aim was to compare the return of bowel sounds with an indicator of the end of POI. Previous research reported a lack of association in randomized trials with design limitations, and studies that compared multiple therapies to rocking chair motion or lacked a specific indicator for the resolution of POI (Huge et al., 2000; Moore et al., 1995; Thomas et al., 1990; Waldhausen & Schirmer, 1990; Waldhausen et al., 1990). A gap existed in the literature regarding an association between return of bowel sounds and a specific indicator for the resolution of POI.

0.909

functioning, thereby lending even more doubt to the reliability of bowel sounds as an indicator of the resolution of POI. In a study of 44 patients undergoing laparotomy, bowel sounds returned on day 2.4 (0.4 days) and passage of flatus and stool occurred on day 5.1 (0.2 days), indicating no correlation between onset of bowel sounds and the resolution of POI (Waldhausen et al., 1990). Also complicating the assessment and treatment of POI after abdominal surgery are other findings that suggest some postoperative patients with normal active bowel sounds continue to suffer from symptoms indicating a lack of GI motility (Huge et al., 2000; Waldhausen et al., 1990). In these studies, patients with normal, active postoperative bowel sounds continued to experience the symptom cluster associated with POI that included abdominal distention, nausea, vomiting, and diet intolerance.

Common Clinical Practice

Despite a lack of compelling evidence, clinical practice continues to promote daily auscultation of the abdomen for a minimum of 5 minutes in each quadrant to determine the return of bowel sounds as an indicator for resolution of POI. In the practice evaluation conducted by Madsen and co-authors (2005) (N=82), 54 advanced practice nurses, 19 staff nurse experts, and 9 surgeons responded to a questionnaire of current practice. Of the 54 advanced practice respondents, 60% (n=32) and 90% (n=17) of the clinical nurses reported they ascultate in four quadrants every 4-8 hours. However, less than 10% (n=5) of the APNs and none of the clinical nurses

reported listening for the recommended 5 minutes in each quadrant of the abdomen. Almost 50% (n=27) of the advanced practice nurses and at least 40% (n= 8) of staff nurses indicated they listen for 30-60 seconds in each quadrant rather than 5 minutes as stipulated in clinical practice guidelines at the institution. Of surgeons, 78% (n=7) reported little benefit from nurses assessing and reporting bowel sounds indicating resolution of POI. Instead, they identified return of flatus (89%, n=8), bowel movement (44%, n=4), and return of appetite (44%, n=4) as primary parameters to indicate POI resolution. They concluded passage of first postoperative flatus, bowel movement, and the concurrent resolution of a symptom cluster (abdominal distention, nausea, vomiting, and diet tolerance) were more reliable indicators for return of GI motility and resolution of POI. As a result of the evidence-based review, the assessment of bowel sounds as a primary indicator of the resolution of POI was discontinued.

Standard Postoperative Care

One noninvasive, postoperative standard of care intervention that is believed to resolve POI is to have the patient get out of bed, sit in a chair, and walk beginning the first postoperative day, increasing the duration each day until passage of flatus or stool occurs (Brieger, 1983; Luckey, Livingston, & Tache, 2003; Waldhausen & Schirmer, 1990; Waldhausen et al., 1990). Evidence that these activities effectively reduce the duration of POI remain unconvincing. However, consensus indicates the postoperative patient experiences other positive benefits,

Methods
Guided by previous evidence, evaluation of the association between onset of bowel sounds and time to first flatus to indicate the resolution of POI was included in a randomized clinical study comparing the effect of rocking chair motion and standard care on postoperative ileus duration in patients with can-

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cer recovering from abdominal surgery (Massey, 2010).

Design
A two-group, post-test only, randomly assigned study completed in 2007 at a major Southwestern cancer center compared the effect of rocking chair motion and standard care on POI duration. This post-test design was chosen because measurement for resolution of POI could occur only after abdominal surgery. The studys primary aim was to examine differences in the duration of POI as indicated by time to passage of first flatus in days between two groups of patients recovering from surgery performed to remove cancerous gastrointestinal tumors (standard care or standard care plus the rocking intervention). Standard postoperative care involved having the patient out of bed sitting in a non-rocking chair and ambulating beginning the first postoperative day, with care continuing until resolution of POI indicated by passage of first postoperative flatus. Care for the intervention group care involved having the patient out of bed rocking in a rocking chair in 10-20 minute increments for at least 1 hour per day, ambulating beginning the first postoperative day, and continuing until passage of first postoperative flatus. There were no significant differences in time rocking in rocking chairs, time sitting in nonrocking chairs, and distances ambulated between the two groups. A secondary aim of the study was to determine if there was an association between the time (day) bowel sounds first were heard with the time (day) passage of first flatus, the indicator used in the study, to indicate the resolution of POI.

patients with digestive system cancers scheduled to undergo abdominal surgery, English speaking, cognitively intact, able to ambulate and sit in a chair or rocking chair, and able to receive patient-controlled intravenous or epidural analgesia. Research team members interviewed patients during their preoperative evaluation in a private room in the Anesthesia Assessment Center. After patients received an explanation of the studys purpose and were allowed to ask questions, they signed a consent form if they desired to participate. Those agreeing to participate were randomized to receive either the standard care (non-rocking) or standard care plus the rocking intervention. Beginning the first postoperative day, the primary investigator assessed the patients at the same time each morning for return of bowel sounds and passage of first flatus. A review of the patients medical record was completed each day after surgery to identify any documentation (date/time) of a return of bowel sounds and/or passage of first flatus by nurses and/or surgeons. Auscultation of all quadrants of the abdomen for 5 minutes was performed by the primary investigator for the presence of bowel sounds regardless of any documentation of bowel sounds in the medical record. All data were documented on a study data sheet by the primary investigator.

not significant (r=0.231, p=0.062), indicating return of bowel sounds and time to first flatus were not associated. Findings from the Massey study support results reported by Madsen and colleagues (2005) for the evidence-based project challenging the auscultation of bowels as a reliable indicator for the end of POI. No association existed between the return of bowel sounds and the end of POI, supporting past evidence and a physiological basis for use of bowel sounds as most likely a poor indicator for the end of POI (Huge et al., 2000; Maron & Fry, 2008; Person & Wexner, 2006; Stewart & Waxman, 2007; Waldhausen & Schirmer, 1990; Waldhausen et al., 1990). Gastrointestinal motility returns in a specific sequence: small bowel within 24 hours, stomach 24-48 hours, and colon 72-120 hours after abdominal surgery. The resolution of POI is also dependent upon return of colon function, the last segment of the GI tract to experience return of motility after abdominal surgery (Delaney, 2004; Kehlet, 2008; Maron & Fry, 2008; Miedema & Johnson, 2003; Person & Wexner, 2006; Stewart & Waxman, 2007). Therefore, nurses should approach the use of return of bowel sounds with caution as an indicator of the end of POI in surgical patients after abdominal surgery.

Results
Sixty-six patients were enrolled in the study, and randomized either to the control (non-rocking) group (n=32) or rocking group (n=34) prior to surgery. Time to first bowel sounds and time to first flatus data were distributed normally, homogeneous for both groups, and indicated no significant differences between the rocking and non-rocking groups (see Table 1). No statistically significant differences were found in time to first bowel sounds between the non-rocking (M=2.25, SD=0.50) and rocking (M=2.21, SD=0.48) groups (t (64)=0.363, p=0.718, p<0.05). Pearsons correlation between time to first flatus and return of bowel sounds for combined groups was

Implications for Nursing

The auscultation for the return of bowel sounds to indicate return of GI motility and/or resolution of POI after abdominal surgery may be a practice tradition that should be used with caution and possibly replaced with other, more reliable indicators for the end of POI after abdominal surgery. Passage of first postoperative flatus, elimination of abdominal distention, nausea, vomiting, and tolerance of diet are indicators that appear to be more reliable indicators for the end of POI (Delaney et al., 2010; Kehlet, 2008; Maron & Fry, 2008; Person & Wexner, 2006; Stewart & Waxman, 2007). Future research and evidencebased evaluation of the passage of
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Procedures
Approval was obtained from the University of Texas MD Anderson Cancer Center Institutional Review Board prior to implementation of the study. Informed consent was obtained prior to surgery from patients who met eligibility criteria. Participant inclusion criteria were all

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first flatus, elimination of abdominal distention, nausea, vomiting, and tolerance of diet is needed and their roles in the resolution of POI is needed. In the meantime, nurses should use the return of bowel sounds with caution as an indicator of the resolution of POI in patients recovering from abdominal surgery.
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