5.Q: A nurse is caring for a client who is 48 hr postoperative following a small bowelresection. The client reports gas pains in the periumbilical area. The nurse should plancare based on which of the following factors contributing to this postoperativecomplication?6.Q: A nurse is reviewing the laboratory values for a client who has a positive Chvostek's Show
sign. Which of the following laboratory findings should the nurse expect? 7.Q: A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube forgastric decompression. Which of the following actions should the nurse include in theplan of care? (Select all that apply)8.Q: A nurse on a surgical unit is receiving a client who had abdominal surgery from the post anesthesia care unit. Which of the following assessments should the nurse makefirst? 9.Q: A client is being discharged home with oxygen therapy via a nasal cannula. Which ofthe following instructions should the nurse provide to the client and family?10. Q: A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the followingfindings by the nurse is another clinical manifestation of fluid volume excess? 11. Q: A nurse is providing teaching about food choices to a client who has a prescription fora clear liquid diet. Which of the following selections by the client indicates anunderstanding of the teaching? Presentations in this section include:
OverviewBowel obstruction occurs when the normal flow of intraluminal contents is interrupted. Obstruction can be mechanical or functional and may occur in the small or large bowel. The small bowel is involved in about 80 percent of cases of mechanical intestinal obstruction. Ischemia, which complicates up to 42 percent of bowel obstructions, significantly increases mortality associated with bowel obstruction. Mechanical bowel obstruction may be classified as partial (incomplete) or complete (see Table 1), simple or complicated (see Table 2). A complete bowel obstruction may progress to complicated bowel obstruction when intestinal ischaemia, necrosis, and/or perforation develop. Table 1: Partial vs Complete bowel obstruction
Table 2: Simple vs Complicated bowel obstruction
Small bowel obstructionAcute, mechanical small bowel obstruction is a common surgical emergency. Without resolution it is fatal, progressing to intestinal necrosis, perforation, sepsis, and multisystem organ failure. Step 1: Pathway EntrySymptoms to consider: Abdominal pain, bloating, nausea, vomiting, inability to pass flatus or stool Signs to consider: Abdominal distension, abdominal tenderness, peritonitis, hyperactive and high pitched bowel sounds, presence of hernias Common risk factors in adults:
Rare causes include radiation enteritis, foreign body ingestion, intra-abdominal abscess (e.g. perforated appendicitis/diverticulitis), gallstone ileus, intestinal bezoar, intussusception and volvulus. Step 2: Is the Patient Stable?
Step 3: Detailed Initial AssessmentStep 4: ImagingPlain films: Initial imaging should include upright CXR and erect/supine AXR films (or lateral decubitus film if the patient cannot sit upright) - these have a sensitivity of 70-83% and specificity of 67-83% for small bowel obstruction. Plain film findings that suggest small bowel obstruction include:
However, obstruction (which may be high-grade mechanical obstruction) may also present with the following features:
CT abdomen: provides more information than plain films. May be useful to identify the specific site (i.e. transition point) and severity of the obstruction (partial vs complete). It will also give information about the aetiology, by identifying hernias, masses or inflammatory changes, and potential complications, such as ischaemia or perforation. Step 5: ManagementEmergency surgery is indicated in:
Patients considered for emergency surgery should be receive preoperative antibiotic prophylaxis and made NBM in preparation for surgery in addition to supportive case detailed below. All patients should receive supportive care:
The need for gastrointestinal decompression varies from patient to patient and remains a matter of clinical judgment. It is suggested with significant distension, nausea, and/or vomiting. Such patients likely have complete or high-grade obstruction; decompression of the distended stomach improves patient comfort and also minimizes the passage of swallowed air, which can worsen distension. For patients with recurrent SBO who have undergone multiple prior operations, and in whom another operation is felt to be particularly risky, nasogastric decompression is a component of conservative management to avoid further surgery. Patients who do not require emergency surgery are initially treated conservatively for 48-72 hours. Failure to respond to conservative treatment would lead to consideration for surgery. Gastrografin may be diagnostic and therapeutic in SBO due to surgical adhesions. The appearance of water-soluble contrast in the colon on an abdominal X ray within 24 hours of its administration predicts resolution of an adhesive small bowel obstruction. While gastrografin does not reduce the need for surgery it does reduce hospital stay in those patients who do not require surgery. Large bowel obstructionAcute colonic distension can occur due to the following causes:
This pathway deals with large bowel obstruction due to mechanical causes. Step 1: Pathway EntrySymptoms:
Signs:
Risk factors:
Step 2: Is the Patient Stable?
Step 3: Detailed Initial AssessmentIn the stable patient a thorough assessment is the next step including a detailed history, a detailed examination, blood tests including FBC, EUC, LFTs, lipase, BSL, an ECG and a CXR. Beta-HCG in women of childbearing age, VBG for lactate. If an alternative diagnosis is made at this time then the steps further down the pathway can be curtailed. Step 4: ImagingSigns on plain films that may demonstrate large bowel obstruction include:
In advanced cases one may see the stigmata of an ischaemic colon, namely:
CT abdomen: more sensitive and specific for colorectal obstruction than plain films (>90% each). Will also distinguish between true obstruction and pseudo-obstruction, as well as determine the cause of obstruction and complications. Step 5: ManagementSupportive care
If there is evidence of perforation or impending perforation, emergency surgery is indicated. In the absence of perforation, definitive treatment depends on cause. Treatment in most cases of mechanical large bowel obstruction is surgery, with the exception of:
Toxic megacolonToxic megacolon is a complication of inflammatory bowel disease (IBD) or infectious colitis that is characterized by colonic dilatation and systemic toxicity. The diagnosis of toxic megacolon should be considered in all patients presenting with abdominal distension and acute or chronic diarrhoea. The diagnosis is clinical, based upon the finding of an enlarged dilated colon accompanied by severe systemic toxicity. The initial evaluation should be aimed at establishing the diagnosis and at determining the underlying cause. Clinical assessment is similar to that for large bowel obstruction, additionally stool specimens should be sent for culture and CDT. X-rays are important in the diagnosis. CT scanning may occasionally be of value in determining the aetiology of megacolon. The most widely radiographic criteria for the clinical diagnosis of toxic megacolon are:
The main goal of treatment is to reduce the severity of colitis in order to restore normal colonic motility and decrease the likelihood of perforation. Initial treatment is medical, which is successful in preventing surgery in up to 50 percent of patients. However the surgical team should be involved early in the patient’s care. Pseudo-obstructionParalytic ileus and colonic pseudo-obstruction (Ogilvie's syndrome) cause functional obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Functional bowel obstruction is characterized by signs and symptoms of a mechanical obstruction of the small or large bowel in the absence of an anatomic lesion that obstructs the flow of intestinal contents. Paralytic ileus occurs to some degree after almost all open abdominal operations. Other causes include peritonitis, trauma, intestinal ischemia, and medications (eg, opiates, anticholinergics). It is exacerbated by electrolyte disorders, particularly hypokalemia. Symptoms are similar to that of mechanical obstruction. However, on imaging there is air in the colon and rectum, and on CT abdomen there is no demonstrable mechanical obstruction. Treatment is dependent on the cause. Prolonged post-operative ileus often responds to conservative treatment with bowel rest, correction of electrolyte disorders and reduction of opioid medications, and drug induced ileus responds to cessation of the precipitating drug. Acute colonic pseudo-obstruction, or Ogilvie's syndrome, is a variant of ileus, characterized by massive colonic dilatation (discussed later). Chronic idiopathic pseudo-obstruction may be due to an underlying neuropathic disorder (involving the enteric nervous system or extrinsic nervous system) or a myopathic disorder (involving the smooth muscle). Acute colonic pseudo-obstruction is associated with an underlying disease in 93% of patients including: postoperative status in 23.1%, cardiopulmonary disease in 17.5%, nonoperative trauma in 11.2%, neurologic disease in 8%, malignancy in 5.4%, intra-abdominal pathology in 4.6%, obstetric disorders in 4.4%, and retroperitoneal pathology in 3.5%. Narcotics and electrolyte disorders are frequent contributing factors. Plain and upright abdominal radiographs show a dilated colon, often from the caecum to the splenic flexure, and occasionally to the rectum; haustral markings are normal. A CT scan is needed to confirm the diagnosis and to exclude mechanical obstruction and toxic megacolon. Treatment aims to relieve discomfort and prevent perforation or ischemia. Treatment in the first instance is supportive care with removal of precipitants. Conservative therapy can be continued for 24 to 48 hours provided that there is no pain or extreme (>12 cm) colonic distension. If conservative treatment fails, then the following options may be considered:
Further resources and referencesOnline Resource: BMJ Best Practice Small bowel obstruction and Large bowel obstuction.(Available through CIAP) References:
Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. Rationale: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client.
Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Rationale: At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse.
In which order would the nursing student arrange the scenarios from the highest the lowest level of needs based on Maslow's hierarchy?Needs lower down in the hierarchy must be satisfied before individuals can attend to needs higher up. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self- actualization.
|