Intestinal Obstruction - Chapter 38 PDF

Intestinal obstruction Lower Gastrointestinal Problem chapter 38 Dr. Raed Shudifat Intestinal obstruction ◼ Occurs when intestinal contents cannot pass through the GI tract ◼ The obstruction prevents the normal flow of intestinal contents through the intestinal tract. ◼ May...

Intestinal obstruction Lower Gastrointestinal Problem chapter 38 Dr. Raed Shudifat Intestinal obstruction ◼ Occurs when intestinal contents cannot pass through the GI tract ◼ The obstruction prevents the normal flow of intestinal contents through the intestinal tract. ◼ May occur in the small or large intestine ◼ Severity depends on the region of the bowel affected, the degree to which the lumen is occluded, and especially the degree to which vascular supply to the bowel wall is disturbed Intestinal obstruction cont. Partial or complete Simple or strangulated Partial obstruction usually resolves with conservative treatment Complete obstruction usually requires surgery. Simple obstruction has an intact blood supply Strangulated obstruction does not have an intact blood supply Potentially life-threatening condition  Intestinal obstruction Types of Intestinal obstruction ▪ Mechanical obstruction ▪ Functional obstruction Mechanical obstruction ◼ More common in small intestine Intestinal obstruction Causes ◼ Postoperative surgical adhesions ( days or years) most common cause of small bowel obstruction ◼ Hernias ◼ Tumors/cancers ◼ Stenosis ◼ Strictures from crohn’s disease ◼ Abscesses ◼ Intussusception: in which one segment of the intestine telescopes inside of another.it usually occurs when the small and large intestines meet Intussusception Intestinal obstruction Functional obstruction /Non-mechanical intestinal obstruction ◼ Intestine cannot propel contents along bowel. Examples ◼ Muscular dystrophy ◼ Endocrine disorders such as DM ◼ Neurologic disorders such as parkinson's disease. ◼ Manipulation of bowel during surgery ◼ Paralytic ileum (temporary) : no intestinal peristalsis and no bowel sounds occur after any abdominal surgery  Intestinal obstruction Pathophysiology ◼ Obstruction ◼ Proximal bowel to obstruction =distension (fluid, gas, intestinal contents) ◼ Intraluminal bowel pressure rises leads to an increase in capillary permeability and extravasation of fluids and electrolytes into peritoneal cavity ◼ Severe reduction in blood volume and results in hypotension and hypovolemic shock. Intestinal obstruction cont. Pathophysiology ◼ Bacterial infection ◼ Ischemia ◼ Necrosis ◼ Rupture leading to infection (peritonitis), septic shock, and death ◼ Strangulation and gangrenes ◼ Fluid electrolyte acid-base imbalance  Assessment and Diagnostic Findings ◼ Physical examination ◼ History ◼ Abdominal x-ray ◼ CT ◼ MRI ◼ Barium studies: contraindicated it can cause constipation ◼ Sigmoidoscopy or colonoscopy Assessment and Diagnostic Findings ◼ Laboratory studies ◼ CBC ◼ Serum electrolytes, BUN, creatinine monitored frequently to assess degree of dehydration. Auscultation of bowel sounds High pitched sounds above area of obstruction May also be absent  Clinical manifestations : Small Bowel Obstruction Small bowel obstruction ◼ Vary depending on location and degree of obstruction ◼ Rapid onset ◼ Initial symptom: cramp abdominal pain (wavelike and colicky. ◼ Blood and mucus pass but no fecal matter and no flatus. ◼ Nausea and Vomiting (foul-smelling), ◼ Abdominal distention. Clinical manifestations : Small Bowel Obstruction complete obstruction ◼ peristaltic waves assume a reverse direction ◼ intestinal contents pushed toward the mouth instead of toward the rectum. ◼ First, the patient vomits stomach contents, then bile-stained contents of the duodenum and jejunum, and finally, with each attack of pain, the darker, fecal-like contents of the ileum. Clinical manifestations Small Bowel Obstruction ◼ signs of dehydration ◼ intense thirst, drowsiness, generalized malaise, and a dry tongue and mucous membranes. ◼ hypovolemic shock occurs from dehydration Small Bowel Obstruction Medical Management ◼ Surgical and medical treatment depends on cause of obstruction. ◼ Decompression of bowel through NG tube or intestinal tubes ( removal of gas and fluids) ◼ Complete obstruction/ strangulated : emergency surgery ◼ hernia and adhesions: repairing hernia or dividing adhesion. ◼ removal of affected portion of bowel and an anastomosis performed. ◼ Before surgery, IV therapy (replace water, NA, CL, and K(. Small Bowel Obstruction Medical Management ◼ Initial medical treatment of bowel obstruction caused by adhesions includes  NPO  Decompression of bowel through NG tube or intestinal tubes ( removal of gas and fluids)  Rectal tube may be used to decompress lower area in bowel  IV fluid therapy ( normal saline or lactated ringer’s solution to maintain fluid and electrolyte balance)  Adding K to IV fluids after verifying renal function  Administering analgesics for pain control. Large Bowel Obstruction ◼ Obstruction can lead to severe distention and perforation Clinical Manifestations ◼ Onset: Gradual ◼ symptoms develop and progress relatively slowly. ◼ Constipation may be only symptom for months in patients with obstruction in sigmoid colon or rectum, ◼ Blood in stool ◼ Iron deficiency anemia. ◼ Weakness, weight loss, anorexia. ◼ Abdominal distension ◼ Visible loops of large bowel ◼ Crampy lower abdominal pain. ◼ Fecal vomiting ◼ Symptoms of shock may occur.  Large Bowel Obstruction Medical Management ◼ colonoscopy: performed to untwist and decompress bowel. ◼ cecostomy: ◼ surgical opening into the cecum ◼ performed in patients with poor surgical risks and urgently need relief from obstruction. ◼ 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. ◼ Surgical resection: removing obstructing segments and anastomose remaining healthy bowel ◼ Temporary or permanent colostomy may be necessary. Intestinal obstruction Nursing Management ◼ Pt assessment( pain, vomitus, abdominal tenderness, ) ◼ Monitor patient for symptoms that indicate that intestinal obstruction is worsening ◼ Maintain patent NG tube ◼ Assess and measure NG output ◼ Assess for fluid and electrolyte imbalance ◼ Maintain strict I & O record, including emesis and tube drainage. ◼ Monitor urine outputs hourly Nursing Management ◼ Monitoring nutritional status ◼ Provide emotional support and comfort. ◼ Administers IV fluids and electrolytes as prescribed. ◼ Prepares patient for surgery. ◼ After surgery, wound care and routine postoperative nursing care are provided. ◼ Intake and output monitoring Intestinal obstruction Nursing care of NG tube ✓ Mouth care ✓ Encourage and help patient to brush teeth frequently. ✓ Mouthwash and water for rinsing mouth and water- soluble lubricant for lips should be readily available to patient. ✓ Check nose for signs of irritation from NG tube. ✓ Clean and dry nose daily, apply water-soluble lubricant, and re-tape tube. ✓ Check NG tube every 4 hours for patency.