2. INTESTINAL OBSTRUCTION
• Intestinal obstruction is an interruption in
the normal flow of intestinal contents
(food-fluid-gas) 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.
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3. Types and Causes
1. Mechanical obstruction(dynamic)
• a physical block to passage of intestinal
contents without disturbing blood supply of
bowel.
Causes include:
• a. inside the lumenof intestine(intramural)
:foreign body in the oesophagus,gall stone,bag
of ascaris worms obstructing the small
intestine,fecal impaction,intussusception .
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4. • b. causes in the wall(mural):tumor of any
layer,crohns disease, diverticulitis of the
colon, congenital atresia.
• c. cauese outside the wall(extramural):
hernia, adhesions(pst operative or
infalmmatory adhesions following TB,typhoid,
ruptured amoebic or appendicular abscess
and PID),volvulus, band.
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5. 2. Paralytic (a dynamic, neurogenic) ileus
• Diminished motor activity due to toxic or traumatic
disturbance of the autonomic nervous system).
• There is no physical obstruction and no interrupted
blood supply.
• There is no movement
Causes include:
i. Spinal cord injuries; vertebral fractures(Ogilvies
syndrome).
ii. Postoperatively after any abdominal surgery.
iii. Peritonitis.pancreatits
iv. Metabolic disorders
v. drugs
.
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8. Pathophysiology
• The intestinal obstruction are affect whole body
fluid/electrolyte balances.
• Proximal to the obstruction, the intestinal tract
dilates as it fills with intestinal secretions and
swallowed air.
• Failure of intestinal contents to pass through the
intestinal tract leads to a cessation of flatus and
bowel movements.
• Intestinal obstruction can be broadly
differentiated into small bowel and large bowel
obstruction.
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9. Pathophysiology
• Fluid loss from emesis, bowel edema, and loss of
absorptive capacity leads to dehydration. loss of
gastric potassium, hydrogen, and chloride ions,
• Significant dehydration stimulates renal to
reabsorption of bicarbonate and loss of chloride
(metabolic alkalosis).
• Intestinal stasis leads to overgrowth of intestinal
flora and lead to the development of feculent
emesis. And bacterial translocation across the
bowel wall.
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10. Pathophysiology
• Ongoing dilation of the intestine increases
luminal pressures. exceed more than venous
pressures. Loss of venous drainage causes
increasing edema and hyperemia of the bowel.
• This may lead to compromised arterial flow to
the bowel, causing ischemia, necrosis, and
perforation.
• Intestinal volvulus, the prototypical closed-loop
obstruction, causes torsion of arterial inflow and
venous drainage, and is a surgical emergency.
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12. Clinical Manifestations
1. Fever
2. Distention and Bloating
3. peritoneal irritation
4. pain that is wavelike and colicky
5. Patient may pass blood and mucus but no fecal matter
or flatus. Vomiting (feculent)
6. Constipation and a lack of gas, if the intestine is
completely blocked.
7. Diarrhea, if the intestine is partly blocked.
8. Toxicity and shock may develop with all types of
intestinal obstruction.
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13. Clinical Manifestations
• Strangulation symptoms are initially those of
mechanical obstruction, but progress
rapidly.
• pain is severe, continuous, and localized.
There is moderate distention, persistent
vomiting, decreased bowel sounds and
marked localized tenderness.
• Stools or vomitus become bloody or contain
occult blood.
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14. Small bowel VS Large intestine obstructions
Small bowel obstructions
›› Severe fluid and
electrolyte imbalance
››Metabolic alkalosis
›› Visible peristaltic waves
(possible)
›› Abdominal pain, discomfort
›› Profuse, sudden projectile
vomiting with fecal odor;
vomiting relieves pain
• Large intestine obstructions
››Minor fluid and
electrolyte imbalance
››Metabolic acidosis (possible)
›› Significant abdominal
distention
›› Intermittent abdominal
cramping
›› Infrequent vomiting
›› Diarrhea or “ribbon-like” stools
around an impaction
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16. Diagnostic Evaluation
1. Fecal material aspiration from NG tube
2. Abdominal and chest X-rays
3. Barium enema may diagnose colon
obstruction.
4. Abdominal CT- SCAN
5. Flexible sigmoidoscopy or colonoscopy
(ingested camera)
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17. Upright abdominal X-ray demonstrating a small bowel
obstruction. Note multiple air fluid levels.
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18. 6. Laboratory tests
• a. May show decreased sodium, potassium,
and chloride levels due to vomiting
• b. Elevated WBC counts due to
inflammation; necrosis, strangulation, or
peritonitis
• c. Serum amylase may be elevated from
irritation of the pancreas by the bowel loop
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19. Management
Nonsurgical Management
1. Correction of fluid and electrolyte with normal
saline or Ringer’s solution with potassium.
2. NG suction to decompress bowel.
3. Treatment of shock and peritonitis.
4. TPN may be necessary to correct protein
deficiency
5. Analgesics
6. Antibiotics to prevent or treat infection.
7. Ambulation for patients with paralytic ileus to
encourage return of peristalsis.
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20. Surgical management
• Surgery is almost always needed when the
intestine is completely blocked or when the
blood supply is cut off.
• Patients may need a colostomy or an
ileostomy after surgery. (Temporary) until
patient recovered
• The diseased part of the intestine is
removed (resection )
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21. Surgery
Options include:
1. Closed bowel procedures: reduction of
volvulus, intussusception,or incarcerated
hernia
2. Enterotomy for removal of foreign bodies
3. Resection of bowel for obstructing lesions,
or strangulated bowel with end-to-end
anastomosis
4. Intestinal bypass around obstruction
5. Temporary ostomy may be indicated
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22. Complications of bowel obs
1. Dehydration due to loss of water, sodium,
and chloride
2. Peritonitis
3. Shock due to loss of electrolytes and
dehydration
4. Death
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23. 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.
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24. Nursing Assessment
• Fluid collects in dependent bowel loops.
• Conduct frequent checks of the patient’s
level of responsiveness; decreasing
responsiveness may indicate an increasing
electrolyte imbalance or shock.
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25. Nursing Diagnoses
• Acute Pain related to obstruction, distention, and
strangulation
• Risk for Deficient Fluid Volume related to
impaired fluid intake, vomiting, and diarrhea
from intestinal obstruction
• Ineffective Breathing Pattern related to
abdominal distention, interfering with normal
lung expansion
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26. Achieving Pain Relief
1. Administer prescribed analgesics.
2. Provide supportive care during NG
intubation to assist with discomfort.
3. turn the patient from supine to prone
position every 10 minutes until enough
flatus is passed to decompress the
abdomen.
4. A rectal tube may be indicated.
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27. Maintaining Electrolyte and Fluid Balance
1. Measure and record all intake and output.
2. Administer I.V. fluids and parenteral
nutrition.
3. Monitor electrolytes, urinalysis, hemoglobin,
and blood cell counts, and report any
abnormalities.
4. Monitor urine output to assess renal function
and to detect urine retention.
5. Monitor vital signs.
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28. Maintaining Proper Lung Ventilation
1. Keep the patient in Fowler’s position to
promote ventilation and relieve abdominal
distention.
2. Monitor ABG levels for oxygenation levels
if ordered.
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