CA - Intestinal Obstruction

Question 1

Whats intestinal obstruction?
NEED TO KNOW

Answer 1

• partial / complete obstruction of the intestinal lumen of the small / large bowel
• Fluid & electrolyte losses associated w colon obstruction < small bowel

Question 2

What are the causes of intestinal obstruction?
NEED TO KNOW

Answer 2

1. Abdominal surgery with adhesions
2. Congenital abnormalities of the bowel
3. Carcinoma

Question 3

What are the symptoms of intestinal obstruction? = what the patient feels & cant be measured
NEED TO KNOW

Answer 3

1. bowel sounds altered
2. cant pass gas
3. pain

FYI: DN TO KNOW
For partial obstruction:
- usually appear more gradually and are milder
- abdominal discomfort after meals
- constipation, diarrhoea / ribbon-like stools.

Complete obstruction:
- symptoms usually appear suddenly
- obstipation = more serious version of constipation: completely cannot pass stool / gas

• dehydration + hypotension, tachycardia, dry mucous membranes and decreased urine output

Bacterial peritonitis / sepsis:
- fever, fatigue or weakness, tachycardia, and tachypnea
- high pitched, tinkling bowel sounds -> mechanical obstruction
- absence of normal bowel sounds = functional obstruction
- palpation of abdomen -> tenderness & rigidity

Question 4

What are the nursing goals & management for a patient with intestinal obstruction?
NEED TO KNOW

Answer 4

1. Maintain fluid and electrolyte balance
   - I/O, vitals, review CBC, BUN, creatinine, electrolytes, and urine-specific gravity
   - administer IV fluids
   - insert IDC -> Prevent urinary retention from abdominal distension
2. NPO status
   - insert NGT
   - semi-Fowler position to prevent aspiration
   - administer antiemetic if they have nausea & vomiting
3. Ask them to describe any pain they are experiencing
   - measuring abdominal girth
   - check for bloating, distension, and their ability to fart
   - Auscultate bowel sounds, noting character and location
   - gently palpate abdomen, noting the presence of tenderness.

Question 5

What pt education will u provide?
NEED TO KNOW

Answer 5

1. Eat several smaller meals each day instead of three large meals
   - drink about 2L of water and other clear liquids throughout the day
   - eat slowly and chew well to promote easier digestion
2. Avoid foods that can cause gas, like broccoli, Brussels sprouts, cabbage, and carbonated beverages,
   - foods that can cause constipation: white bread and rice, highly processed foods, and excessive amounts of red meats
3. eat high-fiber foods such as fruits, vegetables, and whole grains.
4. regular physical activity to promote intestinal mobility.
   - contact HCP immediately if they experience abdominal pain, distention, nausea, vomiting, or constipation.

Question 6

What are the types of bowel obstruction?

Answer 6

1. Mechanical obstruction
   - actual blockages in the small or large intestine

A. Partial obstruction
= gas or liquid stool can pass through the narrowing

B. Complete obstruction
= nothing can pass through

C. Simple obstruction:
- obstructed segment of the intestine still has blood supply

D. Strangulated obstruction
- decreased blood supply

2. Functional
   - disrupts peristalsis
   - no blockage BUT food, liquids and gas don’t move through the intestines

Question 7

What are the mechanical causes of bowel obstruction?

Answer 7

Mechanical causes for intestinal obstruction:
1. Most common: Postoperative adhesions
= bands of fibrous tissue that develop during the healing process after a surgery

2. Hernias
   - a portion of the intestine protrudes out of the abdominal cavity -> can get trapped or tightly pinched where it pokes out
3. Volvulus
   - a loop of intestine twists upon itself, kinking off the lumen
4. Intussusception
   - part of the intestine folds into the lumen of an adjacent section of bowel
5. Strictures (abnormal narrowing of the intestines), fibrous bands (scars), tumors,
   fecal impaction (large hard stools that cant be pushed out), eat foreign object -> stuck in GI tract
   - all causes blockages

Question 8

What are the causes of Functional obstruction?

Answer 8

Anything that decreases smooth muscle contractility

1. most common: postoperative ileus
   - transient paralysis of the smooth muscles in the intestinal wall
   - usually caused by trauma during surgery
2. infections or inflammation
   - eg: appendicitis, hypothyroidism, and intestinal ischemia, due to a thrombus or embolus
3. electrolyte abnormalities
   - hypokalemia and hypercalcemia
   - meds like opioids.

Question 9

What are the risk factors of developing intestinal obstruction?

Answer 9

1. older clients
2. those who have had abdominal or pelvic surgery
3. inflammatory bowel disease, like Crohn’s disease, endometriosis
4. had radiation therapy
   - increased risk of developing strictures -> intestinal obstruction

Question 10

How does intestinal obstruction occur?

Answer 10

Food before the obstruction cannot pass through the GI tract -> accumulates & build up -> distention & presses on the blood vessels, veins & lymphatic tissue -> mucosal edema, inflammation & damage -> even more pressure: will cause ischemia -> hypoxia

Question 11

What are the complications of intestinal obstruction?

Answer 11

1. Severe hypovolemia + NA, K & Cl imbalance -> acute kidney injury & life-threatening hypovolemic shock -> decreased blood flow to vital organs
2. intestinal ischemia can spread from mucosa to all layers of the bowel wall = transmural infarction / strangulation -> bowel perforation = hole in bowel wall that connects the lumen to the peritoneal cavity -> bowel bacteria leak out -> bacterial peritonitis
3. many BVs in the layers of the peritoneum -> alot of bacteria from peritoneal cavity can enter bloodstream -> trigger massive inflammatory response = sepsis -> septic shock & death

Question 12

What are the clinical manifestations (observable signs & symptoms) of intestinal obstruction?

Answer 12

Generally:
- cramping, abdominal pain, vomiting, constipation, and abdominal distention.

Proximal (nearer to trunk of body) small bowel obstruction:
- copious (alot), projectile vomiting
- contains bile or undigested food
- minimal abdominal distension

Distal (further from trunk of body) small bowel obstruction:
- not frequent vomiting
- foul-smelling
- may contain faeces
- abdominal distention more pronounced VS proximal

Large bowel obstruction
- late-onset vomiting or no vomiting
- significant abdominal distension

Proximal means closer to the center of the body, while distal means farther away

Question 13

How to diagnose intestinal obstruction?

Answer 13

1. Abdominal X-ray in upright position
   - Dilated loops of bowel with multiple air-fluid levels = mechanical intestinal obstruction

• generalized, uniform distention of the large and small bowel = functional bowel obstruction
• Free air under diaphragm = pneumoperitoneum = perforation

2. abdominal CT scan with contrast can
   - identify exact location + potential cause of the obstruction
   - show extent of bowel injury and look for potential complications.
3. Abdominal ultrasound, MRI and endoscopy, like sigmoidoscopy and colonoscopy
4. Lab test results are typically non-specific
   - may show elevated hematocrit BUN levels if dehydrated