GI Nursing: Intestinal Obstruction

What are some nursing diagnoses for intestinal obstruction?

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, NG suction and vomiting Imbalanced nutrition: less than body requirements related to intestinal obstruction and vomiting

What is a pseudo obstruction?

Apparent mechanical obstruction without evidence of obstruction on x-Ray - cause usually not known - cause - opiate use

If the surgeon decides to wait to see if obstruction resolves on it's own, what should the nurse do?

Assess the abdomen regularly Monitor patient reports of severe abdominal pain Monitor for signs of fever, leukocytosis and tachycardia

How do bowel sounds sound like w/ bowel obstruction?

Ausculation of bowel sounds reveals high-pitched sounds above the area of the obstruction. Bowel sounds may also be absent Presence of borborygmi may be noted (borborygmi - audible abdominal sounds produced by hyperactive intestinal motility)

intestinal obstruction can either be _____________ or_______________.

Can be partial or complete. Partial obstructions do not completely occlude the intestinal lumen - some fluid & gas pass through

What are the 2 causes of intestinal obstruction?

Causes: mechanical or nonmechanical

Nursing Assessment: Intestinal Obstruction:

Detailed patient history and physical exam Note that the type and location of obstruction cause characteristic symptoms Determine the location, duration, intensity and frequency of abdominal pain and presence of abdominal tenderness and rigidity Record the onset, frequency, color, odor, and amount of vomitus. Assess bowel function, including passage of flatus. Auscultate for bowel sounds and document character and location. Inspect the abdomen for scars, visible masses and distention. Measure abdominal girth and palpate for muscle guarding and tenderness (signs of peritoneal irritation and indications of strangulation). Strict intake and output including emesis and nasogastric tube drainage Urinary catheter to monitor hourly urinary output - report urine output less thatn 0.5 ml/kg of body weight per hour (signals inadequate vascular volume and potential acute renal failure) Monitor BUN and creatinine levels

What is a mechanical obstruction? Where do most mechanical occlusions happen?

Detectable occlusion of the intestinal lumen, most occur in small intestine.

What are the goals for intestinal obstruction patient?

Goals: that the patient with an intestinal obstruction will have: Relief of the obstruction and return to normal bowel function Minimal to to no discomfort Normal fluid and electrolyte and acid-base status

Explain good management of NG tube:

Good oral care Check the nose for signs of irritation from the NG tube Re-tape the NG tube as needed Check the NG tube every 4 hours for patency

What are the diagnostic studies for intestinal obstruction?

History and physical CT scan and abdominal x-Rays (most useful) Sigmoidoscopy / Colonoscopy CBC, serum electrolytes, amylase, BUN / Creatinine

When is emergency surgery needed for a bowel obstruction?

If the bowel is strangulated (blood supply cut off resulting in necrosis of the bowel)

What is a nonmechanical obstruction? What is the most common cause?

May result from a neuromuscular or vascular disorder Most common cause of nonomechanical obstruction: paralytic ileus (lack of intestinal peristalsis and the presence of no bowel sounds) Other cause of paralytic ileus: peritonitis, inflammatory responses (acute pancreatitis, acute appendicitis)

Nursing Implementation: Intestinal Obstruction:

Monitor the patient closely for signs of dehydration and electrolyte imbalances Administer IV fluids as ordered Monitor for symptoms of fluid overload (some patients especially the elderly may not tolerate rapid fluid replacement) Monitor serum electrolytes (CO2) closely -Patient with a high intestinal obstruction - greater risk for metabolic alkalosis -Patient with a low obstruction - greater risk for metabolic acidosis Provide comfort measure to promote a restful environment (patient is frequently very restless)

Explain the pathophysiology of a bowel obstruction (VERY DETAILED)

Normally: fluid enters the small bowel and is absorbed before it reaches the colon 75% of intestinal gas is swallowed air. When an obstruction occurs - fluid, gas and intestinal contents accumulate proximally and the distal bowel collapses. The distention reduces the absorption of fluids and stimulates intestinal secretions. Then - the proximal bowel becomes increasingly distended and bowel pressures rise Increased pressure causes an increase in capillary permeability and extravasation of fluids and electrolytes into the peritoneal cavity Retention of fluids in the intestine and peritoneal cavity (third spacing) leads to a severe reduction in circulating blood volume and results in hypotension and hypovolemic shock If blood flow is inadequate - bowel tissue becomes ischemic - then necrotic and could cause bowel perforation.

When does intestinal obstruction happen?

Occurs when intestinal contents cannot pass through the GI tract

What is the post operative care for intestinal obstruction?

Postoperative care: NG tube to empty the stomach and prevent gastric dilation - monitor color of drainage Monitor for nausea and vomiting Administer antiemetics as needed Monitor for bowel sounds Early ambulation of patient to restore peristalsis and eliminate flatus and gas pain Metoclopromide (Reglan) or alvimopan (Enereg) to stimulate peristalsis

What is the initial nursing management for bowel obstruction? KNOW THIS

Put patient NPO Insert a nasogastric tube IV fluids (NS or Lactated Ringers) because fluid losses from the intestine are isotonic Addition of potassium to IV fluids Analgesics for pain control

What are the key signs if obstruction is located in the proximal small intestine?

Rapid onset of nausea and vomiting Vomitus - contains bile and is projectile in nature Vomiting usually relieves abdominal pain Pain: colicky, cramplike and intermittent Abdominal distention is usually absent or minimal Review table 42-20 p. 951

What is volvulus?

Rare, emergency situation where a loop somewhere in the intestines gets twisted in an abnormal way and obstructs the supply of lumen and blood to that section of the intestines - "necrotic bowel"; "infarcted bowel

If the obstruction does not improve or patient's condition deteriorates then what must happen?

SURGERY! Goal of surgery: relieve the obstruction

Most common cause of small bowel obstructions?

Surgical adhesions from previous abdominal surgeries (within days of surgery or several years later) Other causes include hernias or tumors

What are the types of bowel obstruction surgery?

Types of surgery: Resection of the obstructing bowel segment and anastomosing to the remaining healthy bowel Partial or total colectomy, colostomy, ileostomy if the obstruction is extensive of if necrosis is present. Nonsurgical procedure to relieve obstruction: use of a colonoscope to remove polyps, dilate strictures, amd remove/destroy tumors with a laser

What are the clinical manifestations of a bowel obstruction?

Vary and depend on the location of the obstruction Include nausea, vomiting, poorly localized abdominal pain, abdominal distention, inability to pass flatus, constipation and signs and symptoms of hypovolemia.

How common are vascular obstructions? What are the causes of vascular obstructions?

Vascular obstructions are rare and the result of an interference with the blood supply to a portion of the intestines. Most common causes of vascular obstruction: emboli and atherosclerosis of the mesenteric arteries.

What are the key signs if obstruction is located in the distal small intestine

Vomiting is more gradual in onset Vomitus may be orange-brown in color and foul smelling like feces. Persistent, colicky abdominal pain (because intestinal peristalsis is trying to move bowel contents past the obstructed area) Abdominal distention is markedly increased

Do most bowel obstructions resolve on their own?

YES

Most common cause of large bowel obstruction?

cancer, volvulus and diverticular disease

What are the major concerns w/ bowel obstruction?

prevent fluid and electrolyte deficiencies Early recognition of deterioration of patient's condition (hypovolemic shock; bowel strangulation)

Where does intestinal obstruction happen?

small or large intestine (colon)