Managing the Client With BowelObstruction and Ostomy
Intestinal Obstruction Small and large Partial or complete Failure of intestinal contents to move
Mechanical Causes of Intestinal ObstructionA. Intussusceptions: The prolapse of the intestine into the lumen of the immediate adjacent partB. 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 BowelObstruction Ileus, 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 Obstruction Pathophysiology Obstruction Effluent and flatus collect above abdominal distention Distention 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 BowelObstruction Crampy abdominal pain that is wavelike and colicky Pass blood and mucus but no feces or flatus Vomiting In severe cases reverse peristalsis
Example of an x ray showing a smallbowel obstruction
Large Bowel Obstruction Pathophysiology Obstruction build up of effluent & gas above site severe distention and perforation Often undramatic (unlike sbo) Strangulation and necrosis are life threatening Adenocarcinoid tumors account for the majority of large bowel obstructions
Signs & SXs of Large BowelObstruction Constipation (may be the only sx for months) Alteration in the shape of stool Weakness, anorexia and weight loss May develop iron deficiency anemia Distended abdomen showing the outline of the large bowel
Treatment Options for LBO Monitor symptoms, provide sx relief Surgical resection of bowel and formation of ostomy (temp or permanent) if condition worsens Nursing Care Monitor for improvement, deterioration Fluid and electrolyte balance Pre- & post-op care
Bowel ObstructionClinical Signs & SXs Small Intestine Large IntestineOnset Rapid GradualVomiting Frequent & Copious RarePain Colicky, cramp like, Low grade, crampy intermittentBowel Movements Feces for a short duration Absolute constipationAbdominal 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 ColorectalCancer Predominantly adenocarcinoma (arising from the epithelial cells of the intestine Symptoms •Rectal Right side •Tenesmus •Pain Dull pain •Felling of Melena incomplete Left side evacuation •Bloody stools Pain/cramping Narrowing stools Constipation Bright blood
Nursing Process—Assessment of the PatientWith Cancer of the Colon or Rectum Health history Fatigue and weakness Abdominal or rectal pain Nutritional status and dietary habits Elimination patterns Abdominal assessment Characteristics of stool
Nursing Diagnosis Anxiety Pain Altered nutrition, less than High risk for fluid volume deficit High risk for infection Knowledge deficit Impaired skin integrity Disturbed body image Ineffective sexuality patterns
Potential Complications of Colon orRectal Cancer Intraperitoneal infection Complete large bowel obstruction GI bleeding Bowel perforation Peritonitis, abscess, and sepsis
Managing Nasogastric Tubes Feeding vs. Decompression Placement Verification Guidelines for Flushing Patient Positioning
Nasogastric Tubes Decompress Lavage Diagnose GI motility and other disorders Administer medications and feedings Treat an obstruction Compress a bleeding site Aspirate gastric contents for analysis
Care of the Patient with a G-Tube Check institution’s policy for management Monitor 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 orG-Tube Irrigate 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 NGor G-Tube Assess 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
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