Posted inCardiagtech

Nursing Diagnosis for Small Bowel Obstruction: A Comprehensive Guide

No Comments

Small bowel obstruction (SBO) is a significant clinical condition characterized by a blockage in the small intestine, hindering the normal passage of intestinal contents. This obstruction can be either partial or complete and arises from various etiologies, including postoperative adhesions, hernias, malignancies, and inflammatory bowel diseases. The consequence of SBO is the accumulation of waste products proximal to the obstruction, leading to a cascade of physiological disturbances. Prompt identification and intervention, often surgical, are crucial to mitigate morbidity and mortality associated with SBO.

Nurses play a pivotal role in the multidisciplinary care of patients with SBO. Their responsibilities encompass comprehensive assessment, implementation of therapeutic interventions such as intravenous fluid administration and nasogastric decompression, and patient education regarding risk factors, symptom management, and the overall disease process. This article delves into the essential nursing diagnoses related to small bowel obstruction, providing a framework for effective nursing care planning and intervention.

Nursing Assessment for Small Bowel Obstruction

The cornerstone of nursing care for SBO begins with a thorough nursing assessment. This involves a systematic collection of subjective and objective data to understand the patient’s condition comprehensively.

Review of Health History

1. Elicit General Symptoms:

  • Common presenting symptoms of SBO include abdominal pain and cramping, abdominal distension, bloating, nausea, vomiting, constipation, and anorexia.

2. Characterize Abdominal Pain:

  • Pain associated with SBO is typically described as intermittent and colicky in nature. Importantly, patients often report temporary pain relief following episodes of vomiting.

3. Evaluate Bowel Habit Changes:

  • Disruption in normal bowel patterns is a hallmark of SBO. This can manifest as constipation, obstipation (severe constipation), or paradoxically, loose stools. The presence or absence of flatus should also be noted.

4. Identify Risk Factors for SBO:

  • Postoperative adhesions are the most prevalent cause of small bowel obstruction. Other significant risk factors include incarcerated hernias, malignancy (especially colorectal and ovarian cancers), inflammatory bowel diseases like Crohn’s disease, stool impaction, foreign bodies, and volvulus (intestinal twisting).

5. Pediatric-Specific Risk Factors:

  • In pediatric populations, common causes of SBO differ and include intussusception (telescoping of one part of the intestine into another), pyloric stenosis (narrowing of the pylorus), and congenital atresia (absence or closure of a part of the intestine).

6. Obtain Comprehensive Medical History:

  • A detailed medical history is crucial, focusing on pre-existing conditions that predispose to SBO. These include prior diagnoses of hernias, inflammatory bowel disease, cancer, previous abdominal surgeries (which increase adhesion risk), and congenital conditions affecting the gastrointestinal tract.

Physical Assessment

1. Abdominal Examination:

  • Auscultation of bowel sounds is essential. In SBO, bowel sounds may be diminished or paradoxically high-pitched and hyperactive above the obstruction as the bowel attempts to overcome the blockage. Palpation may reveal abdominal tenderness, which can be localized or widespread, along with distension. The presence of rebound tenderness, guarding, or rigidity is a critical finding suggestive of peritonitis, a serious complication. The abdominal exam should also assess for the presence of hernias, surgical scars, or palpable masses.

2. Rectal Examination:

  • A digital rectal examination is a necessary component of the assessment. It can identify the presence of gross or occult blood, which may indicate bowel ischemia or malignancy. Rectal examination can also detect hernias, masses, or fecal impaction as potential causes of the obstruction, particularly in the distal colon, though it can sometimes offer clues about more proximal issues.

Diagnostic Procedures

1. Blood Sample Analysis:

  • Complete Metabolic Profile (CMP): Initial CMP findings may be within normal limits or show mild elevations. Abnormalities are more likely to reflect complications such as dehydration or electrolyte imbalances secondary to vomiting.
  • Blood Urea Nitrogen (BUN) and Creatinine: Elevated BUN/creatinine levels often indicate dehydration due to fluid volume deficit.
  • Complete Blood Count (CBC): An elevated white blood cell (WBC) count can signal strangulated obstruction or infectious complications. Hematocrit may be increased in the context of dehydration.
  • Lactic Acid: Elevated lactic acid levels are a concerning sign, suggesting bowel ischemia or sepsis.

2. Imaging Studies:

  • Imaging is paramount for confirming the diagnosis and determining the location and nature of the obstruction.
  • CT Enterography/CT Enteroclysis: These specialized CT techniques provide detailed visualization of the small bowel wall and are highly accurate in identifying the site and cause of obstruction, surpassing conventional CT scans in diagnostic precision.
  • CT Scan of the Abdomen: A standard abdominal CT scan is the preferred initial imaging modality, especially in patients with suspected sepsis. CT scans can reveal abscesses, inflammatory processes, and bowel ischemia.
  • Magnetic Resonance Imaging (MRI): While MRI can be used, it is generally less effective than CT in pinpointing the precise location of small bowel obstructions.
  • Plain X-rays: Abdominal X-rays are often used as an initial screening tool to detect air-fluid levels within the dilated bowel loops, a classic sign of obstruction, and to identify free intra-abdominal air, which suggests perforation. However, X-rays have limited sensitivity and cannot definitively rule out SBO.
  • Ultrasound: Abdominal ultrasound is a less invasive and less expensive option than CT. It can be useful to exclude SBO, particularly in certain patient populations, but it is not considered a replacement for CT scanning when SBO is strongly suspected or needs detailed characterization.

Alt text: Abdominal X-ray demonstrating dilated bowel loops and air-fluid levels, key radiographic findings suggestive of small bowel obstruction.

Nursing Interventions for Small Bowel Obstruction

Nursing interventions are critical in managing patients with SBO, focusing on addressing the underlying etiology, alleviating symptoms, and preventing complications.

Etiology-Based Treatment

1. Immediate Surgical Consultation:

  • Most cases of complete small bowel obstruction necessitate prompt surgical intervention. Surgical management is often considered an emergency, and delays can significantly increase the risk of adverse outcomes. Partial obstructions may be managed non-operatively initially, with close monitoring, as they may resolve spontaneously within a few days.

2. Fluid Resuscitation:

  • Aggressive intravenous fluid resuscitation is paramount to correct fluid deficits and electrolyte imbalances, which are common due to vomiting, third-spacing of fluids into the bowel, and reduced oral intake. Isotonic crystalloid solutions such as normal saline or lactated Ringer’s solution are typically administered.

3. Output Monitoring:

  • Accurate monitoring of fluid balance is essential. Insertion of a Foley catheter is usually necessary to closely track urine output. In hemodynamically unstable patients or those with significant comorbidities, central venous or Swan-Ganz catheterization may be required for advanced hemodynamic monitoring.

4. Bowel Decompression with Nasogastric Tube:

  • Nasogastric (NG) tube insertion for bowel decompression is a standard intervention. NG suction helps to remove accumulated fluids and air from the stomach and proximal small bowel, relieving abdominal distension and preventing aspiration of gastric contents, particularly in patients with vomiting. For partial obstructions, NG decompression alone may be therapeutic.

5. Surgical Preparation:

  • When surgery is indicated, either for complete obstruction or strangulation, nurses play a crucial role in preoperative preparation. Laparoscopic surgery is often feasible for SBO and is associated with faster recovery in suitable candidates. Depending on the cause and extent of obstruction, surgical procedures may include lysis of adhesions, hernia repair, bowel resection with anastomosis (removal of diseased bowel segments and rejoining healthy ends), or even ostomy creation in complex cases.

Pain and Nausea Management

1. Pain Control:

  • Effective pain management is essential to patient comfort. Opioid analgesics, such as morphine sulfate, are frequently used for SBO-related pain. Morphine is considered reliable, safe when appropriately monitored, and its effects can be reversed with naloxone if needed.

2. Nausea and Vomiting Management:

  • Nausea and vomiting are distressing symptoms, both from the obstruction itself and potentially from NG decompression. Antiemetic medications, such as ondansetron (a serotonin antagonist) and promethazine (a dopamine antagonist/antihistamine), are commonly prescribed to control nausea and vomiting.

3. Preoperative Antibiotics:

  • Prophylactic antibiotics are often administered preoperatively, especially when surgery is anticipated or if there is concern for bowel strangulation or perforation. Antibiotics typically cover Gram-negative bacteria and anaerobic organisms, which are predominant in the gut flora.

4. Ambulation and Repositioning:

  • Encouraging early ambulation and frequent repositioning, particularly postoperatively, is important. Mobilization helps to improve respiratory function, reduce abdominal pressure, stimulate bowel motility, and prevent complications such as pneumonia and deep vein thrombosis.

Prevention of Complications

1. Vigilant Monitoring for Complications:

  • Intestinal obstruction can compromise blood supply to the bowel wall, leading to serious complications. Bowel ischemia develops due to inadequate blood flow, potentially progressing to tissue necrosis (death), bowel perforation (rupture of the intestinal wall), and subsequent peritonitis (infection of the peritoneal cavity).

  • Nurses must be vigilant in monitoring for signs and symptoms of these complications:

    • Bowel Perforation:

      • Abrupt worsening of abdominal pain and tenderness
      • Changes in vital signs (tachycardia, hypotension)
      • Fever
      • Elevated white blood cell count

    • Bowel Ischemia:

      • Sudden onset of severe abdominal pain, often disproportionate to exam findings initially
      • Abdominal bloating
      • Passage of blood in the stool (hematochezia or melena)
      • Persistent or worsening nausea and vomiting

    • Peritonitis:

      • Abdominal guarding (involuntary muscle contraction with palpation)
      • Abdominal rigidity (board-like abdomen)
      • Rebound tenderness (pain worse upon release of pressure)
      • Systemic signs of infection (fever, elevated WBC, sepsis)

2. Patient Education on Recurrence:

  • Small bowel obstructions, especially those caused by adhesions, have a notable recurrence rate. Comprehensive patient and family education is crucial upon discharge. Patients should be instructed on recognizing the signs and symptoms of SBO recurrence and emphasized the importance of seeking immediate medical attention should these symptoms arise. Delayed treatment of recurrent SBO is associated with increased morbidity and mortality.

Alt text: Nasogastric tube being inserted to achieve bowel decompression, a key intervention for managing small bowel obstruction and relieving abdominal distension.

Common Nursing Diagnoses for Small Bowel Obstruction

Based on the assessment findings and potential complications, several nursing diagnoses are commonly relevant for patients with small bowel obstruction. These diagnoses guide the development of individualized nursing care plans to address patient needs and promote optimal outcomes.

1. Acute Pain

Nursing Diagnosis: Acute Pain related to inflammation and distension of the bowel secondary to obstruction, as evidenced by reports of cramping abdominal pain, restlessness, guarding behaviors, and facial grimacing.

Related Factors:

  • Inflammation of bowel tissue
  • Bowel distension
  • Increased intestinal pressure
  • Surgical incision (if applicable)

As Evidenced By:

  • Verbal reports of pain (e.g., cramping, colicky)
  • Pain rating scales (e.g., numeric pain scale)
  • Restlessness and agitation
  • Guarding of the abdomen
  • Facial grimacing, moaning
  • Changes in vital signs (increased heart rate, blood pressure)

Expected Outcomes:

  • Patient will report a reduction in pain intensity to a tolerable level (e.g., pain score ≤ 3/10).
  • Patient will demonstrate relaxed body posture and facial expressions.
  • Patient will exhibit stable vital signs within patient’s baseline.

Nursing Assessments:

  1. Pain Assessment: Regularly assess pain characteristics including location, quality (sharp, dull, cramping), intensity (using a pain scale), aggravating and relieving factors, and timing. Monitor for changes in pain patterns.
  2. Nonverbal Pain Cues: Observe for nonverbal indicators of pain, especially in patients who may have difficulty verbalizing their pain (e.g., elderly, confused). These include facial expressions, body posture, restlessness, and reluctance to move.
  3. Vital Sign Monitoring: Assess vital signs (heart rate, blood pressure, respiratory rate) and correlate them with pain assessments. While vital signs are not always reliable indicators of pain, significant changes may suggest increased pain or complications.

Nursing Interventions:

  1. Administer Analgesics: Administer prescribed pain medications promptly and as needed. Intravenous (IV) administration is often necessary due to NPO status and potential malabsorption. Opioids are commonly used for severe SBO pain. Consider adjunctive non-opioid analgesics and non-pharmacological pain relief measures.
  2. Comfort Measures: Implement comfort measures to alleviate pain. These may include positioning (e.g., semi-Fowler’s position to reduce abdominal tension), gentle massage (if tolerated and not contraindicated), deep breathing exercises, and guided imagery or relaxation techniques.
  3. Cluster Care: Coordinate nursing activities to minimize disruption and allow for rest periods, especially after pain medication administration. Administer pain medication proactively, before painful procedures or activities, to optimize pain relief.
  4. Nasogastric Tube Management: Ensure proper functioning of the NG tube, as decompression can significantly reduce abdominal distension and pain. Monitor NG tube output and drainage characteristics.

2. Constipation

Nursing Diagnosis: Constipation related to mechanical obstruction, decreased bowel motility, and NPO status, as evidenced by abdominal distension, infrequent bowel movements, straining with defecation, and patient reports of bloating and discomfort.

Related Factors:

  • Mechanical obstruction of the bowel lumen
  • Decreased peristalsis and bowel motility
  • NPO status and reduced oral intake
  • Dehydration
  • Pain medications (opioids can contribute to constipation)

As Evidenced By:

  • Decreased frequency of bowel movements compared to patient’s usual pattern
  • Abdominal distension and bloating
  • Infrequent or absent bowel sounds
  • Straining or pain with defecation
  • Hard, dry stools (if any stool is passed)
  • Patient reports of feeling full, bloated, or unable to pass stool

Expected Outcomes:

  • Patient will experience a return to regular bowel elimination pattern appropriate for their condition.
  • Patient will verbalize strategies to prevent or manage constipation upon discharge.
  • Patient will report decreased abdominal discomfort and bloating.

Nursing Assessments:

  1. Bowel Pattern History: Assess the patient’s usual bowel habits, including frequency, consistency, and any previous history of constipation. Establish a baseline for comparison.
  2. Diet and Fluid Intake Assessment: Evaluate the patient’s dietary intake and fluid status, recognizing that NPO status and reduced oral intake contribute to constipation in SBO. Once oral intake is resumed, assess fiber and fluid consumption.
  3. Defecation Assessment: Inquire about any pain, straining, or difficulty associated with attempted bowel movements. Assess stool characteristics if any are passed.

Nursing Interventions:

  1. Hydration: Once oral intake is permitted, encourage adequate fluid intake to promote stool softening. If NPO, maintain IV fluid hydration as prescribed.
  2. Dietary Fiber (when appropriate): When diet is advanced, encourage a gradual increase in dietary fiber intake to promote bowel regularity. Educate the patient on fiber-rich foods and appropriate fiber supplements.
  3. Encourage Activity: Promote physical activity and ambulation, as tolerated, to stimulate bowel motility. Encourage movement within the hospital room and early ambulation postoperatively.
  4. Stool Softeners/Laxatives (with caution and as prescribed): Stool softeners or mild laxatives may be considered after resolution of the obstruction and resumption of oral intake, and only if prescribed by the physician. Avoid stimulant laxatives in the acute phase of SBO without specific orders.

3. Dysfunctional Gastrointestinal Motility

Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to mechanical obstruction and altered physiological processes, as evidenced by abdominal distension, bloating, altered bowel sounds, nausea, vomiting, and constipation.

Related Factors:

  • Mechanical obstruction (partial or complete)
  • Inflammatory processes in the bowel
  • Ileus (functional bowel obstruction)
  • Surgical manipulation of the bowel
  • Effects of medications (e.g., opioids)

As Evidenced By:

  • Abdominal distension and bloating
  • Abdominal cramping or pain
  • Altered bowel sounds (absent, hypoactive, or high-pitched tinkling sounds)
  • Nausea and vomiting
  • Absence of flatus or bowel movements
  • Reports of early satiety or postprandial fullness
  • Lack of appetite

Expected Outcomes:

  • Patient will demonstrate improved gastrointestinal motility as evidenced by resolution of abdominal distension, return of bowel sounds, and passage of flatus or stool (as appropriate for clinical situation).
  • Patient will report reduced nausea and vomiting.
  • Patient will tolerate gradual advancement of diet as indicated.

Nursing Assessments:

  1. Bowel Sound Assessment: Auscultate and document bowel sounds in all four quadrants of the abdomen. Note the presence, absence, frequency, and characteristics of bowel sounds (e.g., hypoactive, hyperactive, high-pitched, absent).
  2. Abdominal Assessment: Assess for abdominal distension, tenderness, and rigidity. Measure abdominal girth daily if distension is significant.
  3. Symptoms of Dysmotility: Monitor for and document symptoms such as nausea, vomiting (frequency, amount, characteristics), abdominal pain, bloating, early satiety, and passage of flatus or stool.

Nursing Interventions:

  1. Nasogastric Decompression: Maintain NG tube patency and suction as ordered to decompress the stomach and proximal bowel. Monitor NG drainage for amount, color, and consistency.
  2. NPO Status: Maintain NPO status as ordered to allow bowel rest and reduce intestinal workload.
  3. Fluid and Electrolyte Management: Administer IV fluids and electrolytes as prescribed to correct imbalances resulting from vomiting, NG suction, and reduced oral intake.
  4. Ambulation and Positioning: Encourage early ambulation and frequent repositioning to promote bowel motility and reduce abdominal distension.
  5. Prepare for Diagnostic and Therapeutic Procedures: Prepare the patient for diagnostic imaging (e.g., CT scan) and potential surgical interventions as indicated.

4. Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to impaired absorption, NPO status, vomiting, and altered appetite secondary to small bowel obstruction, as evidenced by weight loss, decreased energy, abnormal electrolyte values, and reported lack of appetite.

Related Factors:

  • Impaired nutrient absorption in the small intestine
  • NPO status for bowel rest
  • Vomiting and potential diarrhea
  • Anorexia and reduced appetite
  • Increased metabolic demands due to illness/surgery

As Evidenced By:

  • Weight loss (documented or reported)
  • Decreased muscle mass or weakness
  • Fatigue and decreased energy levels
  • Anorexia or lack of appetite
  • Nausea and vomiting
  • Abnormal serum electrolyte levels (e.g., potassium, sodium, magnesium)
  • Abnormal serum protein levels (e.g., albumin, prealbumin)

Expected Outcomes:

  • Patient will maintain or regain nutritional status as evidenced by stable weight, improved energy levels, and laboratory values within acceptable limits.
  • Patient will demonstrate understanding of nutritional needs and strategies for dietary management post-discharge.
  • Patient will tolerate gradual advancement of diet without recurrence of symptoms.

Nursing Assessments:

  1. Nutritional History: Assess the patient’s pre-illness nutritional status, dietary habits, food preferences, and any food allergies or intolerances.
  2. Weight Monitoring: Monitor daily weight to assess for weight loss or gain. Track trends in weight over time.
  3. Intake and Output (I&O): Accurately record all oral, enteral, and parenteral intake, as well as output from vomiting, NG tube, diarrhea, and urine.
  4. Laboratory Values: Monitor relevant laboratory values, including electrolytes (sodium, potassium, chloride, bicarbonate, magnesium, phosphate, calcium), serum protein levels (albumin, prealbumin, total protein), glucose, and micronutrient levels as indicated.

Nursing Interventions:

  1. Maintain NPO Status Initially: Adhere to NPO orders to rest the bowel and minimize further nutritional losses due to vomiting or malabsorption.
  2. Parenteral Nutrition (if indicated): If prolonged NPO status is anticipated or if malnutrition is severe, parenteral nutrition (PN) may be necessary to provide adequate caloric and nutrient support. Collaborate with the healthcare team and dietitian regarding PN needs.
  3. Advance Diet Gradually: When oral diet is resumed, advance diet slowly and as tolerated, starting with clear liquids, progressing to full liquids, then to a low-residue diet, and finally to a regular diet as tolerated. Monitor for symptom recurrence with diet advancement.
  4. Nutritional Supplements: Consider oral nutritional supplements to augment dietary intake once oral diet is tolerated.
  5. Patient Education: Provide education on nutritional needs, dietary modifications (e.g., low residue diet initially, then gradual reintroduction of fiber), and strategies to prevent nutritional deficiencies post-discharge.

5. Ineffective Tissue Perfusion (Gastrointestinal)

Nursing Diagnosis: Ineffective Tissue Perfusion (Gastrointestinal) related to mechanical obstruction, bowel distension, and potential strangulation, as evidenced by abdominal pain, distension, rigidity, altered bowel sounds, nausea, vomiting, and potential signs of systemic compromise (altered vital signs, blood in stool).

Related Factors:

  • Mechanical obstruction compressing blood vessels
  • Bowel distension increasing intraluminal pressure
  • Strangulation of bowel loops compromising blood flow
  • Inflammatory processes and edema
  • Potential for sepsis and hypovolemia

As Evidenced By:

  • Abdominal pain (sudden onset, severe, or worsening)
  • Abdominal distension and bloating
  • Abdominal rigidity or guarding
  • Altered bowel sounds (absent or markedly diminished)
  • Nausea and vomiting (especially bilious or feculent)
  • Presence of blood in stool (hematochezia or melena)
  • Altered vital signs (tachycardia, hypotension, fever)
  • Elevated lactic acid levels (laboratory finding)
  • Elevated WBC count (laboratory finding)

Expected Outcomes:

  • Patient will maintain adequate gastrointestinal tissue perfusion as evidenced by stable vital signs, resolution of abdominal rigidity, and absence of signs of bowel ischemia or peritonitis.
  • Patient will exhibit laboratory values (WBC, lactic acid) within acceptable limits or trending towards normal.
  • Patient will report resolution or significant reduction in abdominal pain.

Nursing Assessments:

  1. Cardiovascular Assessment: Monitor vital signs frequently (heart rate, blood pressure, respiratory rate, temperature) for signs of hypovolemia, shock, or sepsis. Assess peripheral pulses and capillary refill.
  2. Abdominal Assessment (repeatedly): Perform frequent abdominal assessments, noting changes in pain intensity, location, and character. Assess for increasing distension, rigidity, guarding, and rebound tenderness. Monitor bowel sounds closely.
  3. Signs of Bowel Ischemia/Perforation: Be vigilant for signs of bowel ischemia (severe pain, bloody stools, worsening distension) or perforation (sudden, severe pain, rigid abdomen, signs of peritonitis).
  4. Laboratory Monitoring: Monitor laboratory values, particularly WBC count, hematocrit, electrolytes, BUN/creatinine, and lactic acid, to assess for infection, dehydration, and tissue perfusion status.

Nursing Interventions:

  1. Fluid and Electrolyte Resuscitation: Administer IV fluids and electrolytes aggressively to restore intravascular volume and correct imbalances. Monitor response to fluid resuscitation.
  2. Oxygen Therapy: Administer supplemental oxygen as needed to ensure adequate tissue oxygenation, especially if signs of shock or respiratory compromise are present.
  3. Prepare for Imaging and Surgical Intervention: Promptly prepare the patient for diagnostic imaging (e.g., CT scan) to evaluate for bowel ischemia, strangulation, or perforation. Prepare for urgent surgical intervention if indicated to relieve obstruction and restore blood flow.
  4. Antibiotic Administration: Administer broad-spectrum antibiotics as ordered, especially if bowel strangulation, perforation, or sepsis is suspected.
  5. Continuous Monitoring: Maintain continuous monitoring of vital signs, abdominal status, and laboratory values. Report any changes or concerning findings to the physician promptly.

Conclusion

Nursing diagnoses provide a structured framework for addressing the complex needs of patients with small bowel obstruction. By conducting thorough assessments and utilizing these diagnoses to guide care planning, nurses can effectively contribute to symptom management, prevention of complications, and promotion of positive patient outcomes in this challenging clinical scenario. The nursing diagnoses of Acute Pain, Constipation, Dysfunctional Gastrointestinal Motility, Imbalanced Nutrition, and Ineffective Tissue Perfusion are central to the nursing care of patients with SBO, highlighting the multifaceted role of nurses in their management.

References

Comments

No comments yet. Why don’t you start the discussion?

Leave a Reply

Your email address will not be published. Required fields are marked *