Intestinal Obstruction Prof: Panicker; Health Alterations I Description • An intestinal (bowel) obstruction is a condition where intestinal contents are prevented from passing through the gastrointestinal tract. • Not a disease, but often a secondary diagnosis to several causative maladies (disease). • Often requires immediate medical attention • Can be life-threatening if untreated Etiology and Pathophysiology Intestinal obstruction leads to proximal dilation of the intestine due to accumulation of gastrointestinal secretions and swallowed air. This bowel dilatation stimulates cell secretory activity, resulting in more fluid accumulation. This leads to increased peristalsis above and below the obstruction, with frequent loose stools and flatus early in its course. Etiology and Pathophysiology Intestinal Obstructions are classified into 2 primary categories: Mechanical Obstructions: •Adhesions (stuck together) •Hernias •Neoplasms (cancer) Non-mechanical obstructions: •Ileuses Etiology and Pathophysiology Once the type of obstruction is identified, it is further classified as either: •Complete (nothing pass through) •Partial (some sweep through) Etiology and Pathophysiology Common causes of intestinal obstructions • Adhesions • Strangulated inguinal hernia • Ileocecal intussusception • • • • Intussusception from polyps (Telescope) Mesenteric occlusion (Ischemia) Neoplasm (Abnormal Mass) Volvulus of the sigmoid colon (Twisting) Etiology and Pathophysiology Abdominal adhesions are bands of fibrous tissue that form between abdominal tissues and organs usually as a result of surgery or injury. Etiology and Pathophysiology A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Etiology and Pathophysiology Intussusception A condition in which a part of the intestine has invaginated into another section of intestine, like the way in which the parts of a collapsible telescope slide into one another. Etiology and Pathophysiology Mesenteric Occlusion An example of a non-mechanical obstruction that results usually from ischemia caused by the blockage of the mesenteric vein. Etiology and Pathophysiology Neoplasm An abnormal mass of tissue. For the purposes of this presentation a neoplasm, whether malignant or benign, need only be large enough, or located in such a way as to impede forward movement of intestinal contents. Etiology and Pathophysiology Volvulus of the Sigmoid Colon The twisting of the colon at the site where it joins its mesenteric pedicle Etiology and Pathophysiology Inflammatory Bowel Disease Crohn’s Disease Ulcerative Colitis Etiology and Pathophysiology Ileus(es) Are another non-mechanical form of obstruction often caused by paralysis of part of the intestine due to surgery. Etiology and Pathophysiology The three most common causes of intestinal obstructions are: • Intestinal adhesion • Hernias: ventral, inguinal, femoral, internal • Neoplasms: malignant (primary/metastatic), benign Etiology and Pathophysiology Surgical causes of abdominal adhesions may include, but are not limited to: • tissue incisions • the handling of internal organs • the drying out of internal organs and tissues • contact of internal tissues with foreign materials • blood or blood clots that were not rinsed out during surgery Etiology and Pathophysiology Less common causes of abdominal adhesions are inflammation from sources not related to surgery, including: • appendicitis—in particular, appendix rupture • radiation treatment for cancer • gynecological infections • abdominal infections ★Rarely do abdominal adhesions form without apparent cause. Clinical Manifestations Abdominal swelling (distention) Abdominal fullness from inability to pass gas Abdominal pain and cramping Breath odor (fecal odor) Nausea Vomiting - Associated more with proximal obstructions Diarrhea - An early finding Constipation – a late finding, as evidenced by the absence of flatus or bowel movements • Fever and tachycardia - Occur late and may be associated with strangulation • Previous abdominal or pelvic surgery, previous radiation therapy, or both May be part of the patient's medical history • History of malignancy - Particularly ovarian and colonic malignancy • • • • • • • • Complications • Complications may include or may lead to: • Electrolyte imbalances (Metabolic Alkalosis: High Obstruction) • Dehydration (Rapid in Small Intestine) • Perforation of the intestine • Infection • Jaundice • If the obstruction blocks the blood supply to the intestine, it may cause infection and tissue death (gangrene). Risks for tissue death are related to the cause of the blockage and how long it has been present. Hernias, volvulus, and intussusception carry a higher gangrene risk. • In a newborn, paralytic ileus that destroys the bowel wall (necrotizing enterocolitis) is life-threatening and may lead to blood and lung infections. Collaborative Care • Emergency surgery is performed if the bowel is strangulated. • Many bowel obstructions are resolved by placing the patient on NPO status, inserting an NG tube and IV fluid resuscitation with potassium. • If above treatment fails, surgery is performed to remedy the problem. Relief, resection or removal are all standard. • In cases of surgery, parenteral nutrition and ostomy care and instruction may be required. Nursing Management Assessment • Detailed patient history • Physical examination • Determine type and location of obstruction based on characteristic symptoms. • Determine location, duration, intensity, and frequency of abdominal pain, and whether abdominal tenderness or rigidity is present. • Record the onset, frequency, color, odor, and amount of vomitus. Nursing Management Assessment • Assess bowel function, including passage of flatus. • Ascultate for bowel sounds and document their character and location. • Inspect the abdomen for scars, visible masses and distention. • Measure the abdominal girth, and palpate for muscle guarding and tenderness, as these can be signs of peritoneal irritation and may indicate strangulation. Nursing Management Assessment If the surgeon elects to wait and see if the obstruction resolves on its own: • Assess the abdomen regularly • Monitor patient for complaints of abdominal pain • Assess for leukocytosis (elevated WBS=site of infection), fever, and tachycardia • Maintain a strict intake and output record, including emesis and tube drainage Nursing Management Assessment If a urinary catheter is ordered to monitor hourly urine outputs: • Immediately report a urine output of less than 0.5 mL/kg of body weight per hour because it signals inadequate vascular volume and the potential for acute kidney failure. • Monitor for rising creatinine and BUN levels as these are also indicators for acute kidney failure. Nursing Management Diagnosis Nursing diagnoses for the patient with intestinal obstructions include, but are not limited to, the following: • Acute pain related to abdominal distention and increased peristalsis. • Deficient fluid volume related to decrease in intestinal fluid absorption, third space fluid shifts into the bowel lumen and peritoneal cavity, nasogastric suction and vomiting. • Imbalanced nutrition: less than body requirements related to intestinal obstruction and vomiting. Nursing Management Planning The overall goals the patient with an intestinal obstruction will have: • relief of the obstruction and return to normal bowel functions, • minimal to no discomfort • normal fluid, electrolyte and acid-base status Nursing Management Interventions • Monitor closely for signs of dehydration and electrolyte imbalances. • Administer IV fluids as ordered • Watch carefully for symptoms of fluid overload • Monitor serum electrolytes carefully • Provide comfort measures • Promote restful environment Nursing Management Interventions For care of postoperative patients • Maintain nasogastric tube • Upper GI tract procedures may return dark brown or dark red drainage for the first 12 hours. • After 12 hours expect light yellowish-brown returns, possibly tinged green due to the presence of bile. • If dark or bright red continues or appears it may indicate hemorrhage. Contact health care provider immediately. • “Coffee-ground” granules in the drainage indicate blood that has been modified by acidic gastric secretions. Nursing Management Interventions Post-surgical abdominal distentions can be caused by: • Swallowed air • Reduced peristalsis • Decreased mobility • Manipulation of the abdominal organs • Anesthesia Nursing Management Evaluation Evaluation of the patient with intestinal obstruction include, but are not limited to the following: • Resolution of the cause of the acute pain • Reduced or absent abdominal distention • Returned peristalsis • Normal fluid volume and electrolyte status • Normal nutritional status Diagnostic Tools The quick and certain diagnosis of intestinal obstructions is part of the best course of treatment. • • • • Abdominal CT scan Abdominal X-ray Endo/colonoscopy Upper GI and small bowel series (X-Ray) Student Response Question • The nurse caring for a client with bowel obstruction would plan to implement which nursing intervention first? a. Administer pain medication b. Obtain a blood sample for laboratory studies c. Prepare to insert a nasogastric (NG) tube d. Administer I.V. fluids Student Response Question A patient is admitted with small bowel obstruction from adhesions. Which of the following is NOT an expected finding with this diagnosis? a) Vomitus more than 500 mL and has a fecal odor b) The patient's abdominal pain is persistent and colicky c) The abdomen is firm, rigid, and has positive rebound tenderness (peritonitis) d) The patient states the pain is improved after vomiting Student Response Question A patient is admitted with small bowel obstruction and has a NGT as part of the treatment plan. Which of the following are appropriate actions for the nurse to take in managing the patient's care? (Select all that apply) a) Include the NGT drainage as part of the patient's output b) Assess bowel sounds frequently c) provide oral care d) clamp the NGT for long periods of time whenever the nurse feels it is appropriate
