the following discussion will focus on the GI system in relation to bowel obstructions before you dive into this content be sure you are free from distractions and can debit your full attention be sure that you have read the textbook pages that are associated with this content be prepared to actively learn I will be sharing my knowledge and understanding with you but you must do the learning participate in your learning you will be the nurse next to that patient not me you need to acquire the knowledge skills and attitudes to take care of that patient safety competently and compassionately think beyond your next classroom exam rather think about being that nurse taking care of that patient that is what you are preparing for not classroom examinations listen with curiosity asking questions seeking answers imagine being the nurse responsible for the care of this patient imagine being the patient needing this nursing care think about your prior experiences that are related to this content from both the health care provider's point of view and or the patient's point of view think about building knowledge on the foundation of what you already know be prepared to change your understanding of this content if new information is presented take advantage of this recorded source pause as needed to think about the content or write down notes or questions be curious about learning more review the content and your notes as needed to gain understanding that you seek test yourself on the content to determine if you really learned it or not the first thing I want you to do is pause and reflect I want you to start by stopping the recording and thinking and writing down in these three areas I want you to think about what you already know about this topic and write down at least three to five items I want you to stop and think about any of your prior experiences related to the content I want you to write down your thoughts and feelings related to your experiences lastly I want you to think about what you don't know about this content think about you know acts of knowledge and understanding and things that you're curious about learning write down at least three to five items then you'll be ready to dive into the content this line contains learning objectives that you should meet upon completion of this content I recommend that you pause the recording read these carefully and make sure that you understand the purpose of this learning session and that you can measure that you have accomplished then at the end obstructions in the small or large bottle can be either partial or complete partial occlusions will allow some fluid and gas to pass through the intestines and is often allowed to resolve itself without surgery frequently just using interventions to help manage the symptoms while the system the body of the patient corrects the problem a complete occlusion will usually require a surgical treatment there are simple obstructions and strangulated obstructions that are described as such depending upon whether there is still a blood supply going to that section of the bowel and a strangulated obstruction means that there is tissue not receiving blood flow therefore there is ischemia and eventually necrosis developing mechanical or non-mechanical is another way that just obstructions are described mechanical actually has a physical blockage in the intestinal lumen in those small a bowel this is frequently caused by adhesions from previous surgical procedures sometimes from hernias or a cancerous tumor so strictures or intussusception in the large bowel mechanical blockages are frequently caused by colorectal cancer adhesions ischemia vovolis and Crohn's disease non-mechanical obstructions are caused by a lack of peristalsis for whatever reason a paralytic ileus is the most frequently seen non-mechanical cause and it is common to some degree after surgical procedures because the use of anesthesia causes sometimes the bowels to be slow to wake up or delayed enough that it causes um no movement no peristalsis um but they're even more frequently seen if the surgical procedure is in the abdomen because those tissues and organs have been manipulated to some degree and that can cause a paralytic Ileus other causes of paralytic ileus include peritonitis inflammatory responses to pancreatitis and appendicitis and electrolyte imbalances especially hypokalemia sometimes also thoracic or lumbar spinal fractures because that impairs the nerve conduction um remember that there is an estimated volume of nine liters nine liters of total secretions in the GI tract on a daily basis these are the normal functionings of the system secretions coming from the mouth from the stomach from the liver from the pancreas from the small intestines all of these contributing to the bowel and the GI system working well in the bowels become obstructed these fluids are still being created so the fluids start to be backed up along with any air that the patient has swallowed or contents that were already in the intestines at the time the blockage occurred none of this can move forward which leads to the signs and symptoms that we commonly see in this condition and these include abdominal distension as the bowel is full of these contents and it can't move them through like normal um nausea and vomiting because the bowel this stuff is backing up and that leads to the nausea and vomiting patients will complain of pain which I think we can all understand why they would be in pain with all of this distension sometimes constipation is a complaint and then there'll be changes in the bowel sounds the buildup of the fluids the gas the intestinal contents will create kind of a colicky abdominal pain which is kind of like a crampy Grumpy off and on pain um proximal if there's a small bowel obstruction proximal to the obstruction the bowel sounds are often high pitched um and in the case of paralytic ileus there's usually no bowel sounds they legit are absent so when you're doing your thorough abdominal assessment for a patient you need to make sure that you are listening carefully to these bowel sounds and if you don't hear metal sounds in quadrants then you have to listen for at least five minutes before you can declare that there's no sounds whatsoever if you find that there is no sounds you make sure you notify that provider that is an emergency situation um sometimes patients will experience I mentioned nausea and vomiting symptoms they'll actually experience projectile vomiting with this with these obstructions depending upon its location and whether it's complete or not um with large bowel destructions there's usually a good deal of abdominal distension and the cramping pain is more persistent and the vowel sounds are usually initially present but become progressively hypoactive and patient doesn't as complain as frequently of nausea and vomiting in a large bowel obstruction both will have abdominal tenderness and rigidity they may be guarding their abdomen and not want you to touch it to palpate um these patients are frequently dehydrated because of um a lot of reasons because of the nausea and the vomiting because of the lack of intake from the condition and sometimes what's going on is when there's an injury or an obstruction an insult inside the body one of the things that our system is designed to do is to send fluids and help to that part of the body to help relieve the problem to try to fix it well that means that that is being pulled out of the the volume of the bloodstream and maybe other tissues to send it to the area of injury so that's going to add to the dehydration we'll often see fluid and electrolyte or acid Basin balances in patients with obstructions remember that the signs of dehydration include how the patient being tachycardic having dry mucous membranes having hypotension perhaps tinting of the skin when you check for skin Terror and they also could have an elevated temp with dehydration the most likely um acid-base imbalance you're going to look at is metabolic alkalosis because of the loss of the acids leading to an alkalotic State and the most likely electrolyte imbalances hypokalemia because there's a lot of potassium in the GI tract and when that is lost then we're going to see the hypokalemia here's an opportunity for you to pause and to think and try to apply some of this information I want you to consider how the following conditions can lead to a bowel obstruction how is it that adhesions from a prior surgery could make an obstruction or a bobolis or a cancerous tumor about peritonitis or hypokalemia how can all of these things contribute to causing a bowel obstruction a thorough assessment should always be completed starting with asking about the onset of the current condition the signs and symptoms that have been experienced remember that anytime a patient has vomited we need to find out if the aspirated and we need to do a good assessment of their lung sounds because now we may have the vomiting and the vomiting and the nursing vomiting leading to aspiration pneumonia in some cases that can happen ask about the episodes of vomiting and the approximate volume Association for their hydration status find out about this pain where is it located how long has it lasted the intensity the frequency you know all the questions to do a complete pain assessment do one for this patient um record information about the emesis okay what's coming out what's the color what's the odor what's the volume um often we'll measure the patient's abdominal girth this would be a good measure to find out if there is distention and it's getting worse when you do pal paint be gentle okay um a because the patient hurts but also because vigorous palpation if we're talking about a bowel that is so distended because of the obstruction and then all the fluid that's rushed to that area to try to help fix it and it's very distended vigorous palpation could actually cause it to perforate okay so we want to be very careful about that you also want to assess for the last time they had a bowel movement or if they're still passing gas some of the orders that you couldn't expect in most cases would be some kind of Imaging x-ray CT MRI that will depend upon the provider's decisions they may have a scope depending on what's going on they may want to have a upper or a lower GI scope there's probably going to be some blood work done I would expect this patient to be NPO and have some bowel rest they may be allowed clear liquids if it's mainly determined that it's a partial obstruction instead of a complete one but know that if the ball is completely blocked we're already trying to manage this fluid that the body is creating by like perhaps suctioning it out with an NG tube we sure wouldn't want to add extra putting more fluids in orally is just going to add to the problem okay so expect them to probably be NPO we're also going to be monitoring them for changes especially if the order is to Monitor and watch to see if it gets better or worse sometimes this patient will be required to go to surgery often this patient will have an NG tube nasogastric tube that will help decompress the area um the stomach and maybe into the duodenum the upper portion of the small valves to suction out that extra fluid that the body continues to make that causes a lot of the signs and symptoms we use a lot of different types of tubes to treat manage Monitor and diagnose GI symptom problems in the case of bowel obstructions the most frequently used tube is an NG tube to low intermittent suction make sure that you review your nursing skills on inserting and maintaining an NG Tube review how to irrigate the tube what the expected output is how to troubleshoot problems with the tube in the suction system remember what the tube is supposed to be doing and if the patient experiences increasing pain nausea vomiting or abdominal distension there's likely something wrong with the tube or the suction so start looking to figure out what's going on additionally patients are often a little confused about what the tube's function is they mistakenly believe that the tube is going to actually suction out What's blocking we need to correct their misunderstanding and explain that it is really for symptom management until the system this issue is resolved one way or the other another intervention that we can often see in these patients is a cardiac monitor either because they have a prior condition that already requires one or because there's electrolyte changes going on because of the obstruction and the nausea and vomiting and maybe even the suction tube because it's pulling out fluids with it um and these electrolyte changes can lead to dysrhythmias so we might be monitoring this patient sometimes we're called to pawn to prepare the patient for surgery as one of our nursing duties and interventions strangulation or perforation of the bowel aren't medical emergencies and will require surgical interventions um sometimes a tube is in place to decompress the gastric context while the patient waits for surgery or we are monitoring for it to resolve sometimes medications that we use would include steroids to help with inflammation and decrease that distension and reduce the chance of perforation so we're preventing with those steroids expect this patient will be getting IV fluids to either correct or prevent dehydration most likely going to be giving antibiotics according to the provider's order either prophylactically to prevent an infection or in response to elevated wbcs that are already there expect it to be giving antiemetics for this patient either scheduled or PRN and often pain medication and usually for this it's a pretty strong pain medication that's given and it'll be through the IV route because this patient will be NPO um we're going to be watching for the potential complications of perforation um peritonitis fluid and electrolyte imbalances and they're gonna that potentially could cause the patient to have um a deadly arrhythmia another opportunity for you guys to pause and think about it Below in this slide are several interventions that are often used related to the care of a patient with the bowel obstruction you need to make sure as a nurse that anytime there's an intervention you know the rationale why this patient needs this intervention that should always be the question on your mind is this appropriate for my patient why are we doing this okay so stop for a minute think about these interventions that are listed these are very commonly used with a patient with a bowel obstruction and see if you can understand the rationale for each of them now on to educational and psychosocial considerations when we're educating our patient they're going to need to know a lot of information about the cause of the obstruction because that's going to impact the treatment and its resolution it's going to impact what we teach them to prevent reoccurrence of this issue they need to know the location and the type of the obstruction this helps the family understand and the patient understand why they have the signs and symptoms that they do explain the purpose of the diagnostic imaging and what to expect before during and after the testing how soon we should expect to see the results of the report and what the results mean we need to teach them how we're managing their symptoms including pain and the nausea that's often associated with these conditions we need to teach them how to use their incentives spirometer how soon they're going to ambulate if they get up after surgery to to ambulate how much assistance they may need especially initially how to do cough and deep breathe after having had an abdominal surgery we need to teach them the splinting of the abdomen what to expect about their oral intake and how their diet will be Advanced these are questions that patients are really concerned about um if an ostomy is surgically created they need to know when to expect a stool what consistency the stool should have what a healthy stoma looks like how to care for it how to get the supplies that they need psychosocially we are concerned about their body image and any kind of surgical procedure is going to leave scars and that's a concern for some patients they it really bothers them they need to have that addressed and if they have a stoma created that's a whole nother issue of body image this patient might be referred to a support group especially if they end up with a stoma that's a life-changing intervention it will save their life in most cases but it's still something that is different that they're not going to have to live with for in some cases the rest of their life um they're going to need some patience in some cases the stoma that's created is temporary what they'll do is create a stoma from a healthy section of the bowel remove the unhealthy damaged section and leave the lower end of the GI tract where the rectum is and leave its blood supply intact so that if it's possible somewhere down the road that all of this settles down the patient might be able to have those two ends reconnected they'll have a shorter large bowel because of it but the function will be restored and they'll actually be able to go back to having their regular bowel movements um so if that's the possibility for this patient or the plan what the surgeon intends to do then there'll be a discussion about how long it'll be before we can have that second surgery to put everything back together and give them back a regular function another concern that patients will have is how having an ostomy might impact their intimate relationships and their sexual function so these are kind of the things that we need to consider when we're talking to patients and giving them education and psychosocial support here's another opportunity for you to pause and think I want you to consider that sometimes patients need education in areas that nurses are not real comfortable or maybe nervous about talking about they feel and maybe inadequate to talk about it unprepared not sure what to say maybe a little embarrassed thinking about it in advance and having a planned strategy can help we need to be able to hold these kind of conversations with our patients so I want you to stop and think how might you approach teaching a patient about their sexual concerns related to a new ostomy because thinking about it and having some planned strategy can help you to be more successful and be a good educator for your patient now it's time for you to review the content review your notes review your readings test yourself to see if you have met these learning objectives if you still have gaps then you need to dig in deeper and look for the answers to the question so that you can say that you have mastered this content and achieved these learning objectives