Perforated bowel

[MomRN0913]

I'm a new homecare nurse for palliative and hospice. (I have been a nurse for 6 years, just new ot homecare)I had a palliative patient I was seeing with my preceptor. Mainly for pain management (CA patient) was having a difficult time with BM's due to decreased mobility, appetite and pain meds. Had BM's every few days, although small, but not much intake.

Saw patient and patient was feeling better, looked better than he has been. Checked Bowel sounds and they were positive, had BM a few days before and his appetite was improved.

Find out the patient perforated his bowel a few days later and was severely impacted.

It's upsetting me, because he had positive BS and said dulcolax helped. Then, it happened.

I don't know what I'm trying to ask. Can patients have normal bowel sounds with such severe impaction?

[Esme12, ASN, BSN, RN]

Yes they can......usually they are described as "Tinkling" in nature there but quieter/musical in nature. If bowel sound are musical. Where is this patients cancer? Can there be mets there that assisted the process? If the patient isn't C/O pain, distention and problems and looking obviously septic...that is all you can do.

[MomRN0913]

They were actually normal BS. And he looked better than ever the last day we saw him. He got better pain control with a better appetite. Poor guy's intubated with a colostomy now.

It was lung CA. Poor guy has no insurance so he was not getting his chemo. He was waiting for his Medicaid to kick in.

[umcRN, BSN, RN]

In the NICU (where bowel perfs and NEC are far too common) an occasional sign of a bowel that's about to perf is INCREASED or hyperactive bowel sounds, especially if you go from none/hypo to hyper, something's usually up. I remember that was a question on my new grad exam when I started in the nicu

[canesdukegirl, BSN, RN]

It is common to have +BS with impaction. Unfortunately, unless you do a rectal exam, there is no way to know if your pt is impacted. Things are moving through, but come to a roadblock right at the end of the large bowel. Think of a traffic jam on a highway looking from a helicopter...things are moving great the first couple of miles, but are at a standstill on the back half.

I see this pretty frequently with pts who are on heavy narcs/low po intake. Don't beat yourself up for that. You couldn't have known given the reports that he has had small BMs. The bowels are large and can hold an ungodly amount of waste. It may help if you could see his abdominal x-ray; then you won't be so hard on yourself.

[canesdukegirl, BSN, RN]

I forgot to ask you if the pt had a resection with or without a colostomy?

[MomRN0913]

Come to think of it, they were a bit hyperactive. I figured because he was eating much and he was saying at that time he was hungry and his wife was making him bacon and eggs!

His wife was who told me what they did, but she said they went in, cleaned him out and he has a colostomy and they might have to go back in.

I feel a little better now. It just really had me bothered. You begin to question your own assessments, but I specifically remember my preceptor telling me to check bowel sounds and me saying "they are definitely there" and she remembers it too.

I have been out of the bedside for a little over a year. Prior to that i was in the ICU and should really know about this stuff, and I kind of feel like I am questioning myself because it's been a long time. You go on your patients word at home with BM's. You actually see them in the ICU. And an x-ray could be easily ordered if there was any question.

Uggghhhh, something new to get used to. The palliatives are rough. There was another one doing so much better,. stronger, we were about to discharge her and back in the hospital:( They are stage 4's, very deconditioned, but still getting treatment.

Just something I have got to get used to

[leslie :-D]

yep, as stated, w/partial obstxn you'd find high-pitched, hyperactive bs.

i always do digitals with my hospice pts, knowing their perception can be a bit off sometimes.

once someone is totally obstructed is when there'd be no bs...

with fecal vomiting very common.

whenever a pt is going to be on an opioid regimen, it is critical that a bowel regimen is also in place...

esp for those who are immobile and extremely ill.

leslie