Bowel Obstruction: Backup Along the 750

By Shelba Durston, RN, CCRN, MSNNursing made Incredibly Easy! March/April 20092.5 ANCC contact hoursOnline: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Small and Large Intestines

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, and sigmoid colon; rectum Main functions are elimination of waste and

absorption of water

Bowel Obstruction

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

In small bowel obstruction, large amounts of fluid and gases are trapped above the area of 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

Causative Factors

Extrinsic bowel obstruction Begins outside the GI tract 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)

Mechanical Causes

Adhesions: 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

Intussusceptions: Bowel slips into itself

Tumors

Diverticulitis: Pouches push out of mucosal lining of bowel

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

Signs & Symptoms: Small Bowel Obstruction

Crampy abdominal pain (usually seen in small bowel obstruction)

Reflux vomiting if obstruction is complete

Fecal-smelling breath

Dehydration signs: thirst, drowsiness, malaise, achiness, and parched tongue and mucous membranes

Signs & Symptoms: Large Bowel Obstruction

Develop and progress slowly

Constipation may be the only symptom for months

Weakness, weight loss, and anorexia

Marked abdominal distention

Crampy lower abdominal pain

Assessment

Past medical history and history of events leading to seeking care (pain is usually the symptom that causes patient to seek care)

Assess pain characteristics (quality and intensity)

Assess abdomen

Auscultate bowel sounds (Bowel sounds: high-pitched, hyperactive, tinkling, and almost metallic in the area over the obstruction; quiet or absent below the obstruction)

Diagnostic 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

Diagnostic Tests

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

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

Urinary catheter to monitor output

I.V. therapy to replace fluids and electrolytes

Administration of broad-spectrum antibiotics

Conservative control of pain

NG Tube Length Measurement

Confirming NG Tube Placement

To confirm placement after the initial X-ray is done, a combination of three methods is recommended: 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

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

Infection (urinary, peritonitis)

Respiratory impairment (pneumonia, atelectasis)

Alterations in clotting mechanisms (DIC)

Skin breakdown

Preventing Complications

Monitor prothrombin time and INR

Assess skin for petechiae, color, and temperature

Assess body fluids for presence of blood

Assess nutritional status (monitor albumin and prealbumin)

Use an air mattress to prevent skin breakdown

Patient Teaching

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

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

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