Intestinal Obstruction - Med/Surg Lewis

Nursing Assessment

- Detailed patient history History of previous abdominal surgery(ies) and/or a history of gastrointestinal neoplasms (especially colonic & ovarian) should raise red flags immediately. History of hernia or colorectal cancer - Physical examination - Determine type and locate obstruction based on characteristic symptoms - Determine location, duration, intensity, and frequency of abdominal pain, and whether abdominal tenderness or rigidity are present - Record the onset, frequency, color, odor, and amount of vomitus. - 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 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, fever, and tachycardia - Maintain a strict intake and output record including emesis and tube drainage 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.

What is an Intestinal Obstruction?

A condition where intestinal contents are prevented from passing through the gastrointestinal tract. Not a disease in itself, but often a secondary diagnosis to several causative maladies. Often requires immediate medical attention Can be life-threatening if untreated

Hernia

A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. It should be noted here that while strain or injury are often the cause of herniation. Intestinal adhesions are the most prevalent cause of hernias which lead to intestinal obstruction.

Diagnostic Studies

Abdominal CT scan - the best tool Abdominal x-ray Endo/colonoscopy/sigmoidoscopy - may provide direct visualization of the obstruction Upper GI and small bowel series CBC Elevated WBC may indicate strangulation or perforation Evelated hematrocrit may indicate hemoconcentration Increased H/H may indicate bleeding from neoplasm or strangulation with necrosis Electrolytes, BUN and creatine monitored to asses dehydration

Signs and Symptoms

Abdominal swelling (distention) Abdominal fullness from inability to pass gas Colicky Abdominal pain and cramping Breath 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 High pitched sounds above the area of obstruction Bowel sounds may also be absent Borborygmi Temperature rarely above 100 unless strangulation or peritonitis occur

Common Causes

Adhesions Strangulated inguinal hernia Ileocecal intussusception Intussusception from polyps Mesenteric occlusion Neoplasm Volvulus of the sigmoid colon

Mesenteric Occlusion

An example of a non-mechanical obstruction that results usually from ischemia caused by the blockage of the mesenteric vein.

Ileus(es)

Are another non-mechanical form of obstruction often caused by paralysis of part of the intestine due to surgery An ileus (often caused by post-surgical paralysis) suggests that some part of the intestinal tract is not functioning in the manner in which it would in an otherwise healthy individual. An ileus causes blockage because the intestinal contents fail to transit through the effected part of the GI tract causing it to back up proximally to the effected site.

Abdominal adhesions

Bands of fibrous tissue that form between abdominal tissues and organs usually as a result of surgery or injury. Abdominal surgery is the most frequent cause of abdominal adhesions. Almost everyone who undergoes abdominal surgery develops adhesions; however, the risk is greater after operations on the lower abdomen and pelvis, including bowel and gynecological surgeries. Even though the exact cause of intestinal adhesion is unknown they are still the #1 cause of obstructions.

Crohn's Disease Inflammatory Bowel Disease Ulcerative Colitis

Because Crohn's is a inflammatory bowel disease it thickens the walls of the intestine often causing partial or complete obstruction. Fecaliths (deposits of feces that harden) cause obstructions and are not uncommon with Crohn's disease.

Complications

Complications may include or may lead to: Electrolyte imbalances - metabolic alkalosis from vomiting Dehydration 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.

Clinical Manifestations

Early manifestations: colicky abdominal pain, nausea vomiting and abdominal distention Later: Constipation and decreased flatus Proximal small intestine obstruction: Rapid development of nausea and vomiting, which is sometimes projectile and contains bile. Abdominal distention is absent or minimally noticeable Distal obstructions: Vomiting is gradual in onset Long standing obstructions: vomiting that looks like stool, requires immediate surgery Colonic obstruction: abdominal distention, constipation, lack of flatus Higher intestinal obstructions: abdominal pain relieved by vomiting. Risk for metabolic alkalosis Lower intestinal obstruction: persistent colicky abdominal pain. Markedly increased abdominal distention. risk for metabolic acidosis Mechanical obstruction: pain that comes and goes in waves Paralytic ileum: more constant abdominal discomfort Strangulation: causes severe constant pain that is rapid in onset. Abdominal tenderness and rigidity (also for peritonitis)

Nursing interventions for patients with NG Tube

Encourage/help patient to brush teeth frequently Mouthwash and water for rinsing the mouth Water soluble lubricant for the lips Check nose for signs of irritation from NG tube Clean and dry this area daily apply water soluble lubricant and retype tube Check NG tube every 4 hours for patency

Etiology and Pathophysiology

Food piles up and bacteria metabolizes it. This produces gas which leads to bowel distention. Bowel distention compresses blood vessels that supply the bowel leading to venous compression. This means no oxygen is getting to the area. Decreased oxygenation leads to cell death, decreased peristalsis (which increases distention), promotes bacteria to enter circulation which can result in a septic reaction. Breathing air actually aggravates the bowel distention because air gets trapped causing venous compression which leads to fluid secretion into the bowel and we lose water which means we lose fluid and electrolytes resulting in hypotension. Continued fluid depletion can result in shock. Bowel distention also trigger the nerves that activate the vomiting response. This doesn't help because it can also lead to hypovolemic shock as vomiting causes fluid loss. Complications that can arise due to this process are Bowel ischemia - leads to venous compression which leads to liver not being oxygenated which leads to toxins and bacteria moving into circulation Perforation - can be caused by bowel distention due to gas and air. This leads to spillage into the peritoneum and leads to peritonitis Sepsis - due to cell death and perforation

Therapies

Initial medical treatment of bowel obstructions caused by adhesion are resolved by placing the patient on NPO status, insertion of an NG tube and IV fluid therapy with NS or lactated ringers. Adding potassium to IV once renal function is assessed and administering analgesic for pain control. Stents are placed for palliative purposes or until surgery can be performed Corticosteroids that have antiemetic properties and decrease edema and inflammation may be used with stents Venting gastrostomy may be placed endoscopically or percutaneously Colonoscope can be used to remove polyps, dilate strictures and remove and destroy tumors with laser If above treatment doesn't improve the patients condition within 24 hours or if the patients conditions worsen surgery is performed to remedy the problem. Emergency surgery is performed if the bowel is strangulated. Resection of obstructed segment with anastomoses Partial or total colectomy, colostomy or ileostomy when excessive obstruction or necrosis is present In cases of surgery parenteral nutrition and ostomy care and instruction may be required.

What are three most common causes of the intestinal obstructions?

Intestinal adhesion Hernias: ventral, inguinal, femoral, internal Neoplasms: malignant (primary/metastatic), benign

Nursing 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.

Classifications

Mechanical Obstructions A detachable occlusion of the intestinal lumen occurring mostly in the small intestine. Caused by: Adhesion, Tumor, Intussusception, hernia, volvulus Non-mechanical obstructions - ileus are non-occluding but suggest discontinuation of function or paralysis Caused by: Paralytic Ileuses (these can be due to peritonitis, inflammatory responses, and after any abdominal surgery) Pseudo Obstruction Is a mechanical obstruction that doesn't show up on radiologic studies. Caused by collegen vascular disease and neurologic and a endocrine disorders Vascular obstructions Rare. Result of an interference with the blood supply. Caused by Emboli (blood clots) and artherosceloris of the mesenteric arteries. Blood clots can be caused by Atrial Fibrillation, diseased heart valves and prosthetic valves. Venous thrombosis can be caused by low blood flow caused by heart failure and shock Once the type of obstruction is identified it is further classified as either: Complete: Where no gut content at all is passing the site. Partial: where flatus (gas) and liquid stool are still transiting the obstruction site. A/or Simple: Intact blood supply Strangulated : non intact blood supply

Nursing Interventions

Monitor closely for signs of dehydration and electrolyte imbalances. Administer IV fluids as ordered Prepare to insert a nasogastric (NG) tube Watch carefully for symptoms of fluid overload Monitor serum electrolytes carefully Provide comfort measures Promote restful environment

Nursing 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.

Expected outcomes for the patient with bowel obstruction

Resolution of the cause of the acute pain. Reduced or no abdominal distention Regularized peristalsis Normal fluid volume and electrolyte status Normal nutritional status

What can Post-surgical abdominal distentions can be caused by?

Swallowed air Reduced peristalsis Decreased mobility Manipulation of the abdominal organs Anesthesia

Over all Goals

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, and normal fluid and electrolyte and acid-base status

Volvulus of the Sigmoid Colon

The twisting of the colon at the site where it joins its mesenteric pedicle Often caused in infants by a congenital predisposition and misrotation of the intestine on the mesenteric pedicle. Messenteric pedicle refers to the folds of the peritoneum that connect the intestines to the dorsal abdominal wall. Strangulated obstructions are most commonly associated with adhesions and occur when a loop of distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and necrosis. If left untreated, this progresses to perforation, peritonitis, and death.

Intussusception

a condition in which a part of the intestine has invaginated into another section of intestine, similar to the way in which the parts of a collapsible telescope slide into one another Often found to run in families where Peutz-Jehgers Syndrome has become an issue and in infants. This type of obstruction is also found in the presence of intestinal polyps.

What are less common causes of abdominal adhesions?

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.

Neoplasm

is an abnormal mass of tissue caused by neoplasia. 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.

What are surgical causes of abdominal adhesions?

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

Goal of Treatment for patient with bowel obstruction

to regain patency and resolve obstruction