Nursing Diagnosis for Small Bowel Obstruction (SBO): Comprehensive Guide for Nurses

Small bowel obstruction (SBO) is a critical condition referring to a complete or partial blockage in the small intestine. This blockage prevents the normal passage of intestinal contents and can arise from various causes, including scar tissue from previous surgeries, hernias, cancer, and inflammatory bowel diseases such as Crohn’s disease.

When an SBO occurs, the digestive contents, including fluids and gas, accumulate above the point of obstruction. This buildup can lead to significant discomfort, dehydration, electrolyte imbalances, and, in severe cases, bowel ischemia, perforation, and sepsis. Prompt identification and intervention are crucial, as timely surgical intervention (within 24-36 hours) significantly reduces mortality, especially in complete obstructions. Partial obstructions may sometimes resolve with conservative management.

This article provides an in-depth guide for nurses on the nursing process for patients with SBO. It covers essential aspects from assessment to intervention, focusing on nursing diagnoses and care plans to optimize patient outcomes in the inpatient setting. Nurses play a vital role in monitoring, managing, and educating patients with SBO, administering IV fluids, managing nasogastric suctioning, providing pain relief, and preventing complications.

Nursing Process

The nursing process is fundamental in the care of patients with small bowel obstruction. It provides a systematic approach to patient care, ensuring comprehensive and individualized management. Nurses caring for patients with SBO utilize the nursing process to assess patient needs, develop appropriate nursing diagnoses, implement targeted interventions, and evaluate the effectiveness of care. This process involves assessment, diagnosis, planning, implementation, and evaluation, all crucial for achieving positive patient outcomes.

Nursing Assessment

The initial step in providing optimal nursing care is a thorough nursing assessment. This involves gathering comprehensive data, including physical, psychosocial, emotional, and diagnostic information. For patients with suspected SBO, the assessment focuses on identifying key signs and symptoms, risk factors, and relevant medical history to guide subsequent nursing diagnoses and interventions.

Review of Health History

1. Identify General Symptoms: Begin by exploring the patient’s presenting symptoms. Common indicators of SBO include:

• Abdominal pain and cramps: Often the primary symptom, characterized by its intermittent, colicky nature.
• Abdominal distension: Visible swelling of the abdomen due to gas and fluid accumulation.
• Bloating: Subjective feeling of fullness and pressure in the abdomen.
• Nausea: Feeling of sickness in the stomach, often preceding vomiting.
• Vomiting: Expulsion of stomach contents, which may initially be gastric contents and later bilious or fecal in nature.
• Constipation: Infrequent or difficult bowel movements, which can progress to obstipation (complete lack of stool and gas passage).
• Lack of appetite: Reduced desire to eat due to discomfort and nausea.

2. Detailed Abdominal Pain Assessment: Further investigate the nature of the abdominal pain. In SBO, pain is typically described as intermittent, cramping, or colicky, often occurring in waves. Patients may report temporary relief after vomiting, as this can decompress the distended proximal bowel.

3. Bowel Habit Changes: Carefully assess for alterations in bowel patterns. Patients may experience constipation, obstipation (inability to pass stool or flatus), or paradoxically, loose stools (due to irritation and increased secretions proximal to the obstruction). The presence or absence of flatus should also be noted.

4. Risk Factor Identification: Determine potential predisposing factors for SBO. Postsurgical adhesions are the most frequent cause, but other significant risk factors include:

• Incarcerated hernias: Hernias where bowel becomes trapped and obstructed.
• Malignancy: Tumors within the bowel or external compression causing blockage.
• Inflammatory bowel diseases (IBD): Conditions like Crohn’s disease, which can cause strictures and obstructions.
• Stool impaction: Hardened stool mass obstructing the bowel, more common in elderly or immobile patients.
• Foreign bodies: Ingested objects causing blockage, more common in children or individuals with pica.
• Volvulus: Twisting of the intestine, compromising blood supply and causing obstruction.

5. Pediatric Risk Factors: When assessing pediatric patients, consider causes more prevalent in this population:

• Intussusception: Telescoping of one part of the intestine into another.
• Pyloric stenosis: Narrowing of the pyloric sphincter between the stomach and small intestine (typically causes gastric outlet obstruction, but can be related).
• Congenital atresia: Birth defect where a portion of the intestine is absent or abnormally narrowed.

6. Comprehensive Medical History: Obtain a thorough past medical history, paying attention to conditions that increase SBO risk:

• Hernias: History of any type of hernia (inguinal, umbilical, incisional, etc.).
• Inflammatory bowel disease: Diagnosed Crohn’s disease or ulcerative colitis.
• Cancer: History of abdominal or pelvic malignancies.
• Previous abdominal surgery: Any prior surgical procedures in the abdomen, as adhesions are a common sequela.
• Congenital conditions: Known congenital anomalies of the gastrointestinal tract.

Physical Assessment

1. Abdominal Examination: Perform a detailed abdominal assessment, including:

• Auscultation of bowel sounds: Bowel sounds may be altered in SBO. Early obstruction may present with increased, high-pitched bowel sounds (“tinkling” sounds) as the bowel attempts to overcome the blockage. Later in obstruction, or in cases of paralytic ileus secondary to SBO, bowel sounds may be hypoactive or absent.
• Palpation: Assess for tenderness, distension, and masses. Tenderness may be generalized or localized. Distension is a common finding. Palpable masses may indicate tumors or incarcerated hernias.
• Percussion: Tympany (drum-like sound) may be present due to increased gas in the distended bowel.
• Assessment for peritonitis signs: Evaluate for rebound tenderness, guarding (involuntary muscle contraction with palpation), and rigidity (board-like abdomen), which are signs of peritonitis – a serious complication indicating bowel perforation or ischemia.
• Visual inspection: Look for surgical scars, hernias (bulges), or visible masses.

2. Rectal Examination: A rectal exam is an important part of the assessment:

• Assess for stool: Note the presence and characteristics of stool (consistency, color, presence of blood). Absence of stool in the rectal vault may support obstruction.
• Check for occult or gross blood: Blood in the stool can indicate bowel ischemia, inflammation, or malignancy.
• Palpate for masses or hernias: Rectal examination can sometimes detect masses or hernias in the lower pelvis that may be contributing to the obstruction.
• Identify fecal impaction: Rule out fecal impaction as a cause of obstruction, especially in elderly or debilitated patients.

Diagnostic Procedures

1. Blood Samples for Testing: Laboratory tests provide valuable information about the patient’s overall condition and the impact of SBO.

• Complete metabolic profile (CMP): Electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia) and dehydration are common in SBO due to vomiting and fluid sequestration in the bowel. Initially, CMP may be normal or show mild abnormalities, but derangements can become significant as obstruction progresses.
• Blood urea nitrogen (BUN) and creatinine: Elevated BUN/creatinine levels indicate dehydration and potential prerenal azotemia due to fluid volume deficit.
• Complete blood cell count (CBC): White blood cell (WBC) count may be elevated, particularly in cases of strangulated obstruction, bowel ischemia, or perforation with secondary infection. Hematocrit may be increased due to hemoconcentration from dehydration.
• Lactic acid: Elevated lactic acid levels are a critical indicator of bowel ischemia, strangulation, or sepsis, suggesting compromised blood flow to the intestinal tissue.

2. Imaging Scans: Imaging is essential for confirming the diagnosis of SBO, identifying the location and cause of obstruction, and ruling out complications.

• CT enterography or CT enteroclysis: Considered the most accurate imaging modalities for SBO. They provide detailed visualization of the entire bowel wall thickness and lumen, allowing for precise localization of the obstruction and often identifying the underlying cause (e.g., adhesions, tumors, inflammatory changes). CT enterography is generally preferred over conventional CT for SBO diagnosis due to its enhanced detail of the small bowel.

Alt text: Abdominal CT scan demonstrating dilated loops of small bowel, a hallmark sign of small bowel obstruction, indicating a blockage preventing normal intestinal passage.

• CT scan of the abdomen and pelvis: The imaging test of choice, especially when sepsis or complications like perforation are suspected. CT scans can reveal not only the obstruction but also complications such as abscesses, inflammatory processes, ischemia (evidenced by bowel wall thickening, pneumatosis intestinalis, or absent bowel wall enhancement), and free air (indicating perforation).
• Magnetic resonance imaging (MRI): While less commonly used than CT for initial SBO diagnosis, MRI can be helpful in specific situations, especially in pregnant patients or when radiation exposure is a concern. However, it is generally considered slightly less effective than CT in precisely pinpointing the location and cause of obstruction in the acute setting.
• Plain abdominal X-rays: Often used as an initial, readily available test. X-rays can demonstrate dilated loops of small bowel and air-fluid levels (step-ladder pattern), suggestive of obstruction. They can also detect free intra-abdominal air if perforation has occurred. However, plain X-rays have poor sensitivity and specificity for SBO and cannot rule out obstruction. A negative X-ray does not exclude SBO.
• Ultrasound: Less expensive and non-invasive. Ultrasound can be useful in excluding SBO, particularly in experienced hands, by visualizing dilated bowel loops and assessing peristalsis. However, it is operator-dependent and bowel gas can limit visualization. Ultrasound is not a replacement for CT scanning when SBO is suspected, but can be a useful adjunct, especially in pediatric patients or for initial screening.

Nursing Interventions

Effective nursing interventions are crucial for managing patients with SBO, focusing on addressing the underlying etiology, alleviating symptoms, preventing complications, and supporting patient recovery.

Treat According to the Etiology

1. Immediate Surgical Consultation and Preparation: Most cases of complete small bowel obstruction require prompt surgical intervention and should be considered a surgical emergency. Delayed surgical management in complete obstruction significantly increases the risk of complications and mortality. Partial obstructions may be initially managed conservatively, but close monitoring and surgical consultation are still necessary.

2. Fluid Resuscitation and Electrolyte Correction: Aggressive intravenous fluid resuscitation is a cornerstone of SBO management. Patients are often significantly dehydrated due to vomiting, third-spacing of fluids into the bowel lumen and wall, and reduced oral intake. Isotonic crystalloids, such as normal saline or lactated Ringer’s solution, are administered to restore intravascular volume, correct electrolyte imbalances (especially potassium, sodium, and chloride), and improve renal perfusion. The type and rate of fluid administration are guided by the patient’s hemodynamic status, electrolyte levels, and urine output.

3. Output Monitoring: Accurate monitoring of fluid balance is essential. Insertion of a Foley catheter to closely monitor urine output is crucial for assessing the effectiveness of fluid resuscitation and renal function. In critically ill patients or those with hemodynamic instability, a central venous catheter or Swan-Ganz catheter may be required to monitor central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP) to guide fluid management and assess cardiac function.

4. Bowel Decompression with Nasogastric Tube (NGT): Nasogastric tube insertion is a standard intervention for SBO. NGT decompression serves several purposes:

• Gastric and intestinal decompression: Removes accumulated fluids and gas from the stomach and proximal small bowel, reducing abdominal distension, pressure, and discomfort.
• Prevention of vomiting and aspiration: By decompressing the stomach, NGT reduces the risk of vomiting and subsequent aspiration of gastric contents into the lungs, a potentially life-threatening complication.
• Bowel rest: NGT helps to rest the bowel by diverting intestinal contents and reducing intraluminal pressure.
• Assessment of output: NGT output (drainage) should be monitored and documented, providing information about the ongoing fluid losses from the upper gastrointestinal tract.

NGT may be sufficient as primary treatment for partial SBOs, allowing the obstruction to resolve spontaneously with bowel rest and decompression. For complete obstructions, NGT is a temporizing measure prior to surgery.

5. Surgical Preparation and Management: Surgery is typically indicated for complete bowel obstruction, strangulation, or when conservative management of partial obstruction fails to resolve the obstruction within a reasonable timeframe (usually within 24-72 hours). Surgical options include:

• Laparoscopic surgery: Minimally invasive approach, often feasible for adhesive SBO or when the cause is clear and localized. Laparoscopy may involve lysis of adhesions (adhesiolysis) or resection of the affected bowel segment.
• Open laparotomy: Traditional open surgical approach, necessary for complex cases, strangulation, perforation, or when laparoscopic approach is not feasible. Open surgery allows for thorough exploration of the abdomen, resection of necrotic or diseased bowel, and repair of any complications. Bowel resection with anastomosis (reconnection of bowel ends) or creation of a stoma (ostomy) may be required depending on the extent and location of the obstruction and bowel viability.

Manage Pain and Nausea

1. Pain Control: Pain management is a priority in SBO. Abdominal pain can be severe and debilitating.

• Opioid analgesics: Morphine sulfate is frequently used for SBO pain due to its efficacy, reliability, and reversibility with naloxone in case of over-sedation. Other opioids like hydromorphone or fentanyl may also be used. Pain should be assessed regularly using a pain scale, and analgesics administered as prescribed, often intravenously initially due to NPO status and potential malabsorption. Patient-controlled analgesia (PCA) may be appropriate for some patients to provide more individualized pain management.

2. Nausea Management: Nausea and vomiting are prominent symptoms of SBO. Effective antiemetic therapy is crucial.

• Antiemetics: Medications such as ondansetron (5-HT3 receptor antagonist) and promethazine (dopamine antagonist, antihistamine) are commonly used to control nausea and vomiting. These can be administered intravenously or rectally if oral route is not feasible. Combination therapy with different classes of antiemetics may be necessary for refractory nausea.

3. Preoperative Antibiotics: Prophylactic antibiotics are often administered, particularly when surgery is anticipated, or in cases of suspected strangulation or perforation.

• Broad-spectrum antibiotics: Antibiotics are aimed at covering gram-negative bacteria and anaerobic microorganisms, which are commonly involved in intra-abdominal infections. Agents like cefoxitin, cefotetan, or combination regimens (e.g., ceftriaxone and metronidazole) may be used. Antibiotics are typically given intravenously preoperatively and continued postoperatively depending on the surgical findings and risk of infection.

4. Ambulation and Repositioning: Encouraging early ambulation and frequent repositioning, especially postoperatively, is important.

• Promote bowel motility: Ambulation helps stimulate peristalsis and bowel function recovery after surgery.
• Reduce abdominal pressure: Repositioning and upright posture (when tolerated) can help relieve abdominal pressure and improve respiratory function.
• Prevent respiratory complications: Early mobilization reduces the risk of postoperative pulmonary complications such as pneumonia and atelectasis.

Prevent Complications

1. Monitor for and Prevent Complications: SBO can lead to serious complications if not promptly and effectively managed. Nurses must be vigilant in monitoring for signs of these complications:

• Bowel perforation: A life-threatening complication where the bowel wall ruptures, leading to peritonitis and sepsis.

  • Signs and symptoms: Sudden worsening abdominal pain and tenderness, abdominal rigidity, rebound tenderness, fever, tachycardia, hypotension, increased WBC count, and changes in mental status.

• Bowel ischemia and strangulation: Compromise of blood supply to the bowel wall, leading to tissue necrosis and potentially perforation. Strangulation is a surgical emergency.

  • Signs and symptoms: Severe, constant abdominal pain (in contrast to the intermittent pain of simple obstruction), bloating, abdominal distension, fever, tachycardia, blood in the stool (hematochezia or melena), nausea, vomiting, elevated lactic acid, and features of sepsis.

• Peritonitis: Inflammation of the peritoneum (lining of the abdominal cavity), typically caused by bowel perforation or leakage of intestinal contents.

  • Signs and symptoms: Severe abdominal pain, guarding, rigidity, rebound tenderness, fever, tachycardia, decreased or absent bowel sounds, nausea, vomiting, and signs of systemic infection.

2. Patient and Family Education on Recurrence: Patients with SBO, particularly those with adhesive SBO, have a significant risk of recurrence. Comprehensive patient and family education is essential upon discharge:

• Signs and symptoms of SBO recurrence: Instruct patients and families to recognize and promptly report symptoms such as abdominal pain, distension, nausea, vomiting, and constipation.
• Importance of early medical attention: Emphasize the need to seek immediate medical attention if SBO symptoms recur, as early diagnosis and treatment are crucial to prevent complications and improve outcomes. Explain that mortality increases with delayed surgical intervention in recurrent SBO.
• Lifestyle modifications: Discuss potential lifestyle modifications that may help reduce recurrence risk, although evidence for this is limited. These may include maintaining adequate hydration, regular bowel habits, and avoiding risk factors where possible.

Nursing Care Plans

Once nursing diagnoses are identified, nursing care plans are developed to guide and prioritize nursing care. These plans outline specific assessments, interventions, and expected outcomes, providing a structured approach to achieve both short-term and long-term goals for patients with SBO. Examples of nursing care plans for common nursing diagnoses in SBO are provided below.

Acute Pain

Patients with small bowel obstruction frequently experience acute pain due to the physical obstruction, bowel distension, inflammation, and surgical interventions.

Nursing Diagnosis: Acute Pain

Related to:

• Physical obstruction and bowel distension
• Inflammation of bowel tissue and surrounding structures
• Surgical incision and manipulation (if surgery performed)
• Increased intestinal pressure and spasms

As evidenced by:

• Patient reports of abdominal pain, cramping, or discomfort (using pain scale)
• Restlessness, guarding behaviors, reluctance to move
• Facial grimacing, moaning, or other nonverbal pain cues
• Changes in vital signs (increased heart rate, blood pressure, respiratory rate)

Expected Outcomes:

• Patient will report a decrease in pain intensity to a tolerable level (e.g., pain score ≤ 3/10) within a specified timeframe (e.g., within 1 hour of intervention).
• Patient will demonstrate relaxed body posture, absence of grimacing, and ability to rest comfortably.
• Patient’s vital signs will return to baseline or within acceptable limits for the patient.

Assessment:

1. Pain Assessment: Regularly assess and document the patient’s pain characteristics:

   • Pain intensity: Use a standardized pain scale (e.g., numerical rating scale, visual analog scale) to quantify pain.
   • Pain quality: Ask the patient to describe the pain (e.g., cramping, sharp, dull, colicky).
   • Pain location: Identify the specific location of the pain (generalized, localized, quadrant).
   • Pain onset, duration, and aggravating/relieving factors: Explore what triggers or worsens the pain and what provides relief.
   • Associated symptoms: Note any associated symptoms like nausea, vomiting, distension.

2. Nonverbal Pain Cues: Observe for nonverbal indicators of pain, especially in patients who may have difficulty verbalizing pain (e.g., altered mental status, intubated patients):

   • Facial expressions: Grimacing, furrowed brow, clenched teeth.
   • Body movements: Restlessness, guarding, fetal position, limited mobility.
   • Physiological responses: Sweating, pallor, changes in vital signs (although vital signs are not always reliable indicators of pain).

3. Vital Signs: Monitor vital signs (heart rate, blood pressure, respiratory rate) in conjunction with pain assessment. Elevated vital signs may indicate pain, but consider other potential causes as well. Note that vital signs may not always correlate directly with pain intensity.

Interventions:

1. Administer Pain Medications: Provide analgesics as prescribed and ordered by the physician.

   • Route of administration: Initially, IV analgesia is usually preferred due to NPO status and potential for impaired oral absorption.
   • Regular administration: Administer pain medication regularly, rather than PRN, to maintain consistent pain relief, especially in the acute phase.
   • Opioid analgesics: Administer opioid analgesics (e.g., morphine, hydromorphone, fentanyl) as ordered, monitoring for effectiveness and side effects (respiratory depression, sedation, constipation, nausea).
   • Non-opioid analgesics: Consider adjunct non-opioid analgesics (e.g., acetaminophen, NSAIDs if not contraindicated) for multimodal pain management, if appropriate.

2. Comfort Measures: Implement non-pharmacological pain relief measures:

   • Positioning: Assist the patient to find a comfortable position. Semi-Fowler’s or high-Fowler’s position may reduce abdominal pressure.
   • Massage: Gentle abdominal massage (if not contraindicated by surgical site or peritonitis) or back massage may provide comfort.
   • Relaxation techniques: Encourage deep breathing exercises, guided imagery, meditation, or music therapy to promote relaxation and reduce pain perception.
   • Distraction: Provide activities to distract the patient from pain, such as watching television, reading, or engaging in conversation.

3. Cluster Nursing Care: Coordinate nursing activities to minimize disruptions and maximize rest periods, especially after pain medication administration. Perform necessary care (repositioning, dressing changes, hygiene) when pain medication is at its peak effect to enhance patient comfort.

4. Nasogastric Tube Management: Ensure proper functioning of the nasogastric tube. Effective decompression with NGT can significantly reduce abdominal distension and pressure, thereby alleviating pain related to SBO. Monitor NGT patency, drainage, and patient comfort related to the NGT.

Constipation

Constipation is a common issue in patients with SBO, stemming from the obstruction itself, decreased oral intake, medications, and reduced mobility.

Nursing Diagnosis: Constipation

Related to:

• Mechanical obstruction of the bowel lumen
• Decreased bowel motility secondary to obstruction and inflammation
• Dehydration and decreased fluid intake
• NPO status and reduced dietary fiber intake
• Opioid analgesics and other medications

As evidenced by:

• Infrequent bowel movements or absence of bowel movements
• Abdominal distension and bloating
• Abdominal pain or cramping
• Straining with defecation or feeling of incomplete evacuation
• Hard, dry stools (if any stool is passed)
• Patient verbalization of constipation or feeling “backed up”

Expected Outcomes:

• Patient will report passage of stool without straining or discomfort within 2-3 days.
• Patient will verbalize understanding of strategies to prevent and manage constipation.
• Patient will implement at least two strategies to promote bowel regularity (e.g., increased fluid intake, ambulation when appropriate).

Assessment:

1. Bowel Pattern History: Assess the patient’s usual bowel habits:

   • Frequency: How often does the patient typically have bowel movements?
   • Consistency: What is the usual consistency of their stool (Bristol Stool Chart)?
   • Recent changes: Inquire about any recent changes in bowel habits, especially related to the onset of SBO symptoms.

2. Diet and Fluid Intake: Evaluate dietary and fluid intake patterns:

   • Fluid intake: Assess daily fluid intake, type of fluids, and any factors limiting fluid intake.
   • Fiber intake: Inquire about usual dietary fiber intake. Note that fiber intake is typically restricted in acute SBO management but becomes relevant for post-acute management and prevention.

3. Defecation Assessment: Assess current bowel function:

   • Last bowel movement: When was the last bowel movement?
   • Characteristics of stool: If stool is passed, note the consistency, amount, color, and presence of any abnormalities (e.g., blood).
   • Pain or straining: Inquire about pain, straining, or discomfort associated with attempted defecation.
   • Abdominal assessment: Correlate constipation findings with abdominal examination findings (distension, bowel sounds).

Interventions:

1. Warm Sitz Bath: If appropriate and ordered, provide a warm sitz bath, particularly if the patient experiences rectal discomfort or hemorrhoids related to straining. Warm water can soothe the perineal area and promote relaxation.

2. Hydration: Encourage adequate fluid intake, once oral intake is permitted.

   • Oral fluids: When NPO order is discontinued, encourage oral fluids (water, clear broths, diluted juices) to promote hydration and soften stool.
   • Intravenous fluids: Continue IV fluid administration as ordered to maintain hydration, especially while NPO or with ongoing fluid losses.
   • Avoid dehydrating fluids: Discourage excessive intake of caffeine and alcohol, which can have diuretic effects and contribute to dehydration.

3. Fiber Intake (when appropriate): Once bowel function recovers and diet is advanced, gradually introduce fiber into the diet.

   • Dietary fiber: Encourage consumption of fiber-rich foods (fruits, vegetables, whole grains) as tolerated and as diet progresses.
   • Fiber supplements: Consider fiber supplements (psyllium, methylcellulose) if dietary fiber intake is insufficient, as prescribed by the physician. Introduce fiber gradually to avoid abdominal discomfort or gas.

4. Physical Activity: Encourage physical activity and ambulation as tolerated and as medically appropriate.

   • Ambulation: Promote walking and movement in the hospital setting and at home, as tolerated, to stimulate bowel motility and reduce constipation.
   • Range of motion exercises: For patients with limited mobility, assist with range of motion exercises to promote circulation and bowel function.

Dysfunctional Gastrointestinal Motility

Dysfunctional gastrointestinal motility is a primary manifestation of SBO, resulting from the mechanical blockage and physiological responses to obstruction.

Nursing Diagnosis: Dysfunctional Gastrointestinal Motility

Related to:

• Mechanical obstruction of the small bowel (partial or complete)
• Inflammatory processes in the bowel
• Effects of medications (e.g., opioids)
• Postoperative ileus (if surgery performed)
• Underlying disease processes (e.g., IBD, cancer)

As evidenced by:

• Abdominal distension and bloating
• Abdominal cramping or pain
• Altered bowel sounds (hyperactive early, hypoactive or absent later)
• Nausea and vomiting
• Constipation or obstipation
• Absence of flatus
• Lack of appetite or early satiety

Expected Outcomes:

• Patient will demonstrate improved gastrointestinal motility as evidenced by return of bowel sounds, passage of flatus, and reduction in abdominal distension.
• Patient will be free from nausea and vomiting related to impaired motility.
• Patient will report relief of abdominal cramping and discomfort.

Assessment:

1. Bowel Sounds Assessment: Auscultate and document bowel sounds frequently:

   • Characteristics: Note the character of bowel sounds (normal, hyperactive, hypoactive, absent, high-pitched). In early obstruction, bowel sounds may be increased and high-pitched. Later, or with ileus, they may become hypoactive or absent.
   • Frequency: Assess the frequency of bowel sounds in each quadrant.

2. Diagnostic Studies Review: Review results of diagnostic imaging and laboratory tests:

   • CT scans, X-rays: Confirm the presence and location of SBO. Note findings related to bowel dilation, air-fluid levels, or complications.
   • Electrolyte levels: Monitor electrolyte imbalances (hypokalemia, hyponatremia) that can affect bowel motility.

3. Signs and Symptoms of Decreased Motility: Monitor for clinical manifestations of impaired gastrointestinal motility:

   • Nausea and vomiting: Assess frequency, amount, and characteristics of vomitus (bilious, fecal).
   • Abdominal distension and bloating: Measure abdominal girth daily and assess for subjective feelings of bloating.
   • Abdominal pain and cramping: Evaluate pain characteristics and intensity.
   • Passage of flatus and stool: Document the passage of flatus and bowel movements. Absence of flatus or stool passage suggests significant motility impairment.
   • Appetite and satiety: Assess appetite and any reports of early satiety or fullness.

Interventions:

1. Nasogastric Tube Insertion and Management: Insert and maintain a nasogastric tube as ordered for bowel decompression:

   • Patency: Ensure NGT patency and proper function. Irrigate as needed per protocol.
   • Drainage monitoring: Monitor and record NGT drainage (amount, color, consistency).
   • Comfort: Provide comfort measures related to NGT insertion and maintenance (oral care, nasal skin care).

2. Prepare for Surgical Intervention: Prepare the patient for surgery if indicated (complete obstruction, strangulation, failure of conservative management).

   • Preoperative teaching: Provide preoperative education about the surgical procedure, NPO status, postoperative expectations, and pain management.
   • NPO status: Maintain strict NPO status as ordered to rest the bowel preoperatively.
   • IV fluids and electrolytes: Continue IV fluid and electrolyte replacement therapy.

3. NPO Status: Maintain NPO status as ordered:

   • Bowel rest: NPO status is essential for bowel rest, reducing intestinal secretions and distension.
   • Oral hygiene: Provide frequent oral hygiene to maintain comfort and mucous membrane integrity during NPO period.

4. Ambulation Post-Surgery: Encourage early ambulation after surgery to promote bowel motility recovery.

   • Early mobilization: Assist with ambulation as soon as medically stable postoperatively.
   • Gradual activity increase: Gradually increase activity level as tolerated.

Imbalanced Nutrition: Less Than Body Requirements

Patients with SBO are at risk for nutritional deficits due to reduced intake, impaired absorption, and increased losses from vomiting and bowel decompression.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to:

• Restricted oral intake (NPO status for bowel rest)
• Altered nutrient absorption due to bowel obstruction and inflammation
• Vomiting and nasogastric suctioning leading to nutrient losses
• Increased metabolic demands due to illness and potential infection

As evidenced by:

• Weight loss or inability to maintain weight
• Loss of appetite or anorexia
• Hyperactive bowel sounds (in early obstruction) or hypoactive sounds (later)
• Abnormal electrolyte panel (hypokalemia, hyponatremia)
• Decreased energy levels or fatigue

Expected Outcomes:

• Patient will maintain stable weight during hospitalization without further weight loss.
• Patient will demonstrate electrolyte values within normal limits.
• Patient will report improved appetite and energy levels as condition improves.

Assessment:

1. Laboratory Values: Monitor relevant laboratory data:

   • Electrolytes: Regularly monitor serum electrolytes (sodium, potassium, chloride, magnesium, calcium). Imbalances are common in SBO and can affect nutritional status and overall health.
   • Albumin and prealbumin: Assess serum albumin and prealbumin levels as indicators of protein status and long-term and short-term nutritional status, respectively.
   • Glucose: Monitor blood glucose levels, especially in patients receiving IV fluids with dextrose.

2. Intake and Output (I&O): Accurately monitor and document all intake and output:

   • Oral intake: Record any oral intake (when permitted).
   • IV fluids: Document IV fluid administration.
   • NGT output: Measure and record NGT drainage.
   • Vomitus: Record emesis volume and frequency.
   • Urine output: Monitor urine output as an indicator of hydration status.

3. Nutritional History: Assess the patient’s nutritional history:

   • Usual diet: Inquire about typical dietary patterns and food preferences before illness.
   • Appetite changes: Assess changes in appetite and food intake since the onset of SBO symptoms.
   • Weight history: Obtain pre-illness weight and current weight, if possible, to assess for weight loss.
   • Food intolerances or allergies: Identify any food allergies or intolerances.

Interventions:

1. Maintain NPO Status: Adhere to NPO orders to rest the bowel and reduce further nutrient and fluid losses, especially in the acute phase.

2. Daily Weight Monitoring: Weigh the patient daily at the same time each day, using the same scale, to monitor for weight changes and assess nutritional status trends.

3. Diet Advancement as Tolerated: When NPO status is discontinued, advance diet gradually as tolerated, starting with clear liquids, then full liquids, and progressing to a low-residue diet before advancing to a regular diet, as ordered and tolerated. Monitor for signs of intolerance with diet advancement (nausea, vomiting, distension, pain).

4. Encourage Patient Involvement: Involve the patient in meal planning and food choices when diet is advanced.

   • Food preferences: Consider patient preferences and cultural dietary needs when offering food choices.
   • Small, frequent meals: Offer small, frequent meals rather than large meals to improve tolerance and nutrient intake.
   • Nutritional supplements: Consider oral nutritional supplements if dietary intake is insufficient to meet nutritional needs, as prescribed by a dietitian or physician.

Ineffective Tissue Perfusion (Gastrointestinal)

Ineffective gastrointestinal tissue perfusion is a serious complication of SBO, potentially leading to bowel ischemia, necrosis, and perforation.

Nursing Diagnosis: Ineffective Tissue Perfusion (Gastrointestinal)

Related to:

• Mechanical obstruction of bowel lumen compromising blood flow
• Bowel distension increasing intramural pressure
• Inflammatory processes and edema in the bowel wall
• Potential for bowel strangulation and ischemia
• Hypovolemia and dehydration reducing systemic perfusion

As evidenced by:

• Abdominal pain, which may become severe and constant
• Abdominal distension and bloating
• Abdominal rigidity or guarding
• Nausea and vomiting, potentially with bilious or fecal emesis
• Altered bowel sounds (absent or diminished)
• Blood in stool (hematochezia or melena)
• Altered vital signs (tachycardia, hypotension, fever)
• Abnormal laboratory values (elevated lactic acid, increased WBC count)

Expected Outcomes:

• Patient will maintain adequate gastrointestinal tissue perfusion as evidenced by stable vital signs, absence of signs of bowel ischemia (severe pain, bloody stools), and resolution of abdominal rigidity.
• Patient will exhibit laboratory values (CBC, lactic acid) within acceptable limits.
• Patient will not develop complications related to ineffective tissue perfusion (bowel ischemia, perforation, sepsis).

Assessment:

1. Signs and Symptoms of Decreased Perfusion: Assess for clinical indicators of impaired gastrointestinal tissue perfusion:

   • Abdominal pain: Evaluate pain characteristics – sudden onset, severe, constant pain may suggest ischemia.
   • Abdominal examination findings: Assess for abdominal rigidity, guarding, rebound tenderness, which are signs of peritonitis and potential bowel ischemia or perforation.
   • Nausea and vomiting: Note the nature of vomitus (bilious, fecal).
   • Bowel sounds: Monitor bowel sounds for absence or significant decrease.
   • Rectal bleeding: Assess for blood in stool (hematochezia – bright red blood, melena – dark tarry stools), indicating potential mucosal damage or ischemia.

2. Laboratory Values Monitoring: Monitor laboratory parameters that reflect tissue perfusion and potential complications:

   • Lactic acid: Serial lactic acid levels are crucial to monitor for bowel ischemia. Elevated and rising lactic acid is a strong indicator of compromised tissue perfusion.
   • CBC: Monitor WBC count for elevation, suggesting infection or inflammation. Hemoglobin and hematocrit for signs of bleeding or hemoconcentration.
   • Electrolytes: Monitor and correct electrolyte imbalances which can worsen perfusion.

3. Abdominal Assessment for Complications: Perform frequent abdominal assessments focusing on signs of peritonitis, ischemia, and perforation:

   • Abdominal rigidity: Assess for board-like rigidity, a key sign of peritonitis.
   • Rebound tenderness: Evaluate for rebound tenderness, another sign of peritoneal irritation.
   • Abdominal distension: Monitor for worsening distension.
   • Bowel sounds: Assess for absent bowel sounds.

Interventions:

1. Fluid and Electrolyte Replacement: Administer intravenous fluids and electrolyte replacement as ordered to restore intravascular volume and correct electrolyte imbalances, improving systemic and gastrointestinal perfusion.

2. Oxygen Therapy: Administer supplemental oxygen as needed to maintain adequate oxygen saturation and ensure oxygen delivery to intestinal tissues, especially if hypoxemia is present or suspected.

3. Review Diagnostic Studies: Review results of diagnostic imaging (CT scans, X-rays) to assess the location and severity of obstruction and identify any evidence of bowel ischemia, perforation, or other complications.

4. Prepare for and Assist with Surgical Interventions: Prepare the patient for urgent surgical intervention if bowel ischemia, strangulation, or perforation is suspected or confirmed. Surgical intervention is often necessary to relieve the obstruction, resect nonviable bowel, and address complications to restore tissue perfusion and prevent further deterioration.

References

[References] from the original article are kept as they are assumed to be relevant and valid. (Note: In a real-world scenario, verify and update references as needed.)