Med-Surg - Gastrointestinal System, part 7: Intestinal Obstruction, Ostomies
by Cathy Parkes November 26, 2021 Updated: January 26, 2022 5 min read
Hi, I'm Cathy with Level Up RN. In this video, I am going to talk about intestinal obstruction as well as ostomies. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be making in this video. So definitely stay tuned for that. And if you have our Level Up RN medical, surgical nursing flashcards definitely pull those out so you can follow along with me. First, let's talk about an intestinal obstruction, which is something I see a lot of at the hospital as a wound care nurse. So with an intestinal obstruction, we have the complete or partial blockage of the intestines, and this is a potentially life-threatening situation. So with an intestinal obstruction, we can have a mechanical obstruction, which means the bowel is physically blocked by a tumor, a fecal impaction or adhesions from surgery. Or we can have a non-mechanical obstruction, which is a paralytic ileus, which is caused by a neuromuscular disorder that results in decreased or absent peristalsis. Risk factors for a paralytic ileus include abdominal surgery, electrolyte imbalances, abdominal infections, as well as decreased blood supply to the intestines. Signs and symptoms of an intestinal obstruction include abdominal distension and pain, constipation, possible nausea and vomiting, and absent bowel sounds distal to the obstruction.
If the patient has a small bowel obstruction, that causes profuse vomiting and severe fluid and electrolyte imbalances, it can also cause metabolic alkalosis. If the patient has a large bowel obstruction, that typically doesn't cause much vomiting and usually doesn't result in severe electrolyte imbalances, either. In terms of diagnosis, we would use an abdominal CT with contrast to diagnose an intestinal obstruction. If a patient has an obstruction, we are going to place them on NPO. We're going to place an NG tube to help decompress the stomach, and then we're going to administer fluids and electrolytes as ordered. In terms of surgical interventions, the patient may require a colon resection, which is removal of part of the colon, and they may also need a colostomy, which we're going to talk more about here in just a minute. In terms of nursing care, we're going to maintain strict I's & O's, and then monitor the patient's electrolyte levels and their acid-base balance.
Let's now talk about an ostomy, which is a surgical procedure that reroutes part of the intestine through the abdominal wall, forming a stoma. So an ileostomy is created from the ilium, which is part of the small intestine, and output from an ileostomy will be loose and watery. A colostomy is formed from the large intestine, and the output from the colostomy will vary depending on what type of colostomy the patient has. If the patient has an ascending colostomy, that will be more liquid. If they have a descending or sigmoid colostomy, then their stool output will be more formed. And the reason for this is that the colon, one of its key jobs is to absorb water. So if we're creating an ostomy off of the small intestine, then, there is no chance for the large intestine to absorb that water. And that's why that output is going to be very liquid. If we still have stool going through most of the colon and the ostomy is created out of the descending or sigmoid colon, then the colon had the chance to absorb a lot of that water before we have that output. And that's why it's more formed when we have a descending or sigmoid colostomy. A patient with a new ostomy requires a great deal of education and support. So if you have a patient with a new ostomy, make sure the provider has submitted an order for a wound ostomy nurse to come and help provide some of that teaching. However, you can't rely on the wound ostomy nurse to provide all of that teaching. You need to provide education as well.
So one thing you want to tell your patient to do is to assess their stoma regularly. It should be pink or red, and it should be moist. It should not appear pale or blue, which would indicate the presence of ischemia. If you notice that, that's something you're going to want to alert the provider about right away. You also want to advise your patient to empty their ostomy bag when it is one-third to one-half full. And if there is any leaking, then the whole appliance needs to be changed right away, particularly with ileostomies, because the output from an ileostomy has all of those digestive-type enzymes from the small intestine. And if that stool output sits there on the patient's skin, it will eat away at the patient's skin and cause a great deal of pain and problems. So if you notice that there's any leaking of the ostomy, you need to change the whole thing out and not put a washcloth on there or just tape things on, tape it down. You got to change the whole thing.
When you are changing the appliance, you want to make sure you cut the opening in the barrier - or the wafer, is what it's called sometimes - no more than one-eighth of an inch bigger than the stoma because again, we don't want any stool output on the patient's skin. So the opening needs to be bigger than the stoma, but just barely. So under one-eighth of an inch. In addition, you want to advise your patient to chew their food thoroughly. They should consume a low fiber diet for the first six to eight weeks after they get their ostomy and then avoid foods that cause gas or odor.
All right, it's time for a quiz. I have three questions for you. First question, what type of intestinal obstruction can cause profuse vomiting and severe fluid and electrolyte imbalances? The answer is a small bowel obstruction. Question number two, what type of output would you expect from an ileostomy? The answer is loose and watery output. Question number three, when changing an ostomy appliance, how big should the skin barrier or wafer be cut? The answer is less than one-eighth of an inch bigger than the stoma size. All right. I hope you found this video helpful. If so, be sure to like the video. Leave me a comment. Take care, and good luck with study. Absent bowel sounds below the level of the obstruction, which makes sense, right, if the bowel isn't-- if the, the, the, the, the, the.
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