2. Managing the Client With Bowel
Obstruction and Ostomy

3. Intestinal Obstruction
 Small and large
 Partial or complete
 Failure of intestinal contents to move

4. Mechanical Causes of Intestinal
Obstruction
A. Intussusceptions: The prolapse
of the intestine into the lumen
of the immediate adjacent part
B. Volvulus: Torsion of a loop of
intestine causing an
obstruction (may also have
strangulation)
C. Hernia: An abnormal
protrusion through the
abdominal wall

5. Functional Causes of Bowel
Obstruction
 Ileus, paralytic ileus, adynamic)
 musculature can’t propel bowel contents usually
accompanied by peritonitis
 Symptoms include abdominal pain and distention,
vomiting and constipation. Potential complications
include dehydration and shock.
 Treatment : Decompression with a tube at the site of
the obstruction

6. Small Bowell Obstruction
 Pathophysiology
 Obstruction
 Effluent and flatus collect above  abdominal distention
 Distention and fluid retention  absorp & stimulate
prod of more fluids
  distention   intraluminal press   venous and
art cap press
  edema, congestion, necrosis, rupture

7. Signs and SXs of Small Bowel
Obstruction
 Crampy abdominal pain that is wavelike and colicky
 Pass blood and mucus but no feces or flatus
 Vomiting
 In severe cases reverse peristalsis

8. Example of an x ray showing a small
bowel obstruction

9. Large Bowel Obstruction
 Pathophysiology
 Obstruction  build up of effluent & gas above site
  severe distention and perforation
 Often undramatic (unlike sbo)
 Strangulation and necrosis are life threatening
 Adenocarcinoid tumors account for the majority of
large bowel obstructions

10. Signs & SXs of Large Bowel
Obstruction
 Constipation (may be the only sx for months)
 Alteration in the shape of stool
 Weakness, anorexia and weight loss
 May develop iron deficiency anemia
 Distended abdomen showing the outline of the large
bowel

11. Treatment Options for LBO
 Monitor symptoms, provide sx relief
 Surgical resection of bowel and formation of
ostomy (temp or permanent) if condition worsens
 Nursing Care
 Monitor for improvement, deterioration
 Fluid and electrolyte balance
 Pre- & post-op care

12. Bowel Obstruction
Clinical Signs & SXs Small Intestine Large Intestine
Onset Rapid Gradual
Vomiting Frequent & Copious Rare
Pain Colicky, cramp like, Low grade, crampy
intermittent
Bowel Movements Feces for a short duration Absolute constipation
Abdominal Distention Minimally increased Greatly increased

13. Colorectal Cancer
 Risk Factors (cause unknown):
 Over 40
 Blood in stool
 History of rectal polyps
 Family history
 History of inflammatory bowel disease
 High fat, protein, beef diet; low fiber
 The third most common cause of U.S. cancer deaths
 Risk factors: see Chart 38-8
 Importance of screening procedures
 Manifestations include change in bowel habits; blood in stool—occult, tarry,
bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal;
feeling of incomplete evacuation
 Treatment depends upon the stage of the disease

14. Patho-physiology of Colorectal
Cancer
 Predominantly adenocarcinoma (arising from the
epithelial cells of the intestine
 Symptoms •Rectal
 Right side •Tenesmus
•Pain
 Dull pain
•Felling of
 Melena incomplete
 Left side evacuation
•Bloody stools
 Pain/cramping
 Narrowing stools
 Constipation
 Bright blood

15. Colon Cancer
 Diagnosis
 Abdominal and rectal exam
 Fecal occult blood testing
 Barium enema
 Colonoscopy / sigmoidoscopy with biopsy & cytology
smears
 Carcinoembryonic antigen (CEA) (dx and recurrence)

16. Nursing Process—Assessment of the Patient
With Cancer of the Colon or Rectum
 Health history
 Fatigue and weakness
 Abdominal or rectal pain
 Nutritional status and dietary habits
 Elimination patterns
 Abdominal assessment
 Characteristics of stool

17. Nursing Diagnosis
 Anxiety
 Pain
 Altered nutrition, less than
 High risk for fluid volume deficit
 High risk for infection
 Knowledge deficit
 Impaired skin integrity
 Disturbed body image
 Ineffective sexuality patterns

18. Potential Complications of Colon or
Rectal Cancer
 Intraperitoneal infection
 Complete large bowel obstruction
 GI bleeding
 Bowel perforation
 Peritonitis, abscess, and sepsis

19. Distribution Of Colon Cancer

20. Placement of
Permanent Colostomies
A. Sigmoid
 Feces are
solid
B. Descending
 Feces are
semi-mushy
C. Transverse
 Feces are
mushy
D. Ascending
 Feces are
fluid

21. Stomas should always be beefy red

22. Ostomy Pouches and Accessories

23. Managing Nasogastric Tubes
 Feeding vs.
Decompression
 Placement
Verification
 Guidelines for
Flushing
 Patient Positioning

24. Nasogastric Tubes
 Decompress
 Lavage
 Diagnose GI motility and other disorders
 Administer medications and feedings
 Treat an obstruction
 Compress a bleeding site
 Aspirate gastric contents for analysis

25. Care of the Patient with a G-Tube
 Check institution’s policy
for management
 Monitor GI function and
tube insertion site at least
once per shift
 Assess gastric drainage for
amount and characteristics
each shift

26. Care of the Patient with an NG or
G-Tube
 Irrigate q 4 hours.
 Flush a tube used for feeding with 30ml
 Replace irrigation equipment per protocol.
 Reposition as needed
 Clean nares, apply water soluble lubricant and retape
daily or prn.
 Oral hygiene
 Clean new abdominal tube site

27. Medication Administration by NG
or G-Tube
 Assess for placement and flush with 30 ml water.
 When gastric suction prescribed, clamp tube for 20 minutes after
instillation of medications to allow for absorption.
 Avoid crushing sustained release, enteric coated products, or drugs in a
chewable or sublingual form.
 Administer crushed medications separately; do not mix together in
water.
 Flush with about 15 ml between each medication.
 Some medications, for example Dilantin, are rendered less potent when
given with tube feedings. For these medications, it is important to turn
the feeding off for 30-45 minutes following medication administration.
Check your institution’s policy for specifics.

28. Enteral Feeding
 Verify placement
 Verify formula, amount, and method of
administration upon initiation of feeding
and minimally once per shift there after
 Confirm placement
 Monitor for vomiting, diarrhea, changes in
aspirates, abdominal characteristics,
change in bowel sounds, onset of
respiratory distress, hypotension, fever or
significant change in UO.
 Monitor labs (especially glucose levels).
 Assess weight.
 Elevate HOB 30 degrees – when and why?
 Aspirate for residual