Nursing Diagnosis for Bowel Obstruction

In this article, we walk you through the small bowel obstruction (SBO) diagnosis, potential care plans, case study, patient teachings, nursing considerations, and more.

Updated:  

This article was reviewed and fact-checked by our Editorial Team.
Nursing Diagnosis for Bowel Obstruction

Table of Contents

What is Small Bowel Obstruction (SBO)?

SBO is a potentially life-threatening condition where the small intestine is blocked, preventing the normal passage of food, air, and fluid. This blockage causes a painful build-up of undigested food, gas, and fluid proximal to the intestinal obstruction(7). 

In layperson's terms, this is a severe case of backed-up plumbing.

SBOs can be 

  • complete.
  • incomplete (or partial).
  • non-strangulated.
  • strangulated (medical emergency).

SBO occurs when the small intestine is either:

  • mechanically blocked (mechanical ileus) or
  • non-mechanically blocked  (functional ileus).

Causes

The leading cause of mechanical ileus is intra-abdominal adhesions from prior abdominal surgery (65%), followed by hernias (15%)(7).

Mechanical ileus from intra-abdominal adhesions occurs when a patient had surgery some time ago, and the intra-abdominal adhesions from that surgery are causing pressure on the small intestine.

The leading cause of functional ileus is post-operative ileus(7).  

Post-operative functional ileus occurs 3-5 days post-abdominal surgery. The bowel responds to manipulation by temporarily shutting down(7).

You will encounter both mechanical and functional ileus in medical-surgical nursing. Symptoms for both mechanical ileus and functional ileus are the same and typically have an acute onset. The acute onset of symptoms helps differentiate small and lower bowel obstructions(7).  

Signs and Symptoms

The classic signs and symptoms of SBO are(7):  

  • abdominal distension.
  • abdominal pain.
  • nausea with vomiting. 

SBOs are diagnosed using:

  • abdominal X-ray,
  • ultrasound, and
  • abdominal CT scan with contrast (gold standard)(7, 6).

Diagnostic Considerations

The differential diagnoses for SBO include the following conditions and diseases (not exhaustive):

  • inflammatory bowel disease (IBD)
  • obstruction of the large intestine
  • pancreatitis
  • acute appendicitis
  • intussusception

Physical Examination

Initially, patients may have intensified bowel sounds due to increased motility-as the bowel is trying to overcome the obstruction by increased peristalsis(7). 

The abdomen is typically tender and distended. Early on in SBO, patients can pass gas and have a bowel movement, or they may have diarrhea(6).

Nursing Tip: A common misconception is that bowel sounds are absent in bowel obstructions. That's not true! In the pathophysiology of SBO, bowel sounds can be hyperactive or absent. Hyperactive bowel sounds are common in early SBO. You'll hear high-pitched tinkly sounds in the upper quadrants(2).

Treatment

The blockage's severity, location, and underlying causes dictate treatment. Treatment for mechanical ileus may include surgery, while treatment for functional ileus is supportive and rarely requires surgery(7). Treatment typically includes:

  • nasogastric tube (NGT) to decompress the bowel for vomiting patients(7).  
  • NPO to rest the bowel.
  • intravenous fluid and electrolyte replacement to replace volume and to correct electrolyte or acid-base disturbances(7).  
  • surgery if indicated(6).
  • antibiotics if suspicion of infection or ischemia(7).

Delaying operative treatment (when indicated)  beyond three days after hospital admission results in increased morbidity rates and longer postoperative hospitalization(5).

A serious complication of SBO is peritonitis.

Case Study

This case study, while shorter and simpler, is similar to NCLEX NGN case studies in that it evolves over time.

Thelma is a 55-year-old female who is three days post abdominal hysterectomy. She has a history of hypertension treated with metoprolol and depression treated with Prozac.

Her history includes knee replacement and cholecystectomy. Thelma is complaining of abdominal cramping and nausea.

She has no known allergies. She has a 20 gauge IV heplock in her left forearm.

Vital signs are:  Temp 98.4, HR 96, B/P 140/90 mmHg, RR 18, O2 sat 97% on room air, and pain level of 6 out of 10.

Nursing Assessment

Thelma is sitting on a gurney, and you assist her in lying supine to better assess her abdomen. Place a folded towel under her knees for comfort and to relax the abdominal muscles(2).

Nursing Tip: Always put your eyes on your patient, front and back! Patients may forget they had surgery or think it's not significant enough to mention. You will be surprised at what you discover, from incidental pacemakers to body piercings to old incisions.

Inspect, auscultate, palpate, and percuss all four abdominal quadrants, as there can be different findings in each quadrant. Perform auscultation before palpation and percussion because palpation and percussion can falsely increase bowel sounds(2).

These are your findings.

  • On inspection, her abdomen appears distended and taut. You take note of the scars on her abdomen from her prior open cholecystectomy. Her surgical incision is clean and approximated.
  • On auscultation, you hear high-pitched bowel sounds in the upper quadrants.
  • On palpation, her abdomen is tender, and she demonstrates guarding (voluntary protective contraction of the abdomen)(2).
  • On percussion, you discover the abdomen is tympanic, which indicates gas(2).

Note: If bowel sounds had been absent, listen for a full 3 minutes before confirming their absence(2).

Based on your assessment, you immediately remove her water pitcher, anticipating an NPO order as soon as you call the provider.

What is the significance of the tympanic abdomen? A tympanic abdomen is like a drum with a tight drumskin. Trapped air causes distention and tympany.
What is the significance of the high-pitched bowel sounds in the upper quadrants? High-pitched bowel sounds can be normal, but if they are high-pitched, hyperactive, and found in combination with abdominal tenderness and distention, there is pathology.
What is causing the elevated heart rate and blood pressure? Most likely pain and anxiety.

Nursing Tip: Always compare symptoms and vital signs to the patient's baseline! A patient's variance from baseline drives appropriate, individualized  treatment.

You need to call the provider, who was planning to discharge, but you need to have all pertinent information. Review the chart, anticipating what the provider may ask.

Review chart

You reviewed this morning's resulted labs. Labs come back with an abnormal white blood cell count of 12,000/mm3, slightly elevated but non-specific.

While you're reviewing the chart, Thelma suddenly projectile vomits a large amount of bilious fluid and undigested food.

Nursing Tip: Emesis that is fecal in odor suggests a more distal obstruction while emesis that is bilious with undigested food suggests a more proximal obstruction.

Thelma's vomitus does not have a fecal odor.

The first order of business in suspected SBO is to keep a sufficient number of emesis bags or basins close by within your patient's reach. Vomiting in SBO is sudden and forceful.

Nursing Hack: Put a dab of Mentholatum in your nose under your mask when you're going into a room where you'll be exposed to noxious odors. If you don't have Mentholatum, you can sandwich toothpaste between 2 cloth masks.

What's your assessment at this point? At three days post-op, Thelma is at risk for a functional ileus. With her history of cholecystectomy and possible adhesions, she also has a risk factor for mechanical ileus.
What's your first priority?

When prioritizing, always think airway, breathing, and circulation first. In this case airway, breathing, and circulation are good, so you continue to prioritize the problems at hand.

Knowing that SBOs can be a medical emergency, you prioritize contacting the provider.

Alleviating pain is also a priority, and a colleague or charge nurse can help you.

Thelma has PRN pain medication already ordered in the chart from her surgery. 

Before calling, gather all your information, anticipate questions, and have the electronic medical record open. 

Nursing Tip: Know what orders to expect so you'll know if you don't get them.

You call and reach the on-call surgeon, Dr. Jones, as the operating surgeon is out of town.

Using Situation-Background-Assessment-Recommendation (SBAR)(4), you give the following information: 

S: Patient vomited a large amount of undigested food. Her abdomen is tender, distended, and tympanic with guarding.2 She has hyperactive, high-pitched bowel sounds in the upper quadrants. She is afebrile with temp 98.4, HR 96, B/P 140/90, RR 18, and O2 sat 97%.

B: She's post-op day three total abdominal hysterectomy performed by Dr. Out-of-Town. She has a history of cholecystectomy and no known allergies.

A: My assessment is that she possibly has an SBO. 

R: Would you like me to place an NG tube to low intermittent suction and start IV fluids?

Dr. Jones starts dictating the following orders:

  • Stat CT scan with contrast
  • Basic metabolic panel (BMP) 
  • CBC
  • Ondansetron (Zofran) 8 mg twice daily IV as needed for nausea
  • Lactated Ringers at 125 mL an hour
  • Cefazolin 1 gm IV every 8 hrs
  • NPO 
  • NG tube to low intermittent suction.

You ask Dr. Jones if she will be entering the orders electronically herself, as your facility prohibits telephone and verbal orders unless it's an emergency. She says yes and that she will be in to see the patient soon.

Note: If you must take a telephone order, be sure and conduct a read-back(4).

NG tube

NG suction removes the content closest to the obstruction in patients who are vomiting or distended.

Note: The use of an NG tube is common, although there is no evidence to support its routine placement in the lack of emesis(7,3,6).

NG suction is intermittent, not continuous. 

Nursing Tip: Be sure to set your wall suction to intermittent and not continuous. You don't want the NG tube sticking to the stomach mucosa!

Patients typically feel a great deal of relief once the NG tube is placed.

Now it's time to document your assessment and formulate a care plan. There are always several nursing diagnoses and interventions to choose from, and most electronic documentation platforms make it easy to associate interventions with diagnoses.

In addition, there are different formats for writing a nursing care plan. Nursing students should be aware of what their institution and instructors require.

Nursing Care Plans (NCP) for SBO

The examples below are typical of the detailed kind of handwritten care plan required of a nursing student using NANDA-I approved nursing diagnoses. When creating your care plan, use the nursing process.

Risk of Deficient Fluid Volume Care Plan

Nursing Diagnosis: Risk of deficient fluid volume as evidenced by NPO status, gastrointestinal losses, nausea and vomiting

Assessment:

  • Pt has nausea and vomiting
  • Pt is NPO

Goals & Outcomes:

  • Pt will be free of nausea and vomiting 
  • Pt will be able to take sufficient fluids by mouth
  • Patient will be normovolemic

Nursing Interventions & Rationales:

  • Administer IV fluids 
  • Administer anti-emetics 
  • Monitor I&O

Rationale: Fluid imbalance must be corrected immediately to mitigate severe hypovolemia.

Risk of Electrolyte Imbalance Care Plan

Nursing Diagnosis: Risk of electrolyte  imbalance as  evidenced by gastrointestinal losses.

Assessment:

  • Pt has NG suction

Goals & Outcomes:

  • Serum electrolytes will be within normal range within 24 hrs

Nursing Interventions & Rationales:

  • Monitor serum electrolytes
  • Administer IV electrolyte replacement as needed

Rationale: To mitigate severe electrolyte imbalance, electrolyte imbalance must be corrected immediately.

Gastrointestinal losses, such as vomiting or NG suctioning, can result in hypokalemia(7).

Acute Pain Care Plan

Nursing Diagnosis: Acute abdominal pain r/t pressure, abdominal distention as evidenced by ℅ pain.

Assessment:

  • Pt ℅ acute pain 7/10
  • HR 98, B/P 145/90
  • Facial grimacing

Goals & Outcomes:

  • Pt will describe satisfactory pain control at an acceptable level of 3 or below after PRN pain medication

Nursing Interventions & Rationales:

  • Administer PRN pain medication
  • Assess for pain and after PRN pain meds document
  • Decompress bowel with NG suction

Rationale: NG tube provides symptomatic relief. Abdominal pressure caused by trapped air is painful.

Dysfunctional Gastrointestinal Motility Care Plan

Nursing Diagnosis: Dysfunctional gastrointestinal motility r/t effects of surgery.

Assessment:

  • Abdomen distended tender
  • Intermittent hyperactive bowel sounds in upper quadrants

Goals & Outcomes:

  • Pt will pass flatus freely
  • Pt will have normoactive bowel sounds
  • Pt will be free of abdominal distention and pain

Nursing Interventions & Rationales:

  • Ambulate at least twice daily
  • Encourage patient to pass flatus
  • Monitor for abdominal distention, nausea, and vomiting, tympanny
  • Provide chewing gum

Rationale: Exercise increases motility. Pt  may be reluctant to pass gas due to embarrassment. Ambulation and gum chewing increase peristalsis(7).

Risk for Ineffective Coping Care Plan

Nursing Diagnosis: Risk for ineffective coping related to prolonged hospital stay.

Goals & Outcomes:

  • Patient will express any concerns, fears, and feelings r/t SBO complication

Nursing Interventions & Rationales:

  • Provide opportunity to express concerns, fears, and feelings

Rationale: Verbalization of concerns helps reduce anxiety.

Additional Nursing Diagnoses

Other nursing diagnoses could include imbalanced nutrition and knowledge deficit.

Anecdotal

This is about a rule I routinely broke as an experienced nurse. Disclaimer- I don't recommend breaking the rules, at least until you gain experience and can defend your own nursing practice decisions. 

Once nausea and abdominal pain caused by gas are relieved by the NG tube, the most discomfort by far is from parched mouths and chapped lips.

Lemon glycerin swabs leave the mouth sticky and coated and are terrible. Oral swabs and sponges just aren't effective. I couldn't stand to see patients in so much discomfort for no reason. 

So I would put a few ice chips in the center of a washcloth, fold the washcloth over the ice, and pinch right under the ice to make a lollipop. The portion with ice chips resembles the head of a lollipop. The patient can suck on the washcloth lollipop.

Is this technically allowed if your patient is NPO? No. Is it going to harm your patient? No.

Gas is a good thing

Nursing Tip: Have your patient walk and chew gum! Chewing gum increases peristalsis(7).

Patients often apologize for passing gas. Praise them, encourage them, and tell them it's a good sign!  To help pass gas, have them pull up their knees while in bed, turn side to side, bend over frontwards and walk, walk, walk!

STAFF NOTE: Original Community Post

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:

Quote

I'm having trouble finding an accurate Nursing Diagnosis for my patient. She was admitted for Bowel Obstruction and Hypotension. ABD is distended, but not firm. Patient c/o tenderness only when abd is palpitated. NGT to intermittent suction... which later I had to insert a new one because it was pulled out. The patient is a Diabetic and since admission to the hospital she has had repeated low blood sugars and been given D50 constantly. The doctor only has her on NS @ 125 and when I brought it to the attention of the nurse that the patient may need to be on D5NS or D5 1/2 NS to keep her blood sugars/electrolytes stable, she just said... well that's what he ordered. On my second day to care for the patient, as soon as I went into the room, I noticed the NGT was misplaced again! Her oral mucosa is dry and lips are chapped. I had her remove her dentures to prevent any further irritation. The patient said that she just doesn't know if she can go on anymore. On her CT scan it shows ischemic small bowel and small tumor on the outside of her bowel in the mesentery.

I have to have a physical and a psychosocial diagnosis. I want one that would pertain to the NGT, but I can't find anything that really fits my patient. Can someone please help?

References

1. Ackley, B. J., Ladwig, G. B., Makic, M. Beth Flynn, Martinez-Kratz, M. Reyna, & Zanotti, M. (2020). Nursing diagnosis handbook : an evidence-based guide to planning care. Twelfth edition. St. Louis, Missouri: Elsevier.

2. Ferguson CM. Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 93. Available from: https://www.ncbi.nlm.nih.gov/books/NBK420/

3. Fonseca, A. L., Schuster, K. M., Maung, A. A., Kaplan, L. J., & Davis, K. A. (2013). Routine nasogastric decompression in small bowel obstruction: is it really necessary?. The American Surgeon, 79(4), 422-428.https://journals.sagepub.com/doi/abs/10.1177/000313481307900433

4. Friesen MA, White SV, Byers JF. Handoffs: Implications for Nurses. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 34. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2649/

5.  Keenan, Jeffrey E. MD; Turley, Ryan S. MD; McCoy, Christopher Cameron MD; Migaly, John MD; Shapiro, Mark L. MD; Scarborough, John E. MD. Trials of nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive small bowel obstruction. Journal of Trauma and Acute Care Surgery 76(6):p 1367-1372, June 2014. | DOI: 10.1097/TA.0000000000000246 

6. Long, B., Robertson, J., & Koyfman, A. (2019). Emergency medicine evaluation and management of small bowel obstruction: evidence-based recommendations. The Journal of Emergency Medicine, 56(2), 166-176.https://www.sciencedirect.com/science/article/abs/pii/S0736467918310503 

7. Vilz, T. O., Stoffels, B., Strassburg, C., Schild, H. H., & Kalff, J. C. (2017). Ileus in Adults. Deutsches Arzteblatt international, 114(29-30), 508–518. https://doi.org/10.3238/arztebl.2017.0508

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Nurse Beth

About Nurse Beth, MSN

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Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

You are on the right track. What you need to do next is make a list of all the abnormal data. Try to group it by body systems, or symptoms, that seem kind of similar. Every nursing diagnosis has a set of signs and symptoms called defining characteristics. What you have to do is use a nursing diagnosis reference to find nursing diagnoses that have some of the same symptoms your patient has. Some you may recognize as belonging with certain diagnoses. Some you may not. Try your hand at this first and if you are still having trouble finding matches, ask, and I will help you.

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Thanks! I was thinking about...

"Deficit fluid volume r/t active fluid loss 2nd to continuous nasogastric suction AEB electrolyte imbalance"

I don't think that I mentioned that her Na+ was low and K+ was high. She has non-pitting edema on her back and upper arms, but no where else. Or maybe I should do "Fluid volume excess"? Even though she does have the NGT she still is retaining fluid instead of losing it. Her I/O's aren't matching up with almost a 1000mL difference. That's why I asked why she wasn't on 1/2 NS instead?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Do you have a pathophysiology textbook? With bowel obstructions, there is fluid loss because fluid builds up in the bowel. That's where your patient's abdominal distension is most likely coming from. That fluid is lost because it cannot be absorbed back into the body. And, it's rich with electrolytes. Double whammy. So, deficient fluid volume r/t active fluid loss is correct but it is not due to nasogastric suction. It is due to the bowel obstruction. What do they think is causing this bowel obstruction? Bowel obstructions don't show up out of the blue in healthy people. Did she have prior abdominal surgery? Have they confirmed a malignancy? Your aeb items must be the symptoms, or evidence that support the problem (in this case, the deficient fluid volume). How does an imbalance of electrolytes, specifically hyponatremia and hyperkalemia, cause dehydration? Doesn't. But, that's basically what your statement is saying. The symptoms of this diagnosis are listed under the heading "Defining characteristics" on these webpages. Since the definition of this diagnosis specifically says it is referring to dehydration, I would say that any signs or symptoms of dehydration not listed by nanda would also be acceptable.

Why, beside electrolyte disturbances, do people retain fluid and have non-pitting edema on back and upper arms? Pitting edema of the back and arms is odd and seems more like a circulation problem. I would think that something else is going on. Did this lady have a mastectomy or a splenectomy in the past? What other things went on in her past medical history? Hypotension would suggest that her blood is not being pumped around very efficiently which could result in edema. Knowledge of the underlying pathophysiology of patient's medical conditions is very important in determining etiologies of nursing diagnoses.

Your patient also has acute pain. It doesn't matter that it is only when the abdomen is palpated. Pain is pain. I had colon cancer and one of the things my oncologist never fails to do is assess for or treat abdominal pain no matter how insignificant it might be.

What do you want to do about her dry lips and mouth (impaired oral mucous membranes)?

What about her depression (anticipatory grieving, hopelessness, powerlessness)?

There is a listing of all the psychosocial diagnoses on post #145 of this sticky thread: https://allnurses.com/desperately-need-help-with-care-t126139/

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Yes, she's had a left mastectomy. She has a hx of hypertension, but was experiencing hypotension upon admission to the hospital. She's had umbilical hernia repair and has had a hx on bowel obstructions. Yes there is a tumor, not in her bowel but on the outside of it.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

That is all important information that contributes to and helps explain the pathophysiology of some of these abnormal things you are seeing in this patient's assessment and you can't ignore it.

With mastectomies lymph nodes are also removed making edema of the arm on the affected side a potential complication. If this patient is immobile it increases the likelihood of this happening since the lymphatic system runs parallel to the circulatory system. It also begs the question of metastasis. Breast cancer often metastasizes to the nearby lungs and bone. This brings in the issue of hypotension.

Any time there has been previous abdominal surgery and a history of bowel obstructions there is a risk for obstructions happening again. A tumor in the mesentery is bad news: (1) they are hard to detect (2) when they are found they are generally already well established, and (3) don't you suspect she was told her diagnosis by the doctor if she's making statements like she doesn't know if she can go on anymore? Did anyone ask her?

Your job is to put this information together, determine her nursing problems, and develop intelligent nursing interventions and outcomes based on what you now know.

I asked those questions because they were ones I would have been asking. Of course I have many years of experience so I have a better idea of what to ask. In time and with experience, so will you. I wanted you to get an idea of how you need to be thinking when you are caring for patients. You have to always be thinking "Why is this happening to her?" and hunt down the reasons. Assessment and information gathering (and putting it together) is a never-ending pursuit. You have to be like a detective always looking for information and clues and trying to figure out how they fit into the bigger picture. Making those connections helps in planning nursing care.

Now, some of this patient's oral and throat discomfort is from the presence of the n/g tube (look up the effects of a foreign body on the body--inflammation and immune response: https://allnurses.com/histamine-effect-t177109/.

But the suctioning out of gastric secretions while it may contribute to some electrolyte imbalances (you need lab values to support this), her fluid losses are due to fluid collecting and being lost in her intestines secondary to the bowel obstruction. That fluid collecting in her bowel is only coming out through (1) the orifice, (2) the front end via a cantor tube, (3) on the surgical table if or when she gets opened up.

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Fluid volume deficit would be my focus

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What should know as a student when diagnosis is a priority?

With bowel obstruction, pain or fluid deficit, which diagnosis is my priority?

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Nicky the conure said:

What should know as a student when diagnosis is a priority?

With bowel obstruction, pain or fluid deficit, which diagnosis is my priority?

It would help to make your own post. The priority diagnosis would differ based on your specific patient. But, when trying to figure out your priority diagnosis, you should ask yourself, which is the most danger to my patient? For a bowel obstruction, what are you watching for in terms of possible complications? What diagnosis are those related to?

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

Please never think of nursing diagnosis solely as a subset or result of medical diagnosis. It's not your fault that "Nursing diagnosis handbooks" are all catalogued by medical diagnosis.

As Esme used to say, look at your patient. What do you observe? What do your findings suggest? Flip through your NANDA-I and see what symptoms match; that's how you make (not choose) a nursing diagnosis.

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Specializes in Tele, ICU, Staff Development.

With gastrointestinal losses due to the NG tube, you could pick

  • Risk of electrolyte imbalance 
  • Risk of deficient fluid volume
  • Imbalanced nutrition

A psychosocial diagnosis r/t her condition and NG tube could be

  • Ineffective coping

You can also do

  • Knowledge deficit r/t disease process

Hope this helps!

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

We spend all this time trying to make diagnosticians out of new nurses , teach them that a diagnosis is something a professional MAKES, and then somebody (regrettably, maybe your faculty) comes along and says, "You could PICK one of these off a list.” Do you stop there? Would that be "enough, it's all they wanted"? That's stifling, and limiting.

Students, you don't PICK diagnoses from a list based on a medical diagnosis. You can consider them, assess for them, think about them... but until you do an actual assessment, you cannot write them down as plan faits accomplis.

In this example, your actual patient may or may not actually have the data to allow you to make any of those. You will have to find out before the fact, not go into the room with diagnoses all set in your mind, is all. 

You can certainly assess for risks, as some of these suggest. You have to— a big part of nursing is pt safety, and that means being in the lookout for risks! Just don't let anybody tell you that a risk diagnosis isn't somehow a real diagnosis. We hear students all the time ask for "three actual diagnoses and two potential ones for a patient with myocardial infarction.” They're all real. 

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