MICRO T E A C H I N G

ON
INTESTINAL
OBSTRU CTION
(Y.SOUJANYA)
 LESSON PLAN

NAME OF THE STUDENT : SOUJANYA.Y

TOPIC : Intestinal Obstruction
GROUP : Primary School Teacher

PLACE : JS College of Nursing

METHOD OF TEACHING : Lecture

DURATION :45min
TEACHING AIDS : Charts, FlashCards, Leaflets, pamphlets, OHP, LCD
DATE :
TIME :11 A.M
NAME OF THE :Mrs.R.Supriya
GUIDE
 REFERENCES
 https//en. Wikipedia . org/wiki organ donation.
 www.jeevandan.gov.in.
 International Journal of Innovative research in
Science Engineering and Technology :vol4,issue
4, April 2015
 National Journal of Research in Community
Medicine. vol.2.Issue 2. July-Sep. 2013(079-
148).
 International Journal of Medical Science and Clinical Invention. Volume 1 issue 6 2014 page
no.275.
 www.ap7am.com/ english-news-9017-first-brain -dead-personal.html.
 OBJECTIVES
General objectives:

By the of the class students will gain knowledge regarding intestinal obstruction
The structured teaching program is amid at bringing a complete awareness about intentional 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

OBJECTIVES TIME CONTENT METHOD STUDENT AV AIDS EVALUATION
OF
TEACHING ACTIVITY
 3min INTRODUCTION:
Impairment of the forward flow of intestinal content is
known as intestinal obstruction. About 90% of bowel Lecture Listening Black What do
obstructionoccurs in the small bowel. Large bowel obstruction cum actively you know
usually occurs in the sigmoid colon obstruction. Produce Discussion boad about intestinal
nausea, vomiting, dehydration and severe pain. obstruction

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

1. MECHANICAL OBSTRUCTION: An intra

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

Discuss 4min
th Black
ETIOLOGY:
eetiological
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:
1. Factors that cause intestinal obstruction
2min
may be mechanical, Neurogenic, Vascular. Lecture Active
a. Mechanical factors: cum listening What are risk
● Adhesion: loops of intestine become adherent to Discussion factors
Flash cards
areas that heal slowly or scar after abdominal surgery.
Adhesion is probably the most common cause of
obstruction in boththe 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
sigmoid colon. cum
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
Vascular factors: actively
Body is interrupted, the part ceases to function and pain
occurs.

There are two types of obstructions

● Small bowel obstruction
● Large bowel obstruction

SMALL BOWEL OBSTRUCTION:

4min
Understand the PATHOPHYSIOLOGY:
pathophysiology Intestinal contents, fluid and gas accumulate above the
of intestinal
intestinal obstruction. The abdominal distention and retention
obstruction
of fluid reduce the absorption of fluids and stimulate Model
Lecture
more gastric secretion. With increasing distention, pressure
cum
within
Discussion
the intestinal lumen increases, causing a decrease in
venous andarteriolar 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 Listening

the stomach, leading to reduction of chlorides and potassium in actively

Lecture
the blood and to metabolic alkalosis. Dehydration and acidosis
cum
2min develop from loss of water and sodium. With acute fluid losses, What are
Discussion
hypovolemic shock may occur.
the
CLINICAL MANIFESTATIONS: manifestatio
Power ns
INITIAL SYMPTOMS: point
Explain clinical
● Crampy pain that is wave like and colicky presentati
manifestations
● The patient may pass blood and mucus but no fecal o
matterand no flat
 ● 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 contents, then the bile-stained contents of the Listening
duodenum and the jejunum, and finally, with each actively
paroxysm of pain, the darker, fecal-like contents of the
ileum. The signs of dehydration become evident: intense
thirst, drowsiness, generalized malaise, aching, and a Lecture
parched tongue and mucous membranes. The abdomen cum
becomes distended. The lower the obstruction is the Discussion
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 ASSESSMENT AND DIAGNOSTIC FINDINGS: List out the
anddiagnostic 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
studies (i.e electrolyte studies and a complete blood cell count) Black
reveal a picture of dehydration, loss of plasma volume, and
possible infection. boad

Know the 2min

medical MEDICAL MANAGEMENT
management
Decompression of the bowel through a nasogastric tube
ofthe intestinal Listening
is successful in most cases. When the bowel is completely
obstruction actively
obstructed, the possibility of strangulation warrants
surgical
intervention. Before surgery, IV therapy is necessary to
replace the depleted water, sodium, chloride, and potassium.
Lecture
The surgical treatment of intestinal obstruction
cum Black
depends largely on the cause of the obstruction. In the most
Discussion
common causes of obstruction, such as hernia and adhesions,
boad
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 management
Nursing management of the non surgical patient
ofintestinal for the client
obstruction witha small bowel obstruction includes maintain the function of
the nasogastric tube, assessing and measuring the
nasogastric output,assessing for fluid and electrolyte
imbalance, monitoring
nutritional status, and assessing improvement (e.g.
Lecture
return of bowel sounds, decreased abdominal distention,
cum Handout
subjective Discussion
improvement in abdominal pain and tenderness,
passage of 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 Listening
Pathophysiology : cum actively Explain the
As in small bowel obstruction, large bowel obstruction Discussion
Explain the Pathophysiology
results in an accumulation of intestinal contents fluid and
Pathophysiolog
gas proximal to the obstruction. Obstruction in the large bowel
y
can lead to serve distention and perforation unless some gas
and fluid can flow back through the ileal valve. Large bowel
obstruction , even if complete, may be undramatic if the blood chart
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 Listening
cum actively
CLINICAL MANIFESTATIONS: Discussion
Discuss clinical
Large bowel obstruction differs clinically from small
2min
manifestations 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 Power
months. The shape of the stool is altered as it passes the point
obstruction that is gradually increase in size. Blood in the stool prese
ntatio
may result in iron deficiency anemia. The patient n

may experience weakness, weight loss, and anorexia.

Lecture
Eventually, the
cum
abdomen becomes markedly distended, loops of large
bowel Discussion
become visibly outlined through the abdominal wall, and
Understand
the patient has crampy lower abdominal pain. Finally, fecal
assessment
vomiting develops, symptoms of shock may occur.
anddiagnostic
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.
2min Barium studies are contraindicated.

Know the Lecture Listening

MEDICAL MANAGEMENT
medical cum actively
managemen Discussion
t Restoration of intravascular volume, correction of electrolyte
abnormalities, and nasogastric aspiration.

Discuss
nursing NURSING DIAGNOSIS:
diagnosis Based on the assessment data, the major nursing diagnosis may
include the following List out the
nursing
● Imbalanced nutrition (less than body requirements
diagnosis
related to nausea and anorexia
● Risk for deficient fluid volume related to vomiting and
dehydration
1min
● Anxiety related to impending surgery and the diagnosis
ofcancer
● Risk for ineffective therapeutic regimen management
related to knowledge deficit concerning the diagnosis, Pamphlet
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 Listening
cum actively

Discuss about Discussion

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
attainmentof 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

Lecture Listening
and the impact on himself or herself; and avoidance
1min cum actively
of
Explain nursing Discussion
complications.
interventions
NURSING 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
lowin 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
fluids and to prevent abdominal distention Listening
● Nurse monitors the abdomen for increasing distention, actively
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
permanentstoma.
● All members of the health care team, including the
enterostomal therapist, should be available for
assistance and support. Lecture Listening
● The nurse’s role is to assess the patient’s anxiety level cum actively
and coping mechanisms and suggest methods for Discussion
reducing anxiety, such as deep- breathing exercises and
visualizing a successful recovery from surgery and cancer.
Handout
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
fearby 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
repeatsome 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,
competent attitude that promotes confidence.
Lecture
cum
PROVIDING POSTOPERATIVE CARE: Discussion

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
withabdominal 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
actively Handout
day 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

thepatient with a colostomy.
● The patients avoids foods that cause excessive odour
and
gas, including foods in the cabbage family, eggs, fish,
beans, and high-cellulose products such as peanuts. Handout
Lecture cum
 ● 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 off for a week. This process is hastened by mechanical Lecture
irrigation of the wound or with sitz baths performed two or cum
three times each day initially. The condition of the perineal Discussion
Listening
wound and any bleeding, infection, or necrosis are actively
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 abdominal girth, to detect bowel obstruction. The Handout
nurse monitorsvital 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 APPLIANCE actively
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
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 Handout
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
sides of the pouch will keep is secure during bathing. To remove cum
the appliance, the patient assumes a comfortable sitting or Discussion
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 care not to rub the area. The patient can lightly dust
nystatin (Mycostatin) powder on the peristomal skin if irritation Listening
of yeast growth is present. actively

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 Handout
empty 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 stoma at a regular time, there is less gas and Lecture Listening
retention of the irrigant. The time for irrigating the colostomy cum actively
should be consistent with the schedule Person will follow after Discussion
leaving thehospital.

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, social worker, and dietitation.
● Patients are given specific information, individualized to
Handout
their needs, about ostomy care and signs and symptoms
ofpotential 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
question questions
stoma care techniques before discharge home. Many
s
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:
Students have gained knowledge regarding the intestinal
obstruction and the medical, surgicaland Handout
nursing management
of the client with the intestinal obstruction.
ASSIGNMENT:
Write nursing care plan for the client suffering from
intestinalobstruction

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 forcontinuity
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