DRG Category: 329
Mean LOS: 15.7 days
Description SURGICAL: Major Small and Large Bowel Procedures with Major CC
DRG Category: 389
Mean LOS: 4.9 days
Description MEDICAL: Gastrointestinal Obstruction with CC
Intestinal obstruction occurs when a blockage obstructs the normal flow of contents through the intestinal tract. Obstruction of the intestine causes the bowel to become vulnerable to ischemia. The intestinal mucosal barrier can be damaged, allowing intestinal bacteria to invade the intestinal wall and causing fluid exudation, which leads to hypovolemia and dehydration. About 7 L of fluid per day is secreted into the small intestine and stomach and usually reabsorbed. During obstruction, however, fluid accumulates, causing abdominal distention and pressure on the mucosal wall, which can lead to peritonitis and perforation. Obstructions can be partial or complete. The most common type of intestinal obstruction is one of the small intestine from fibrous adhesions.
The patient's mortality depends on the type of lesion causing the small bowel obstruction (closed-loop or strangulated), and the time until diagnosis and treatment; when an early diagnosis is made, mortality is low, but if more than 75% of the small bowel is necrotic at the time of surgery, the mortality rate is 65%. Complications of intestinal obstruction include bacteremia, secondary infection, or metabolic alkalosis or acidosis. If it is left untreated, a complete intestinal obstruction can cause death within a few hours from hypovolemic or septic shock and vascular collapse.
The two major types of intestinal obstruction are mechanical and neurogenic (or nonmechanical). Neurogenic obstruction occurs primarily after manipulation of the bowel during surgery or with peritoneal irritation, pain of thoracolumbar origin, or intestinal ischemia. It is also caused by the effect of trauma or toxins on the nerves that regulate peristalsis, electrolyte imbalances, and neurogenic abnormalities such as spinal cord lesions. Mechanical obstruction of the bowel is caused by physical blockage of the intestine. Examples of mechanical obstruction include adhesions and strangulated hernias (usually associated with the small intestine); volvulus (twisting of the intestine) of the cecum or sigmoid; intussusception (telescoping of the bowel); strictures; fecal or barium impaction; carcinomas (usually associated with the large intestine); or foreign bodies such as gallstones and fruit pits.
No clear genetic contributions to susceptibility have been defined.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Intestinal obstructions can occur at any age, in all races and ethnicities, and in both sexes but are more common in patients who have undergone major abdominal surgery or have congenital abnormalities of the bowel. When it occurs in a child, the obstruction is most likely to be an intussusception. Although small bowel obstructions in children are uncommon, the diagnosis should be considered for any child with persistent vomiting, abdominal distention, and abdominal pain; early diagnosis is critical because delayed diagnosis and treatment are associated with significant complications.
GLOBAL HEALTH CONSIDERATIONS
No data available.
HISTORY. Establish any predisposing factors: surgery, especially abdominal surgery; radiation therapy; gallstones; Crohn's disease; diverticular disease; ulcerative colitis; or a family history of colorectal cancer. Ask if the patient has had hiccups, which is often a symptom of intestinal obstruction.
To establish the diagnosis of small bowel obstruction, ask about vomiting fecal contents, wavelike abdominal pain, or abdominal distention. Elicit a history of intense thirst, generalized malaise, or aching. A paralytic ileus usually causes a distended abdomen, with or without pain, but usually without cramping. To establish the diagnosis of large bowel obstruction, which has a slower onset of symptoms, ask about recent constipation with a history of spasmodic abdominal pain several days afterward. Establish a history of hypogastric pain and nausea. Ask if the patient has been vomiting. To establish neurogenic obstruction, ask about abdominal pain. Neurogenic obstruction characteristically produces diffuse abdominal discomfort rather than colicky pain. Establish a history of vomiting; ask the patient to describe the vomitus, which may consist of gastric and bile contents but rarely fecal contents.
PHYSICAL EXAM. Inspect the patient's abdomen for distention. Observe the patient's abdomen for signs of visible peristalsis or loops of large bowel. Measure the patient's abdominal girth every 4 hours to observe the progress of an obstruction. Auscultate the patient's abdomen for bowel sounds in all four quadrants; you may hear rushes or borborygmus (rumbling noises in the bowels). Always auscultate the abdomen for up to 5 minutes for bowel sounds before palpation. Lack of bowel sounds can indicate a paralytic ileus. High-pitched tingling sounds with rushes can indicate a mechanical obstruction. Palpate all four quadrants of the abdomen to determine areas of localized tenderness, guarding, and rebound tenderness.
Assess the patient for tachycardia, a narrowed pulse pressure, urine output less than 30 mL/hr, and delayed capillary blanchingall indicators of severe hypovolemia and impending shock. Assess for fever, which may indicate peritonitis. Inspect the patient's skin for loss of turgor and mucous membranes for dryness.
PSYCHOSOCIAL. The patient with an intestinal obstruction is acutely ill and may need emergency intervention. Assess the patient's level of anxiety and fear. Assess the patient's coping skills, support system, and the significant others' response to the illness.
|Test||Normal Result||Abnormality with Condition||Explanation|
|Chest and abdominal x-ray||Normal abdominal structures||Distended loops of bowel; may have a ladderlike pattern with air-fluid levels||Identifies free air under the diaphragm if perforation has occurred or blockage of lumen of bowel with distal passage of fluid and air (partial) or complete obstruction|
|Water-soluble contrast enema||Normal abdominal structures||Blockage of lumen of bowel||Identifies site and severity of colonic obstruction|
Complete blood count, serum electrolytes, blood urea nitrogen, colonoscopy, sigmoidoscopy, abdominal computed tomography scan with contrast, abdominal ultrasound.
PRIMARY NURSING DIAGNOSIS
DIAGNOSIS. Fluid volume deficit related to abnormal loss of gastrointestinal fluids
OUTCOMES. Fluid balance; Hydration; Nutritional status: Food and fluid intake; Bowel elimination; Knowledge: Disease process
INTERVENTIONS. Fluid management; Intravenous insertion and therapy; Surveillance; Venous access devices maintenance; Vital signs monitoring
SURGICAL. Surgery is often indicated for a complete mechanical obstruction. The operative procedure varies with the location and type of obstruction. A strangulated bowel constitutes a surgical emergency. A bowel resection may be necessary in some obstructions.
Postoperative care includes monitoring the patient's cardiopulmonary response and identifying surgical complications. The highest priority is maintaining airway, breathing, and circulation. The patient may require endotracheal intubation and mechanical ventilation temporarily to manage airway and breathing. The circulation may need support from parenteral fluids, and total parenteral nutrition may be prescribed if the patient has protein deficits. Care for the surgical site, and notify the physician if you observe any signs of poor wound healing, bleeding, or infection.
MEDICAL. Medical management with intravenous fluids, electrolytes, and administration of blood or plasma may be required for patients whose obstruction is caused by infection or inflammation or by a partial obstruction. Insertion of a nasogastric (NG) tube, often ordered by the physician to rest and decompress the bowel, greatly decreases the abdominal distention and the patient's discomfort.
Analgesic medication may be ordered after the cause of the obstruction is known, but it may be withheld until the diagnosis of intestinal obstruction is confirmed so as to not mask pain, which is an important clinical indicator. Explore nonpharmacologic methods of pain relief. The physician may order oxygen. Usually, until the patient is stabilized, her or his condition precludes any oral intake.
|Medication or Drug Class||Dosage||Description||Rationale|
|Antibiotics||Varies with drug||Broad-spectrum antibiotic coverage||Antibiotics may be prescribed when the obstruction is caused by an infectious process|
Focus on increasing the patient's comfort and monitoring for complications. Elevate the head of the bed to assist with patient ventilation. Position the patient in the Fowler or semi-Fowler position to ease respiratory discomfort from a distended abdomen. Reposition the patient frequently.
Instruct the patient about the need to take nothing by mouth. Frequent mouth care and lubrication of the mucous membranes can assist with patient comfort. Patient teaching should include the indications and function of the NG tube. Discuss care planning with the patient and the family.
Teach the causes, types, signs, and symptoms of intestinal obstruction. Explain the diagnostic tests and treatments, preparing the patient for the possibility of surgery. Explain surgical and postoperative procedures. Note the patient's and significant others' responses to emergency surgery if needed, and provide additional support if the family or patient copes ineffectively.
Physical findings: Vital signs, abdominal assessments, pulmonary assessment, fluid volume status
Response to pain medications, antibiotics, NG intubation, and suctioning
Presence of complications (preoperative): Peritonitis, sepsis, respiratory insufficiency, hypovolemia, shock
Presence of complications (postoperative): Poor wound healing, hemorrhage, or infection
DISCHARGE HOME HEALTHCARE
Teach postoperative care to patients who have had surgery. Teach the patient how to plan a paced progression of activities. Teach the patient the dosages, routes, and side effects for all medications. Review drug and food interactions with the patient. Instruct the patient to report bowel elimination problems to the physician. Emphasize that in the case of recurrent abdominal pain, fever, or vomiting, the patient should go to the emergency department for evaluation.
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