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1. CASE PRESENTATION:
Intestinal Obstruction (Volvulus) in
Geriatric Patient
Reynel Dan L. Galicinao, RN
Student, Master in Nursing
Major in Nursing Educational Administration

2. Contents
Objectives
Overview
Nursing Health Assessment
Gordon’s Assessment
Physical Examination and Review of Systems
Pathophysiology
Laboratory and Diagnostic Tests

3. Contents
Medical Management
Surgical Management
Summary of Medications
Drug Study
Nursing Care Plan
Concept Map
Discharge Plan

4. OBJECTIVES

5. General Objectives
• Within the case presentation session, the
audience will be able to discuss the
etiology, pathophysiology, and
medical, surgical, and nursing interventions of
intestinal obstruction.

6. Specific Objectives
Within the case presentation session, the audience will be
able to:
1. Describe intestinal obstruction
2. List the risk factors of intestinal obstruction
3. Trace the pathophysiology of intestinal obstruction
4. Determine the signs and symptoms associated with intestinal obstruction
5. Identify diagnostic and laboratory procedures for intestinal obstruction
and their corresponding nursing responsibilities
6. Enumerate possible medical and surgical interventions for intestinal
obstruction
7. List the medications to be given for intestinal obstruction
8. Identify possible nursing diagnoses for intestinal obstruction
9. Plan appropriate independent and interdependent nursing interventions
for intestinal obstruction
10. Write a discharge plan for intestinal obstruction

7. OVERVIEW

8. Intestinal Obstruction
• Interruption in the normal flow of intestinal
contents along the intestinal tract
• The block:
– may occur in the small or large intestine
– may be complete or incomplete
– may be mechanical or paralytic
– may or may not compromise the vascular
supply
• Obstruction most frequently occurs in the young
and the old

9. Causes
(A) Intussusception - shortening of
the colon by the movement of
one segment of bowel into
another
(B) Volvulus of the sigmoid colon -
the twist is counter clockwise
in most cases of sigmoid
volvulus
(C) Hernia (inguinal) - the sac of
the hernia is a continuation of
the peritoneum of the
abdomen and that the hernial
contents are
intestine, omentum, or other
abdominal contents that pass
through the hernial opening
into the hernial sac

10. TYPES OF INTESTINAL
OBSTRUCTION

11. Mechanical obstruction
• A physical block to passage of intestinal contents
without disturbing blood supply of bowel
• Causes:
– Extrinsic—adhesions from surgery, hernia, wound
dehiscence, masses, volvulus
– Intrinsic—hematoma, tumor, intussusception,
stricture or stenosis, congenital, trauma, inflammatory
diseases
– Intraluminal—foreign body, fecal or barium impaction,
polyp, gallstones, meconium in infants.

12. Paralytic (adynamic, neurogenic)
ileus
• Peristalsis is ineffective
• There is no physical obstruction and no
interrupted blood supply
• Disappears spontaneously after 2 to 3 days
• Causes:
• Spinal cord injuries; vertebral fractures.
• Postoperatively after any abdominal surgery.
• Peritonitis, pneumonia.
• Wound dehiscence (breakdown).
• GI tract surgery.

13. Strangulation
• Obstruction compromises blood supply, leading to
gangrene of the intestinal wall
• Caused by prolonged mechanical obstruction.

14. NURSING HEALTH
ASSESSMENT

15. Demographic Data
• Name: “Mr. William Lippincott”
• Address: Poblacion, Midsalip, Zamboanga del
Sur
• Age: 77 years old
• Sex: Male
• Status: Widower
• Religion: Roman Catholic
• Occupation: Bookkeeper

16. Health History
A. Chief Complaint/s:
• Abdominal pain
B. Impression/Admitting Diagnosis:
• Acute abdominal problem secondary to volvulus; gangrenous
ileum 35 cm from ileocecal valve with ileoileal anastomoses.
C. History of Present Illness:
• One month prior to admission, patient had complaints of
epigastric pain, described as crampy, graded at 8/10,
intermittent, aggravated by eating solid foods, patient can
only tolerate to eat porridge with flaked fish sprinkled on it,
alleviated by application of Efficascent oil to abdomen, and
rest. Patient had a feeling of strong urge to fart or expel flatus
but was unable to do.

17. Health History (cont.)
• Patient had loose bowel movement for 3 days prior to
admission, intermittent, brown-colored, unformed stool.
• Few hours prior to admission, pain became generalized and
unrelieved with oral medications thus prompted admission;
no fever, no vomiting, no tarry stool. Last bowel movement
was the morning before admission (September 26, 2011)
with mucoid stool. Patient is a bookkeeper and a regular
member of parish church.
D. History of Past Illness/es:
• Patient was hospitalized for 1 week last July 2008 due to
Pneumonia. Patient reported he had “complete
immunization”. Patient takes Centrum 500 mg 1 tablet, once
a day. Patient had blood transfusion (1989) but he could not
recall the details. No known allergies. Born via NSVD.

18. Health History (cont.)
E. Health Habits
Frequency Amount Period
Tobacco None None None
Alcohol None None None
OTC drugs/non-prescription drugs
Specify: Centrum OD 500 mg Tab 1 year
F. Family History with Genogram
History of Heredo-familial diseases:
Cancer X
_____
DM /
_____
Asthma X
_____
Hypertension X
_____
Cardiac Disease _____
X
Mental Disorder _____
X
Others _____
X

19. Health History (cont.)
G. Patient’s Perception of
• Present Illness: Pt reported, “Nawala naman ang sakit
sa akong tiyan karon, bag-o paman gud ko gitagaan ug
tambal para mawala ang sakit.”
• Hospital Environment: Pt reported, “Ok raman ang
kwarto dire aircon, komportable ra man.”
H. Summary of Interaction
• Patient was sleeping upon nurse’s arrival. During physical
assessment, patient woke up and nurse continued
assessment. Patient appears weak but still answered the
nurse’s interview questions and cooperated in the
assessment.

20. GORDON’S
ASSESSMENT

21. Normal Pattern Before Hospitalization Clinical Appraisal
Activities – Rest Pt usually sleeps at 9 pm, and Pt has been lying on bed the
a. Activities then wakes up at 6 am. Pt whole day. Moves/ changes
b. Sleeping pattern takes a bath every day except position with assistance. Pt
c. Rest for Tuesdays and Fridays r/t was not able to sleep in the
his cultural belief. Pt goes to morning due to pain, but was
work as a bookkeeper, and able to sleep for 2 hours in
then goes to city hall, BIR, the evening. Pt appeared
and then church. Few weeks very weak and sleepy.
PTA, pt usually takes naps in
the afternoon.
Nutrition – Metabolic Few days PTA, pt only eats Pt is on NGT early this
a. Typical intake (food or quaker oats, drinks water, morning, but was removed
fluid) coffee, and flaked fish on later in the morning then diet
b. Diet porridge. No diet restriction. changed to clear liquids
c. Diet restriction Weight not taken, unknown. limited to 15 ml/ hr Pt is
d. Weight Takes Centrum 500 mg tab taking Paracetamol 500 mg 1
e. Medication/Supplem once a day. tab every 4 hours, prn;
ent food Telmisartan (Micardis) 40 mg
tab OD every HS.

22. Normal Pattern Before Hospitalization Clinical Appraisal
Elimination Pt was able to urinate Pt was able urinate once on
a. Urine (frequency, approximately 1-2 times per his diaper, with clear and
color, transparency) day, with clear and yellow yellow urine, had changed
b. Bowel (frequency, urine. Pt defecated > 3x for diaper once. Pt has not
color) LBM with color brown, been able to defecate this
unformed, intermittent LBM day.
for 3 days.
Ego Integrity Pt reported, “ok ra baya Pt reported “ok ko ron”. Pt
a. Perception of Self akong kinabuhi”. Pt has 8 has 8 children, with his
b. Coping Mechanism children, has been living whole family visiting him
c. Support Mechanism with his daughter. He goes regularly, with friends also
d. Mood/Affect to work, and a part of lay visiting him regularly. He
minister of parish church, he prays for his health
goes to church regularly. Pt condition. Pt appears very
has normal affect congruent weak but with normal affect
to behavior c calm mood. congruent to behavior, with
calm mood.

23. Normal Pattern Before Hospitalization Clinical Appraisal
Neuro-Sensory Pt is in well mental being. Pt Pt is in well mental being,
a. Mental State speaks clearly and logically speaks clearly and logically
b. Condition of 5 with normal pace. Pt has within normal pace. Pt has
senses (sight, intact senses: Able to read intact senses as tested: Able
hearing, smell, with aid, hear, feel, touch to read with aid, hear, feel,
taste, touch) and discriminate, smell and touch and discriminate,
taste. smell and taste.
Oxygenation and Vital VS not taken but has history RR: 22 cpm
Signs of Pneumonia and was PR: 86 bpm
a. Respiratory rate hospitalized for a week last HR: 86 bpm
b. Pulse rate 2007. BP: 130/80 mmHg
c. Heart Rate Pt has decreased breath
d. Blood pressure sounds on lower lobes.
e. Lung sounds Pt has history of pneumonia
f. History of and was hospitalized for a
respiratory week last July 2008.
problems

24. Normal Pattern Before Hospitalization Clinical Appraisal
Pain – Comfort Epigastric pain, graded Pain – 0/10 upon
a. Pain (location, 8/10, for 2 weeks already, assessment since pt has
onset, intensity, with LBM for 3 days but just been given an
duration, associated intermittent with brown analgesic.
symptoms, unformed stool, aggravated
aggravation) with solid foods; alleviated
b. Comfort with Efficascent oil and rest.
measures/alleviatio
n
c. Medication/s
Hygiene and activities of Pt takes a bath everyday Pt has not taken a bath
daily living upon waking up except for since admission. Pt changes
Tuesdays and Fridays. Pt position with assistance lies
goes to work as on bed the whole day. Sleep
bookkeeper, goes to City is disturbed due to pain; was
Hall, BIR, and church. He only able to sleep for 2
sleeps at 9 pm-6 pm hours this evening for this
day.

25. Normal Pattern Before Hospitalization Clinical Appraisal
Sexuality Patient is a male, 77 Patient is a male, 77
a. Male years old, widower, with years old, widower, with
(circumcision, 8 children, circumcised 8 children, circumcised
civil status, at 6 years old. at 6 years old.
number of
children)

26. PHYSICAL
EXAMINATION AND
RREVIEW OF SYSTEMS

27. General
• Patient is male, 77 y/o, lying semi-fowler’s position in
bed, sleeping, but later was awakened.
• Has mild body and breath odor.
• Conscious, and oriented to person, and place.
• Calm and with normal affect congruent to
behavior, speaks clearly, logically, and with normal
pace.
• Appears very weak and sleepy
• Has #17 D5 LR 1 L with 650 cc left, hooked at right
arm, regulated at 30 gtts/min, patent and infusing
well.

28. HEENT
• H- Patient has wavy, white-streaked hair, equally distributed,
no infestations, facial features are symmetric, slightly oval in
shape. Skin is wrinkled at the forehead and cheeks.
• E- has moist, pink conjunctiva, anicteric sclera, able to read
with aid, pupils are black, constricts 2 mm when lighted, 4
mm when not, PERRLA.
• E- able to hear adequately; ears have dry, brown cerumen,
level with eyebrows
• N- able to smell adequately, patent and equal nostrils, no
nasal flaring, nasal septum at midline, with dried up mucus.
• T- oral mucosa is pale and dry, lips are parched. Tongue is
pink, dry, and parched. With dental carries, tonsils are not
enlarged/flat. Has slight breath odor, able to swallow, and gag
reflex present.

29. Integumentary System
• Patient’s skin is dry, warm, rough in some parts, and
brownish in color; Temperature is 37.8 ˚C.
• Skin in feet is dry, scaly, and pale
• has body hairs equally distributed on contralateral parts of
the body
• Has good skin turgor, with nonpitting edema on dorsal part
of both feet, but with a grade 1+ pitting edema on the
ankles
• Has median incision on abdomen; open wound below the
umbilicus, with length of 9 cm and width of 6 cm, yielding
yellow-greenish drainage with foul odor.
• Nails are long, no clubbing, CRT 2-3 sec; nails are in normal
angle and shape/ curvature, but with pale nail beds

30. Respiratory System
• Patient has chest shape 1:2 anteroposterior to transverse.
• Chest movement is symmetric, diaphragmatic exursion is equal
and symmetric, but restricted. Spine is vertically aligned. Chest
expansion is slightly restricted.
• Tactile fremitus is palpated, symmetrical bilaterally.
• Breath sounds on the upper lung fields are clear, but decreased
breath sounds on the lower fields. RR-22 cpm, and with effort
• Uses abdominal accessory muscles and internal intercostal
muscles when breathing. Flaring nostrils noted. Pt breathes
with open mouth.
• Respiration is rhythmic, with regular pattern and normal depth.
No adventitious breath sounds
• Has moderate ascites that pushes the diaphragm upwards, thus
restricting lung expansion, as reflected on UTZ, and physical
assessment.

31. Cardiovascular System
• Patient is pale, with pale extremities
• Anterior chest has symmetrical features
• Neck veins are flat on semi-fowler’s position.
• Skin is warm to touch. PMI is at fifth intercostal space, left
midclavicular line
• Pulse is graded 1+ on all extremities, equal
bilaterally, weak, and thready as palpated
• Nonpitting edema on both feet. CRT is 2-3 sec. HR-86
bpm, PR-86 bpm, resonant to dull at midclavicular line
• S1 is heard best on apex, S2 at base. No murmurs. Heart
sounds have irregular pattern, with S4.

32. Digestive System
• Abdomen is flabby/globular, light brown, uniform all over.
Umbilicus is at midline, with median incision on abdomen.
Landmarks are palpated in appropriate places, liver
borders, xiphoid process, and bladder. No signs of
enlargement
• Chest rises on inspiration and deflates on expiration.
Hypoactive bowel sounds of 3/min. dull on liver, tympany
on intestine, flat on ribs upon percussion
• No pulsations or masses with thickness only on deep
palpation. Abdominal girth is 107 cm
• Oral mucosa is pale and dry; tongue is pink, dry, and
parched. With dental carries, has slight breath odor, able to
swallow, and gag reflex present
• On clear liquid diet. Pt has moderate ascites.

33. Excretory System
• Patient has urinated on diaper, which was changed once
for the whole day, with clear, yellow urine
• No burning sensation upon urination
• Bladder is slightly palpable
• Unable to defecate for 2 days already.

34. Musculoskeletal System
• Patient’s muscles on upper extremities are equal in size
bilaterally, measures 24.5 cm thigh 23.5 cm on right and
27.5 cm on left, calf is 35 cm on right and 31.5 cm on left.
• Has firm tone, smooth and coordinated in movement
graded 4+ on extremities
• PROM and AROM performed
• Patient is able to change position with assistance
• Patient is able to move toes
• Pt has nonpitting edema on both feet, pitting on the
ankles grading 1++. Pt has moderate ascites.

35. Nervous System
• Patient is conscious, and oriented to person, place, but
confusion noted at times
• Calm and with normal affect congruent to
behavior, speaks clearly, logically, and with normal pace
• Cranial nerves tested and found functioning
• Reflexes are 2+ bilaterally, superficial reflexes present
• Able to contrast pain, temperature appropriately and able
to differentiate temperatures
• Able to move but slowly and with assistance.
GCS=14, muscle strength 4+ on all extremities.

36. Endocrine System
• Patient has no history of hormonal/endocrine problems,
thyroid is not enlarged, skin is dry and warm to touch.
Patient has no known allergies.
Reproductive System
• Patient is a widower, with eight children, was circumcised
at age 6 y/o. no pain upon urination, no abnormal masses
on his reproductive organ reported by patient.

41. LABORATORY AND
DIAGNOSTIC TESTS

42. Hematology
NORMAL Sep 26 Sep 27 Sep 28 Sep 29 Sep 30 Oct 1 IMPLICATIONS
VALUE
135-160 Anemia, decreased 2° to
Hgb 133 136 105 103 116 110
g/L blood loss 3° surgery
Decreased, anemia 2°
Hct 0.40-0.48 0.4 0.4 0.31 0.21 0.34 0.32
blood loss 3° surgery
Increased, indicates
infection 2° current
WBC 5-10 x10/L 11.3 12.8 13.1 12.8
abdominal problem and
surgical procedures
Increased, indicates
Neutrophil 0.55-.65 0.79 0.84 0.88 0.8
bacterial infection
Decreased, indicates
bacterial infection,
Lymphocyte 0.25-0.4 0.21 0.14 0.1 0.2 decreased because
outnumbered by
neutrophils
Monocyte 0.02-0.06 0.01 Indicates infection
Eosinophil 0.01-0.05 0.01 0.02 Normal

43. Urinalysis (10/2/2011)
NORMAL VALUE RESULT IMPLICATIONS
Color yellow/amber dark yellow normal
pH 4.5-8.0 6 normal
Sp. Gravity 1.005-1.030 1.015 normal
Sugar negative ++ normal
Protein negative 8-10/hpf Indicates proteinuria
Pus negative 8-10/hpf Indicates bacteriuria
RBC negative 2.4/hpf Indicates hematuria
Epithelial cells rare few normal
Indicates dehydration, or
Crystals negative moderate improper hydration
Bacteria negative moderate indicates bacteriuria, UTI
Granular cast
(coarse) 2-4/hpf 8-10/hpf indicates ineffective GRF

44. Blood Chemistry
NORMAL Sep 28 Oct 2 Oct 3 IMPLICATIO
VALUE NS
SODIUM 135-148 143.4 Normal
mmol/L mmol/L
POTASSIU 3.5-5.3 4.88 5.19 4.83 Normal
M mmol/L mmol/L mmol/L mmol/L

45. Chest X-ray AP view (9/30/2011)
INDICATION NORMAL VALUE RESULT IMPLICATIONS
Used to Normally appearing Hazy densities at the right - cardiomegaly
diagnose and positioned paracardiac aorta and left - calcified aorta
pulmonary chest, bony thorax lung base suggestive of - pneumonitis
diseases and (all bones present, PNEUMONITIS. There is - pneumo-
disorder of aligned, suspicious free-peritoneal peritoneum
mediastinum, symmetrical, and air below the hemi-
and bony normally shaped), diaphragm suggestive of:
thorax, to soft tissues, pneumo-peritoneum
evaluate heart mediastinum, lungs, cardiomegaly AP view
condition. pleura, heart, and Calcified aorta
aortic arch.

46. Ultrasound-Liver (10-5-2011)
INDICATION NORMAL VALUE RESULT IMPLICATIONS
Valuable in The size and shape of Normal in size exhibiting Ultrasonically
detecting a the abdominal homoenous parenchymal normal size
variety of organs appear Echo pattern in relation to the liver
pathologies, normal. The liver, system Moderate
including spleen, and pancreas It has smooth outline ascites
fluid appear normal in size No definite focal nor diffuse Incidental
collections, and texture. No mass lesions small pleural
masses, abnormal growths No dilated intrahepatic vessels fluid, right
infections are seen. No fluid is There is moderate amount of
and found in the free- intraperitoneal fluid
obstruction. abdomen. collection

47. Fasting Blood Sugar (9/29/2011)
INDICATION NORMAL VALUE RESULT IMPLICATIONS
To monitor the blood
glucose level of a Increased, possible
patient and is vital for DM
72-125 mg/dL 131 mg/dL
component of And advanced liver
diabetes disease
management.

48. MEDICAL
MANAGEMENT

49. IDEAL ACTUAL
Diagnostic Evaluation Diagnostic Evaluation
Fecal material aspiration from NG tube Hematology
Abdominal and chest X-rays Chest X-ray -AP view
o May show presence and location of small or large intestinal distention, gas or Blood Chemistry
fluid Abdominal Ultrasound
o “Bird beak” lesion in colonic volvulus Urinalysis
o Foreign body visualization Abdominal X-ray flat plate and upright
Contrast studies Treatment
o Barium enema may diagnose colon obstruction or intussusception. With oxygen inhalation at 2-3L/min
o Ileus may be identified by oral barium or Gastrografin. NGT removed
Laboratory tests Drainage of transudate fluid with suction
o May show decreased sodium, potassium, and chloride levels due to vomiting Fluid taken for cell block, cell count
o Elevated WBC counts due to inflammation; marked increase with necrosis, Vital signs monitoring every hour
strangulation, or peritonitis Intake and output monitoring every shift
o Serum amylase may be elevated from irritation of the pancreas by the bowel Refer if urine output is less than 30mL/hr
loop On general liquids diet
Flexible sigmoidoscopy or colonoscopy may identify the source of the obstruction such Medication
as tumor or stricture Tramadol 50mg IVTT q8h
Ketorolac 30mg IVTT q6h RTC
Nonsurgical Management Cefuroxime 750mg IVTT q8h
Correction of fluid and electrolyte imbalances with normal saline or Ringer's solution Metronidazole 500mg IVTT q8h
with potassium as required. Paracetamol 300mg IVTT for temp>38°C
NG suction to decompress bowel. Azithromycin
Treatment of shock and peritonitis. Telmisortan
TPN may be necessary to correct protein deficiency from chronic obstruction, paralytic Simvastatin
ileus, or infection. Furosemide 20mg IVTT now
Analgesics and sedatives, avoiding opiates due to GI motility inhibition. IVF
Antibiotics to prevent or treat infection. D5LR
Ambulation for patients with paralytic ileus to encourage return of peristalsis. D5NM

50. SURGICAL
MANAGEMENT

51. IDEAL ACTUAL
Surgery Exploratory
Consists of relieving obstruction. Options include: Laparotomy
Closed bowel procedures: lysis of adhesions, reduction of volvulus, intussusception, Ileal Resection
or incarcerated hernia and
Enterotomy for removal of foreign bodies or bezoars Anastomosis
Resection of bowel for obstructing lesions, or strangulated bowel with end-to-end
anastomosis  Surgical
Intestinal bypass around obstruction preparation
Temporary ostomy may be indicated done.
 Surgical preparation is often lengthy, taking as long as 6 to 8 hours.  Postoperative
 It includes correction of fluid and electrolyte imbalances; decompression of the care done.
bowel to relieve vomiting and distention; treatment of shock and peritonitis; and
administration of broad-spectrum antibiotics.
 Often, decompression is begun preoperatively with passage of a nasogastric (NG)
tube attached to continuous suction. This tube relieves vomiting, reduces abdominal
distention, and prevents aspiration.
 In strangulating obstruction, preoperative therapy also usually requires blood
replacement and I.V. fluids.
 Postoperative care involves careful patient monitoring and interventions geared to
the type of surgery.
 Total parenteral nutrition may be ordered if the patient has a protein deficit from
chronic obstruction, postoperative or paralytic ileus, or infection.

52. SUMMARY OF
MEDICATIONS

53. DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS
09/27-10/2 Tramadol 100 mg IV PUSH q 8 hrs
Ketorolac 30 mg IV PUSH q 6 hrs RTC
09/27-10/4 Cefuroxime 750 mg IV PUSH q 8 hrs
Metronidazole 500 mg IV PUSH q 8 hrs
Paracetamol 500 mg tab PO q 4 hrs, PRN
10/1-10/3 Azithromycin 50 mg tab PO OD Administere
10/1-10/4 Telmisartan 40 mg tab PO OD d and
Simvastatin 40 mg tab PO q HS tolerated
10/5 Metronidazole 500 mg IV PUSH q 8 hrs well
Cefuroxime 750 mg IV PUSH q 8 hrs
Tramadol 50 mg IV PUSH q 8 hrs
Ranitidine 50 mg IV PUSH q 8 hrs
Ketorolac 30 mg IV PUSH q 6 hrs

54. NURSING CARE PLAN

55. Nursing Assessment
Assess the nature and location of the patient's pain, the
presence or absence of distention, flatus, defecation,
emesis, obstipation.
Listen for high-pitched bowel sounds, peristaltic rushes, or
absence of bowel sounds.
Assess vital signs.
Watch for air-fluid lock syndrome in elderly patients, who
typically remain in the recumbent position for extended
periods.
o Fluid collects in dependent bowel loops.
o Peristalsis is too weak to push fluid “uphill”.•
o Obstruction primarily occurs in the large bowel.
Conduct frequent checks of the patient's level of
responsiveness; decreasing responsiveness may offer a
clue to an increasing electrolyte imbalance or impending
shock.

56. Nursing Diagnoses
• Acute Pain related to obstruction, distention, and
strangulation
• Risk for Deficient Fluid Volume related to impaired fluid
intake, vomiting, and diarrhea from intestinal obstruction
• Diarrhea related to obstruction
• Ineffective Breathing Pattern related to abdominal
distention, interfering with normal lung expansion
• Risk for Injury related to complications and severity of
illness
• Fear related to life-threatening symptoms of intestinal
obstruction

57. Nursing Interventions
Achieving Pain Relief
• Administer prescribed analgesics.
• Provide supportive care during NG intubation to assist
with discomfort.
• To relieve air-fluid lock syndrome, turn the patient from
supine to prone position every 10 minutes until enough
flatus is passed to decompress the abdomen. A rectal tube
may be indicated.

58. Nursing Interventions
Maintaining Electrolyte and Fluid Balance
• Measure and record all intake and output.
• Administer I.V. fluids and parenteral nutrition as
prescribed.
• Monitor electrolytes, urinalysis, hemoglobin, and blood
cell counts, and report any abnormalities.
• Monitor urine output to assess renal function and to
detect urine retention due to bladder compressions by
the distended intestine.
• Monitor vital signs; a drop in BP may indicate decreased
circulatory volume due to blood loss from strangulated
hernia.

59. Nursing Interventions
Maintaining Normal Bowel Elimination
• Collect stool samples to test for occult blood if ordered.
• Maintain adequate fluid balance.
• Record amount and consistency of stools.
• Maintain NG tube as prescribed to decompress bowel.

60. Nursing Interventions
Maintaining Proper Lung Ventilation
• Keep the patient in Fowler's position to promote
ventilation and relieve abdominal distention.
• Monitor ABG levels for oxygenation levels if ordered.

61. Nursing Interventions
Preventing Injury Due to Complications
• Prevent infarction by carefully assessing the patient's status;
pain that increases in intensity or becomes localized or
continuous may herald strangulation.
• Detect early signs of peritonitis, such as rigidity and
tenderness, in an effort to minimize this complication.
• Avoid enemas, which may distort an X-ray or make a partial
obstruction worse.
• Observe for signs of shock—pallor, tachycardia, hypotension.
• Watch for signs of:
– Metabolic alkalosis (slow, shallow respirations; changes in
sensorium; tetany).
– Metabolic acidosis (disorientation; deep, rapid breathing;
weakness; and shortness of breath on exertion).

62. Nursing Interventions
Relieving Fears
• Recognize the patient's concerns, and initiate measures to
provide emotional support.
• Encourage presence of support person.

63. Patient Education and
Health Maintenance
• Explain the rationale for NG suction, NPO status, and
I.V. fluids initially. Advise the patient to progress diet
slowly as tolerated once home.
• Advise plenty of rest and slow progression of activity
as directed by surgeon or other health care provider.
• Teach wound care if indicated.
• Encourage the patient to follow-up as directed and
to call surgeon or health care provider if increasing
abdominal pain, vomiting, or fever occur prior to
follow-up.

64. Evaluation: Expected
Outcomes
• Maintains position of comfort, states pain decreased
to 3 or 4 level on 0-to-10 scale
• Urine output greater than 30 mL/hour; vital signs
stable
• Passed flatus and small, formed brown stool,
negative occult blood
• Respirations 24 breaths per minute and unlabored
with head of bed elevated 45 degrees
• Alert, lucid, vital signs stable, abdomen firm, not rigid
• Appears relaxed and reports feeling better

65. CONCEPT MAP

66. 10
INEFFECTIVE AIRWAY RISK FOR INJURY r/t HYPERTHERMIA r/t Increased 9
CLEARANCE r/t Ineffective Generalized Weakness and Metabolic Demands 2° to
1 Cough Reflex 2° Pain in Activity Intolerance Disease Process
Incision Site and Generalized
Weakness
ACTIVITY INTOLERANCE r/t
Generalized Weakness 2° to 8
INEFFECTIVE BREATHING Mr. William Lippincott Surgical Procedure
2 PATTERN r/t Restricted Lung 77 years old, Male
Expansion 2° to Moderate Abdominal Pain
Ascites Acute Abdominal Problem 2°
to Volvulus; Gangrenous Ileum RISK FOR SECONDARY
35 cm from Ileus Cecal Valve INFECTION r/t Traumatized
DECREASED CARDIAC with Ileo-ileal Anastomoses Tissue 2° to Surgical 7
3 OUTPUT r/t Impaired Heart Procedure
Contractility 2° to
Cardiomegaly
5
FLUID VOLUME DEFICIT IMPAIRED SKIN INTEGRITY r/t
ACUTE PAIN r/t Abdominal
(Isotonic) r/t Active Fluid Loss Abdominal Incision 2° to 6
4 Incision 2° to Surgical
2° to Ascites Fluid and Fluid Surgical Procedure
Procedure
Drainage

67. DISCHARGE
PLAN

68. • Date of Discharge: October 7, 2011
• Condition upon Discharge: Improved
Review the proper use of prescribed medications, focusing on
their correct administration, desired effects, and possible
adverse reactions.
Medication
Instruct client not to abruptly stop the medication without any
order from the physician.
Discuss side effects of the drugs
Allow physical exercises as tolerated.
Ensure adequate physical activity.
Exercise
Encourage patient to have adequate rest periods to prevent
fatigue.

69. Advice patient to progress diet slowly as tolerated once home.
Encourage high-calorie, high vitamins foods.
Teach patient about the food pyramid and recommended daily
servings for age.
Diet
Advice patient and SO to have adequate intake of nutritious foods
like vegetables, fruits and other foods rich in vitamins.
Encourage patient to have adequate intake of fluids to help in
elimination and prevent dehydration 2-3 L of fluids per day.
Teach the patient about his disorder, focusing on his type of
intestinal obstruction, its cause, and signs and symptoms.
Health Teaching Listen to his questions and took time to answer them.
Demonstrate techniques for coughing and deep breathing.
Teach wound care.
Encourage patient to follow-up as directed.
Schedule for Next Instruct patient to call surgeon or health care provider if
Visit increasing abdominal pain, abdominal distention, nausea,
vomiting, or fever occur prior to follow-up.

70. Encourage client to always pray and never give up hope in
any cases or conditions they may pass through.
Also encourage client to have faith and seek for strength
Spiritual
in God
Respect beliefs of clients but be ready to explain and
correct misconceptions.
Advise plenty of rest and slow progression of activity as
directed by surgeon or other health care provider.
Encourage a healthy lifestyle by eating a well-balanced
Lifestyle
diet and maintaining proper body exercise.
Encourage active lifestyle and participation in activities
appropriate for age and socialization.
Refer to the barangay health center/station for follow up
check-up and evaluation.
Referral
Refer also to health center for minor problems.
Refer to nearest hospital for any complications.