Managing the Client With Bowel Obstruction and Ostomy

Intestinal ObstructionSmall and large

Partial or complete

Failure of intestinal contents to move

Mechanical Causes of Intestinal Obstruction

A. Intussusceptions: The prolapse of the intestine into the lumen of the immediate adjacent part

B. Volvulus: Torsion of a loop of intestine causing an obstruction (may also have strangulation)

C. Hernia: An abnormal protrusion through the abdominal wall

Functional Causes of Bowel ObstructionIleus, paralytic ileus, adynamic)

musculature can’t propel bowel contents usually accompanied by peritonitis

Symptoms include abdominal pain and distention, vomiting and constipation. Potential complications include dehydration and shock.

Treatment : Decompression with a tube at the site of the obstruction

Small Bowell ObstructionPathophysiology

ObstructionEffluent and flatus collect above abdominal distentionDistention and fluid retention absorp & stimulate prod

of more fluids distention intraluminal press venous and art

cap press edema, congestion, necrosis, rupture

Signs and SXs of Small Bowel ObstructionCrampy abdominal pain that is wavelike and

colickyPass blood and mucus but no feces or flatusVomitingIn severe cases reverse peristalsis

Example of an x ray showing a small bowel obstruction

Large Bowel ObstructionPathophysiology

Obstruction build up of effluent & gas above site severe distention and perforationOften undramatic (unlike sbo)Strangulation and necrosis are life threatening

Adenocarcinoid tumors account for the majority of large bowel obstructions

Signs & SXs of Large Bowel ObstructionConstipation (may be the only sx for months)Alteration in the shape of stoolWeakness, anorexia and weight lossMay develop iron deficiency anemiaDistended abdomen showing the outline of

the large bowel

Treatment Options for LBOMonitor symptoms, provide sx reliefSurgical resection of bowel and formation of

ostomy (temp or permanent) if condition worsensNursing Care

Monitor for improvement, deteriorationFluid and electrolyte balancePre- & post-op care

Bowel ObstructionClinical Signs & SXs

Small Intestine Large Intestine

Onset Rapid Gradual

Vomiting Frequent & Copious Rare

Pain Colicky, cramp like, intermittent

Low grade, crampy

Bowel Movements Feces for a short duration

Absolute constipation

Abdominal Distention

Minimally increased Greatly increased

Colorectal Cancer Risk Factors (cause unknown):

Over 40 Blood in stool History of rectal polyps Family history History of inflammatory bowel disease High fat, protein, beef diet; low fiber

The third most common cause of U.S. cancer deaths

Risk factors: see Chart 38-8

Importance of screening procedures

Manifestations include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation

Treatment depends upon the stage of the disease

Patho-physiology of Colorectal CancerPredominantly adenocarcinoma (arising

from the epithelial cells of the intestineSymptoms

Right side Dull pain Melena

Left side Pain/cramping Narrowing stools Constipation Bright blood

• Rectal• Tenesmus• Pain• Felling of

incomplete evacuation

• Bloody stools

Colon Cancer

DiagnosisAbdominal and rectal examFecal occult blood testingBarium enemaColonoscopy / sigmoidoscopy with biopsy & cytology

smearsCarcinoembryonic antigen (CEA) (dx and recurrence)

Nursing Process—Assessment of the Patient With Cancer of the Colon or RectumHealth history

Fatigue and weakness

Abdominal or rectal pain

Nutritional status and dietary habits

Elimination patterns

Abdominal assessment

Characteristics of stool

Nursing DiagnosisAnxietyPainAltered nutrition, less thanHigh risk for fluid volume deficitHigh risk for infectionKnowledge deficitImpaired skin integrity

Disturbed body image

Ineffective sexuality patterns

Potential Complications of Colon or Rectal CancerIntraperitoneal infection

Complete large bowel obstruction

GI bleeding

Bowel perforation

Peritonitis, abscess, and sepsis

Distribution Of Colon Cancer

Placement of Permanent ColostomiesA. Sigmoid

Feces are solid

B. Descending Feces are

semi-mushyC. Transverse

Feces are mushy

D. Ascending Feces are

fluid

Stomas should always be beefy red

Ostomy Pouches and Accessories

Managing Nasogastric TubesFeeding vs.

DecompressionPlacement

VerificationGuidelines for

FlushingPatient Positioning

Nasogastric TubesDecompress LavageDiagnose GI motility and other disordersAdminister medications and feedingsTreat an obstructionCompress a bleeding siteAspirate gastric contents for analysis

Care of the Patient with a G-TubeCheck institution’s policy

for managementMonitor GI function and

tube insertion site at least once per shift

Assess gastric drainage for amount and characteristics each shift

Care of the Patient with an NG or G-TubeIrrigate q 4 hours.Flush a tube used for feeding with 30ml Replace irrigation equipment per protocol.Reposition as needed Clean nares, apply water soluble lubricant and retape

daily or prn. Oral hygiene Clean new abdominal tube site

Medication Administration by NG or G-TubeAssess for placement and flush with 30 ml water.When gastric suction prescribed, clamp tube for 20 minutes after

instillation of medications to allow for absorption. Avoid crushing sustained release, enteric coated products, or drugs in a

chewable or sublingual form.Administer crushed medications separately; do not mix together in

water. Flush with about 15 ml between each medication.Some medications, for example Dilantin, are rendered less potent when

given with tube feedings. For these medications, it is important to turn the feeding off for 30-45 minutes following medication administration. Check your institution’s policy for specifics.

Enteral Feeding Verify placement Verify formula, amount, and method of

administration upon initiation of feeding and minimally once per shift there after

Confirm placement Monitor for vomiting, diarrhea, changes in

aspirates, abdominal characteristics, change in bowel sounds, onset of respiratory distress, hypotension, fever or significant change in UO.

Monitor labs (especially glucose levels). Assess weight. Elevate HOB 30 degrees – when and why? Aspirate for residual