INTEST

CONTENTS
Introduction

Prepared by
Majeda Abdulla Abou foor
Intestinal obstruction

College of Nursing
Medical Surgical Nursing
Bridging Program
Academic Year 1434-1435 / 2013-2014

2140030005

Outline :

Introduction
Definition
Classification
prognosis
Causes of intestinal obstruction
Anatomy & physiology
Pathophysiology , s&s
Diagnostic test
Complication
Treatment
Nursing interventions
Patients health education
reference



Introduction
The 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.
Classification
Dynamic/Mechanic
al obstruction
Intramural(tumors and
polyps)
Intussusception
Volvulus
Congenital
Intraluminal
(foreign bodies)
Adynamic
obstruction.
Hypodynamic
state (ileus)
Strangulation/
incarceration
Impaction of stool
Foreign bodies
2. paralytic /Functional obstruction:
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.




Pathophysiology
simple 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.

Diagnosis
ASSESSMENT :
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
prognosis
The 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 Management
Nursing 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 Interventions
Achieving 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 clients physical status and progress towards
recovery is assessed. The clients 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 patients family the need take precautions regarding medication therapy, activity, and
dietary restriction.
Discuss with the patients family ways to cope with stressful situations in positive manner.

Instruct patients family to report for immediate occurrence of signs and symptoms to a health care
professional.
Reinforce and supplement patients family knowledge about diagnosis, prognosis, and expected level of
function.
Provide patients 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 patients self-concept by providing positive feedback, emphasizing strengths and
encouraging social interaction and pursuit of interests.
Treatment
o Explain to the significant others the need to continue drug therapy
o Provide patients 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 clients family the importance of hygiene like daily oral care, bathing and
changing clothes.
Proper Wound care must be observed.
Diet
Emphasize to the clients family the importance of proper nutrition, its need for early recovery. This can aid
in restoring body functioning.
Provide dietary instructions to help patients 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 Suddarths Textbook of Medical Surgical Nursing.
12
th
Ed. Philadelphia: Lippincott Company, 2010.
http:// www MedicinePlus.com
http://nanda-nursinginterventions.blogspot.com