CASE PRESENTATION

ON

SMALL BOWEL OBSTRUCTION

Submitted to: Ms. Rimple Sharma

Lecturer, CON, AIIMS

Submitted by: MohmmadToseef

M.Sc nursing I year
CON, AIIMS
HISTORY COLLECTION
DEMOGRAPHIC PROFILE:
Name : Mr.Deshraj
Age : 45years
Sex : Male
UHID number : 100784609
Ward/bed no : c-7
Address : 92 Sewapark ,Najafgarh Road ,New Delhi
DOA : 05/02/2015
Diagnosis : small bowel obstruction (exploratory laprotomy +resection anastomosis
done for intestinal obstruction)
CHIEF COMPLAINTS:
Patient complain of pain in abdomen since from last four days.
Patient complains increase in the size of the abdomen from last two days .”
HISTORY OF PRESENT ILLNESS:
Patient has history of recurrent admission (3-4times) on hospital. He had abdominal pain from
from last 4 days . Now the problem is increased, pain in lower abdomen is occurring since from
last 4 days, which is insidious in onset , no passing of flatus/stool .Abdomen was distended . He
went to the private hospital they done investigation and place Nasogastric on 3rdfeb night at that
hospital. Passed flatus and loose stools in today morning (5/02/2014). He had not taken any
things orally from since 4 days.
HISTORY OF PAST ILLNESS-
Past histroy- History of tuberculosis since 2005for which he had taken ATT treatment for 9
months .
No history diabetes mellitus ,hypertension,asthma,sezuriesandany communicable

FAMILY HISTORY:
Family histroy of tuberculosis ,Father is affected with tuberculosis
No histroy of diabetes ,hypertension or other disease
Father Mother ,healthy
67 year 64year
(T.B.)

Patient Healthy
45year 35 year

12year 5year

PERSONAL HISTORY:
He is taking non vegetarian diet and he takes approximately 2L of water in a day and 3 meals in
a day .
Smoking history present since from last 16 years
Alcohol history present since from last 15 years

SOCIO-ECONOMIC HISTORY:
 Lives in a pakka house which is well ventilated
 Proper sanitation.
 Drinking water source is from tap.

PHYSICAL EXAMINATION
GENERAL APPEARANCE:
Patient is conscious and oriented to time, place and person. He is moderately built and
malnourished.
Height –160cm
Weight – 52kg

Vital signs:
Temperature – 98.6F
Pulse – 90 beats/min
Blood Pressure- 110/80mmof hg
Respiratory rate-16 breaths/min
CNS:
Patient is conscious. Pupils are reacting to light. He has sensory and motor function normal.
CVS:
S1, S2 Heard no murmurs present.
Respiratory system:
Chest is symmetrical. Normal vesicular breath sound present.
Gastro Intestinal system:
No abnormalities like ascites,hepatomegaly are seen. Bowel sound are sluggish.
Renal System:
Patient maintained normal urine output with positive balance.
Integumentary System:
She has no abnormalities like scabies, infection etc, in the skin.
Musculo-skeletal System:
All range of motion exercises are not possible in all her four extremities.
PER ABDOMENEXAMINATION-
Inspection- Abdomen distended
No abnormal peristalsis visible.
No dilated veins and scar
Palpitation-Abdomen diffusely tender and tensed
Marked tenderness in left illiac fossa
Percussion-Resonance note on all of the abdomen.
No fluid thrill.
Auscultation- bowel sound sluggish

MEDICATIONS
 Medication Dosage Route Frequency
Inj.Pantocid 40mg IV once daily
InjMagnex 1gm IV twice daily
Inj.Metrogyl 500mg IV once daily
InjAmikacin 500mg IV twice daily
InjEmset 8 mg IV tds
Inj.Dynapar 75 mg IV bd
InjPerfalgan 1 gm IV qid

INVESTIGATIONS:
1. Blood investigations:
Investigation 5/2/2015 6/2/2014 7/2/2015 8/02/2015

Hemoglobin 14.8g/dl 14.7gm/dl 13.7 -

TLC 5.2 5.0 9.6 -
RBC 4.70 4.68 4.69 -
Hct 45.6 45.4 - -
Platelet 127 130 165 -
Bilirubin Total 0.8 - 0.6 -

Urea 19mg% 20mg% 20 2-3

Creatinine 0.8mg% 0.7mg% 0.8 0.8
Sodium 139mEq/L 141meql/L 140 142
Potassium 4.0 mEq/L 4.0 mEq/L 3.7 4.0
Calcium - - 0.8 -
Urine Examination ( 5/2/2014)
 Reaction-6.0 pH
 Specific gravity-1.030
 Protein-1+
 Sugarnil
Microscopic examination(urine)-
 Rbc-25-30 /HPF
 Wbc-0-1 /HPF
 Epithelial cells- 1-2 / HPF
 Cast -nil
 Bacteria-nil
 Yeast-nil
 Mucus-nil
 Ketones- 2+
 Bile pigment- 2+

CT-Whole abdomen(4/02/2015)dialated small bowel loop intestine with noted pleural effusion
(R>L)with moderate ascites.
No granulation is seen or identified.

DISEASE CONDITION

Definition:-Bowel obstruction occurs when the normal flow of intraluminal contents is

interrupted.Obstruction can be functional or due to a mechanical obstruction. It can be acute or
chronic.
The small bowel is involved in about 80 percent of cases of mechanical intestinal
obstruction.The incidence is similar for males and females.Acute, mechanical small bowel
obstruction is a common surgical emergency.

RISK FACTORS- There are modifiable and non-modifiable risk factors. The modifiable risk
factors are hernia, inflammatory bowel disease, cancer, severe constipation, vertebral fracture,
thrombosis, embolism.
The non-modifiable risk factors are age (young-congenital bowel deformities and old age),
Family history of colorectal cancer.
Classification of causes intestinal obstruction:Based on the etiology, intestinal obstruction is
classified into,
1. Mechanical obstruction
2. Paralytic ileus
Mechanical obstruction:
It is further classified into,
i) Obturation obstruction
a. Polypoid tumor
b. Intussusception
c. Gall stones
d. Foreign bodies
e. Bezoars
f. Feces
ii) Intrinsic bowel lesion
a. Atresia
b. Stenosis
c. Stricture
d. Vascular abnormality
iii) Extrinsic bowel lesion
a. Adhesion
b. Hernia
c. Neoplasm
d. Volvulus
e. Congenital bands

Functional bowel obstruction:

- Paralytic ileus

Functional bowel obstruction:

Paralytic ileus:Ileus is a type of non-mechanical bowel obstruction.It results when peristalsis
stops. Peristalsis is the wavelike contractions that help push stool through the colon and small
bowel
Causes:
 Damage to the nerves controlling the intestines from surgery, Infection,
 Decreased blood flow, unrelieved mechanical obstruction, Electrolyte imbalance
(hypokalemia),Medications,Changes in the body chemistry.

Types of bowel obstruction:

• ONSET
A. Acute
B. Chronic

SITE
• Small bowel obstruction – obstruction in the small intestine
• Large bowel obstruction – obstruction in any part of the large intestine
Pathophysiology Of Intestinal Obstruction

ETIOLOGY----------------------- FUNCTIONAL PARALYTIC ILEUS

 Pathophysiology of intestinal obstruction:

 .Clinical manifestation of intestinal obstruction:

IN BOOK IN PATEINT
 Cramping and belly pain that comes and goes. • Pain in the abdomen.
 The pain can occur around or below the belly button. • No passing of flatus or
 Vomiting – as obstruction progress, the character of vomitus gas.
changes from digested food to feculent material.
 Bloating and a large, hard belly.
 Constipation and a lack of gas, if the intestine is completely
blocked
 Diarrhea, if the intestine is partly blocked,
 Inability to have a bowel movement or pass gas, • Swelling of the
 Swelling of the abdomen (distention) abdomen (distention)

Diagnostic evaluation:
History collection, Physical examination, Laboratory investigation reveal decreased sodium,
potassium, chloride; Elevated serum amylase. Elevated WBC due to inflammation, seen in
peritonitis and strangulation, Upper GI and small bowel series, Colonoscopy, Barium enema,
Abdominal X-ray and computed tomography
Blood investigaion,urine examination and ct was done.
Management of intestinal obstruction:
Management:
a)Medical management:
Management of intestinal obstruction is directed at correcting physiologic derangements caused
by the obstruction, bowel rest, and removing the source of obstruction. Fluid resuscitation should
be started with intravenous isotonic solution, Nasogastric decompression, Correction of
electrolyte imbalance, Correction of metabolic acidosis/alkalosis.
Nasogastric decompression is done.
If bowel ischemia or infarction is suspected, antibiotics should be given (eg, a 3rd-
generationcephalosporin, such as cefotetan 2 g IV) before operative exploration.
Patient can be diagnosed with various imaging technique only when he is stable, or else
exploratory laparotomy should be done.
b)Surgical Management:
i. Adhesiolysis:Laparoscopic surgery is performed by making two or three small punctures
(about 0.5 to 1 cm in size) on the abdomen.Laparoscope is the only way confirming their
presence. If adhesions are encountered, they can be easily divided using long laparoscopic
instruments. The procedure is called adhesiolysis.
ii. Excision/resection: Any damaged parts of bowel will be repaired or removed. This procedure
is called bowel resection
iii. Bypass/proximal decompression:When part of the intestine is removed and the ends cannot
be reconnected, one end out through an opening in the abdominal wall. This may be done using
a colostomy, ileostomy or mucous fistula.
SURGICAL MANAGEMENT -EXPLORATORY LAPROTOMY AND END TO END
ANASTOMOSIS WAS DONE
NURSING MANAGEMENT:
Nursing diagnosis:

 Acute pain related to intestinal obstruction

 Constipation related to presence of obstruction or absence of peristalsis
 Fluid volume deficit related to vomiting
 Fear related to life-threatening symptoms of intestinal obstruction
 Risk for infection related to disease progression

ACUTE PAIN IS PRESENT

ABDOMINAL DISTENSION IS PRESENT BEFORE PREOPERATIVE PERIOD.
Nursing interventions:
i)Acute pain related to intestinal obstruction:
- Assess the intensity, location and frequency of pain. If colicky pain suddenly becomes
constant, it could signal perforation.
- Provide comfortable position to the patient.
- Provide diversional therapy to the patient
- Administer analgesics as prescribed by the physician
ii . Abdominal distension related to intestinal obstruction.
 Asses the location , cause and severity of abdomen distension
 Provide comfortable position
 Measured the abdominal girth as ordered by physician
 Insert the nasogastric tube for decompression of bowel, as ordered
 Maintain the patency of NG tube
iii. Anxiety related to disease and its treatment.
 Asses the level of the anxiety
 Provide calm and comfortable environment
 Provide preoperative teaching to the client regarding breathing exercises etc
 Explain the whole procedures to the client regarding duration of surgery , medications
needed , length of the surgery and outcomes of the surgery

Nursing diagnosis- post-operative:

 Impaired breathing pattern related to post-operative status
 Acute pain related to surgical incision
 Impaired nutrition less than body requirement related to surgery

Nursing interventions:
i)Impaired breathing pattern related to post-operative status:-
-Assess the respiratory rate, saturation and breathing pattern of the patient.
- Provide semi-fowler’s position to the patient.
- Provide incentive spirometry, deep breathing and coughing exercises to the patient.
- Administer oxygen to the patient if prescribed
ii. Acute pain related to surgical incision
-Assess the intensity, location and frequency of pain.
- Provide comfortable position to the patient.
- Provide diversional therapy to the patient
- Administer analgesics as prescribed by the physician
ii)Impaired nutrition less than body requirement related to surgery:
- Monitor the patient for return of bowel sounds, passage of stool and gas.
- Administer IV fluids and add vitamins to the IV fluids if prescribed.
- Slowly progress diet from clear liquid to semi-solid diet, once bowel sounds return
- Monitor weight and intake, output chart
Conclusion:
Bowel obstruction occurs when the normal flow of intraluminal contents is interrupted.
Although, diagnosis of intestinal obstruction is important, the treatment should not be delayed to
prevent complications
References:
Sleisenger/Fordtran,”Gastrointestinal disease pathophysiology, diagnosis, management” 4th
edition, pg:369-380
www.aafp.org › Journals › afp › Vol. 83/No. 2(January 15, 2011)
www.mayoclinic.org/diseases.../intestinal-obstruction/basics/.../con-2002
www.healthline.com/health/intestinal-obstruction
www.nlm.nih.gov/medlineplus/ency/article/002927.