Caring for a patient with a bowel obstruction [Новость добавлена - 10.10.2007]

by VICKY P. KENT RN, CNE, PHD LPN2007 September/October 2007, Volume 3 Number 5,Pages 30 - 38

KENT, VICKY P. RN, CNE, PHD

Bowel obstructions can occur at all ages and for a variety of reasons, and they're more prevalent than you might think—in the United States, 12% of all hospital stays involve patients diagnosed with bowel obstructions. Early intervention is vital, so you need to recognize the signs and symptoms to help ensure that your patient has a positive outcome.
 HOW URGENT A PROBLEM is bowel obstruction? Most patients with this condition are admitted to the hospital through the emergency department, and 10% to 20% of them are acute surgical cases. Because a bowel obstruction can be deadly if not treated promptly, it requires precise identification for proper treatment. In this article, I'll review what a bowel obstruction is, what causes it, the signs and symptoms to look for, and how to care for a patient who presents with this diagnosis.

A bowel obstruction, or intestinal obstruction, is anything that stops, delays, or changes the advancing of solid and liquid material through the small and/or large bowel. Treatment for bowel obstructions ranges from medical management to surgical intervention.

Bowel obstructions are classified as mechanical or nonmechanical (also called a functional obstruction ), partial or complete , and acute or insidious . Their signs and symptoms differ, according to their category, position, and severity. Initial indicators of a bowel obstruction can include a feeling of fullness, a swollen or stretched abdomen, nausea, mild or severe vomiting, stomach cramps, an absence of bowel sounds or high-pitched and resonant sounds, and diarrhea or constipation.

First, let's review the two types of bowel obstructions—mechanical and nonmechanical.

A mechanical bowel obstruction is something that decreases the diameter of the bowel's opening from either the inside or outside. It physically blocks the movement of material through the intestines. Possible mechanical obstructions could be due to:

In a simple mechanical obstruction, ingested liquids and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel enlarges and the distal bowel collapses. Normal bowel function decreases, and the bowel wall becomes edematous and congested. Blood flow to the intestines is also impaired, which can cause the tissue to die. This can lead to bacterial infection, sepsis, dehydration, and electrolyte abnormalities.

A nonmechanical bowel obstruction is caused by something that decreases the muscle action of the bowel and affects the ability of fecal matter and fluid to move through the intestines. A nonmechanical obstruction could be related to:

Bowel obstructions can also be classified as being partial or complete . A partial bowel obstruction indicates that some, but not all, of the food and air in the intestines can move. A complete bowel obstruction indicates complete blockage, and no food or air can move through the intestines.

Two more classifications for bowel obstructions are acute and insidious . Acute bowel obstructions cause a rapid onset of cramps, abdominal distension, vomiting, and severe constipation. Insidious obstructions develop over a period of weeks and are more often associated with large bowel obstructions.

The location of a bowel obstruction is important in making a proper assessment. Let's look at where they can occur.

Most mechanical obstructions (80%) occur in the small bowel. Small-bowel mechanical obstructions are usually caused by:

Large-bowel mechanical obstructions are less common (20%) and are usually caused by:

Small- and large-bowel obstructions cause similar symptoms, although the intensity of discomfort and pain varies. Let's examine the clues that can help determine if your patient has a bowel obstruction.

Upon first assessment, a patient with a small- or large-bowel obstruction may have the symptoms already described plus the following signs and symptoms:

If the condition worsens, the patient may also begin to exhibit signs and symptoms of fluid and electrolyte imbalance and possibly metabolic acidosis or alkalosis.

Along with these basic signs and symptoms, patients will have other symptoms depending on whether they have a small-bowel or large-bowel obstruction. Here's how to tell the difference.

Patients with a small-bowel obstruction will usually have the following signs and symptoms.

Abdominal pain. The patient with a small-bowel obstruction presents with a pain that can be cramp-like or colicky. The pain is episodic and generally occurs in the mid-to-upper abdomen. If the obstruction is partial, the pain worsens right after the patient eats and improves with digestion. Distention and generalized discomfort without colicky pain may indicate a lack of movement in the intestines caused by paralysis of the bowel (paralytic ileus). Sometimes the patient gets pain relief after changing position or vomiting.

Nausea and vomiting occur as a result of increased peristaltic activity, but the intestinal contents reverse direction instead of moving forward. The vomiting is often projectile, especially if there's obstruction high in the small bowel. Another sign of obstruction high in the small intestine is vomit that's odorless or looks or smells like bile (a greenish yellow fluid that has a bitter, offensive odor).

In small-bowel obstructions, a patient will experience abdominal distention, a feeling of fullness, and a change in bowel sounds. The sounds range from hyperactive bowel sounds (increased loudness, tone, and regularity) to totally absent bowel sounds, typical of a paralytic ileus.

Constipation is a common sign of small-bowel obstruction. However, in a partial obstruction, the patient may have diarrhea and pass some gas. In a complete obstruction, the patient may have a bowel movement if the obstruction is above the stool that's already in the bowel.

Abdominal distension may be caused by obstructions in the lower abdomen. With a complete obstruction, high-pitched bowel sounds can be heard.

Patients with a large-bowel obstruction will usually have the following signs and symptoms.

A patient with an obstruction in the large bowel may describe pain as cramping, deep, and long lasting. Acute pain may indicate strangulation or perforation of the bowel.

The occurrence of constipation or diarrhea will depend on whether the obstruction is complete or partial.

This may be absent at first. As the large-bowel obstruction worsens, the patient's vomit may smell like feces.

Bloating is more visible in patients with a large-bowel obstruction.

When a patient has abdominal pain and complains of nausea and vomiting, it's critical that you begin your assessment by taking a complete and detailed history. Ask the patient about his bowel habits, and find out about any surprising changes. Ask when he had his last bowel movement. Were there prior surgeries? Abdominal trauma? Hernias? Peptic ulcer disease? Does the patient experience constipation or indigestion? Has he had gallstones? Tumors? Radiation therapy to the abdomen or the peritoneal area? Has he ever had an eating disorder? Find out about current and past medications.

Be thorough as you ask your patient about his current symptoms. Ask about the location, duration, and the type of pain. Ask what, if anything, relieves the pain. Find out if he has nausea or vomiting, and, if so, with what frequency, consistency, color, and odor.

Once you obtain a thorough history, it's time to assess the patient. This is done through abdominal inspection, auscultation, percussion, and palpation. For a visual guide to assessing bowel sounds, see Some sound advice .

Follow these tips for assessing bowel sounds:

After your initial assessment, the patient's health care provider will order a number of diagnostic tests to determine the location, extent, and severity of the obstruction. These tests include:

As soon as the health care provider arrives at a definitive diagnosis, the best course of action is to treat the patient quickly to prevent bowel perforation or strangulation. He may receive medical treatment or require surgery. Immediate surgery is necessary if he has vascular insufficiency, perforation, or strangulation of the bowel.

Medical treatment depends on the extent and severity of symptoms, and the type and location of the obstruction. In cases of malignant obstructions, the patient's condition and prognosis are important factors in treatment decisions.

Treatment begins with conservative medical management, which is often sufficient for partial small-bowel obstruction or adhesions. Conservative treatment includes:

If surgery is required, the health care provider may order antibiotics to minimize the risk of infection that may result from the contents of the intestines spilling into the peritoneal and abdominal cavities. The choice of surgical procedure depends on the type and location of the bowel obstruction.

Surgery in the small bowel can be a resection with end-to-end anastomosis. In this procedure, the surgeon removes the diseased tissue and reattaches either end of the healthy intestinal tissue to the other.

When surgery is chosen for a large-bowel obstruction, the predominant cause of the obstruction is often a malignant tumor. If there's perforation or diverticula, the surgery may be a resection with anastomosis. If there's a tumor in the colon, a hemicolectomy (removal of the diseased part of the colon) may be appropriate.

Once a patient is diagnosed with a bowel obstruction, it's crucial to completely assess his physiologic and psychological needs and to keep him safe. All three are important, but he may have a particularly difficult time dealing with body image issues if he needs an ostomy, a surgically created opening in the body for the discharge of body waste. (A colostomy is created for problems associated with the blockage of the large intestine. An ileosotomy is an opening created for problems in the small intestine.) This is when your support, understanding, and ability to educate are an essential part of your patient care.

During treatment, your patient's vital signs can serve as a potential warning of complications. If his temperature is elevated, it could be a sign of infection or possible perforation. When you take his pulse, be aware that tachycardia can be related to possible hypovolemic shock or septicemia.

When you measure blood pressure, keep in mind that hypotension is secondary to low circulating fluid volume. Make sure enough oxygen is available in the patient's blood to supply his tissues.

Carefully monitor the patient's fluid and electrolyte balance. What's the intake and output? Hydration is very important to maintain renal function and tissue perfusion, to prevent shock, and to maintain adequate blood pressure.

Monitor your patient's lab results, such as CBC and serum creatinine, amylase, and BUN levels. The results will indicate if the problem is worsening or resolving. Notify the health care provider of any abnormal results.

If your patient has abdominal distention, measure his girth every shift. Each time, make sure the patient is in the supine position if he's comfortable and it's not contraindicated; use the same measuring tape, measure at the same time, and mark the site on his abdomen to ensure accuracy.

After a patient undergoes surgery for a bowel obstruction, be aware of any changes in his vital signs, hydration, fluid, electrolytes, abdominal distention, and comfort. Determine if his bowel function has improved by noting the absence of nausea and vomiting. Listen for bowel sounds and note any expulsion of flatus and stools. Look for a decrease in abdominal distention. Measure the patient's urinary output. Listen for improved lung sounds.

Notice what the patient says and does. Can you detect a reduction in his anxiety? Has his pain lessened? Examine the incision. Is there drainage from the wound? Skin separation at the point of incision? Unusual lung sounds? Foul-smelling or unclear urine? If your patient returns from surgery with an ostomy, assess the stoma and be sure the pouch protects the skin and contains drainage. Comfort and reassure the patient. Teach him what to expect during his recovery period. Be sure to include the patient's family and caregivers in the plan of care when appropriate.

In terms of pain management, administer all medications as prescribed and assess for adverse effects. Medications may include opioids or opioid derivatives (note that morphine increases nausea and vomiting and causes constipation). Pain medications are also useful to control the patient's anxiety. An example of a drug to manage pain is morphine sulfate (MS Contin). The administration route will depend on the patient's overall condition.

When combined, antiemetic and opioid drugs depress the central nervous system. Be alert for changes in the patient's mental status and for signs and symptoms of respiratory depression and hypotension.

While your patient can't take nutrition by mouth, provide good mouth care. Use a water-soluble lubricant for lip care and care of the nasal mucosa. If he has an NG tube in place, provide the appropriate care for the tube as well as for the patient. When your patient is ready to eat, usually within 24 to 48 hours after surgery or at the first sounds of peristalsis, a progressive diet will be ordered as tolerated.

Provide comfort measures to bring relief when possible. Simply raising the head of the bed to 45 degrees helps the patient breathe better and can help create a more restful environment.

Be sure to provide psychological comfort and reassurance. Include family members in your care and patient education.

In addition to prescribing opioid and analgesic medications, the health care provider may order broad-spectrum antibiotics such as cefotetan (Cefotan) or cefuroxime (Ceftin) to prevent the possibility of infection. The patient may also receive metronidazole (Flagyl) in combination with antibiotics to protect against anaerobic bacteria. The type of antibiotic depends on the microorganism's susceptibility. The route of administration depends not only on the patient's condition but on the action of the drug.

Explain to your patient the purpose of any tubes and clarify the sequence of procedures to alleviate his anxiety. Advise the patient to engage in the level of activity that's appropriate for his condition. Teach him how and when to take his prescribed medications. Counsel the patient to drink plenty of fluids if not contraindicated and when applicable and to choose nutritious foods. Teach him to recognize signs and symptoms of recurrent problems, such as infection, so he'll know when to seek help from his health care provider.

Unlike some other dysfunctions, a bowel obstruction can be a complex condition to diagnose. You must be aware of the clues that help determine where the obstruction is located. Whether the problem is managed medically or through surgical intervention, your participation throughout the process will go a long way in helping the patient achieve a speedy recovery.

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WebMD Digestive Disorders Health Center: http://www.webmd.com/digestive-disorders/tc/Bowel-Obstruction-Topic-Overview

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