Bowel Obstruction/Elimination Flashcards
Adhesions main cause, hernias too.
Ahesions following surgery, hernia, intussusception, lymphoma, stricture
Small bowel obstruction
carcinoma, diverticulitis, volvulus or intussusception (telescoping) impacted stool, IBD, Ogilivie’s, stricture (scaring-inflammation)
Lg bowel obstruction
obstruction leads to accumulation of gastric, biliary and pancreatic secretions.
- increased pressure can lead to third spacing of fluid
- increased pressure leads to bacterial translocation into blood stream, leading to bacteremia, sepsis
- strangulation can occur, when bowel wall edema, and intraluminal pressure prevents perfusion to an affected area of bowel. Necrosis occurs, then perforation.
Pathophysiology
-Severe, constant abdominal pain, abdom. distention, decreased bowel movements, decreased flatus, bilious and feculent vomiting, Obstipation.
-Pain in periumbulical, contstant with intermittant worsening
-Look out for surgical scars, and obvious hernias.,
-previous hx of abdom. surg, any hx of malignancy
-Any hx of hernias
-Bowel sounds can be increased (early) or absent/decreased
Hiccups; common with all types of bowel obstruction
high temp. elevated pulse; suspect peritonitis, strangulation
Any blood?
Signs and symptoms of obstruction
Standard Labs; CBC, lytes, creat, BUN, Lfts, amylase, urinalysis, evid. dehydration
Plain flims. XRAY; useful, look for dilated bowel loops, air fluid levels, free air, Can be wrong in 10-20% of cases
CT if xray wasn’t helpful.
With Sepsis, necrosis, or bowel ischemia, you will see increased Lactic Acidosis, metabolic acidosis, etc
CT: useful for confirming dx, locating pt. of obstruction, partial or complete, cause and determining if ischemia is present
Small bowel series; gold standard for determining if partial or complete
Tests
3 main problems.
` No passage. Vomitting/no intake
` Bowel wall; swells, oozing fluid into perintineal
` Ischemic/ no blood perforation
Consequences of small bowel obstruction
Outside or Inside
Outside: Scar tissue in peritoneum, Adhesions from previous surgery. Bowel getting caught up.
Hernia. bowel caught
Inside: Masses, tumors, strictures, telescoping intussusception.
Crohns disease
Complete/partial obstruction. High grade or low grade
Causes of SBO
Hx; abdominal pain, intermittant Content goes through lumen Vomitting, no gas passing abdom. distended diarrhea early on then stops
Physical; hypotensive, tachycardiac abdom. distention hyper active bowel sounds early hypo active bowel sounds late ~Perferative; peritoneal signs Looks septic Adhesions main cause. Look for scars from prior surgery./hernias. Men testicular exams
Presentation of patient with SBO
Plain xrays
Upright CXR; look for free air, under diaphragm
Upright and Supine AXR; air more than 3 cm. No air in colon or rectum.
Xrays not perfect; 75%
CT; If plain films not helpful
Whats causing obstruction, narrow of lumen Picking of perferation
Labs; CBC’s, Cr., lytes, T&S, INR, PTT, hydration status
Endoscopy; sigmoidoscopy, colonoscopy
Dx of SBO
Tests
ABC’s airway and breathing
Circulation; hypotensive/ tachycardiac. hydration with IV fluids to increase BP normalize HR
Pain meds; parallel with investigation; peritonitis ABX’s
If Surgery: operation needed perferation and peritonitis OR.
If stable: NG tube to decompress stomach.
Vitals/ VX meds
Tests/Labs
Salem sump; low continuous suction
Amt/character of drainage
30 ml NSS q 4hrs (Paralytic Ileus; non surgical tx)
Treatment of SBO
non mechanical; Paralytic ileus (adynamic)
Peristalsis decreased or absent due to neuromuscular disturbance
Functional Non mechanical Intestinal obstruction
Physically blocked;
Inside Tumors, fecal impaction
Outside tumors, adhesions. in bowel wall Crohn’s
Mechanical Intestinal obstruction
Plasma leaks into peritoneal cavity
Fluid gets trapped in the intestinal lumen decreases ability to absorb fluid and electrolytes in to vascular system.
becomes hypovolemic and electrolyte imbalance occurs.
At risk for hypovolemic shock
Bacteria stagnant in bowel increase risk of infection.
Intestional Obstruction
Blocks high in sm. intestine; metabolic alkalosis may occur.
Obstruction below the duodenum but above the large bowel; Acid base usually not compromised.
Obstruction end of small intestine to low large bowel; metabolic acidosis.
Acid/Base and Electrolyte Imbalance
over 65; most common causes are Diverticulitis, tumors and fecal impaction. Adhesions Appendicitis Hernias Strictures due to Crohn's disease or radiation tx Intussusception Volvulous Fibrosis Vascular disorder (emboli)
Etiology; Mechanical BO
Paralytic ileus
handling of the intestine during surgery
fx lost for few hrs to several days
Electrolyte disturbances, esp hypokalemia
Peritonitis; severe irritation/inflammation
Vascular insufficiency; intestional ischemia
Mesenteric blood flow decreased
Thrombosis, heart failure, severe shock
Etiology; Non Mechanical SBO
Obstruction caused by tumor or diverticulitis requires colon resection with primary anastomosis or colostomy.
If intestinal infarction noted will require resection of the gangrenous bowel.
NGT ususally place post op until peristalsis returns (flatus, bm)
Clamping of NGT; clamp for 1-2 hrs after po fluids; assess for N and V.
Residual assessed
Surgical Care for SBO
Teach; high fiber foods, raw fruit and veggies.
Adequate amounts of fluids
Lax abuse decreases abdom. tone and contributes to atonic colon.
exercise/walking promotes intestinal motility
Warms bev. and prune juice stimulates peristalsis.
Oozing of soft or diarrhea stool may indicate fecal impaction.
Sitting on a toilet or bedside commode rather than on a bedpan for elimination.
Older Adult Prevention of Fecal Impaction
When preforming a physical assessment on a pt. with a small bowel obstruction. which key feature does the nurse most likely find?
Pain is in the mid epigastric region for small bowel obstructions.
Which observation of a patient with an intestinal obstruction does the nurse report immediately?
Abdominal pain changing from colicky to constant discomfort. Intermittent pain. this could signal a perforation of the bowel and be a medical emergency requiring immediate surgery. Peritonitis or Sepsis may ensue.
Your patient is recovering post op small bowel resection for adhesions and is on a clamping schedule for the NGT? The patient takes in 240 ml’s po. After 2 hrs, your patient c/o nausea and when you reconnect the NGT to low suction and get 400 ml return of bile material. What should you do next?
Hold clamping schedule and report to physician. N and V and increased or equal amount of what was taken inpo indicated the bowel is not functioning properly yet.
Discomfort/pain is upper and middle abdomen. Upper epigastric distention N and V; may be fetid Obstipation Severe fluid and electrolyte imbalance. Metabolic alkalosis
Small Bowel Assessment findings
Intermittent Abd. cramping Lower abd. distention Minimal or no vomiting obstipation or ribbon like stools no major f & e imbalances Metabolic acidosis
Large Bowel assessment findings
