INTESTINAL OBSTRUCTION P 1029 1034 Mechanical Detectable occlusion of the intestinal lumen Occur in the small intestine o o Surgical adhesion as most common cause that occurs days of surgery or several years later Also caused by hernias tumors Large bowel obstruction o Caused by carcinoma and bolbolus o Diverticular disease Nonmechanical Neuromuscular vascular disorder Paralytic ileus most common form of nonmechnical obstruction o Occurs after abdominal surgery o Also caused by peritonitis inflammatory responses appendicitis and pancratitis hypokalemia thoracic and lumbar spinal fractures Vascular obstructions o Rare o Results from blood supply experiences interference when reaching the portion of intestines Causes are emboli venous thrombosis Etiology and Pathophysiology With obstruction fluid gas and intestinal contents accumulate proximally and the distal bowel collapses Increased pressure increase in capillary permeability and extravasation of fluids and electrolytes in peritoneal cavity Retention of fluid severe reduction in circulating blood volume hypotention and hypovolemic shock Inadequate blood flow ischemic bowel tissue necrosis perforation of bowel Distended bowel arrested blood flow edema cyanosis and gangrene of bowel segment intestinal strangulation or infarction If not corrected quickly bowel becomes necrotic and rupture death Location of obstruction determines the extent of fluid electrolyte and acid base imbalances o High obstruction pylorus metabolic alkalosis from loss of gastric HCl through vomiting and NG intubation o o Small bowel dehydration occurs rapidly Below proximal colon fecal material accumulates until symptoms of discomfort disappear Some resolve without surgery Others strangulated require emergency surgery for removal Classifications based on clinical symptoms Clinical Manifestation Onset Vomiting Pain Abdominal distention Small Intestine Rapid Frequent Copious Colicky Cramplike Intermittent Greatly increased OBSTRUCTION High pitched sounds above area of strangulation Absent bowel sounds Borborygmi Small Intestine Obstruction Proximal obstruction o Nausea o o o minimal or absent abdominal distention projectile vomiting with bile vomiting relieves abdominal pain Distal obstruction o more gradual onset with orange brown and foul smelling like feces CLINICAL MANIFESTATIONS OF SMALL AND LARGE INTESTINAL OBSTRUCTION Large Intestine Gradual None Low grade Increased Paralytic Ileus More constant generalized discomfort Strangulation o o o o severe constant pain that is rapid abdominal tenderness rigidity Temperature above 100 F Low Intestinal Obstruction persistent colicky pain Mechanical obstruction Pain that comes and goes in waves Diagnostic Studies Thorough history and physical examination CT scans and abdominal x rays for diagnostic aids Upright and lateral abdominal x rays gas and fluid in intestines Intraperitoneal air perforation Sigmoidoscopy or colonscopy direct visualization of obstruction in colon Laboratory tests o CBC Elevated WBC strangulation or perforation Elevated hematocrit Decreased H H bleeding from neoplasm or strangulation o o o Serum electrolyte dehydration Amylase BUN determinations Stools for occult blood Metabolic alkalosis from vomiting Collaborative Care Emergency surgery for bowel strangulation Conservative treatment o NPO status o NG tube o Colonscope to remove polyps Stricture dilation Destroy tumors with laser Parenteral nutrition to correct nutritional deficits Nursing Management Assessment IV fluids with NS or LR fluids in gut are isotonic Surgery if obstruction does not improve within 24 hours to relieve obstruction o Resecting the obstructing segment of bowel and anastomosing the healthy bowel together o o Partial or total colectomy Ileostomy Detailed patient history and physical exam Determine location duration intensity and frequency of abdominal pain Assess for abdominal tenderness or rigidity Record frequency color odor and amount of vomitus Assess bowel function and flatus Auscultate for bowel sounds and document character and location Inspect abdomen for scars masses distention Measure abdominal girth Palpate for muscle guarding and tenderness peritoneal irritation and indicative of strangulation Strict I O record including emesis and tube drainage Urinary catheter to monitor hourly urine outputs Less than 0 5 mL kg body weight inadequate vascular volume and potential for acute renal failure o o Rising creatinine and BUN levels renal failure Diagnosis Acute pain r t abdominal distention and increased peristalsis Deficient fluid volume r t decrease in intestinal fluid absorption third space fluid shifts into bowel lumen and peritoneal cavity NG suction and vomiting Imbalanced nutrition less than body requirements r t intestinal obstruction and vomiting Nursing Implementation Monitor for signs of dehydration and electrolyte imbalances Administer IV fluids as ordered o Watch for signs of fluid overload Monitor serum electrolyte levels High intestinal obstruction metabolic alkalosis Low intestinal obstruction metabolic acidosis Provide comfort measures and promote restful environment Care for NG tubes o Oral care o o Mouthwash and water for rinsing mouth o o Check nose for signs of irritation from the NG tube o Retape tube o Check patency every 4 hours Petroleum jelly or water soluble lubricant for lips Assist and encourage patient to brush teeth frequently