INTEST

CONTENTS• Introduction

Intestinal obstruction

College of Nursing Medical Surgical Nursing

Bridging Program Academic Year 1434-1435 / 2013-

2014

2140030005

Intestinal obstruction

Outline :

Introduction DefinitionClassificationprognosisCauses of intestinal obstructionAnatomy & physiologyPathophysiology , s&sDiagnostic testComplicationTreatmentNursing interventionsPatients health educationreference

IntroductionThe bowel, or intestine, is the part of the digestive tract that absorbs nutrients from foods we eat. The residue of digested food passes through the bowel and is excreted during elimination, the final stage of digestion. This process can be interrupted or halted by the presence of a bowel obstruction, which is a blockage that prevents the passage of intestinal contents. Definition

The term intestinal obstruction refers to any form of impedance to the normal passage of the bowel contents through the small or large intestine. It is a common cause of acute abdominal pain.

classification

1.Causes of mechanical obstruction Adhesions

the most common cause of small bowel obstruction. Intussusceptions One part of the intestine slips into another part located below it. Volvulus-Bowel twists and turns on itself. StrangulatedHernia-Protrusion of intestine through a weakened

area in the abdominal muscle or wall. Tumor -a tumor that exists within the wall of the

intestine or a tumor outside the intestine causes pressure on the wall of the intestine.

Impaction of stool Foreign bodies2. paralytic /Functional obstruction:

Classification Dynamic/Mechanical obstructionIntramural(tumors and polyps) Intussusception Volvulus CongenitalAdynamic obstruction. Hypodynamic state (ileus)Strangulation/ incarceration

Failure of peristalsis to move intestinal contents: due to neurologic or muscular impairment.

• in which The intestinal muscles cannot propel)push) the contents along the bowel.

Causes; Abdominal surgery and trauma. Spinal injuries Peritonitis Vascular insufficiency muscular dystrophy,

Normal anatomy (http://www.youtube.com/watch?v=18M96_p7jSQ) The intestine is made up of the small intestine and

the large intestine (colon). The small intestine runs from the stomach to the large intestine. The colon runs from the end of the small intestine to the anus. The intestine absorbs nutrients and water from the diet.

Obstruction of the intestine occurs when food and water cannot pass through the intestine. The area of intestine nearest to the obstruction becomes dilated and non-functioning. If the obstruction is not relieved, it can lead to intestinal gangrene and perforation.

Pathophysiologysimple mechanical obstruction, blockage occurs without vascular compromise. Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel distends, and the distal segment collapses. The normal secretory and absorptive functions of the mucosa are depressed, and the bowel wall becomes edematous and congested. Severe intestinal distention is self-perpetuating and progressive, intensifying the peristaltic and secretory derangements and increasing the risks of dehydration and progression to strangulating obstruction.

Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25% of patients with small-bowel obstruction. It is usually associated with hernia, volvulus, and intussusception. Strangulating obstruction can progress to infarction and gangrene in as little as 6 h. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and perforation. In large-bowel obstruction, strangulation is rare (except with volvulus).Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation occurs. The risk is high if the cecum is dilated to a diameter ≥ 13 cm. Perforation of a tumor or a diverticulum may also occur at the obstruction site.Summery of path physiology Intestinal contents, fluid, and gas accumulate above the

obstruction. Resulting in abdominal distention and retention of fluid. With increasing distention, pressure within the lumen increases,

causing a decrease in venous and arteriolar capillary pressure. This causes edema, congestion, necrosis, and perforation of the

intestinal wall. vomiting may be caused by abdominal distention. Vomiting results in a loss of H+andK+from the stomach, leading

to a reduction of CL-andK+in the blood, resultinginmetabolic alkalosis.

With acute fluid losses, hypovolemic shock may occur.

Clinical manifestation It depends on the level of the block, type and degree of obstruction and its cause.1. Acute onset of the disease.2. Periodic acute diffuse pain of wavelike character which results in shock.3. Constant vomiting and nausea without any relief.4. Signs of dehydration and intoxication (The patient looks anxious, with drawn features, hollowed-eyed, his lips and tongue are dry, with brown fur).

5. Retention of stool and gases.

DiagnosisASSESSMENT :

History Physical examination

Imaging Radiography Ultrasonography Endoscopy CT Barium Enema

Laboratory examination Complete blood count Serum Urea & electrolytes Liver function test Serum amylase

Complication Dehydration Ischemic bowel disease Intestinal perforation Peritonitis Sepsis

prognosisThe outcome depends on the cause of the blockage. Most of the time the cause is easily treated.

Treatment:

In most cases the patient is kept NPO. NG tube to decompressed , which relieves symptoms and may resolve the

obstruction. I.V solution with electrolytes is initiated to correct the fluid and electrolyte

imbalance. IV antibiotics .The surgical treatment of intestinal obstruction depends largely on the cause of the obstruction.

In the most common causes of obstruction, such as hernia and adhesions, the surgical procedure involves repairing the hernia or dividing the adhesion to which the intestine is attached.

In some instances, the portion of affected bowel may be removed and an anastomosis performed.

A colonoscopy may be performed to untwist and decompress the bowel. A cecostomy, in which a surgical opening is made into the cecum, may be performed for patients who are poor surgical risks and urgently need relief from the obstruction. The procedure provides an outlet for releasing gas and a small amount of drainage.

A rectal tube may be used to decompress an area that is lower in the bowel. The usual treatment, however, is surgical resection to remove the obstructing lesion.

A temporary or permanent colostomy may be necessary. An ileoanal anastomosis may be performed if it is necessary to remove

the entire large colon.

Nursing ManagementNursing Assessment:• Assess the nature and location of the patient's pain, the presence or

absence of distention, flatus, defecation, emesis, obstipation.• Listen for high-pitched bowel sounds, peristaltic rushes, or absence of

bowel sounds.• Assess vital signs.

Nursing Diagnoses:• Acute Pain related to obstruction, distention, and strangulation.• Risk for Deficient Fluid Volume related to impaired fluid intake,

vomiting, and diarrhea from intestinal obstruction.• Diarrhea/Constipation may be related to presence of

obstruction/changes in peristalsis, possibly evidenced by changes in frequency and consistency or absence of stool, alterations in bowel sounds, presence of pain, and cramping.

• Ineffective Breathing Pattern related to abdominal distention, interfering with normal lung expansion.

• Risk for Injury related to complications and severity of illness.• Fear related to life-threatening symptoms of intestinal obstruction.

Nursing InterventionsAchieving Pain Relief:

Administer prescribed analgesics.Provide supportive care during NG intubation to assist with discomfort.To relieve air-fluid lock syndrome, turn the patient from supine to prone position every 10 minutes until enough flatus is passed to decompress the abdomen. A rectal tube may be indicated.

Maintaining Electrolyte and Fluid Balance:Measure and record all intake and output.Administer I.V. fluids and parenteral nutrition as prescribed.Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts, and report any abnormalities.Monitor urine output to assess renal function and to detect urine retention due to bladder compressions by the distended intestine.Monitor vital signs; a drop in BP may indicate decreased circulatory volume due to blood loss from strangulated hernia.

Maintaining Normal Bowel Elimination:Collect stool samples to test for occult blood if ordered.Maintain adequate fluid balance.Record amount and consistency of stools.Maintain NG tube as prescribed to decompress bowel.

Maintaining Proper Lung Ventilation:Keep the patient in Fowler's position to promote ventilation and relieve abdominal distention.Monitor ABG levels for oxygenation levels if ordered.

Preventing Injury Due to Complications:Prevent infarction by carefully assessing the patient's status; pain that increases in intensity or becomes localized or continuous may herald strangulation.Detect early signs of peritonitis to minimize this complication.Avoid enemas, which may distort an X-ray or make a partial obstruction worse.Observe for signs of shock.Watch for signs of (metabolic alkalosis and metabolic acidosis.

Patient and family education When client is to be discharged from the hospital, nursing care is still continued. With sufficient support at home, most client recover gradually. During home visits, the client’s physical status and progress towards

recovery is assessed. The client’s understanding of therapeutic regimen is also assessed, and previous teaching is reinforced.

Instruct the significant others to take the following home medication as ordered by the physician.Explain to the significant others the drug names as well as the right route and dosage.Inform the significant others about the side effects that may occur brought by the medication.Encourage the significant others to comply and follow religiously the right timing in taking the medication.Confer with the patient’s family the need take precautions regarding medication therapy, activity, and dietary restriction.Discuss with the patient’s family ways to cope with stressful situations in positive manner.

Instruct patient’s family to report for immediate occurrence of signs and symptoms to a health care professional.Reinforce and supplement patient’s family knowledge about diagnosis, prognosis, and expected level of function.Provide patient’s family with specific directions about when to call the physician and what complications require prompt attention.Peer support and psychological counseling may be helpful for some families.

Exercise/ Environment Once at home, patient may resume much of the normal activity short of

aggressive physical exercise. Walk short distances everyday and gradually increase activity. No lifting of a weight greater than 20 lbs (9kg) for 6 weeks. Exercise

should be started cautiously. Encourage to practice deep breathing exercise and range of motion

exercises up to the level of capability. Explain the need for rest periods both before and after certain

activities. Teach client the importance of stress management through relaxation

technique, Help improve patient’s self-concept by providing positive feedback,

emphasizing strengths and encouraging social interaction and pursuit of interests.

Treatmento Explain to the significant others the need to continue drug therapy

o Provide patient’s family with a list of medications, with information on action, purpose and possible side effects.

o Advise significant others to always comply with the medications. Call the physician if there is a problem taking them.

Hygiene Keep proper hygiene. Teach client’s family the importance of hygiene

like daily oral care, bathing and changing clothes. Proper Wound care must be observed.

DietEmphasize to the client’s family the importance of proper nutrition, its need for early recovery. This can aid in restoring body functioning.Provide dietary instructions to help patient’s family identify and eliminate foods that is needed by the patient.Soft or low residue diet upon discharge; this should be continued at home for approximately 2 weeks (this includes breads, cereals, chicken, fish, and soup). Avoid large quantities of raw fruits and vegetables. After 2 weeks, gradually reintroduce your regular diet.Encourage to drink plenty of fluids.Take nutrition supplements

Outpatient• Advise to visit or have her follow up check-up with her attending

physician.• Advise to call and notify the attending physician for any unusual ties

that may occur• Routinely, follow up check – up with patients within two weeks. If there

are staples that require removal, postoperative problems, or wound issues, a follow-up appointment will be scheduled sooner.

References: Smeltzer, S.C. & Bare, B.G. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 12th Ed. Philadelphia: Lippincott Company, 2010.http:// www MedicinePlus.com

http:// nanda-nursinginterventions.blogspot.com