INTESTINAL OBSTRUCTION

Ms. Aditi Bahuguna

Msc Nursing 1st year
HCN, SRHU
Objectives:-
At the end of the class students will be able to-
1. Define intestinal obstruction
2. Enlist the causes
3. List the types of intestinal obstruction
4. Discuss its type
5. Enlist the sign and symtoms
6. Discuss the Medical and Surgical managment of
intestinal obstruction
7. Discuss the nursing managment of patient having
intestinal obstruction
 Overview:

• The small intestine and colon are components of digestive tract,

which processes the foods what we eat.
• The small intestine and colon extract nutrients from the foods.
What isn't absorbed by the small intestine and colon continues
along the digestive tract and is expelled as stool during a bowel
movement.
 DEFINITION:-

Partial or complete impairement of the forward

flow of intestinal content is known as Intestinal
obstruction
INTRODUCTION:
• Intestinal obstruction occurs when the passage of
intestinal contents through the lumen is impaired.
• Intestinal obstruction is an interruption in the
normal flow of intestinal contents along the
intestinal tract.
• The block may occur in the small or large intestine,
may be complete or incomplete, may be mechanical
or paralytic, and may or may not compromise the
vascular supply.
• Obstruction most frequently occurs in the young
and the old.
vvv •
• Bowel obstruction can occur in both the small and
large bowel.
• The small bowel is most commonly affected, with
the ileum as the most common site of obstruction.
• Large bowel obstruction accounts for only 15% of
cases of bowel obstruction and the sigmoid colon
is the most common site of obstruction.
• The location of the obstruction, the degree of
obstruction, and the presence of ischemia are
important distinctions because treatment varies.
Types of Intestinal Obstruction:

1. Mechanical obstruction.

2. Paralytic (adynamic, neurogenic) ileus.

3. Strangulation obstruction.
Mechanical obstruction:
• It is a physical block to passage of
intestinal contents without disturbing
blood supply of bowel.
• High small-bowel (jejunal) or low small-
bowel (ileal) obstruction occurs four
times more frequently than colonic.
• Caused by:
1. Extrinsic adhesions: from surgery, hernia,
wound dehiscence, masses, volvulus (twisted
loop of intestine). Up to 70% of small bowel
obstructions are caused by adhesions.
2. Intrinsic: hematoma, tumor, intussusception
(telescoping of intestinal wall into itself),
stricture or stenosis, congenital (atresia,
imperforate anus), trauma, inflammatory
diseases (Crohn's, diverticulitis, ulcerative
colitis)
……Continue

3. Intraluminal: foreign body, fecal or

barium impaction, polyp, gallstones,
meconium in infants
4. In postoperative patients,
approximately 90% of mechanical
obstructions are due to adhesions. In
nonsurgical patients, hernia (most often
inguinal) is the most common cause of
mechanical obstruction.
Paralytic (adynamic, neurogenic) ileus:
• Peristalsis is ineffective (diminished
motor activity perhaps because of toxic or
traumatic disturbance of the autonomic
nervous system).
• There is no physical obstruction and no
interrupted blood supply.
• Disappears spontaneously after 2 to 3
days.
..…Continue

• Causes include:
Spinal cord injuries; vertebral fractures.
Postoperatively after any abdominal
surgery.
Peritonitis, pneumonia.
Wound dehiscence (breakdown).
GI tract surgery.
Strangulation Obstruction:

• It compromises blood supply, leading to

gangrene of the intestinal wall.
• Caused by prolonged mechanical obstruction.
Risk Factors:
• Diseases and conditions that can increase risk of
intestinal obstruction include:
 Abdominal or pelvic surgery, which often causes
adhesions.
Crohn's disease.
 Cancer within your abdomen, especially if their a
surgery to remove an abdominal tumor or
radiation therapy.
• Physical exam.
• Fecal material aspiration from NG tube
• Abdominal and chest X-rays:
1. May show presence and location of small or large
intestinal distention, gas or fluid.
2. Bird beak lesion in colonic volvulus.
3. Foreign body visualization.
Physical Examination

Local signs in the abdomen are:

➤ Inspection :-
• Scar
• Distension, central in small bowel obstruction and
peripheral in large bowel obstruction
• Visible peristalsis
➤ Palpation:
• Abdominal mass may suggest carcinoma or
strangulated bowel.
• Rigidity and rebound tenderness, indicates ischemia &
peritoneal irritation.
➤ Percussion:
• Resonance because of gas filled bowel
• Tenderness on percussion indicates the presence of
peritonitis.
➤ Auscultation:
• Bowel sounds
• Tympani
• Metallic clicks as pressure is raised if much gas is
present in the bowel.
• Gurgling borborygmi if gas and fluid are present in the
bowel.
• Silence if generalized peritonitis or paralytic ileus is
present.
……Continue

• Contrast Studies:
 Barium enema may diagnose colon obstruction or
intussusception.
 Ileus may be identified by oral barium or Gastrografin.
• Laboratory Tests:
 May show decreased sodium, potassium, and chloride levels
due to vomiting.
 Elevated WBC counts due to inflammation; marked increase
with necrosis, strangulation, or peritonitis.
 Serum amylase may be elevated from irritation of the pancreas
by the bowel loop.
• Flexible sigmoidoscopy or colonoscopy may identify the
source of the obstruction such as tumor or stricture.
Treatment
Three main measures-
1. GI drainage
2. Fluid & Electrolyte replacement
3. Relief of obstruction, usually surgical
CONSERVATIVE TREATMENT
1) Correction of fluid and electrolyte imbalances with
normal saline or Ringer's solution with potassium as
required.
2) NG suction to decompress bowel.
3) TPN may be necessary to correct protein deficiency
from chronic obstruction, paralytic ileus, or infection.
4) Analgesics and sedatives, avoiding opiates due to GI
motility inhibition.
5) Antibiotics to prevent or treat infection.
6) Ambulation for patients with paralytic ileus to
encourage return of peristalsis.
MANAGEMENT OF ACUTE CASE (Plan)

I.V Fluids and electrolytes rescusitation for all

N.G tube if repeated vomiting
Antibiotics for all
• Hernia → Operation
• Adhesions → Conservative first
• Obstruction → Remove
• Volvulus → Derotate and or Operate
• Mesenteric ischemia → Operate
• Abscess or Peritonitis → Drain and Treat
• Intussusception → Pneumatic or Barium Reduction or
Operate
Surgery:
• Consists of relieving obstruction. Options
include:
Closed bowel procedures: lysis of adhesions,
reduction of volvulus, intussusception, or
incarcerated hernia
Enterotomy for removal of foreign bodies.
Resection of bowel for obstructing lesions, or
strangulated bowel with end-to-end anastomosis
Intestinal bypass around obstruction
Temporary ostomy may be indicated.
Complications:
Dehydration due to loss of water, sodium, and
chloride.
Peritonitis.
Shock due to loss of electrolytes and dehydration.
Death due to shock.
PRE OPERATIVE PHASE

Pre-operative begins with the decision to perform

surgery and continue untill client has reached the
operating area.

# ROLE OF NURSE IN THE PREOPERATIVE

PHASE

• pre-operative Assesmenet
• Obtaining Informed Consert
• Pre-operative teaching
• physical preparation of patient
• Psychological preparation of patient
Pre-operative Assessment

Review pre-operative laboratory and diagnostic studies

1. Complete blood count
2. Blood type and cross match
3. Serum Electrolytes
4. Urinalysis
5. Chest X-Rays
6. Electrocardiogram
Medical history and clinical assessment

A detailed medical history and a thorough clinical

assessment of the patient’s physical and psychological
condition are of utmost importance, as it may help to
identify patient risk factors for imminent morbidity
ormortality (e.g. an unappreciated reduction of
physicalfitness, specific medications or newly developed
medical illness).

Pre-operative Risk assessment

The definition of being “high risk” for poor outcome after
surgery is nebulous, as it is influenced by many
variables thatvary from patient to patient and from one
surgical procedure toanother
Medication

Beta-adrenergic blockers
Beta-adrenergic blockers are frequently used in the perioperative
management of patients with cardiac disease dueto their
favourable effect on the supply and demand ratio of myocardial
oxygen.

Diuretics
Diuretics should not be used on the day of surgery because
this may increase the risk of intraoperative hypovolaemia.

Metformin
The relevance of the oral anti-diabetic drug metformin for
inducing lactic acidosis has been controversially discussed
in the literature. Regardless, it is recommended that its
intake be stopped 48 h prior to the surgery.
Acetylsalicylic acid and thienopyridine derivatives

Anti-platelet therapy (usually 100 mg of acetylsalicylic

acid daily) is standard for most patients with coronary
artery disease.

 SAFETY PROTOCOL
• Identify the patient
• Proper ID band with Patient name,
UHID,Age,Treating doctor name should be written
• OT gown, Cap, and Mask to be wear
Surgical Site marking
 VITAL SIGNS
 PSYCHOLOGICAL PREPARATION
POST OPERATIVE CARE

*Definition:-

Post operavtive care is the care that the patient receives

after a surgical proceduice. The type of past operative
care that the patient need depends on the type of
surgery as well as the patients History. It often depends
upon pain management and wound care

#PHASES:
• Immediate (Past-Anesthenie) Phase 1
• Intermediate (Hospital stay) Phase 2
• Convalescent (After discharge to full resorry)
# PURPOSES

• To enable a Successful and faster recovery of the

patient post operatively
• To reduce post-operative mortality rate.
• To reduce the Jergth of hospital stay of the patient
• To provide quality care service
POST OPERATIVE CARE UNIT OR PACU
PACU Should be
• sound proof
• isolated
These features will help the pateint to reduce anxiety
and promote comfort
*PHASE 1 (IMMEDIATE PHASE)
• It is the immediate recovery phase and requires
intensive nursing care to detect early sign of
complicatons
• Receive a complete patient record from the operating
room when to plan post operative care
• It is designed for care of surgical patient immediately
after surgery and patient requiring close monitoring
PHASE 2 (INTERMEDIATE PERIOD)
• The intermediate phase begin with complete recovery
from anesthesia and lasts for the rest of hospital stay
• Patient requiring less observation and less nursing
care the PHASE 1
• The phase is also known as step down or progressive
care
PHASE 3 (CONVALESCENT PHASE)
The convalscent phase is a transition period from the
time of hospital discharge to full recovery

COMPLICATIONS
1. Shock
2. Hemmorrhage
3. Deep vein thrombosis
4. pulmonary embolism
5. urinary retention
6. intestinal obstruction
Nursing Assessment:
1. Assess the nature and location of the
patient's pain, the presence or absence of
distention, flatus, defecation, emesis,
obstipation.
2. Listen for high-pitched bowel sounds,
peristaltic rushes, or absence of bowel
sounds.
3. Assess vital signs.
Nursing Diagnoses:
1. Acute Pain related to obstruction, distention, and
strangulation.
2. Risk for Deficient Fluid Volume related to impaired
fluid intake, vomiting, and diarrhea from intestinal
obstruction.
3. Diarrhea related to obstruction.
4. Ineffective Breathing Pattern related to abdominal
distention, interfering with normal lung expansion.
5. Risk for Injury related to complications and severity
of illness.
6. Fear related to life-threatening symptoms of
intestinal obstruction.
Nursing Interventions:
Achieving Pain Relief:
Administer prescribed analgesics.
Provide supportive care during NG intubation to
assist with discomfort.
To relieve air-fluid lock syndrome, turn the patient
from supine to prone position every 10 minutes
until enough flatus is passed to decompress the
abdomen.
A rectal tube may be indicated.
Maintaining Electrolyte and Fluid Balance:
Measure and record all intake and output.
Administer I.V. fluids and parenteral nutrition as
prescribed.
Monitor electrolytes, urinalysis, hemoglobin, and
blood cell counts, and report any abnormalities.
Monitor urine output to assess renal function and
to detect urine retention due to bladder
compressions by the distended intestine.
Monitor vital signs; a drop in BP may indicate
decreased circulatory volume due to blood loss
from strangulated hernia.
Maintaining Normal Bowel Elimination:
Collect stool samples to test for occult blood if
ordered.
Maintain adequate fluid balance.
Record amount and consistency of stools.
Maintain NG tube as prescribed to decompress
bowel.
 Maintaining Proper Lung Ventilation:

• Keep the patient in Fowler's position to

promote ventilation and relieve abdominal
distention.
• Monitor ABG levels for oxygenation levels if
ordered.
Preventing Injury Due to Complications:
Prevent infarction by carefully assessing the
patient's status; pain that increases in intensity or
becomes localized or continuous may herald
strangulation.
Detect early signs of peritonitis to minimize this
complication.
Avoid enemas, which may distort an X-ray or make
a partial obstruction worse.
Observe for signs of shock.
Watch for signs of (metabolic alkalosis and
metabolic acidosis.
Conclusions:

Intestinal obstruction remains still a common and

important surgical emergency. Obstruction due to
adhesions increasing in incidence due to increased
abdominal & pelvic surgeries. The obstruction due to
external hernias decreasing due to early elective
surgeries.
BIBLIOGRAPHY:-
1. Brunner and suddharth`s Textbook of Medical
Surgical Nursing ,Tweleth edition ,Janice L.Hinkle
Kerry H. cheever
2. Lewis Medical Surgical Nursing Assessment and
Management of clinical problem fourth south Asia
edition,Chintamani
3. Black`s Medical Surgical Nursing (clinical
Management for positive outcome ) First South
edition ,Joyce M. Black
Prepare a Nursing care plan using the Nursing
diagnosis discussed about patient with Intestinal
obstruction