Perforated Bowel, S/S in narcotic user?

[nerdtonurse?, BSN, RN]

Had a pt with significant hx of pain (she actually did have a reason, she had degenerative disease in her spine, multiple surgeries and fusions). Came in with back pain to get her normal block, had bowel sounds, etc. This pt had been on pretty heavy narcotics for years, and eerily enough, I did talk to her about trying non-narcotic things for her chronic pain, since that was probably causing the constipation. I've seen too many people end up with colostomies because of narcotic use....She said she had to use "the green liquid stuff" to have a bowel movement, which I charted, and told her I wouldn't give her MOM or anything until the doc saw her; I wanted him to get her on something healthier than "liquid green stuff" whatever that was.... When I had her, her VS were all within bounds, no C/O nausea, belly pain, etc. No obvious abd. distention, but her BMI was about 40, so you could have hid a Buick in there...

Long story short, 4 days later she was dead. They gave her everything in the dibold from MOM to GOLYTELY PREP to try to move her bowels --the Golytely ruptured her colon, they didn't realize what was up until she began throwing up bowel contents. Pt didn't make it.

So....

Given this woman was on major leage narcotics, how could I have known the problem she was having (had I been there when it happened), or is it something you'd had to done a CT of the abdomen to see? Any ideas?

[leslie :-D]

kub gives view of the colon and its contents.

digital exam would have likely revealed hard stool.

really sad...

leslie

[nerdtonurse?, BSN, RN]

I asked day shift if they did a digital and they said they got nothing. I think they said the rupture was in the transverse where it made the turn on the left....She had bowel sounds for 2 days after I had her, then they stopped, and things went bad.

I just wonder if there's anything I could have spotted, given that she wouldn't have reported pain d/t the pain meds she was already on, and you couldn't tell distention d/t her morbid obesity....when I had her, she might have just been constipated, and the rupture hadn't happened yet, but I just haven't seen this enough to get a good mental picture of what to look for.

[angelique777]

I dont know the answer to your question. Out of curiosity how many days since her last Bowel Movement at the time of her visit to the clinic when she saw you. Really curious about that and how long after she saw the provider did she die. How old was she ????

Really sorry she passed on terrible it was not caught in time but based on what you said she was asymtomatic and didnt complain of abdominal pain. Really sad

[nerdtonurse?, BSN, RN]

It was just 3 days when I saw her, and within her normal pattern -- she usually said she had a BM about once a week, but had to take "the green stuff" to make it happen. They started giving her MOM, colace, miralax that day, then moved on to everything in the dibold the next day as she continued to complain of constipation. I think that was the day she started vomiting fecal material, and then they took her to surgery for exploratory and found the perforation, but she had peritonitis and just crashed in ICU that night.

I guess what's tripping me out is she was in her mid 40's -- only 3 months older than me.

[Virgo_RN, BSN, RN]

Bowel perfs can have a sudden onset, with rigid, boardlike abdomen, sudden onset of severe abdominal/shoulder pain, and hypoactive to absent bowel tones being your clinical manifestations. It sounds to me like she didn't have the perf yet when you had her.

Even with an obese abdomen, you can still palpate firm or soft underneath the layer of adipose tissue. Also, while on narcs for her chronic back pain, she may well have experienced a change in the location and quality of her pain that would indicate something was different from the norm for her. The absence of bowel tones is obviously a clue.

[litbitblack, ASN, RN]

Bowel perfs can have a sudden onset, with rigid, boardlike abdomen, sudden onset of severe abdominal/shoulder pain, and hypoactive to absent bowel tones being your clinical manifestations. It sounds to me like she didn't have the perf yet when you had her.

I also understood that if you were already having severe abd pain that another sign is the sudden disappearance of that pain. Had that happen once, i did catch it and the pt went to surgery within 2 hours....

[leslie :-D]

with obstxn, bowel sounds can also be hyperactive w/tinkling sounds.

i've seen that quite often as well...

who knew?

leslie

eta: hyperactive/high-pitched sounds can be indicative of early bowel obstxn...

which inevitably leads to absent bs.