Elimination/Bowel Obstruction

characterized by lack of intestinal peristalsis and bowel sounds

paralytic ileus

Bowel obstruction will always present with absent bowel sounds TRUE/FALSE

False

What is the most common cause of mechanical colon obstruction

cancer

Five Years have passed. On a slow-ish Tuesday night you realize the next patient being worked up is you old friend, AD! He presents with nausea and vomiting. Abdomen is distended. Bowel sounds are present, slightly hyperactive. He has not had a bowel movement in 6 days. The physician suspects a bowel obstruction. What type of obstruction do you suspect? A. Mechanical due to surgical adhesions/scar tissue B. Non-Mechanical post operative ileus C. Mechanical - intussusception

A (Yes - with his history of abdominal surgeries, and presence of bowel sounds the most likely type of obstruction would be mechanical.)

High Intestinal Obstruction Onset: A. Acute B. Slow/insidious Pain: A: Less intensity, vague and mild or sharp and severe, depending on the cause B. Crampy pain, colicky, intermittent Vomiting: A. Late, feculent odor may be absent, but serious if noted B. Early, profuse, biliary Abdominal distension A. Greatly increased B. Increased Constipation: A. Absolute constipation with lack of flatus and some diarrhea B. +Feces for a short time? Electrolytes: A. Rapid loss of Cl, K, Na B. Late imbalance?

A, B, B, A, B, A

After a few more days in the hospital, you are finally ready to discharge A.D. In his discharge instructions you will include: A. Eat small, soft, frequent meals B. Maintain a high carbohydrate, high protein diet C. Monitor incision for redness, swelling, or drainage. Notify health care provider if these occur. D. Report any increased nausea and/or vomiting, epigastric pain, bloody emesis, or tarry stools. E. Eliminate high concentrated sweets from the diet. F. Limit fluid intake to 1 quart a day. G. Avoid using NSAIDS for pain relief

A, C, D, E, G (A: eating smaller meals more frequently will decrease the risk of nausea and dumping syndrome. Softer foods will be better at first for his healing stomach. C. Signs of infection D. Would be a sign GI tract bleeding E: with removal of part of the stomach, he is at risk for dumping syndrome and post-prandial hypoglycemia, so less concentrated sweets will be best. G: We know AD is prone to ulcers, and since NSAIDs are linked to ulcer risk, he should avoid this category of medication.)

Which type of obstruction will most often result in diminished or absent bowel sounds? A. Mechanical B. Non-Mechanical

B

Low Intestinal Obstruction Onset: A. Acute B. Slow/insidious Pain: A: Less intensity, vague and mild or sharp and severe, depending on the cause B. Crampy pain, colicky, intermittent Vomiting: A. Late, feculent odor may be absent, but serious if noted B. Early, profuse, biliary Abdominal distension A. Greatly increased B. Increased Constipation: A. Absolute constipation with lack of flatus and some diarrhea B. +Feces for a short time? Electrolytes: A. Rapid loss of Cl, K, Na B. Late imbalance?

B, A, A, B, A, B

Until A.D's obstruction resolves, you anticipate orders for: A. Jejunostomy/J-Tube B. IV Fluids or TPN C. Activity: Strict Bedrest D. NG tube to low continuous suction E. Strict I/O F. Activity: Up with assist G. Regular diet H. NPO I. Chloraseptic or lidocaine throat spray J. IV Proton Pump inhibitor (such as Pantoprazole) K. Ibuprofen (Advil/Motrin) PO for pain

B, D, E, F, H, I, J (B: We need to make sure AD doesn't become dehydrated/under-nourished D: With a bowel obstruction (mechanical or non-mechanical) the course of treatment is NG to suction to remove all gastric contents to "decompress" the GI tract to prevent N/V E. We must ensure AD is not become dehydrated and I/O measurements are critical for this F. We want to avoid further complications d/t immobility (weakness/pneumonia, etc) H. No bowel sounds/obstruction= NPO status I. This can be an effective treatment for the sore throat may pts have d/t large tube in their throat. If allowed, lozenges or ice chips can also help J: We know that AD has problems with ulcers, so a PPI IV push would be reasonable for this pt to reduce any further acid production and ulcers. Once he can take the PPI orally, that would be a good option)

He presents with nausea and vomiting. Abdomen is distended. Bowel sounds are present, slightly hyperactive. He has not had a bowel movement in 6 days. Consider AD's symptoms, and explain why the physician (and you!) would suspect a bowel obstruction rather than Cholelithiasis. Answer like this:: If it were cholelithiasis he would...... But instead, AD............ The way these are kind of similar.....

CHOLELITHIASIS SIGNS If it were cholelithiasis, AD would have more PAIN in the RUQ/back. More likely female. He would report fat intolerance and possibly be jaundiced. OBSTRUCTION SIGNS But instead AD...... He has not had a bowel movement in 6 days. No complaints of pain. SIMILAR. Nausea/vomiting. Abdominal distention.

Intestinal Obstruction: - ______ scan and ___________ __________ - Sigmoidoscopy or ____________ - _______, ________, ________

CT, abdominal x-ray, colonoscopy, CBC, WBC, BUN

36 hours (1.5 days) after surgery, you are once again A.D's nurse A.D. reports that he feels slightly nauseated. His abdomen is soft and only tender at his incision site. You auscultate and hear no bowel sounds. At this time, you are concerned A.D. has developed a bowel obstruction. Which type of bowel obstruction would you expect? Explain WHY.

Due to the fact that A.D. has no bowel sounds, the most likely scenario is that he has a non-mechanical bowel obstruction. More specifically, a paralytic ileus caused by abdominal surgery. (Hopefully, this ileus will resolve on its own. Anesthesia and surgery on the abdomen can cause the GI system to "shut down" in response to this stress. For some patients, it can unfortunately take a while for the GI system to wake up again.)

Causes of Paralytic Ileus: - ____________ _____________** - _____________ or other inflammatory process - ______________ abnormalities (HYPOKALEMIA) - ____________ ____________*

abdominal surgery, peritonitis, electrolyte, spinal fractures

Intestinal Obstruction: Nursing Implementation - ______ ________ as ordered (watch for fluid overload) - Maintain _____ _________ - _________ care - Skin care to ________ - Monitor _____________ - Education

IV fluids, NG tube, oral, nose, electrolytes

Intestinal obstruction primary diagnostic tool

abdominal x-ray

What is the most common diagnostic test ordered to diagnose a bowel obstruction?

abdominal x-ray

Intestinal Obstruction: Collaborative Care - _______ - Inserting _______ ______ to __________ ________ - _____ _______ therapy - _______ control - _____________ -- last resoirt

NPO, NG tube, decompress bowel, IV fluid, pain, surgery

The most common cause of non-mechanical obstruction

paralytic ileus

Intussusception diagnosing tests (2)

X-ray, ultrasound

Intussusception conservative treatment

air or barium contrast enema

Intestinal Obstruction: Nursing Assessment - ________ ________ - Abdominal _________ - Signs of ___________ - _______ and _______ - __________ - Labs

bowel sounds, girth, tenderness, intake, output, pain

Intussusception is most common in

children younger than 2 years of age

Intussusception in Adults: S/S RARE - Pain _________ and _______ - ___________ and __________ may occur - Causes: ___________, polyp or ________, __________, _________ disease

comes, goes, nausea, vomiting, surgery, tumor, adhesions, Crohn's

Intussusception in children: S/S - Sudden, loud ___________ - Infants may pull ________ to _________ - Pain ________ and _____, usually every _____-______ __________ at first, then _________ - ________ mixed with ________ and _________ - ___________ - ________ in abdomen - Lethargy - ________________ - _____________

crying, knees, chest, comes, goes, 15-20 minutes, longer, stool, blood, mucus, vomiting, lump, diarrhea, fever

Main cause of vascular obstruction

emboli and atherosclerosis of the mesenteric arteries

Intestinal Obstruction: Pathophysiology - Fluid, ______, and intestinal contents accumulate - __________ ___________ collapses - As the bowel becomes ___________, __________ bowel _________ rises - Increased ______________: Fluid cannot get ___________ properly (it is not reaching most of the intestine) --> Increased capillary _____________ and _____________ of fluids and electrolytes into the ____________ cavity - ______________ and _____________ _________ - May cause __________ bowel, or bowel ____________

gas, distal bowel, distended, intralumenal, pressure, pressure, absorbed, permeability, extravasation, peritoneal, hypotension, hypovolemic shock, necrotic, perforation

Protrusion of a loop of an organ or tissue through an abnormal opening (mechanical obstruction)

hernia

Occurs when intestinal contents cannot pass through the GI tract (small intestine or large intestine, partial or complete)

intestinal obstruction

The exact cause is unknown but in most cases, it is preceded by a virus that produces swelling of the lining of the intestine, which then slips into the intestine below (telescoping)

intussusception

Intestinal Obstruction: Clinical manifestations vary depending on ____________ Early S/S - __________ __________ _________ - ___________ and __________ - __________ __________-

location, colicky abdominal pain, nausea, vomiting, abdominal distension

Detectable occlusion of the intestinal lumen

mechanical obstruction

Non-mechanical obstructions can result from _____________ or ____________ disorders

neuromuscular, vascular

Obstruction that results from a neuromuscular or vascular disorder

non-mechanical

Most mechanical obstructions occur in the

small intestine

Most common cause of mechanical obstruction

surgical adhesion

Mechanical Obstruction: Causes (5)

surgical adhesions, cancer, hernias, volvulus, intussusception

Obstruction that results from an interference with blood supply to a portion of the intestines

vascular obstruction

twisting of the bowel on itself, causing mechanical obstruction

volvulus