Bowel Obstruction/Elimination

Question 1

Adhesions main cause, hernias too.

Ahesions following surgery, hernia, intussusception, lymphoma, stricture

Answer 1

Small bowel obstruction

Question 2

carcinoma, diverticulitis, volvulus or intussusception (telescoping) impacted stool, IBD, Ogilivie’s, stricture (scaring-inflammation)

Answer 2

Lg bowel obstruction

Question 3

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.

Answer 3

Pathophysiology

Question 4

-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?

Answer 4

Signs and symptoms of obstruction

Question 5

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

Answer 5

Tests

Question 6

3 main problems.
` No passage. Vomitting/no intake
` Bowel wall; swells, oozing fluid into perintineal
` Ischemic/ no blood perforation

Answer 6

Consequences of small bowel obstruction

Question 7

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

Answer 7

Causes of SBO

Question 8

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

Answer 8

Presentation of patient with SBO

Question 9

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

Answer 9

Dx of SBO

Tests

Question 10

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)

Answer 10

Treatment of SBO

Question 11

non mechanical; Paralytic ileus (adynamic)

Peristalsis decreased or absent due to neuromuscular disturbance

Answer 11

Functional Non mechanical Intestinal obstruction

Question 12

Physically blocked;
Inside Tumors, fecal impaction
Outside tumors, adhesions. in bowel wall Crohn’s

Answer 12

Mechanical Intestinal obstruction

Question 13

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.

Answer 13

Intestional Obstruction

Question 14

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.

Answer 14

Acid/Base and Electrolyte Imbalance

Question 15

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)

Answer 15

Etiology; Mechanical BO

Question 16

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

Answer 16

Etiology; Non Mechanical SBO

Question 17

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

Answer 17

Surgical Care for SBO

Question 18

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.

Answer 18

Older Adult Prevention of Fecal Impaction

Question 19

When preforming a physical assessment on a pt. with a small bowel obstruction. which key feature does the nurse most likely find?

Answer 19

Pain is in the mid epigastric region for small bowel obstructions.

Question 20

Which observation of a patient with an intestinal obstruction does the nurse report immediately?

Answer 20

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.

Question 21

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?

Answer 21

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.

Question 22

Discomfort/pain is upper and middle abdomen.
Upper epigastric distention
N and V; may be fetid
Obstipation
Severe fluid and electrolyte imbalance.
Metabolic alkalosis

Answer 22

Small Bowel Assessment findings

Question 23

Intermittent Abd. cramping
Lower abd. distention
Minimal or no vomiting
obstipation or ribbon like stools
no major f & e imbalances
Metabolic acidosis

Answer 23

Large Bowel assessment findings