Signs and symptoms (S/S) of intestinal obstruction
Can be mechanical (adhesions, tumor, stool, herniation, intussession, involvus) or nonmechanical
(neuromuscular or vascular eg paralytic ileus – no peristalsis/ bowel
...
Signs and symptoms (S/S) of intestinal obstruction
Can be mechanical (adhesions, tumor, stool, herniation, intussession, involvus) or nonmechanical
(neuromuscular or vascular eg paralytic ileus – no peristalsis/ bowel sounds). Most occur in small
bowel, most adhesions (days or years after surgery)
Paralytic ileus occurs to some degree after abdom surgery – can be hard to tell if PI or adhesions
Distention leads to ↑intraluminal bowel pressure, = ↑ capilliary permeability, = fluid extravasation,
= reduction in circulating blood vol/ hypovolemia + hypovolemix shock.If blood flow inadequate,
bowel tissue becomes ischemia. Can lead to perforation, systemic infection, death.
If obstruction is high (eg pylorus), metabolic alkalosis may result from loss of gastric HCl acid
through vomiting or NG intubation. If located in small bowel, dehydration occurs rapidly.
Dehydration and lyte imbalances do not occur if obstruction occurs in large bowel.
General
o Nausea/vomiting
o Poorly localized abdominal pain
o Abdominal distention
o Inability to pass flatus
o Obstipation (failure to pass stool or gas)
o S/S of hypovolemia
o High pitched bowel sounds above obstruction leading to absent bowel sounds
Proximal small intestine obstructions
o Rapidly developing nausea & projectile vomiting of bile
o Vomiting usually relieves pain
o Usually no abdominal distention
Distal small intestine obstruction
o Gradual onset
o Vomitus may be orange-brown and smell like feces
o Abdominal distention is common
Lower intestinal obstruction
Persistent colicky pain
Mechanical obstruction
o Pain that comes and goes in waves as peristalsis tries to push past obstruction (in
contrast, PI produces more constant generalized discomfort)
Strangulation (lack of blood flow to intestine)
Severe, constant pain with a rapid onset
Abdominal distension is usually absent or minimally noticeable in proximal small intestine
onstructions and markedly increased in lower intestinal obstructions. Abdominal tenderness and
rigidity are usually absent unless strangulation or peritonitis has occurred.
Ascultation reveals high pitched sounds above area of obstruction, bowel sounds may also be
absent. Patient often notes borborygmi (audible sounds produced by hyperactive motility). Temp
rarely rises above 100 F (37.8 C) unless strangulation or peritonitis has occurred.
Intestinal Obstruction—complete or partial blockage of the small or large
intestine; can be due to mechanical problems such as tumors, neurological
difficulties such as paralytic ileus; increased pressure above blockage and
decreased peristalsis below; higher the obstruction, the more severe the
symptoms.
1. Assessment
a. Small intestine obstruction
(1) Vomiting—possibly fecal
(2) Abdominal distention
(3) Absence of stools
(4) Dehydration
b. Large bowel obstruction—slower progression of symptoms
(1) Constipation
(2) Abdominal distention
(3) Cramplike pain in lower abdomen
2. Medical Diagnosis
a. Patient history and physical exam
b. Flat plate x-ray of abdomen
c. Laboratory studies
3. Medical Treatment
a. Surgery
b. Miller-Abbott or Cantor tube for intestinal decompression
c. IV hydration
d. Prophylactic antibiotics
e. I & O monitoring
4. Nursing Interventions
a. Assess and document patient’s symptoms
b. Record intake and output, including amount and character of drainage
from decompression tube
c. Maintain NPO
d. Monitor hydration
e. Routine postop care if surgery
2. Medical and surgical recommendation for patients with polyps: sessile, hyerplastic,
adenomatous, and familial adenomatous polyposis
All polyps are considered abnormal and should be removed
o Colonoscopy with polypectomy is preferred method
Sessile: Flat, broad based, small
Pedunculated: large, attached by a small stalk
Tend to start sessile and become pedunculated – commonly found in rectosigmoid area. Most
asymptomatic, rectal bleeding and occult blood in stool most common signs.
Hyperplastic: Benign, non-neoplastic. Usually <5mm. Never cause clinical symptoms
Adenomatous: Precursor to cancer. Tubular, villous adenomas. Neoplastic; closely related to
colorectal adenocarcinoma
o Risk of CA increases with polyp size
Familial adenomatous polyposis: thousands of polyps, 80% lifetime risk of colorectal cancer.
o Autosomal dominant (so 50% of offspring will have – anyone with a family history of
FAP should have genetic testing in childhood) disorder causing hundreds or thousands of
polyps that will become cancerous (80% lifetime risk), usually before age 40. If gene is
present colorectal screening begins at puberty, and annual colonoscory at age 16.
o Tx: prophylactic removal of colon and rectum with ileostomy or ileo-anal anastomosis,
usually by age 25. Pts with FAp also at risk for other cancers so lifetime surveillance
essential.
Polypectomy, colectomy
Removing the adenomatous polyps decreases the occurrence of colorectal cancer.
NB Colonoscopy, sigmoidoscopy, barium enema, and CT/MRI colonography (virtual colonoscopy)
are used to discover polyps. All are considered abnormal and should be removed. Colonoscopy
preferred becaue it allows evaluation of total colon and polyps can be removed immediately
(polypectomy). Only polyps in the distal colon and rectum can be detected and removed during
sigmoidoscopy. After polypectomy observe for rectal bleeding, fever, severe abdominal pain, and
abdom distention – may indicate hemorrhage or performation.
3. Nursing management and D/C teaching for patients with diverticulosis and
diverticulitis (TC) (slide 24 in lower GI lecture, p.1047)
Diverticulosis = outpouching of mucosa through the intestinal wall, forming sacs
Diverticulitis = inflammation, infection, perforation of sacs, peritonitis, GI bleed
Dietary recommendation: high fiber, ↑ fluids, ↑ physical activity
Conservative therapy:
High fiber diet (fruits/ veg, decreased fat intake/ red meat). No evidence that nuts and seeds
should be avoided – in fact, nuts and popcorn may have a protective effect.
Dietary fiber supplements
Stool softners
Anticholinergics
Mineral oil
Bed rest
Clear liquid diet
Oral antibiotics
Bulk laxatives
Weight reduction (if overweight)
Avoid increasing intra abdominal pressure – valsalva, straining to poo, vomiting, bending, lifting,
and tight restrictive clothing.
Acute care:
Abx, NPO, IV fluids
Possible resection of involved colon for obstruction or hemorrhage
Possible temporary colostomy
Bed rest
NG suction
For acute diverticulitis, goal of tx is to let colon rest and inflammation subside
Pts at home can be managed with oral abx and clear liquid diet.
Hospitalize if cannot tolerate oral fluids, severe symptoms, co-morbid conditions,
immunosuppressed.
Pts in hospital are kept on NPO status, bed rest, and fluids and IV abx are given
Observe for signs of abscess, bleeding, peritonitis, and monitor WBC count
When acute episode subsides, give oral fluids and then progress to semisolids diet. Pt can
ambulate too.
Surgery is reserved for patients with complications such as abcess or obstruction that cannot be
managed medically. Usu resecation + anastome (temporary colostomy may be required).
Provide patient will a full explanation of the condition to increase compliance to regimen.
Diverticular Disease (Diverticulosis/Diverticulitis)—Diverticulosis is an
outpouching of the mucosa of the colon; diverticulitis is an inflammation of
the outpouching (diverticulum).
1. Assessment
a. Abdominal cramps
b. Lower-quadrant tenderness
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