Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

COLLEGE OF NURSING
University Town, Musuan, Maramag, Bukidnon
E-mail: nursing@cmu.edu.ph

INTESTINAL OBSTRUCTION

In Partial Fulfillment of the Requirements in

NCM 74: MEDICAL-SURGICAL II

KOTICO, HOSEA DANIEL E.

FEBRUARY 2022
INTESTINAL OBSTRUCTION: Intestinal obstruction
is significant mechanical impairment or complete
arrest of the passage of contents through the intestine
due to pathology that causes blockage of the bowel.
Partial or complete blockage of the lumen of the small
or large intestine causing an interruption in the normal
flow of intestinal contents along the intestinal tract
An intestinal is a potentially serious condition in which
the intestines are blocked. The blockage may either
be partial or complete, occurring at one or more
locations. Both the small intestine and large intestine
can be affected. When a blockage occurs, food and
drink cannot pass through the body. Obstructions are
serious and need to be treated immediately. They may
even require surgery.
Precipitating Factor
✓ Poor Hygiene
✓ Sepsis
✓ Acute illness
✓ Constipation
✓ Untreated pain
Predisposing Factor
✓ Age
✓ Severe illness
✓ Functional dependency
✓ Malnutrition
Etiology
• Sepsis
• Anti-motility drugs
• Diabetic gastroparesis
• Impacted feces
• Post-operation
• Post-abdominal surgery
• Hernia
Overall, the most common causes of
mechanical obstruction are adhesions, hernias, and
tumors. Other general causes are diverticulitis,
foreign bodies (including gallstones), volvulus
(twisting of bowel on its mesentery), intussusception
(telescoping of one segment of bowel into another),
and fecal impaction. Specific segments of the
intestine are affected differently.
What causes Intestinal Obstruction?
• Fetal and neonatal blockages are caused by
the intestinal atresia where there is an
absence of a part of the intestine or a
narrowing.
• Non-mechanical obstructions are caused due
to inflammation or due to the side effects or
infections of certain medicines.
• Other causes are hernias, cancer, and Crohn's
disease.
• Sometimes a change in the food habits and
lifestyles also causes such issues. It may
make the waste material get harder and it
becomes difficult to be eliminated.
• It may be due to tumors.
• Narrowing or twisting of intestines or scar
tissues may be one of the reasons. Such
blockages are mechanical blockages.
• In addition to changed food habits, changes in
the water intake, as well as exercise changes,
may also lead to bowel obstruction
sometimes.
• Bowel obstruction may sometimes be due to
the changes within the walls of the abdomen
area, bowel lumen, or external to the belly
area.
Pathophysiology
In 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 hours. 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.
Signs and Symptoms of Intestinal Obstruction
Symptoms include cramping pain, vomiting,
obstipation, and lack of flatus. Diagnosis is clinical
and confirmed by abdominal x-rays. And:
• Cramping and pain
• Abdominal fullness
• Bad breath
• Abdominal bloating
• Constipation
• Diarrhea
• Vomiting
Obstruction of the small bowel causes symptoms
shortly after onset: abdominal cramps centered
around the umbilicus or in the epigastrium, vomiting,
and—in patients with complete obstruction—
obstipation. Patients with partial obstruction may
develop diarrhea. Severe, steady pain suggests that
strangulation has occurred. In the absence of
strangulation, the abdomen is not tender.
Hyperactive, high-pitched peristalsis with rushes
coinciding with cramps is typical. Sometimes, dilated
loops of bowel are palpable. With infarction, the
abdomen becomes tender and auscultation reveals
a silent abdomen or minimal peristalsis. Shock and
oliguria are serious signs that indicate either late
simple obstruction or strangulation.
Obstruction of the large bowel usually causes
milder symptoms that develop more gradually than
those caused by small-bowel obstruction. Increasing
constipation leads to obstipation and abdominal
distention. Vomiting may occur (usually several
hours after onset of other symptoms) but is not
common. Lower abdominal cramps unproductive
feces occur. Physical examination typically shows a
distended abdomen with loud borborygmi. There is
no tenderness, and the rectum is usually empty. A
mass corresponding to the site of an obstructing
tumor may be palpable. Systemic symptoms are
relatively mild, and fluid and electrolyte deficits are
uncommon.
Diagnostic
• Physical exam. Your doctor will ask about
your medical history and your symptoms. He
or she will also do a physical exam to assess
your situation. The doctor may suspect
intestinal obstruction if your abdomen is
swollen or tender or if there's a lump in your
abdomen. He or she may listen for bowel
sounds with a stethoscope.
• X-ray. To confirm a diagnosis of intestinal
obstruction, your doctor may recommend an
abdominal X-ray. However, some intestinal
obstructions can't be seen using standard X-
rays.
• Computerized tomography (CT). A CT scan
combines a series of X-ray images taken from
different angles to produce cross-sectional
images. These images are more detailed than
a standard X-ray and are more likely to show
an intestinal obstruction.
• Ultrasound. When an intestinal obstruction
occurs in children, ultrasound is often the
preferred type of imaging. In youngsters with
an intussusception, an ultrasound will typically
show a "bull's-eye," representing the intestine
coiled within the intestine.
• Air or barium enema. An air or barium enema
allows for enhanced imaging of the colon. This
may be done for certain suspected causes of
obstruction. During the procedure, the doctor
will insert air or liquid barium into the colon
through the rectum. For intussusception in
children, an air or barium enema can actually
fix the problem most of the time, and no further
treatment is needed.
Medical Management
• Correction of fluid and electrolyte imbalances
with normal saline or Ringer's solution with
potassium as required.
• NG suction to decompress bowel. Treatment
of shock and peritonitis.
• Analgesics and sedatives, avoiding opiates
due to GI motility inhibition.
• Antibiotics to prevent or treat the infection.
• Ambulation for patients with paralytic ileus to
encourage return of peristalsis.
• TPN may be necessary to correct protein
deficiency from chronic obstruction, paralytic
ileus, or infection.
Nursing Management
Primary Prevention
• Encourage well balanced and high-fiber diet
• Encourage regular exercise
• Encourage elderly for regular check-up
Secondary Prevention
• Insert an NG tube to decompress the bowel
as ordered.
• Maintain the function of the nasogastric tube.
• Assess the measure of the nasogastric output
• Maintain fluid and electrolyte balance by
monitoring electrolyte, blood urea nitrogen,
and creatinine levels
• Begin and maintain I.V. Therapy as ordered.
• Monitor Nutritional Status.
• Continually assess his pain. Colicky pain that
suddenly becomes constant could signal
perforation
• Assess improvement (return of normal bowel
sounds, decreased abdominal distention,
subjective
• improvement in abdominal pain and
tenderness, the passage of flatus or stool).
• Look for signs of dehydration (thick, swollen
tongue; dry, cracked lips; dry oral mucous
membranes)
• Watch for signs of metabolic alkalosis.
• Report discrepancies in intake and output,
worsening of pain or abdominal distention
and increased nasogastric output.
• Watch for signs and symptoms of secondary
infection, such as fever and chills.
• Administer analgesics, broad-spectrum
antibiotics, and other medications as ordered.
• Keep the patient in semi-Fowler's or Fowler's
position as much as possible. These
positions help to promote pulmonary
Volvulus
Intestinal Obstruction
An intestinal obstruction occurs when
the large or small intestines are blocked.
Blockage in the intestine prevents the passing
of fluids, gas, and food through your intestine
in the normal way. The food, fluids, gas build
up behind the blockage site. With no
treatment, the blocked parts of intestine may
die, causing serious problems. But, with early
medical care, intestinal obstruction can often
be treated successfully.
ventilation and ease respiratory distress from
abdominal distention.
• Monitor urine output carefully to assess renal
function, circulating blood volume, and
possible urine retention due to bladder
compression by the distended intestine.
• If the patient’s condition does not improve,
prepare pt for surgery.
Tertiary Prevention
• Insert an NG tube to decompress the bowel as
ordered.
• After surgery, provide all necessary
postoperative care. Care for the surgical site,
maintain fluid and electrolyte balance, relieve
pain and discomfort, maintain respiratory
status, and monitor intake and output.
• Explain the rationale for NG suction, NPO
status, and I.V. fluids initially.
• Advise patient to progress diet slowly as
tolerated once home.
• Advise plenty of rest and slow progression of
activity as directed by surgeon or other health
care provider.
• Teach wound care if indicated.
• Encourage patient to follow-up as directed and
to call surgeon or health care provider if
increasing abdominal pain, vomiting, or fever
occur prior to follow-up.
Nursing Diagnosis of Intestinal Obstruction
1. Deficient Fluid Volume related to nausea,
vomiting, fever or diaphoresis.
Goal:
• Fluid requirements are met
Expected outcomes are:
• Normal vital signs
• Balanced input and output
2. Acute Pain related to distention, rigidity.
Goal:
• The pain is resolved or controlled
Expected outcomes are:
• Patients revealed a decrease discomfort
 • States pain level can be tolerated, 4. Anxiety related to crisis situations and changes in
• Indicate relaxed. health status.

3. Ineffective Breathing Pattern related to Goal:

abdominal distension and or rigidity. • Anxiety is resolved

Goal: Expected outcomes are:

• The pattern of breathing becomes effective.
Expected outcomes are:
• Patients showed the ability to do breathing
exercises
• Breathing deeply and slowly.
• Patients expressed an understanding of
current disease
• Demonstrating positive kooping skills in
dealing with anxiety.
 INTESTINAL OBSTRUCTION QUIZ
5 ITEMS

1. Which of the following best describes the initial stages of strangulating obstruction of the small bowel?

A. Arterial occlusion
B. Blockage without vascular compromise
C. Blockage with vascular compromise
D. Ischemia of the bowel wall

Rationale: C, Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly
25% of patients with small-bowel obstruction. Venous obstruction occurs first, followed by arterial
occlusion (choice A), resulting in rapid ischemia of the bowel wall (choice D). Strangulating obstruction
can progress to infarction and gangrene in as little as 6 hours. B: In simple mechanical obstruction,
blockage occurs without vascular compromise.

2. Which of the following statements about the treatment of small-bowel obstruction is NOT true?

A. Most partial obstructions resolve with nonoperative treatment.

B. Most complete obstructions require surgery.
C. Diarrhea requires surgery.
D. Supportive care is similar for small- and large-bowel obstruction.

Rationale: C, Diarrhea. Patients with partial obstruction may develop diarrhea, and 85% of partial small-
bowel obstructions resolve with nonoperative treatment (choice A). B: About 85% of complete small-
bowel obstructions require surgery. D: Supportive care is similar for small- and large-bowel obstructions:
nasogastric suction, IV fluids (0.9% saline or lactated Ringer’s solution for intravascular volume repletion),
and a urinary catheter to monitor fluid output.

3. The commonest cause of bowel obstruction in adult is?

A. Hernia
B. Neoplasia
C. Adhesions
D. Miscellaneous

Rationale: A, In general, a hernia starts with pressure on an organ or your intestines. A hernia forms
when this pressure happens in the same area as a weakened muscle or tissue. Some people are born
with weak muscles or tissue that isn't fully developed. However, most people get hernias as their bodies
age and their muscles weaken.

4. The nurse is caring for a client with a bowel obstruction. The client has a nasogastric tube in place
set to low intermittent suctioning (LIS). The nurse notes an output of 750 mL during the first half of
the shift. The nurse reviews the client’s lab values and notes a pH of 7.48, CO2 of 35 mEq/L, and
HCO3 of 28 mEq/L. Which of the following conditions does the nurse suspect?

A. Respiratory alkalosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis

Rationale: C, This client's lab values indicate metabolic alkalosis. The client's pH is high, indicating
alkalosis. The CO2 is normal, and the bicarbonate is high, which indicates a metabolic source. The nurse
can conclude that the loss of acid is due to the high output of the nasogastric tube. Regarding B, The
client is losing acidic stomach contents, and the pH of the blood is alkaline, so it is not metabolic acidosis.
Regarding C and D, there is no indication of a respiratory issue.
 5. Based on the clinical presentation and the radiologic and pathologic data provided, what is the most
likely etiology of her small bowel obstruction?

A. Strangulated hernia.
B. Intramural hematoma.
C. Volvulus.
D. Adhesions.
E. Mesenteric artery embolism.

Rationale: B, intramural hematoma. Small intestinal obstruction caused by intramural hematoma is

uncommon, but well-recognized, entity. In adults, approximately two-thirds of these cases are
preceded by abdominal trauma. The remaining one third is caused by a variety of problems, including
coagulation abnormalities, pancreatic disease, alcoholism, a complication from jejunal biopsy, and
Henoch-Schönlein purpura.

REFERENCE:

Intestinal obstruction - Symptoms and causes. (2021, January 20). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/syc-

20351460#:%7E:text=The%20most%20common%20causes%20of,Colon%20cancer.

Ansari, P. (2022, February 22). Intestinal Obstruction. MSD Manual Professional Edition.

https://www.msdmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-

gastroenterology/intestinal-obstruction

Upadhyay, P. (2021, June 3). Intestinal Obstruction - Factors, Types and Treatment. Apollo Hospitals Blog.

https://healthlibrary.askapollo.com/intestinal-obstruction-factors-types-and-treatment/

Dan, R. (2012, April 12). Intestinal Obstruction. Reynel Dan. https://www.slideshare.net/reynel89/intestinal-

obstruction-6336289