Small bowel obstruction (SBO) refers to a complete or partial blockage in the small intestine. It can be caused by scar tissue from a previous surgery, hernias, cancer, and inflammatory bowel disorders.
SBO prevents contents from passing through into the large intestine. This causes waste products to build up above the portion of the obstruction. Surgery is required for most instances of SBO, except in cases of partial obstructions. SBO must be identified promptly, as mortality can be reduced when surgery is performed within 24-36 hours.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Constipation
- Dysfunctional Gastrointestinal Motility
- Imbalanced Nutrition: Less Than Body Requirements
- Ineffective Tissue Perfusion
Nursing Process
Nurses will be involved in caring for patients with an SBO in the inpatient setting. Depending on the severity of the blockage, patients will need to receive IV fluids to maintain hydration and nasogastric suctioning to allow the bowel to rest and recover. Nurses will educate patients on risk factors, symptoms, and management of their condition.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to small bowel obstruction.
Review of Health History
1. Determine the patient’s general symptoms.
The most common symptoms include:
- Abdominal pain and cramps
- Abdominal distension
- Bloating
- Nausea
- Vomiting
- Constipation
- Lack of appetite
2. Inquire further about abdominal pain.
Pain with SBO is often described as intermittent and colicky and improves with vomiting.
3. Assess for changes in bowel habits.
Constipation, obstipation, and loose stools may all occur. Flatus may or may not be present.
4. Determine the risk factors.
Postsurgical adhesions most frequently cause small intestinal obstruction. Other causes include:
- Incarcerated hernias
- Malignancy
- Inflammatory bowel illnesses (Crohn’s disease)
- Stool impaction
- Foreign bodies
- Volvulus (twisting of the intestines)
5. Assess for risk factions in pediatric patients.
Common causes of SBO in children include:
- Intussusception
- Pyloric stenosis
- Congenital atresia
6. Obtain a thorough history.
The patient may have a medical history that includes:
- Hernias
- Inflammatory bowel disease
- Cancer
- Previous abdominal surgery
- Congenital conditions that can cause small bowel obstruction
Physical Assessment
1. Perform an abdominal examination.
Bowel sounds may be reduced and high-pitched. Tenderness on palpation may be widespread or localized with distension. Rebound tenderness, guarding, and rigidity identify peritonitis. The examination may reveal hernias, scars, or masses.
2. Do a rectal examination.
During a rectal examination, note gross or occult blood. Hernias, masses, and fecal impaction can be identified via the rectum as possible causes of small bowel obstruction.
Diagnostic Procedures
1. Obtain blood samples for testing.
- Complete metabolic profile findings are often normal or slightly elevated. Abnormal results are typically caused by vomiting or dehydration.
- Blood urea nitrogen (BUN)/creatinine levels increase due to low fluid volume in the body related to dehydration.
- Complete blood cell (CBC) count. WBC is elevated in strangulated obstructions, and hematocrit is increased during dehydration.
- Lactic acid will be elevated in the presence of sepsis.
2. Schedule an imaging scan.
Imaging scans allow for the detection of obstruction in the small bowel.
- CT enterography/CT enteroclysis evaluates the entire bowel thickness. CT enterography is more accurate than conventional CT scans at locating the cause and site of obstruction.
- CT scan of the abdomen is the imaging test of choice for patients with signs of sepsis. CT scans can reveal abscesses, inflammatory diseases, and ischemia.
- Magnetic resonance imaging (MRI) is slightly less effective in identifying the location of obstructions.
- Plain X-rays are used as a preliminary test to look for air-fluid levels and free intra-abdominal air. X-rays have poor sensitivity and cannot be used to rule out SBO.
- Ultrasound is less expensive and invasive than a CT scan and can reliably exclude SBO, but it is not a replacement for CT scanning.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with small bowel obstruction.
Treat According to the Etiology
1. Schedule surgery immediately.
Most cases of small bowel obstruction necessitate immediate surgical management as it is an emergency. If surgical management is delayed, it can be fatal. Partial bowel obstructions may not require surgery if they resolve within three days.
2. Start fluid resuscitation.
Administering intensive fluid therapy through an IV and correcting any electrolyte imbalances is crucial. It involves administering isotonic saline or lactated Ringer’s solution to help restore the body’s fluid balance. IV resuscitation may also be used to address other complications, such as dehydration or shock.
3. Monitor the output.
It is necessary to use a Foley catheter to monitor the urine output and fluid balance. Sometimes, a central venous or Swan-Ganz catheter may also be required to monitor hemodynamics.
4. Decompress the bowel.
A nasogastric tube allows for the decompression of the stomach and helps prevent aspiration. This may be all that is needed for partial obstructions.
5. Prepare for surgery.
In cases where there is complete blockage or strangulation of the small intestine, surgery is necessary. Laparoscopic surgery is effective in many cases. Diseased sections of the bowel may require resection and removal.
Manage the Pain and Nausea
1. Control the pain.
Morphine sulfate is considered the preferred drug for SBO pain. It is reliable, safe, and easily reversed with naloxone.
2. Manage nausea.
Nausea may occur from the obstruction and with NG decompression. Medications like ondansetron and promethazine can treat nausea and vomiting.
3. Initiate antibiotics preoperatively.
Gram-negative bacteria and anaerobic microorganisms are treated with antibiotics. Antibiotics are used prophylactically when surgery is anticipated.
4. Encourage ambulation and frequent repositioning.
Encourage frequent position changes and early ambulation, especially after surgery, to reduce abdominal pressure and improve breathing.
Prevent Complications
1. Prevent the development of complications.
The bowel can lose blood flow due to intestinal blockage. The bowel wall deteriorates due to a lack of blood, causing tissue death (ischemia), perforation in the intestinal wall, and infection.
Monitor for signs of the following common complications:
- Bowel perforation:
- Abdominal pain and tenderness
- Changes in vital signs
- Fever
- Increased white blood cell count
- Bowel ischemia:
- Sudden abdominal pain
- Bloating
- Blood in the stool
- Nausea and vomiting
- Peritonitis:
- Guarding
- Rigidity
- Rebound tenderness
- Signs of infection
2. Educate on signs of recurrences.
Complete bowel obstructions have a high recurrence rate. Educate patients and families on signs and symptoms and to seek treatment immediately as mortality rises when surgery is delayed.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for small bowel obstruction, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for small bowel obstruction.
Acute Pain
Patients with small bowel obstruction can experience pain due to inflammation and blockage within the small intestine.
Nursing Diagnosis: Acute Pain
Related to:
- Inflammation of scar tissue
- Constipation
As evidenced by:
- Reports of cramping
- Restlessness
- Guarding behaviors
- Facial grimacing
Expected outcomes:
- Patient will report a decrease or relief in cramping and pain.
- Patient will display a relaxed appearance with vital signs within normal limits.
Assessment:
1. Assess the patient’s pain level.
Assess the patient’s type of pain and pain level. Observe where the pain is located, a description of the pain (sharp, dull, continuous), and the intensity. Assess regularly for any changes in pain levels or location.
2. Assess nonverbal pain cues.
Observe for nonverbal cues that may indicate a patient is in pain, even when they deny it. Nonverbal cues include facial grimacing, restlessness, sweating, and abdominal guarding.
3. Assess changes in vital signs.
Changes in vital signs can signify increased pain. A patient may become hypertensive or tachycardic when their pain increases from their baseline. Note pain level when taking vital signs to help compare patient’s vital signs with their verbal and nonverbal pain assessments. Keep in mind the patient can still experience pain without a change in vital signs.
Interventions:
1. Administer pain medications as ordered.
Managing pain is better achieved when pain medications are given routinely. Pain medication will likely be administered IV as the patient with an SBO will likely not be able to tolerate oral medications and will be prescribed NPO status for bowel rest.
2. Provide comfort measures.
Comfort measures such as massage, deep breathing, and guided imagery can help ease a patient’s pain. Additionally, distraction activities such as watching TV, playing games, or reading can help focus their mind on something else as a way of coping with the pain.
3. Cluster nursing care with pain medication.
Perform nursing care when the pain medication is at its peak therapeutic level. Anticipate administering pain medication before pain is severe, and then waiting until the relief is at its highest, so the patient is most comfortable and in the least amount of pain before tasks such as repositioning, ambulating, or bathing.
4. Place nasogastric tube.
A patient with small bowel obstruction will need a nasogastric tube to help decompress the stomach. The decompression will relieve abdominal distention and help decrease the patient’s pain.
Constipation
Patients with a small bowel obstruction can experience varying degrees of constipation.
Nursing Diagnosis: Constipation
Related to:
- Inflammation within the bowels
- Malabsorption
- Narrowing of the lumen
As evidenced by:
- Abdominal pain
- Abdominal distention
- Infrequent passage of stool
- Straining and discomfort with defecation
- Verbalizes feeling bloated
Expected outcomes:
- Patient will verbalize having a bowel movement without straining.
- Patient will implement two strategies to relieve constipation.
- Patient will have a bowel movement at least every 2-3 days.
Assessment:
1. Assess their usual pattern.
Assess the patient’s pattern for bowel movements, including the frequency and consistency of the stools. This provides a baseline to assess for any changes in their status.
2. Assess diet and fluid intake.
Inquire about the patient’s diet and fluid intake. Ask if they have noticed specific foods that cause constipation or a change in the color and consistency of their stool. Assess the amount and type of liquids the patient consumes.
3. Assess for pain or straining with defecation.
Ask the patient if they have pain with defecating. Hemorrhoids are often caused by straining and can cause pain themselves, contributing to the patient withholding stooling, which creates a cycle of constipation.
Interventions:
1. Provide a warm sitz bath as appropriate.
The warm water of a sitz bath can help relieve pain and discomfort for a patient experiencing constipation related to an SBO or hemorrhoids.
2. Encourage hydration.
Once the patient is allowed to consume fluids, encourage hydration. Discourage them from drinking alcohol or caffeine, and educate these fluids can dehydrate them. Adequate fluid intake helps soften the stool, making it easier to pass through the intestines and rectum.
3. Encourage fiber when appropriate.
Fiber should be encouraged to help with constipation but needs to be introduced very slowly. Too much fiber too quickly can cause abdominal distress or diarrhea. The patient may need education on fibrous foods or supplements at discharge.
4. Encourage physical activity.
A sedentary lifestyle can contribute to constipation. Encourage walking in the hospital and once discharged as this increases gastric motility and emptying.
Dysfunctional Gastrointestinal Motility
Blockages in the bowel prevent the passage of gastric contents causing delayed GI motility.
Nursing Diagnosis: Dysfunctional Gastrointestinal Motility
Related to:
- Disease process
- Partial or complete obstruction
- Inflammatory bowel conditions
- Cancer
- Hernias
- Previous abdominal surgery
- Scarring
As evidenced by:
- Abdominal distension
- Abdominal bloating
- Abdominal cramping or pain
- Absence of flatus
- Altered bowel sounds
- Constipation
- Nausea
- Vomiting
- Lack of appetite
Expected outcomes:
- Patient will be free from abdominal pain, bloating, and distension.
- Patient will demonstrate active bowel sounds and the passage of flatus.
Assessment:
1. Assess bowel sounds and note characteristics and frequency.
Bowel sounds indicate disruptions in gastrointestinal function and motility. Bowel sounds may be reduced and high-pitched in instances of obstruction.
2. Assess diagnostic studies.
CT scans can help confirm bowel obstruction contributing to dysfunctional gastrointestinal motility as well as the presence of abscesses, tumors, and ischemia.
3. Assess for signs and symptoms of decreased gastrointestinal motility.
Signs and symptoms of dysfunctional gastrointestinal motility include nausea, vomiting, early satiety, postprandial fullness, bloating, and abdominal pain.
Interventions:
1. Insert a nasogastric tube.
NG tubes are recommended for simple or partial obstructions to decompress the stomach.
2. Prepare and assist in surgical intervention.
Surgery is indicated for SBO if the small intestine is strangulated or completely blocked to treat the underlying cause of decreased gastrointestinal motility.
3. Keep the patient NPO.
NPO status ensures adequate bowel rest allowing ample time for recovery from a bowel obstruction.
4. Assist with ambulation.
Ambulation post-surgery is necessary to restart bowel motility and prevent further complications.
Imbalanced Nutrition: Less Than Body Requirements
Patients with small bowel obstruction can experience imbalanced nutrition due to impaired digestion and lack of absorption in the bowel.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Restricted intake as ordered to rest the bowel
- Altered absorption of nutrients
- Vomiting or diarrhea
As evidenced by:
- Hyperactive bowel sounds
- Loss or lack of appetite
- Weight loss
- Abnormal electrolyte panel
- Decreased energy
Expected outcomes:
- Patient’s weight will become stabilized while in the hospital without further weight loss.
- Patient will maintain nutritional and electrolyte lab values within normal range.
- Patient will report an increase in appetite and energy levels.
Assessment:
1. Assess lab values.
The nurse can monitor for abnormalities in nutritional lab values such as albumin and electrolyte levels such as potassium and sodium.
2 . Monitor intake and output.
SBO can cause the patient to experience vomiting, which can worsen malnutrition and electrolyte abnormalities. It’s important to record all intake and output sources accurately.
3. Assess nutrition and diet.
Talk with the patient about their current nutritional intake. Inquire about foods that exacerbate symptoms or any food allergies they are aware of.
Interventions:
1. Maintain NPO status as ordered.
Patients will generally be NPO at first to rest the bowel. This reduces hyperactivity in the bowel and decreases vomiting which will limit the loss of fluids and nutrients, therefore decreasing further malnutrition.
2. Weigh daily.
Daily weight can help evaluate the patient for malnutrition. It also provides information on how effective the ongoing treatment is while the patient is in the hospital.
3. Resume diet as tolerated.
Once the patient is no longer NPO and is cleared to eat, encourage the patient to advance their diet slowly. Starting with a clear liquid diet and then moving on to smaller meals gives the small intestine a chance to readjust and absorb what is being introduced.
4. Encourage patient involvement.
The patient may be hesitant about eating, fearing that food may cause more symptoms. Encouraging them to make a list of foods they enjoy and would be willing to try may help them feel in control. Also having a chance to eat the foods they most enjoy will help increase their appetite and willingness to eat.
Ineffective Tissue Perfusion
Gastrointestinal tissue perfusion is reduced with small bowel obstruction causing insufficient blood flow that may cause serious complications.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Inflammatory process
- Obstruction
- Ischemia
- Bleeding
- Perforation
- Infection
As evidenced by:
- Abdominal bloating
- Abdominal distension
- Abdominal pain
- Abdominal rigidity
- Altered bowel sounds
- Nausea
- Vomiting
- Blood in the stool
- Altered vital signs
- Altered lab values
Expected outcomes:
- Patient will demonstrate vital signs and complete blood count within acceptable limits.
- Patient will not experience sudden abdominal pain or worsening in distension, tenderness, or rigidity.
Assessment:
1. Assess for signs and symptoms of decreased gastrointestinal tissue perfusion.
Signs and symptoms of decreased gastrointestinal tissue perfusion can appear suddenly or gradually and may include severe abdominal pain, abdominal bloating, nausea, vomiting, and alterations in vital signs.
2. Monitor laboratory values.
Small bowel obstruction can cause dehydration and fluid and electrolyte imbalances. Bleeding may result in low hemoglobin levels. Lactic acid and WBC counts will rise with infection.
3. Assess the abdomen for signs of complications.
Peritonitis causes a rigid abdomen and rebound tenderness. Ischemia may cause sudden abdominal pain, nausea and vomiting, distension, and blood in the stool.
Interventions:
1. Administer fluid and electrolyte replacement.
Small bowel obstruction can cause dehydration, nausea, and vomiting, further decreasing tissue perfusion. Fluids and electrolytes must be replaced for optimal hemodynamics.
2. Administer oxygen therapy.
Oxygen administration prevents hypoxic episodes and ensures adequate oxygen reaches intestinal tissues.
3. Review diagnostic studies.
Diagnostic studies, including abdominal X-rays and CT scans, can help determine the location and severity of the obstruction and any complications in perfusion.
4. Prepare and assist in surgical interventions.
Bowel obstruction can cause abdominal compartment syndrome and increased intraabdominal pressure, resulting in multiple organ failure and death. Surgical intervention can help relieve obstruction, prevent complications, and resolve perfusion problems.
References
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