LESSON PLAN

ON
INTESTINAL
OBSTRUCTION
 0BJECTVES

General objectives:

By the of the class students will gain knowledge regarding intestinal obstruction

Specific objectives:

By the end of the class students will be able to

● Define intestinal obstruction

● Know the incidence of intestinal obstruction
● Discuss the etiological factors and risk factors
● Understand the pathophysiology of intestinal obstruction
● Describe the assessment and diagnostic findings
● Know the medical management of the intestinal obstruction
● Understand the surgical management of intestinal obstruction
● Discuss the nursing management of intestinal obstruction
● Understand the complications of intestinal obstruction
● Summarize the topic
 METHOD
OBJECTIVES TIM CONTENT OF STUDENT AV AIDS EVALUATIO
E TEACHIN ACTIVIT N
G Y
 3min INTRODUCTION:
Impairment of the forward flow of intestinal content is
known as intestinal obstruction. About 90% of bowel obstruction Lecture cum Listening Black What do you
occurs in the small bowel. Large bowel obstruction usually Discussion actively board know about
occurs in the sigmoid colon obstruction. Produce nausea, intestinal
vomiting, dehydration and severe pain. obstruction

2min INCIDENCE:
Know the
Intestinal obstruction has a high mortality rate. If it is not Taking
incidence
diagnosed and treated within 24 hours. The mortality rate for notes
acute obstruction in the small bowel is 10% are in the large
bowel 30%
5min DEFINITION:
Define intestinal
Impairment of the forward flow of intestinal content is Over head
obstruction
known as intestinal obstruction. Two types of processes can projector
impete this flow.
- Brunner and Siddhartha

A bowel obstruction happens when either your small or

large intestine is partly or completely blocked. The blockage
 prevents food, fluids, and gas from moving through the
intestines in the normal way.
Intestinal obstruction refers to the partial or complete
mechanical or non mechanical blockage of the small or large
intestine.
- Medical dictionary

Discuss types of 2min 1. MECHANICAL OBSTRUCTION: An intra luminal Lecture cum Listening
obstruction obstruction from pressure on the intestinal wall occurs. Discussion actively
Eg. Intussusceptions, polyploidy tumors and neoplasm,
stenosis, strictures, adhesion, hernia and abscess. What do you
2. FUNCTIONAL OBSTRUCTION: The intestinal know about
musculature cannot propel the contents along the bowel. mechanical
Eg. Amyloidosis, muscular dystrophy, endocrine Asking obstruction
disorders such as diabetes mellitus or neurologic questions answering
disorders such are Parkinson’s disease.

4min
Discuss the ETIOLOGY:
Black
etiological Obstruction of the large intestine may be caused by narrowing of
factors and risk the intestinal lumen as a result of inflammation, neoplasm, Lecture cum Taking board What are the
factors adhesion, hernia, food blockages. A cancer account for about Discussion notes etiological
80% of obstruction of the large intestine with most occurring in factors
colitis, and previous abdominal surgery.

RISK FACTORS:
2min 1. Factors that cause intestinal obstruction may be
mechanical, Neurogenic, Vascular. Lecture cum Active
a. Mechanical factors: Discussion listening What are risk
● Adhesion: loops of intestine become adherent to areas Flash cards factors
that heal slowly or scar after abdominal surgery. Adhesion
is probably the most common cause of obstruction in both
the small and large intestine.
● Hernia: protrusion of intestine through a weakened area
in the abdominal muscle or wall, may or may not cause
obstruction depending on the size of the hernial ring
● Volvulus: It is a twisting of the bowel that commonly
occur about a stationary focus in the abdominal cavity
● Intussusception: Which some time complicate
inflammatory bowel disease, is a telescoping of the
bowel.
 ● Cancer: Cancer accounts for about 80% of mechanical
obstruction in the large bowel and mostly asset the Lecture cum
sigmoid colon. Discussion

Neurogenic factors:
Neurogenic factors are responsible for a dynamic
obstruction, the most common type of intestinal obstruction. A
dynamic obstruction called paralytic ileus is caused by lack of
peristaltic movement.
Listening
actively
Vascular factors:
Body is interrupted, the part ceases to function and pain
occurs.

There are two types of obstructions

● Small bowel obstruction
● Large bowel obstruction

4min SMALL BOWEL OBSTRUCTION:

Understand the PATHOPHYSIOLOGY:
pathophysiology Intestinal contents, fluid and gas accumulate above the
of intestinal intestinal obstruction. The abdominal distention and retention of
obstruction fluid reduce the absorption of fluids and stimulate more gastric Model
secretion. With increasing distention, pressure within the Lecture cum
intestinal lumen increases, causing a decrease in venous and Discussion
arteriolar capillary pressure. This causes edema, congestion,
necrosis, and eventual rupture of perforation of the intestinal
wall, with resultant peritonitis.
Reflux vomiting may be caused by abdominal distention.
Vomiting results in loss of hydrogen ions and potassium from
the stomach, leading to reduction of chlorides and potassium in
the blood and to metabolic alkalosis. Dehydration and acidosis Listening
develop from loss of water and sodium. With acute fluid losses, Lecture cum actively
hypovolemic shock may occur. Discussion
2min What are the
CLINICAL MANIFESTATIONS: manifestations
INITIAL SYMPTOMS:
● Crampy pain that is wave like and colicky Power
● The patient may pass blood and mucus but no fecal matter point
Explain clinical
and no flat presentatio
manifestations
 ● Vomiting n

IF OBSTRUCTION IS COMPLETE
● The peristaltic waves initially become extremely vigorous
and eventually assume a reverse direction, with the
intestinal contents propelled toward the mouth instead of
toward the rectum. If the obstruction is in the ileum, fecal
vomiting takes place. First, the patient vomits the stomach
Listening
contents, then the bile-stained contents of the duodenum
actively
and the jejunum, and finally, with each paroxysm of pain,
the darker, fecal-like contents of the ileum. The signs of
Lecture cum
dehydration become evident: intense thirst, drowsiness,
Discussion
generalized malaise, aching, and a parched tongue and
mucous membranes. The abdomen becomes distended.
The lower the obstruction is the GI tract, the more marked
the abdominal distension. If the obstruction continues
uncorrected, hypovolemic shock occurs from dehydration
and loss of plasma volume.

Describe the 2min

assessment and ASSESSMENT AND DIAGNOSTIC FINDINGS: List out the
diagnostic diagnostic
findings findings
Diagnosis is based on the symptoms described on imaging
studies. Abdominal x-ray and CT findings include abnormal
qualities of gas, fluid, or both in the intestines. Laboratory
Black
studies (i.e electrolyte studies and a complete blood cell count)
board
reveal a picture of dehydration, loss of plasma volume, and
possible infection.
2min
Know the
medical
MEDICAL MANAGEMENT
management of
Decompression of the bowel through a nasogastric tube is Listening
the intestinal
successful in most cases. When the bowel is completely actively
obstruction
obstructed, the possibility of strangulation warrants surgical
intervention. Before surgery, IV therapy is necessary to replace
the depleted water, sodium, chloride, and potassium. Lecture cum Black
The surgical treatment of intestinal obstruction depends Discussion board
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 Listening
performed. The complexity of the surgical procedure for actively
2min intestinal obstruction depends on the duration of the obstruction
of the intestine.
Discuss the What is the
nursing nursing
Nursing management:
management of management for
Nursing management of the non surgical patient with
intestinal the client
a small bowel obstruction includes maintain the function of the
obstruction
nasogastric tube, assessing and measuring the nasogastric output,
assessing for fluid and electrolyte imbalance, monitoring
nutritional status, and assessing improvement (e.g. return of
bowel sounds, decreased abdominal distention, subjective
Lecture cum
improvement in abdominal pain and tenderness, passage of
Discussion Handout
flatus or stool).
● The nurse reports discrepancies in intake and output,
worsening of pain or abdominal distension, and increased
nasogastric output.
● If the patient’s condition does not improve, the nurse
prepares him or her for surgery.
● The exact nature of the surgery depends on the cause of
the obstruction.
 ● Nursing care of the patient after surgical of a small bowel
obstruction is similar to that for other abdominal
surgeries.

LARGE BOWEL OBSTRUCTION:

3min
Lecture cum Listening
Pathophysiology : Discussion actively Explain the
Explain the As in small bowel obstruction, large bowel obstruction Pathophysiolog
Pathophysiolog results in an accumulation of intestinal contents fluid and gas y
y proximal to the obstruction. Obstruction in the large bowel can
lead to serve distention and perforation unless some gas and
fluid can flow back through the ileal valve. Large bowel chart
obstruction , even if complete, may be undramatic if the blood
supply is cut off, intestinal strangulation and necrosis ( i.e.,
tissue death) occur, this condition is life threatening. In the large
intestine, dehydration occurs more slowly than in the small
intestine because the colon can absorb its fluid contents and can
distend to a size considerably beyond its normal full capacity
Adenocarcinoid tumours account for the majority of large
bowel obstructions. Most tumours occur beyond the splenic
 flexure, making them accessible with a flexible sigmiodoscope.
Lecture cum Listening
Discussion actively
CLINICAL MANIFESTATIONS:
Discuss clinical
Large bowel obstruction differs clinically from small
manifestations 2min
bowel obstruction in that the symptoms develop and progress
relatively slowly. In patients with obstruction in sigmoid colon
or the rectum, constipation may be the only symptom for
months. The shape of the stool is altered as it passes the
Power
obstruction that is gradually increase in size. Blood in the stool
point
may result in iron deficiency anemia. The patient may
presentatio
experience weakness, weight loss, and anorexia. Eventually, the
n
abdomen becomes markedly distended, loops of large bowel
become visibly outlined through the abdominal wall, and the
Lecture cum
patient has crampy lower abdominal pain. Finally, fecal
Discussion
vomiting develops, symptoms of shock may occur.

Understand
ASSESSMENT AND DIAGNOSTIC FINDINGS:
assessment and
diagnostic
findings Diagnosis is based on symptoms and on imaging studies.
Abdominal x-ray and abdominal CT or MRI findings reveal a
 distended colon and pinpoint the site of the obstruction. Barium
2min studies are contraindicated.

Know the Lecture cum Listening

MEDICAL MANAGEMENT
medical Discussion actively
management
Restoration of intravascular volume, correction of electrolyte
abnormalities, and nasogastric aspiration.
Discuss nursing
diagnosis
NURSING DIAGNOSIS:
Based on the assessment data, the major nursing diagnosis may
List out the
include the following
nursing
● Imbalanced nutrition (less than body requirements related
diagnosis
to nausea and anorexia
● Risk for deficient fluid volume related to vomiting and
dehydration
1min
● Anxiety related to impending surgery and the diagnosis of
cancer
● Risk for ineffective therapeutic regimen management
Pamphlet
related to knowledge deficit concerning the diagnosis, the
surgical procedure, and self care after discharge
1min
● Disturbed body image related to colostomy
 ● Ineffective sexuality patterns related to presence of
ostomy and changes in body image and self-concept Lecture cum Listening
Discussion actively
Discuss about
COLLABORATIVE PROBLEMS/ POTENTIAL
complications
COMPLICATIONS:

Potential complications that may develop include the following

● Intraperitoneal infection
● Complete large bowel obstruction
2min
● GI bleeding
● Bowel perforation
Listening
● Peritonitis, abscess, and sepsis
actively Pamphlet
PLANNING AND GOALS:
The major goals for the patient may include attainment
of optimal level of nutrition:
● Maintenance of fluid and electrolyte balance, surgical
procedure, and self-care after discharge;
● maintenance of optimal tissue healing;

protection of peristomal skin;

● learning how to irrigate the colostomy and change the
 appliance;
● expressing feelings and concerns about the colostomy and
the impact on himself or herself; and avoidance of Lecture cum Listening
1min complications. Discussion actively
Explain nursing
NURSING INTERVENTIONS:
interventions
PREPARING THE PATIENT FOR SURGERY:
● Patients awaiting surgery for colorectal cancer have many
concerns, needs and fears. They may be physically
deliberated and emotionally distraught with concerns an
out lifestyle changes after surgery, prognosis ability to
perform in established roles, and finances.
● Nursing care include preparing the patient physically for
surgery, providing information about postoperative care
(stoma care if a colostomy care is to be created) and
support.
● Physical preparation for surgery involves building the
patient’s stamina in the days preceeding surgery and
cleaning and sterilizing the bowel the day before surgery.
● If the patient’s condition permits, the nurse recommends a
diet high in calories, protein, and carbohydrates and low
in residue for several days before surgery to provide
 adequate nutrition and minimize cramping by decreasing Handout
excessive peristalsis. A full liquid diet may be prescribed
24 to 48 hours before surgery to decrease bulk. If the
patient is hospitalized in the days preceeding surgery,
parentral nutrition is administered orally the day before
surgery to reduce intestinal bacteria. The bowel is
cleansed with laxatives, enemas, or colonic irrigations the
evening before and the morning of surgery.
● For the patient who is very ill and hospitalized, the nurse
measures and records intake and output, including
vomitus, to provide an accurate record of fluid balance.
● The nurse administers antiemitics as prescribed
● A nasogastric tube may be inserted to drain accumulated Listening
fluids and to prevent abdominal distention actively
● Nurse monitors the abdomen for increasing distention,
loss of bowel sounds and pain or , which may include
obstruction or perforation. It is also important to monitor
IV fluids and electrolytes.

PROVIDING EMOTIONAL SUPPORT:

Patients anticipating bowel surgery for colorectal cancer
may be very anxious. They may grieve about the diagnosis, the
impending surgery, and possible permanent colostomy. Patients
undergoing surgery for a temporary colostomy may express fears
and concerns similar to those of a person with a permanent
stoma.
● All members of the health care team, including the
enterostomal therapist, should be available for assistance Lecture cum Listening
and support. Discussion actively
● The nurse’s role is to assess the patient’s anxiety level and
coping mechanisms and suggest methods for reducing
anxiety, such as deep- breathing exercises and visualizing Handout
a successful recovery from surgery and cancer. Other
supportive measures include providing privacy and
teaching relaxation techniques to the patient.
● Time is set aside to listen to the patient who wishes to
talk, cry, or ask questions. The nurse can arrange a
meeting with a spiritual advisor if the patient desires or
with the physicians if the patient wishes to discuss the
treatment or prognosis.
● The patient undergoing a colostomy may find the
anticipated changes in body image and lifestyle
 profoundly disturbing. Because stoma is located on the
abdomen, the patient may think that everyone will be Handout
aware of the ostomy. The nurse helps to reduce this fear
by presenting facts about the surgical procedure and the
creation and management of the ostomy. If the is
receptive, the nurse can use use diagrams, photographs,
and appliances to explain and clarify. Because patient
experiences emotional stress, the nurse may need to repeat
some of the information.
● The nurse provides time for the patient and family to ask
questions; the nurse’s acceptance and understanding of
the patients concern’s and feelings convey a caring, Lecture cum
competent attitude that promotes confidence. Discussion

PROVIDING POSTOPERATIVE CARE:

Postoperative nursing care for the patients undergoing

colon resection or colostomy is similar to nursing care
for any abdominal surgery patient.
● Nurse monitors the patient for complications such as
leakage from the site of the anastomosis, prolapsed of the
 stoma, perforation, stoma retraction, fecal impaction, skin
irritation and pulmonary complications associated with
abdominal surgery. The nurse assesses the abdomen for
returning peristalsis and assesses the initial stool
characteristics. It is important to help patient with a Listening
colostomy out of the bed on the first postoperative day actively Handout
and encourage them to begin participating in managing
the colostomy

MAINTAINING OPTIMAL NUTRITION

The nurse teaches all patients undergoing surgery for

colorectal cancer about the health benefits gained from
consuming a healthy diet. The diet is individualized as long as it
is nutritionally sound and does not cause diarrhoea or
constipation the return to a normal diet is rapid.
● A complete nutritional assessment is important for the
patient with a colostomy.
● The patients avoids foods that cause excessive odour and
Handout
gas, including foods in the cabbage family, eggs, fish,
Lecture cum
beans, and high-cellulose products such as peanuts.
 ● It is important to determine whether the elimination of Discussion
specific foods is causing any nutritional deficiency
● Nonirritating foods are substituted for those that are
restricted so that deficiencies are corrected
● The nurse advises the patient to experiment with an
irritating food several times before restricting it. The
nurse can help the patient identify any foods or fluids that
may be causing diarrhea, such as fruits, high-fibre foods,
coffee, tea or carbonated beverages. Diphenoxaylate with
atropine (lomotil) may be prescribed as need to control
the diarrhea. For constipation, prune or apple juice or a
mild laxative is effective. The nurse suggests fluid intake
of at least 2 L/day.

PROVIDING WOUND CARE:

The nurse frequently examines the abdominal dressing
during the first 24 hours after surgery to detect signs of
hemorrhage . it is important to help the patient splint the
abdominal incision during coughing and deep breathing to lesson
tension on the edges of the incision. The nurse monitors
temperature, pulse, and respiratory rate for elevations, which
may indicate an infectious process. If the patient has a
colostomy, the stoma is examined for swelling (slight edema
from surgical manipulation is usual), colour (a healthy stoma is
pink or red), discharge (a small amount of oozing is expected), Handout
and bleeding(an abnormal sign). If the malignancy has been
removed using the perineal route, the perineal wound is observed
for signs of hemorrhage. This wound may contain a drain or
packing, which is removed gradually. Bits of tissue may slough Lecture cum
off for a week. This process is hastened by mechanical irrigation Discussion
of the wound or with sitz baths performed two or three times Listening
each day initially. The condition of the perineal wound and any actively
bleeding, infection, or necrosis are documented.

MONITORING AND MANAGING COMPLICATIONS

The patient is observed for signs and symptoms of

complications. It is important to frequently assess the abdomen,
including decreasing or charging bowel sounds and increasing Handout
abdominal girth, to detect bowel obstruction. The nurse monitors
vital signs for increased temperature, pulse, and respirations and
for decreased blood pressure, which may indicate an intra-
abdominal infectious process. it is important to report rectal
bleeding immediately because it indicates hemorrhage. The
nurse monitors hemoglobin and hematocrict levels and
administers blood competent therapy.
Listening
REMOVING AND APPLYING THE COLOSTOMY actively
APPLIANCE
The colostomy begins to function 3 to 6 days after surgery.
The nurse manages the colostomy and teaches the patient about
this care until the patient can take over its management. The
nurse teaches skin care and how to apply and remove the
drainage pouch. Care of the peristomal skin is an ongoing
concern because excoriation or ulceration can develop quickly.
The presence of such irritation makes adhering the ostomy Handout
appliance to irritated skin can worsen the skin condition. The
effluent discharge and the degree to which it is irritating vary
with the type of ostomy. With a transverse colostomy, the stool
is soft, mushy and irritating to the skin. With a descending or
sigmoid colostomy, the stool is fairly solid and less irritating to
the skin. Other skin problems include yeast infections and
allergic dermatitis.
 If the patient wants to bath or shower before or shower
before putting on the clean appliance, microphone tape to the Lecture cum
sides of the pouch will keep is secure during bathing. To remove Discussion
the appliance, the patient assumes a comfortable sitting or
standing position and gently pushes the skin down from the
faceplate while pulling the pouch up and away from the stoma.
Gentle pressure prevents the skin prevents the skin from being
traumatized and any liquid fecal contents from spilling out. The
nurse advises the patient to protect the peristomal skin by then
washing the area gently with a moist soft cloth and a mild soap.
Soap acts as a mild abrasive agent to remove enzyme residue
from fecal spillage. The patient should remove any excess skin
barrier. While the skin, is being cleansed, a guaze dressing can
cover the stoma, or a vaginal tampon can be inserted gently to
absorb excess drainage. Completely dry with a guaze pad, taking Listening
care not to rub the area. The patient can lightly dust nystatin actively
(Mycostatin) powder on the peristomal skin if irritation of yeast
growth is present.

IRRIGATING THE COLOSTOMY:

The purpose of irrigating a colostomy is to empty the
colon of gas, mucus, and feces so that the patient can go about
social and business activities without fear of fecal drainage. A
stoma does not have voluntary muscular control and may empty Handout
at irregular intervals. Regulating the passage of fecal material is
achieved by irrigating the colostomy or allowing the bowel to
evacuate naturally without irrigations. The choice often depends
on the person and the type of the colostomy. By irrigating the Lecture cum Listening
stoma at a regular time, there is less gas and retention of the Discussion actively
irrigant. The time for irrigating the colostomy should be
consistent with the schedule Person will follow after leaving the
hospital.

PROMOTING HOME AND COMMUNITY-BASED

CARE:
TEACHING PATIENTS SELF CARE:
Patient education and discharge planning require the
combined efforts of the physician, nurse, enterostomal therapist, Handout
social worker, and dietitation.
● Patients are given specific information, individualized to
their needs, about ostomy care and signs and symptoms of
potential complications.
 ● Dietary instructions are essential to help patients identify Lecture cum
and eliminate irritating foods that can cause diaarhoea or Discussion
constipation.
● It is important to teach patients about their prescribed
medications (i.e action, purpose, and possible side and
toxic effects)
● The nurse reviews treatments (eg. Irrigations wound
cleansing) and dressing changes and encourages the
family to participate. Because the hospital stay is the Asking Answering
family to patient may not be able to become proficient in questions questions
stoma care techniques before discharge home. Many
patients need referral so a home care and the agency and
the hospital

SUMMARY
We have discussed regarding the intestinal obstruction,
definition, etiology, Pathophysiology, clinical manifestations,
assessment, diagnostic findings and management.
CONCLUSION:
Handout
Students have gained knowledge regarding the intestinal
obstruction and the medical, surgical and nursing management
of the client with the intestinal obstruction.
ASSIGNMENT:
Write nursing care plan for the client suffering from intestinal
obstruction

BIBLIOGRAPHY:
✓ Lippincot Williams and Wilkins Text book of manual of
nursing practice, , ninth edition page no- 687-690

✓ Joyce M. Black, A text book of medical surgical nursing,

Elsevier publications, 7th edition,vol-1 page no: 843-846
✓ Joyce M. Black, Esther Matassarin Jacobs A text book of
Medical Surgical Nursing clinical management for
continuity of care, 5th edition, Harcourtbrace Asia saulders
page no:843-848
✓ B.T.Basavanthappa Text Book of Medical Surgical
Nursing, Jaypee publications, 2nd edition page no: 509-514
✓ Loise White Gena Dunacan Text Book of Medical Surgical
Nursing, delman Thomson learning, 2nd edition, page no:
757-758
 ✓ Phipp’s Text Book of Medical Surgical Nursing, Mosby
publishers, 8th edition, page no: 1268-1271

REGISTRATION NO : 1213605
COURSE : M.Sc (N) I YEAR

SUBJECT : NURSING EDUCATION

TOPIC : INTESTINAL OBSTRUCTION

DATE : 06. NOVEMBER.2013

TIME : 9:00 AM

PLACE : APOLLO COLLEGE OF NURSING

GROUP : B.SC (N) II YEAR STUDENTS

METHOD OF TEACHING : LECTURE CUM DISCUSSION

A.V. AIDS : BLACK BOARD, OVER HEAD PROJECTOR, CHART,

MODEL, PAMPHLET, HANDOUT,

POWER POINTPRESENTATION