Nursing care of the patients with Bowel obstruction
I. Introduction
- Accounts for 5% of all acute surgical admissions
- Pts are often extremely ill requiring pompt assessment, resuscitation and intestine
monitoring
- Definition: Bowel obstruction is the disruption of the movement of substances in the
intestinal contents( including water, solids, gasses, microbacteria), from the angle of
Tritz to the anus. This process can happen slowly or suddenly, partial or complete.
II. Classification according to the Mechanism
- Obstruction: A mechanical blockage arising from a structural abnormality that
presents a physical barrier to the progression of gut contents. Intestinal peristalsis is
normal. Bowel obstruction can:
+ Partial or complete
+ Simple or strangulated
- Ileus: is a paralytic or functional variety of obstruction
III. Classification according to the Anatomy
- Small intestine ( longest organ in the GI tract)
+ Three major divisions : duodenum, jejunum, ileum.
+ Main function is complete digestion of food
+ Most nutrients and water are absorbed in 6- to 8- hour passage
- Large intestine
+ Segments: cecum, appendix, ascending, transverse, descending, sigmoid colon and
rectum.
+ Main function are elimination of waste and absorption water
IV. Physiopathology
- In small bowel obstruction, large amounts of fluid and gasses are trapped above the
area of the obstruction, leading to abdominal distention
- Dehydration can develop from loss of water and sodium
- 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.
V. Causative Factors
- Extrinsic bowel obstruction
+ Begins outside the GI tract
+ Such as Adhesions, herniations, or masses
- Intrinsic bowel obstruction
+ Lumen blockage
+ Caused by acute or chronic bowel disease
+ Inflammation, congenital defects, or tumors
- Intraluminal bowel obstruction
+ Caused by the inability of material to pass through the GI tract ( meconium, foreign
bodies, impactions)
VI. Mechanical causes
- Adhesion : Loops of intestine become adherent to areas that heal slowly or scar
after abdominal surgery( most common cause of small bowel obstruction)
- Herniations: The intestine protrudes through a weakened area in the abdominal
muscle or wall
- Volvulus: Bowel twists and turns on itself, laxative use may be the cause
- Intussusception :Bowel slips into itself
- Tumors
- Diverticulitis: Pouches push out of mucosal lining of bowel
- Et cetera…
VII. Functional causes
- Intestinal muscles are unable to propel contents forward, such as in:
+ Muscular dystrophy
+ Endocrine disorders ( such as diabetes)
+ Neurological disorders ( such as Parkinson’s disease)
+ Electrolyte imbalances
+ Uremia
+ Spinal cord lesions
VIII. Clinical signs of bowel obstruction
- Functional signs:
+ Intermittent crampy abdominal pain ( usually seen in small bowel obstruction)
+ Reflux vomiting if obstruction is complete or nausea
+ No gasses, no shitting
- Systemic signs: coming early few changes; late:
+ Dehydration signs: thirst, drowsiness, malaise, achiness, and parched tongue and
mucus membranes.
+ Signs of electrolyte loss
- Physical signs:
+ Visible: abdominal distension, old scar, floating bowel loops, visible peristalsis (
snake signs)
+ Touch: pain point, the reaction of the abdominal wall, abdominal rigidity, peritoneal
touch.
+ Typing: opaque lower area
+ Auscultation: bowel sound in the area over the obstruction; quiet or absent below the
obstruction
+ Rectal examination
IX. Diagnosis tests
- 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
- Liver enzymes will be elevated in response to other GI organs
- Metabolic acidosis may occur as perfusion decreases
- X-ray of the abdomen will show dilation of the bowel
- CT scan may show mechanical changes ( addition of contrast may show vascular
changes)
Plain Abdominal Radiography
CT Scan of Abdomen ( search gg)
X. Treatment
- For incomplete obstruction, medical management is the treatment of choice
- The patient will have an NG tube inserted, which may provide resolution for many
bowel obstructions
- Urinary catheter to monitor output
- I.V. therapy to replace fluids and electrolytes
- Administration of broad-spectrum antibiotics
- Conservative control of pain
XI. Surgical treatment
- Depends largely on the cause
- In some cases, the portion of the affected bowel may be resected and anastomosed.
- Some patients will undergo a temporary colostomy or ileostomy
PRE AND POST OPERATIVE
NURSING MANAGEMENT
Phases of Nursing care management of bowel obstruction
- Preoperative Phase: The period of time from when decision for surgical intervention
is made to when the patient is transferred to the operating room late.
- Intraoperative Phase: Period of time from when the patient is transferred to the
operating room table to when he or she is admitted to the postanesthesia care unit
- Postoperative Phase: Period of time that begins with the admission of the patient to
the postanesthesia care unit and ends after follow-up evaluation in the clinical setting
or home.
A. PREOPERATIVE PHASE
- Begins with decision to proceed with surgical intervention
- Baseline evaluation
- Preparatory education
PREOPERATIVE NURSING MANAGEMENT
1. Prepare medical records of patients
2. Patient education
- Teaching deep breathing and coughing exercises
- Encouraging mobility and active body movement. e.g Turning ( change position),
foot and leg exercise
- Explaining pain management
- Teaching cognitive coping strategies
- Managing nutrition and fluids:
+ The major purpose of withholding food and fluid before surgery is to prevent
aspiration
+ A fasting period of 8 hours or more os recommended for a meal that includes
fried or fatty foods or meat
- Preparing the bowel for surgery: Enema is not commonly ordered, unless the patient
is undergoing abdomen or pelvic surgery .e.g( cleaning enema , laxative)
- Preparing the skin: The goal of preoperative skin preparation is to decrease bacteria
without injuring the skin.
3. Immediate preoperative nursing intervention:
- Administering preanesthetic medication
- Maintaining the preoperative record. e.g. Final checklist, consent form, identification.
B. INTRAOPERATIVE PHASE
- Begins when pt is transferred to operating room table
- Provide for pt safely
- Maintain aseptic environment
- Provide surgeon with supplies and instruments
- Documentation
C. POSTOPERATIVE PHASE
- After surgery, most pt are taken to the postanesthesia care unit
- When they are stable , they are transferred to their room
- Upon waking from anesthesia, the pt has
+ Intravenous line
+ Urinary catheter ( remove in a day or two)
+ Nasogastric ( remove day 2 or 3rd after surgery)
+ Abdominal drain ( remove day 3 or 4 after surgery)
+ Abdominal incision ( Care the incision every day)
+ Pouching options ( tui hau mon nhan tao)
- Nutrition:
+ In the early days: They are not allowed t eat or drink : Intravenous completely
+ When bowel sounds return (2 or 3 after surgery) : Liquid food
- Movement:
+ The day after surgery, most pt can get out of bed. The best ways to prevent
postoperative complications.
