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
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complete.
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incomplete (or partial).
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non-strangulated.
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strangulated (medical emergency).
SBO occurs when the small intestine is either:
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mechanically blocked (mechanical ileus) or
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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):
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abdominal distension.
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abdominal pain.
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nausea with vomiting.
SBOs are diagnosed using:
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abdominal X-ray,
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ultrasound, and
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abdominal CT scan with contrast (gold standard)(7, 6).
The differential diagnoses for SBO include the following conditions and diseases (not exhaustive):
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inflammatory bowel disease (IBD)
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obstruction of the large intestine
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pancreatitis
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acute appendicitis
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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:
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nasogastric tube (NGT) to decompress the bowel for vomiting patients(7).
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NPO to rest the bowel.
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intravenous fluid and electrolyte replacement to replace volume and to correct electrolyte or acid-base disturbances(7).
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surgery if indicated(6).
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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.
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.
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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.
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On auscultation, you hear high-pitched bowel sounds in the upper quadrants.
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On palpation, her abdomen is tender, and she demonstrates guarding (voluntary protective contraction of the abdomen)(2).
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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:
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Stat CT scan with contrast
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Basic metabolic panel (BMP)
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CBC
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Ondansetron (Zofran) 8 mg twice daily IV as needed for nausea
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Lactated Ringers at 125 mL an hour
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Cefazolin 1 gm IV every 8 hrs
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NPO
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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.
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:
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Pt has nausea and vomiting
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Pt is NPO
Goals & Outcomes:
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Pt will be free of nausea and vomiting
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Pt will be able to take sufficient fluids by mouth
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Patient will be normovolemic
Nursing Interventions & Rationales:
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Administer IV fluids
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Administer anti-emetics
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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:
Goals & Outcomes:
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Serum electrolytes will be within normal range within 24 hrs
Nursing Interventions & Rationales:
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Monitor serum electrolytes
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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:
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Pt ℅ acute pain 7/10
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HR 98, B/P 145/90
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Facial grimacing
Goals & Outcomes:
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Pt will describe satisfactory pain control at an acceptable level of 3 or below after PRN pain medication
Nursing Interventions & Rationales:
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Administer PRN pain medication
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Assess for pain and after PRN pain meds document
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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:
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Abdomen distended tender
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Intermittent hyperactive bowel sounds in upper quadrants
Goals & Outcomes:
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Pt will pass flatus freely
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Pt will have normoactive bowel sounds
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Pt will be free of abdominal distention and pain
Nursing Interventions & Rationales:
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Ambulate at least twice daily
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Encourage patient to pass flatus
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Monitor for abdominal distention, nausea, and vomiting, tympanny
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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:
Nursing Interventions & Rationales:
Rationale: Verbalization of concerns helps reduce anxiety.
Additional Nursing Diagnoses
Other nursing diagnoses could include imbalanced nutrition and knowledge deficit.
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
