Transcript Bowel Obstruction: Backup Along the 750

Bowel Obstruction:
Backup Along the 750
By Shelba Durston, RN, CCRN, MSN
Nursing made Incredibly Easy!
March/April 2009
2.5 ANCC contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Small and Large Intestines
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Small intestine (longest organ in the GI tract)
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Three major divisions: duodenum, jejunum, ileum
Main function is complete digestion of food
Most nutrients and water are absorbed in 6- to 8hour passage
Large intestine
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Segments: cecum; appendix; ascending,
transverse, descending, and sigmoid colon; rectum
Main functions are elimination of waste and
absorption of water
Bowel Obstruction
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Occurs in the small (most common) or large
intestine (sigmoid colon most common)
Can be partial or complete
Severity depends on the region of the bowel, the
degree of occlusion, and the degree of vascular
disruption
Bowel Obstruction
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In small bowel
obstruction, large
amounts of fluid and
gases are trapped
above the area of
obstruction, leading to
abdominal distention
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Dehydration can
develop from loss of
water and sodium
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Hypovolemia occurs
as fluids are pulled
from the vascular bed
to the site of the
obstruction
Peristalsis below the
obstruction decreases,
which leads to
bacterial overgrowth
and may lead to
peritonitis
If the blood supply is
cut off, it can lead to
necrosis
Causative Factors
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Extrinsic bowel obstruction
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Intrinsic bowel obstruction
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Begins outside the GI tract
Adhesions, herniations, or masses
Lumen blockage
Caused by acute or chronic bowel disease
inflammation, congenital defects, or tumors
Intraluminal bowel obstruction
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Caused by the inability of material to pass through
the GI tract (meconium, foreign bodies, impactions)
Mechanical Causes
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Adhesions: Loops of
intestine become
adherent to areas that
heal slowly or scar
after abdominal
surgery (most
common cause of
small bowel
obstruction)
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Herniations: The
intestine protrudes
through a weakened
area in the abdominal
muscle or wall
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Volvulus: Bowel
twists and turns on
itself; laxative use
may be the cause
Intussusceptions:
Bowel slips into itself
Tumors
Diverticulitis:
Pouches push out of
mucosal lining of
bowel
Functional Causes
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Intestinal muscles are unable to propel contents
forward, such as in:
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Muscular dystrophy
Endocrine disorders (such as diabetes)
Neurological disorders (such as Parkinson’s disease)
Electrolyte imbalances
Uremia
Spinal cord lesions
Signs & Symptoms:
Small Bowel Obstruction
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Crampy abdominal pain (usually seen in small
bowel obstruction)
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Reflux vomiting if obstruction is complete
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Fecal-smelling breath
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Dehydration signs: thirst, drowsiness, malaise,
achiness, and parched tongue and mucous
membranes
Signs & Symptoms:
Large Bowel Obstruction
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Develop and progress slowly
Constipation may be the only symptom for
months
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Weakness, weight loss, and anorexia
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Marked abdominal distention
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Crampy lower abdominal pain
Assessment
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Past medical history and history of events leading
to seeking care (pain is usually the symptom that
causes patient to seek care)
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Assess pain characteristics (quality and intensity)
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Assess abdomen
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Auscultate bowel sounds (Bowel sounds: highpitched, hyperactive, tinkling, and almost metallic
in the area over the obstruction; quiet or absent
below the obstruction)
Diagnostic Tests
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Lab values will determine fluid and electrolyte
management
Emesis causes loss of sodium, potassium, chloride,
and hydrogen
Sodium, blood urea nitrogen, and creatinine levels
will be elevated as fluid shifts out of the vascular
bed
White blood cell count will be elevated as
inflammation develops
Hemoglobin and hematocrit will be elevated
relative to fluid loss
Diagnostic Tests
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Liver enzymes will be elevated in response to
other GI organs
Metabolic acidosis may occur as perfusion
decreases
Frank blood is an indication of perforation
(requires immediate surgical intervention)
X-ray of the abdomen will show dilation of the
bowel
CT scan may show mechanical changes (addition
of contrast may show vascular changes)
Treatment
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For incomplete obstructions, medical
management is the treatment of choice
The patient will have an NG tube inserted, which
may provide resolution for many bowel
obstructions
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Urinary catheter to monitor output
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I.V. therapy to replace fluids and electrolytes
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Administration of broad-spectrum antibiotics
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Conservative control of pain
NG Tube Length Measurement
Confirming NG Tube Placement
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To confirm placement after the initial X-ray is
done, a combination of three methods is
recommended:
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Measure the length of the exposed portion of the
tube every shift and compare it with the original
measurement. An increase in length of exposed
tube may indicate dislodgment or a leaking or
ruptured balloon if the tube has a balloon.
Visually assess the color of aspirate to help
distinguish between gastric and intestinal
placement.
Measure the pH of aspirate, which is a more
accurate method of confirming tube placement than
measuring the exposed tube length or assessing
tube aspirate.
Surgical Treatment
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Depends largely on the cause
In some cases, the portion of the affected bowel
may be resected and anastamosed
Some patients will undergo a temporary
colostomy or ileostomy
Types of Bowel Resections
and Stomas
Complications
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Infection (urinary, peritonitis)
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Respiratory impairment (pneumonia, atelectasis)
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Alterations in clotting mechanisms (DIC)
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Skin breakdown
Preventing Complications
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Monitor prothrombin time and INR
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Assess skin for petechiae, color, and temperature
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Assess body fluids for presence of blood
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Assess nutritional status (monitor albumin and
prealbumin)
Use an air mattress to prevent skin breakdown
Patient Teaching
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Discuss bowel regime with patient, including
avoiding laxative use, increasing fluids, and
increasing fiber
Teach personal care to a patient who has
undergone surgery with an ileostomy or
colostomy (selection of the proper size of
appliances, care of the site and skin near the
ileostomy or colostomy, and dietary changes to
help reduce gas production)
Guidelines for Changing an
Ileostomy Appliance
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Changing an ileostomy appliance is necessary to
prevent leakage (the whole appliance, including the
flange or wafer, is usually changed every 5 to 7 days).
Routine changes should be performed early in the
morning before breakfast or 2 to 4 hours after a meal,
when the bowel is least active.
Have the patient assume a relaxed position, provide
privacy, and explain the details of the procedure.
Remove the appliance. Have the patient sit on the
toilet or on a chair facing the toilet. A patient who
prefers to stand should face the toilet. The appliance
(pouch) can be removed by gently pushing the skin
away from the adhesive.
Guidelines for Changing an
Ileostomy Appliance
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Clean the skin. Wash the skin gently with a soft cloth
moistened with tepid water and mild soap; the patient
may prefer to bathe before putting on a clean
appliance. Rinse and dry the skin thoroughly after
cleaning.
Apply an appropriate skin barrier to the peristomal skin
before applying the appliance. Remove the cover from
the adherent surface of the disk of the disposable
plastic appliance and apply it directly to the skin. Press
firmly in place for 30 seconds to ensure adherence.
When skin irritation is present, clean the skin
thoroughly, but gently; pat dry. Apply triamcinolone
acetonide spray, blot excess moisture with a cotton
pledget, and dust lightly with nystatin powder.
Check the pouch bottom for closure; use the rubber
band or clip provided.
Pouching Options