Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

COLLEGE OF NURSING
University Town, Musuan, Maramag, Bukidnon
E-mail: nursing@cmu.edu.ph

INTESTINAL OBSTRUCTION

In Partial Fulfillment of the Requirements in

NCM 74: MEDICAL-SURGICAL II

KOTICO, HOSEA DANIEL E.

FEBRUARY 2022
INTESTINAL OBSTRUCTION: Intestinal obstruction make the waste material get harder and it
is significant mechanical impairment or complete becomes difficult to be eliminated.
arrest of the passage of contents through the intestine • It may be due to tumors.
due to pathology that causes blockage of the bowel. • Narrowing or twisting of intestines or scar
tissues may be one of the reasons. Such
Partial or complete blockage of the lumen of the small blockages are mechanical blockages.
or large intestine causing an interruption in the normal • In addition to changed food habits, changes in
flow of intestinal contents along the intestinal tract the water intake, as well as exercise changes,
may also lead to bowel obstruction
An intestinal is a potentially serious condition in which sometimes.
the intestines are blocked. The blockage may either • Bowel obstruction may sometimes be due to
be partial or complete, occurring at one or more the changes within the walls of the abdomen
locations. Both the small intestine and large intestine area, bowel lumen, or external to the belly
can be affected. When a blockage occurs, food and area.
drink cannot pass through the body. Obstructions are
serious and need to be treated immediately. They may
even require surgery.
Pathophysiology
Precipitating Factor
In simple mechanical obstruction, blockage
✓ Poor Hygiene occurs without vascular compromise. Ingested fluid
✓ Sepsis and food, digestive secretions, and gas accumulate
✓ Acute illness above the obstruction. The proximal bowel distends,
✓ Constipation and the distal segment collapses. The normal
✓ Untreated pain secretory and absorptive functions of the mucosa are
Predisposing Factor depressed, and the bowel wall becomes edematous
and congested. Severe intestinal distention is self-
✓ Age perpetuating and progressive, intensifying the
✓ Severe illness peristaltic and secretory derangements and
✓ Functional dependency increasing the risks of dehydration and progression to
✓ Malnutrition strangulating obstruction.
Etiology Strangulating obstruction is obstruction with
compromised blood flow; it occurs in nearly 25% of
• Sepsis
patients with small-bowel obstruction. It is usually
• Anti-motility drugs
associated with hernia, volvulus, and intussusception.
• Diabetic gastroparesis
Strangulating obstruction can progress to infarction
• Impacted feces and gangrene in as little as 6 hours. Venous
• Post-operation obstruction occurs first, followed by arterial occlusion,
• Post-abdominal surgery resulting in rapid ischemia of the bowel wall. The
• Hernia ischemic bowel becomes edematous and infarcts,
leading to gangrene and perforation. In large-bowel
Overall, the most common causes of obstruction, strangulation is rare (except with
mechanical obstruction are adhesions, hernias, and volvulus).
tumors. Other general causes are diverticulitis, Perforation may occur in an ischemic segment
foreign bodies (including gallstones), volvulus (typically small bowel) or when marked dilation occurs.
(twisting of bowel on its mesentery), intussusception The risk is high if the cecum is dilated to a
(telescoping of one segment of bowel into another), diameter ≥ 13 cm. Perforation of a tumor or a
and fecal impaction. Specific segments of the diverticulum may also occur at the obstruction site.
intestine are affected differently.

Signs and Symptoms of Intestinal Obstruction

What causes Intestinal Obstruction?
Symptoms include cramping pain, vomiting,
• Fetal and neonatal blockages are caused by obstipation, and lack of flatus. Diagnosis is clinical
the intestinal atresia where there is an and confirmed by abdominal x-rays. And:
absence of a part of the intestine or a
narrowing.
• Cramping and pain
• Non-mechanical obstructions are caused due
to inflammation or due to the side effects or • Abdominal fullness
infections of certain medicines. • Bad breath
• Other causes are hernias, cancer, and Crohn's • Abdominal bloating
disease. • Constipation
• Sometimes a change in the food habits and • Diarrhea
lifestyles also causes such issues. It may • Vomiting
Obstruction of the small bowel causes symptoms may be done for certain suspected causes of
shortly after onset: abdominal cramps centered obstruction. During the procedure, the doctor
around the umbilicus or in the epigastrium, vomiting, will insert air or liquid barium into the colon
and—in patients with complete obstruction— through the rectum. For intussusception in
obstipation. Patients with partial obstruction may children, an air or barium enema can actually
develop diarrhea. Severe, steady pain suggests that fix the problem most of the time, and no further
treatment is needed.
strangulation has occurred. In the absence of
strangulation, the abdomen is not tender. Medical Management
Hyperactive, high-pitched peristalsis with rushes
coinciding with cramps is typical. Sometimes, dilated • Correction of fluid and electrolyte imbalances
with normal saline or Ringer's solution with
loops of bowel are palpable. With infarction, the
potassium as required.
abdomen becomes tender and auscultation reveals
• NG suction to decompress bowel. Treatment
a silent abdomen or minimal peristalsis. Shock and
of shock and peritonitis.
oliguria are serious signs that indicate either late
• Analgesics and sedatives, avoiding opiates
simple obstruction or strangulation.
due to GI motility inhibition.
• Antibiotics to prevent or treat the infection.
Obstruction of the large bowel usually causes
• Ambulation for patients with paralytic ileus to
milder symptoms that develop more gradually than
encourage return of peristalsis.
those caused by small-bowel obstruction. Increasing
• TPN may be necessary to correct protein
constipation leads to obstipation and abdominal
deficiency from chronic obstruction, paralytic
distention. Vomiting may occur (usually several ileus, or infection.
hours after onset of other symptoms) but is not
common. Lower abdominal cramps unproductive Nursing Management
feces occur. Physical examination typically shows a
distended abdomen with loud borborygmi. There is Primary Prevention
no tenderness, and the rectum is usually empty. A
mass corresponding to the site of an obstructing • Encourage well balanced and high-fiber diet
tumor may be palpable. Systemic symptoms are • Encourage regular exercise
relatively mild, and fluid and electrolyte deficits are • Encourage elderly for regular check-up
uncommon.
Secondary Prevention

Diagnostic • Insert an NG tube to decompress the bowel

as ordered.
• Physical exam. Your doctor will ask about
• Maintain the function of the nasogastric tube.
your medical history and your symptoms. He
• Assess the measure of the nasogastric output
or she will also do a physical exam to assess
your situation. The doctor may suspect • Maintain fluid and electrolyte balance by
intestinal obstruction if your abdomen is monitoring electrolyte, blood urea nitrogen,
swollen or tender or if there's a lump in your and creatinine levels
abdomen. He or she may listen for bowel • Begin and maintain I.V. Therapy as ordered.
sounds with a stethoscope. • Monitor Nutritional Status.
• X-ray. To confirm a diagnosis of intestinal
• Continually assess his pain. Colicky pain that
obstruction, your doctor may recommend an
abdominal X-ray. However, some intestinal suddenly becomes constant could signal
obstructions can't be seen using standard X- perforation
rays. • Assess improvement (return of normal bowel
• Computerized tomography (CT). A CT scan sounds, decreased abdominal distention,
combines a series of X-ray images taken from subjective
different angles to produce cross-sectional • improvement in abdominal pain and
images. These images are more detailed than
tenderness, the passage of flatus or stool).
a standard X-ray and are more likely to show
an intestinal obstruction. • Look for signs of dehydration (thick, swollen
• Ultrasound. When an intestinal obstruction tongue; dry, cracked lips; dry oral mucous
occurs in children, ultrasound is often the membranes)
preferred type of imaging. In youngsters with • Watch for signs of metabolic alkalosis.
an intussusception, an ultrasound will typically • Report discrepancies in intake and output,
show a "bull's-eye," representing the intestine worsening of pain or abdominal distention
coiled within the intestine.
and increased nasogastric output.
• Air or barium enema. An air or barium enema
allows for enhanced imaging of the colon. This
• Watch for signs and symptoms of secondary ventilation and ease respiratory distress from
infection, such as fever and chills. abdominal distention.
• Administer analgesics, broad-spectrum • Monitor urine output carefully to assess renal
antibiotics, and other medications as ordered. function, circulating blood volume, and
• Keep the patient in semi-Fowler's or Fowler's possible urine retention due to bladder
position as much as possible. These compression by the distended intestine.
positions help to promote pulmonary • If the patient’s condition does not improve,
prepare pt for surgery.

Tertiary Prevention

• Insert an NG tube to decompress the bowel as

ordered.
• After surgery, provide all necessary
postoperative care. Care for the surgical site,
maintain fluid and electrolyte balance, relieve
Volvulus pain and discomfort, maintain respiratory
status, and monitor intake and output.
• Explain the rationale for NG suction, NPO
status, and I.V. fluids initially.
• Advise patient to progress diet slowly as
tolerated once home.
• Advise plenty of rest and slow progression of
activity as directed by surgeon or other health
care provider.
• Teach wound care if indicated.
• Encourage patient to follow-up as directed and
to call surgeon or health care provider if
increasing abdominal pain, vomiting, or fever
occur prior to follow-up.

Nursing Diagnosis of Intestinal Obstruction

1. Deficient Fluid Volume related to nausea,
Intestinal Obstruction vomiting, fever or diaphoresis.

An intestinal obstruction occurs when Goal:

the large or small intestines are blocked. • Fluid requirements are met
Blockage in the intestine prevents the passing
of fluids, gas, and food through your intestine Expected outcomes are:
in the normal way. The food, fluids, gas build • Normal vital signs
up behind the blockage site. With no
• Balanced input and output
treatment, the blocked parts of intestine may
die, causing serious problems. But, with early
medical care, intestinal obstruction can often 2. Acute Pain related to distention, rigidity.
be treated successfully.
Goal:
• The pain is resolved or controlled

Expected outcomes are:

• Patients revealed a decrease discomfort
 • States pain level can be tolerated, 4. Anxiety related to crisis situations and changes in
• Indicate relaxed. health status.

3. Ineffective Breathing Pattern related to Goal:

abdominal distension and or rigidity. • Anxiety is resolved

Goal: Expected outcomes are:

• The pattern of breathing becomes effective. • Patients expressed an understanding of
Expected outcomes are: current disease
• Patients showed the ability to do breathing • Demonstrating positive kooping skills in
exercises dealing with anxiety.
• Breathing deeply and slowly.
 INTESTINAL OBSTRUCTION QUIZ
5 ITEMS

1. Which of the following best describes the initial stages of strangulating obstruction of the small bowel?

A. Arterial occlusion
B. Blockage without vascular compromise
C. Blockage with vascular compromise
D. Ischemia of the bowel wall

Rationale: C, Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly
25% of patients with small-bowel obstruction. Venous obstruction occurs first, followed by arterial
occlusion (choice A), resulting in rapid ischemia of the bowel wall (choice D). Strangulating obstruction
can progress to infarction and gangrene in as little as 6 hours. B: In simple mechanical obstruction,
blockage occurs without vascular compromise.

2. Which of the following statements about the treatment of small-bowel obstruction is NOT true?

A. Most partial obstructions resolve with nonoperative treatment.

B. Most complete obstructions require surgery.
C. Diarrhea requires surgery.
D. Supportive care is similar for small- and large-bowel obstruction.

Rationale: C, Diarrhea. Patients with partial obstruction may develop diarrhea, and 85% of partial small-
bowel obstructions resolve with nonoperative treatment (choice A). B: About 85% of complete small-
bowel obstructions require surgery. D: Supportive care is similar for small- and large-bowel obstructions:
nasogastric suction, IV fluids (0.9% saline or lactated Ringer’s solution for intravascular volume repletion),
and a urinary catheter to monitor fluid output.

3. The commonest cause of bowel obstruction in adult is?

A. Hernia
B. Neoplasia
C. Adhesions
D. Miscellaneous

Rationale: A, In general, a hernia starts with pressure on an organ or your intestines. A hernia forms
when this pressure happens in the same area as a weakened muscle or tissue. Some people are born
with weak muscles or tissue that isn't fully developed. However, most people get hernias as their bodies
age and their muscles weaken.

4. The nurse is caring for a client with a bowel obstruction. The client has a nasogastric tube in place
set to low intermittent suctioning (LIS). The nurse notes an output of 750 mL during the first half of
the shift. The nurse reviews the client’s lab values and notes a pH of 7.48, CO2 of 35 mEq/L, and
HCO3 of 28 mEq/L. Which of the following conditions does the nurse suspect?

A. Respiratory alkalosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis

Rationale: C, This client's lab values indicate metabolic alkalosis. The client's pH is high, indicating
alkalosis. The CO2 is normal, and the bicarbonate is high, which indicates a metabolic source. The nurse
can conclude that the loss of acid is due to the high output of the nasogastric tube. Regarding B, The
client is losing acidic stomach contents, and the pH of the blood is alkaline, so it is not metabolic acidosis.
Regarding C and D, there is no indication of a respiratory issue.
 5. Based on the clinical presentation and the radiologic and pathologic data provided, what is the most
likely etiology of her small bowel obstruction?

A. Strangulated hernia.
B. Intramural hematoma.
C. Volvulus.
D. Adhesions.
E. Mesenteric artery embolism.

Rationale: B, intramural hematoma. Small intestinal obstruction caused by intramural hematoma is

uncommon, but well-recognized, entity. In adults, approximately two-thirds of these cases are
preceded by abdominal trauma. The remaining one third is caused by a variety of problems, including
coagulation abnormalities, pancreatic disease, alcoholism, a complication from jejunal biopsy, and
Henoch-Schönlein purpura.

REFERENCE:

Intestinal obstruction - Symptoms and causes. (2021, January 20). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/syc-

20351460#:%7E:text=The%20most%20common%20causes%20of,Colon%20cancer.

Ansari, P. (2022, February 22). Intestinal Obstruction. MSD Manual Professional Edition.

https://www.msdmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-

gastroenterology/intestinal-obstruction

Upadhyay, P. (2021, June 3). Intestinal Obstruction - Factors, Types and Treatment. Apollo Hospitals Blog.

https://healthlibrary.askapollo.com/intestinal-obstruction-factors-types-and-treatment/

Dan, R. (2012, April 12). Intestinal Obstruction. Reynel Dan. https://www.slideshare.net/reynel89/intestinal-

obstruction-6336289