Intestinal Obstruction - Med Surg 2

Define Intestinal Obstruction

Results from mechanical or nonmechanical causes

Define Mechanical Obstruction (2)

• Obstruction occurs when bowel is blocked by something outside or inside the intestines (adhesions, fecal impactions)

• Complete mechanical obstructions addressed surgically

Define Non-Mechanical Obstruction (2)

• Obstruction caused by diminished peristalsis within the bowel (paralytic illeus)

• Can occur post op

Types of Intestinal Obstruction (5)

• Herniation - Bowel trapped in weakened abdominal wall area

• Adhesions - Encircles or compresses intestines; Bands of scar tissue cause intestines to stick together (small)

• Intussception - Telescoping of bowel segments, one part of bowel slides into another blocking stool passage and compressing blood vessels; small

• Volvulus - Twisting of bowel segemnts

• Paralytic Illeus - Non-mechanical obstruction, decreased peristalsis.

Expected Findings - Small & Large Intestine Obstruction (4)

• Obstipation- Inability to pass stool &/or flatus for more than 8 hr despite feeling urge to defecate

• Abdominal distention

• High-pitched bowel sounds above site of obstruction (borborygmi) with hypoactive bowel sounds below, or overall hypoactive

• Absent bowel sounds later in process

Expected Findings - Small Bowel Obstruction (5)

• Severe fluid & electrolyte imbalance

• Metabolic alkalosis (vomiting)

• Epigastric or upper abdominal distention

• Abdominal pain or discomfort

• Profuse, sudden projectile vomiting with fecal odor

Expected Findings - Large Bowel Obstruction (6)

• Minor fluid & electrolyte imbalance

• Metabolic acidosis

• Lower abdominal distention

• Intermittent abdominal cramping

• Infrequent vomiting

• Diarrhea or ribbon-like stools around an impaction

Labs (4)

• Dehydration Indication - Increased H&H, BUN, & creatinine

• Strangulating Obstructions - Increased serum amylase & WBC count

• ABGs - Indicate metabolic imbalances

• Decreased sodium, chloride, & potassium

Diagnostics (3)

• X-ray - Evaluates presence of free air & gas patterns

• Endoscopy - Determines cause of obstruction

• CT scan - Determines cause & exact location of obstruction

Mechanical Obstruction - Nursing Care (2)

Prep for surgery & provide pre-op care

Withhold intake until peristalsis returns

Non-Mechanical Nursing Care

• NPO with bowel rest

• Assess bowel sounds

• Provide oral hygiene

• Administer IV fluid and electrolyte therapy

• Manage pain

• Encourage ambulation

• Semi-Fowler’s position

Medications (2)

Opioid Antagonists

Broad-Spectrum Antibiotics - Suspected bowel strangulation

Define Opioid Antagonist (4)

• To reverse action of opioids on bowel motility with a post-op paralytic ileus

• Alvimopan

• Short term use

• Monitor for myocardial infarction

Therapeutic Procedure (7)

• NGT with a vent (prevents damage to stomach mucosa) to decompress bowel with intermittent suction

• Irrigate w 30 mL (patency) NS Q4h as prescribed

• Maintain in SF’s position

• Monitor & assess gastric output

• Monitor nasal area for skin breakdown

• Oral hygiene q2h

• Monitor vitals, skin integrity, weight & I&O

Surgical Interventions (8)

• Procedure based on cause of obstruction

• Lysis of adhesions

• Colon resection

• Colostomy creation (temporary or permanant)

• Embolectomy

• Thrombectomy

• Resection of gangrenous intestinal tissue

• Complete colectomy

Exploratory Laparotomy - Surgical Interventions (6)

• Determines & corrects cause of obstruction

• Monitor hemodynamics for instability

• IV fluids

• Monitor bowel sounds

• NGT - Measure output, maintain patency, clamp to assess tolerance before removal

• Advance diet as tolerated - Start with clear liquids; Clamp tube 1-2 hrs after eating

Small Bowel Obstruction - Complications (3)

• Dehydration - Persistent vomiting

• Electrolyte imbalance - Persistent vomiting

• Metabolic alkalosis - Persistent vomiting, leading to a loss of gastric hydrochloride

Dehydration - Nursing Actions (3)

• Assess hydration through evaluation of hematocrit, BUN, orthostatic vitals, skin turgor/mucous membranes, urine output, & specific gravity

• Notify provider of a fluid imbalance.

• Administer IV fluids as prescribed.

Electrolyte Imbalances - Nursing Actions (3)

• Monitor electrolytes, especially potassium levels.

• Notify the provider of an electrolyte imbalance.

• Administer IV fluids as prescribed to replace electrolytes.

Metabolic Alkalosis - Nursing Actions (4)

• Monitor for hypoventilation (confusion, hypercarbia), a compensatory action by the lungs.

• Obtain ABGs & notify provider of unexpected lab findings.

• Replace fluid & electrolytes as prescribed.

• Provide oral hygiene to alleviate increased thirst response. Thirst response is decreased in the older adult. Provide oral hygiene routinely to ensure maintenance of moist mucous membranes

Large Bowel Obstruction - Complications

Metabolic Acidosis - Caused by a lower level obstruction

Metabolic Acidosis - Nursing Actions (2)

• Monitor for deep, rapid respirations (compensatory action by lungs), confusion, hypotension, & flushed skin.

• Obtain ABGs & notify provider of unexpected lab findings.