Bowel Obstruction: Backup Along the 750 By Shelba Durston, RN, CCRN, MSN Nursing made Incredibly...
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Transcript of Bowel Obstruction: Backup Along the 750 By Shelba Durston, RN, CCRN, MSN Nursing made Incredibly...
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