Small Bowel Obstruction

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I am developing a case study on a patient who had a a emergent SBO with anostomosis due to a mechanical obstruction

Past history CRF, AF, DM type I

The patient continued to be firm and distensed after surgery. No fluactus. Complaints of pain with morphine 5 mg being given. Blood pressure remains in norm range but HR always slightly elevated after surgery. Urine output ususally slightly above the 30 cc an hour guideline.

Doctors pushed fluids and Lasix to encourage urine output to increase. Had wheezes (expiratory & inspiratory) about 2 days out of surgery.

Due to AF put on Lovenox (taken of Coumadin prior to surgery with FFP given in surgery for reveral) 2 days after surgery.

Four days after surgery patient crashes. H/H had been slowly going downward in this time period.

How long does distension last after surgery? Ect.

Sorry, but I am not a med-surg nurse and have never cared for a SBO patient. Need some ideas.

RW

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Specializes in med-surg.

well, what came to mind while reading this is hemmorage. Hemmorage(spelling?) is a compication of small bowel surgery.The low urine output and the decreasing H and H seems to fit.

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

I'm a little confused, was the original surgery for an obstruction, or did she develop the SBO post op? also, how did she "crash", what events happened that day, what was done, what was the outcome?

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Specializes in Med surg, Critical Care, LTC.

I agree, hypovolemia, low urine output, low H&H seems most likely cause. But then infection could cause sepsis too. Really need more details.

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

it sounds like you are probably a student doing an essay type of care plan. there is information on writing care plans in the student forums on this sticky thread:

when trying to solve a problem (such as figuring out why a patient has distention after bowel surgery) or care planning (which is determining many patient nursing problems and strategies to solve them) we have been provided with a tool called the nursing process to assist us. it contains 5 steps that should be followed in sequence. i've expanded on the first 2 steps to help students understand what needs to be done in each step as these two steps are where the most errors and exclusions are made:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

to find out about abdominal surgery and distension following a mechanical obstruction you need to do some reading about the pathophysiology of a bso. also, you didn't mention what the cause of this mechanical obstruction was and what the findings were during surgery. i think that may be important to why there is still distension unless the surgeon made a mistake and perforated this patient's bowel during the surgery or there is a peritonitis going on (both complications of the surgery). was there any cancer or some other disease process going on that may still be present?

this thread in the student forums has good website links you can go to for information to help you complete the assessment phase of this case study:

keep in mind that as nurses we do not diagnose the medical condition, we can only try to understand what is going on by knowing the pathophysiology behind it. all we do is assess the symptoms the patient is having (step #1 of the nursing process), determine what their nursing problems are based upon those symptoms (step #2 of the nursing process) and then develop strategies, or nursing interventions to intervene (step #3 of the nursing process).

from what you've posted, your patient's symptoms include the following, and your nursing diagnoses would be based upon:

  • abdomen firm and distended after surgery
  • no flatus
  • pain
  • hr slightly elevated (this is a symptom of pain)
  • urine output usually slightly above the 30 cc an hour guideline
  • expiratory & inspiratory wheezes (atelectasis, pneumonia, and pulmonary embolism are potential complications of anesthesia)
  • h/h had been slowly going downward (hemorrhage is a complication of the surgery)

since this is a surgical patient, it would be a good idea to consider the complications of undergoing general anesthesia because it sounds like this patient may be experiencing several:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

since this patient also has medical conditions of crf, af, and dm type i it would be a good idea to research a little about each of them as well.

good luck with this case study.

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