Volvulus, nursing, medical, surgical managements

1. Intestinal Obstruction
Volvulus
NURSING MANAGEMENT
IDEAL
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.
Nursing Diagnoses
 Ineffective Breathing Pattern related to abdominal distention, interfering with normal lung expansion
 Ineffective tissue perfusion: GI
 Acute Pain related to obstruction, distention, and strangulation
 Imbalanced nutrition: Less than body requirements
 Risk for Deficient Fluid Volume related to impaired fluid intake, vomiting, and diarrhea from intestinal obstruction
 Risk for Injury related to complications and severity of illness
 Constipation
 Diarrhea related to obstruction
 Fear related to life-threatening symptoms of intestinal obstruction
Nursing Interventions
 Allow the patient nothing by mouth, as ordered, but make sure to provide frequent mouth care to help keep mucous membranes moist.
 Look for signs of dehydration (thick, swollen tongue; dry, cracked lips; dry oral mucous membranes). If surgery won't be performed, the patient may be allowed a few ice
chips. Avoid using lemon-glycerin swabs, which can increase mouth dryness.
 Insert an NG tube to decompress the bowel as ordered. Attach the tube to low-pressure, intermittent suction. Monitor drainage for color, consistency, and amount. Irrigate
the tube, if necessary, with normal saline solution to maintain patency.
 Begin and maintain I.V. therapy as ordered. Monitor intake and output.
 Maintain fluid and electrolyte balance by monitoring electrolyte, blood urea nitrogen, and creatinine levels. Provide I.V. fluids to keep levels within normal ranges.
 Administer analgesics, broad-spectrum antibiotics, and other medications as ordered. Monitor the patient for the desired effects and for adverse reactions.

2.  To ease discomfort, help the patient change positions frequently. Continually assess his pain. Remember, colicky pain that suddenly becomes constant could signal
perforation.
 Watch for signs of metabolic alkalosis (changes in sensorium; slow, shallow respirations; hypertonic muscles; tetany) or acidosis (shortness of breath on exertion;
disorientation; and later, deep, rapid breathing, weakness, and malaise).
 Watch for signs and symptoms of secondary infection, such as fever and chills.
 Monitor urine output carefully to assess renal function, circulating blood volume, and possible urine retention due to bladder compression by the distended intestine. If you
suspect bladder compression, catheterize the patient for residual urine immediately after he has voided.
 Measure abdominal girth frequently to detect progressive distention.
 Keep the patient in semi-Fowler's or Fowler's position as much as possible. These positions help to promote pulmonary ventilation and ease respiratory distress from
abdominal distention.
 Listen for bowel sounds, and watch for other signs of resuming peristalsis (passage of flatus and mucus through the rectum).
 If surgery is scheduled, prepare the patient as required.
 After surgery, provide all necessary postoperative care. Care for the surgical site, maintain fluid and electrolyte balance, relieve pain and discomfort, maintain respiratory
status, and monitor intake and output.
Patient Teaching
 Teach the patient about his disorder, focusing on his type of intestinal obstruction, its cause, and signs and symptoms. Listen to his questions and take time to answer
them.
 Explain the rationale for NG suction, NPO status, and I.V. fluids initially. Advice patient to progress diet slowly as tolerated once home.
 Explain necessary diagnostic tests and treatments. Make sure the patient understands that these procedures are necessary to relieve the obstruction and reduce pain.
 Prepare the patient and family members for the possibility of surgery. Provide preoperative teaching, and reinforce the physician's explanation of the surgery.
Demonstrate techniques for coughing and deep breathing, and teach the patient how to use incentive spirometry.
 Tell the patient what to expect postoperatively. After surgery, review incisional care. Provide emotional support and positive reinforcement before and after surgery.
 Discuss postoperative activity limitations and point out why these restrictions are necessary.
Health Maintenance
 Review the proper use of prescribed medications, focusing on their correct administration, desired effects, and possible adverse reactions.
 Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider.
 Teach wound care if indicated.
 Encourage patient to follow-up as directed and to call surgeon or health care provider if increasing abdominal pain, abdominal distention, nausea, vomiting, or fever
occur prior to follow-up.
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

3. MEDICAL MANAGEMENT
IDEAL
Diagnostic Evaluation
 Fecal material aspiration from NG tube
 Abdominal and chest X-rays
o May show presence and location of small or large intestinal distention, gas or fluid
o “Bird beak” lesion in colonic volvulus
 Contrast studies
o Barium enema may diagnose colon obstruction.
 Laboratory tests
o May show decreased sodium, potassium, and chloride levels due to vomiting
o Elevated WBC counts due to inflammation; marked increase with necrosis, strangulation, or peritonitis
o Serum amylase may be elevated from irritation of the pancreas by the bowel loop
o Hemoglobin concentration and hematocrit may increase, indicating dehydration
Nonsurgical Management
 Correction of fluid and electrolyte imbalances with normal saline or Ringer's solution with potassium as required.
 NG suction to decompress bowel.
 Rarely, a long nasointestinal tube is used for decompression.
 Treatment of shock and peritonitis.
 Analgesics and sedatives, avoiding opiates due to GI motility inhibition.
 Antibiotics to prevent or treat infection.
 In both surgical and nonsurgical treatment, drug therapy includes antibiotics and analgesics or sedatives, such as meperidine or phenobarbital (but not opiates because
they inhibit GI motility).

4. SURGICAL MANAGEMENT
IDEAL
Surgery
Surgery is usually the treatment of choice for complete obstructions.
Consists of relieving obstruction. Options include:
 Closed bowel procedure: lysis of adhesions, reduction of volvulus
 Resection of bowel for obstructing lesions, or strangulated bowel with end-to-end anastomosis
 Intestinal bypass around obstruction
 Temporary ostomy may be indicated
 Surgical preparation is often lengthy, taking as long as 6 to 8 hours.
 It includes correction of fluid and electrolyte imbalances; decompression of the 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.