The Ostomy Files: Patient Teaching: Intestinal Obstruction
Because bowel obstruction is a common complication that quickly can become a medical emergency, patients with ileostomies and colostomies should be educated on the etiology of intestinal obstruction, ways to protect against its occurrence, steps to take at home, and when they should seek professional medical intervention.
Generally, bowel obstructions (often referred to as blockages by patients) can be categorized into two groups: 1) physical, mechanical, or dynamic obstructions; and 2) adynamic obstructions, also called paralytic ileus or ileus.
Dynamic obstructions can occur in both the large and small intestine; however, most occur in the small intestine. This type of mechanical obstruction can occur inside the lumen of the bowel, inside the bowel wall, or external to the bowel. Dynamic obstructions in the large bowel usually develop over time (eg, malignancy), but those in the small intestine often occur more rapidly (eg, food blockage). Adhesions from previous abdominal surgery are the most common cause of small intestine dynamic obstruction, but Crohn's disease is also a frequent culprit. Malignancy such as left-sided primary adenocarcinoma of the colon and ovarian cancer are among the most common causes of dynamic obstruction of the colon, but severe constipation is also a common etiology, especially in older persons with a colostomy.
Adynamic obstruction is also a common complication, but differs from dynamic obstruction in that it is the result of loss of normal peristalsis due to abdominal surgery, administration of narcotics or anesthesia, manipulation of the bowel during surgery, infection, or even severe electrolyte imbalance. Symptoms of adynamic obstruction mimic those of dynamic obstruction except bowel sounds are absent on auscultation. Adynamic obstruction is a frequent postoperative complication of intestinal surgery.
Distinct physiological changes occur when the bowel is obstructed. Bowel proximal to an obstruction becomes hyperactive as it tries to push the bowel contents around and past the obstruction. Peristalsis may be visible on the patient's abdomen and bowel sounds increase and are often high-pitched on auscultation. As bowel distal to the obstruction collapses, reverse peristalsis causes vomiting. As the obstruction progresses, the proximal bowel continues to distend and becomes atonic. Bowel sounds halt as the abdominal distention continues. Enormous volumes of fluid are shifted into the bowel, causing fluid and electrolyte imbalances in addition to the fluid and electrolyte losses from vomiting. Dynamic and adynamic obstructions can partially or completely obstruct the bowel. A small amount of mucous or liquid stomal output accompanied by the classic signs of obstruction usually indicates a partial blockage. Complete obstruction should be suspected if no stool or gas output from the stoma occurs.
Patients usually present with an acute onset of symptoms including abdominal cramping, abdominal distention, stomal edema, nausea, vomiting, muscle cramps, minimal-to-no passage of stool or flatus through the stoma, and dehydration. Every new ostomy patient should be instructed to recognize these symptoms, what to do before seeking medical assistance, and when to seek professional assistance. Patients suspected of having a bowel obstruction should be evaluated by a physician or WOC nurse in a timely fashion, as imbalances in fluids and electrolytes must be corrected and the etiology of the obstruction determined. Unresolved bowel obstructions can lead to perforation and may require emergency surgical intervention.
Nurses caring for ostomy patients should include an in-depth educational session on bowel obstruction as part of routine pre- and postoperative patient teaching. Handouts should be developed that list the common signs and symptoms of bowel obstruction, a list of actions the patient should and should not take if obstruction is suspected, as well as the contact information for appropriate medical personnel (eg, colorectal surgeon, WOC nurse, local emergency room). A patient teaching session on diet and fluid and electrolyte balance segues naturally into a discussion of bowel obstruction.
Tables 1, 2, and 3 detail some suggestions for content to include in patient teaching materials on intestinal obstruction.
The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.