Evidence Based Research Proposal: Small Bowel Obstruction

When working on a telemetry medical surg unit we are exposed to many diseases, one comes to mind that is complex in nature and high acuity with nursing care for the patient. This disease is that of small bowel obstruction. A small bowel obstruction is caused by abdominal adhesions, hernias, Crohn disease, malignancies, and volvulus (also known as a kink in the bowel). In essence, when a patient is faced with a small bowel obstruction, the bowel is prohibiting the passage of all things digested through the normal route of the bowel.

This will in turn make the patient feel weak, nauseous, and present with moderate to severe abdominal pain.

There are different routes of treatment when faced with small bowel obstruction, one can conservatively manage it with gut rest. If this doesn’t help, then decompression with nasogastric tube suctioning with gut rest. If the above, do not resolve the obstruction then surgery is the next step. Monitoring the patient closely is critical, therefore I propose to aide in a quicker recovery the healthcare team should not do clamping trials of the nasogastric tube which can do more harm than good.

The gastrointestinal system is complex, it consists of the upper GI: mouth, pharynx, esophagus, and stomach; and the lower GI tract: small intestine, large intestine, and anus (Story, L., 2015). As mentioned above, there are mechanical and functional problems with the intestines that will cause a blockage (Story, L.,2015). When patient’s present with an intestinal obstruction it is pertinent to find out what is causing the obstruction. At times, there are underlying disorders that are causing the obstruction, which in retrospect prolong the healing process. As a nurse that cares for patients in such a condition, which involves a high acuity of care, I would propose not to trial clamp the nasogastric tubes due to delaying the gut healing process as well as prolonging peristalsis, and it could cause more harm than good as research proves.

Pathophysiology, Etiology, and Clinical Manifestation

Depending on what is causing the blockage and where it is, the blockage can occur slowly or really fast. Bowel obstructions can be caused by many things, it can be mechanical or false obstruction. To name a few mechanical obstructions such as, scar tissue, previous abdominal surgeries, tumors/cancer, hernias, and twisting of the bowels. False obstructions consist of myopathy or neuropathy which is a deficiency in bowel functions itself (Baiu, I., et al, 2018).

As the blockage progresses whether partial or complete, at the site of the blockage the patient will exhibit buildup of chyme, gas, gastric juices, bile, and pancreatic juices (Story, L., 2015). While the buildup of gastrointestinal juices is being blocked from normal flow, there will be a shift in electrolyte disturbances, buildup of gas which will in turn cause bowel distension. As gas builds up, we see constriction of veins in the abdominal cavity which also decreases oxygen flow which causes cells to die, decreasing peristalsis; therefore, adding to abdominal distension (Hasudungan, A., 2016).

As food or ingested particles sit in the intestine it becomes exposed to the bacteria that lives in our gastrointestinal tract, because of a decrease of oxygen flow it causes these bacteria to enter into our circulation, causing what nurses know as sepsis (Hasudungan, A., 2016). The patient also ends up losing water due to the compression in the gastrointestinal system, as fluid builds up it starts to secrete or leak out between the bowel which then imbalances the bodies electrolytes and can result in shock to the patient’s body.

Classic symptoms patient’s will typically present with nausea, abdominal cramping, vomiting, inability to pass poop, distended abdomen, and fever (Ekin, O., et al 2018). The older in age a person is, often times there is a mis-diagnosis of small bowel obstruction due to poor appetite, decreased renal function which at times will not be beneficial for a CT scan, and symptoms present differently because of their bodies baseline changes as the elderly age (Ekin, O., et al 2018).

Diagnostics, Nursing Management, and Teaching

The healthcare team needs to obtain an extensive history on the patient. This history can give information of past abdominal surgeries, current medical history, medications the patient is taking, and can give insight to possibly why the patient is experiencing a small bowel obstruction (Ekin, O., et al, 2018). As well as obtaining health history, the nurse and physician will want to do an assessment on the patient to gather objective and subjective data to help diagnosing what is happening.

The most definitive study to determine if there is an obstruction is to do a CT scan. In the past radiography images were used, now a computed tomography is more concise to diagnose an obstruction due to greater sensitivity while using a contrast media (Baiu,I., et al, 2018). In conjunction with a CT, the physician would possibly want to order abdominal x-ray, arterial blood gases, complete blood count, and if warranted barium enema and colonoscopy (Story, L., 2016). As the patient is faced with a small bowel obstruction, pending not emergent, the first line of management will be bowel rest (Baiu, I., et al, 2018).

Bowel rest will consist of no food or fluid intake by way of the mouth. The doctor will order intravenous fluids to replenish electrolytes and to combat against hypotension. With close monitoring of gut rest, if the patient still feels nauseous with vomiting, has increased abdominal pain and distension then the doctor will order for a nasogastric tube insertion. As the nurse inserts the nasogastric tube through the nose, ending in the stomach, before anything can be done with it there has to be x-ray confirmation for the right placement. Once the radiologist confirms correct placement then the tube can then be hooked up to low intermittent suction.

When connecting the tube to suction, this will decompress the stomach and the buildup of stomach and intestinal contents will be suctioned out (Baiu, L., et al 2018). This suctioning will allow the patient some relief from pain and lessen the nausea and vomiting. While performing doctor orders it always crucial to educate our patients and their families through the process. Most of the time the family will wonder how long before the patient can have something to eat. Each person’s body responds differently, a concise answer will be when the symptoms of nausea lessen, the abdomen is less tight, and when bowel sounds start to wake up.

The nurse can explain to the patient and caregiver, if food was given to the patient it could make the symptoms worse and cause the body to go into shock. The first step to managing a bowel obstruction is to see if it will reverse on its own, if not then surgical management is necessary for the patient. The healthcare staff will have to substitute parental nutrition to keep patient hydrated and sustain a good caloric intake which aides in the healing process (Ekin, O., et al, 2018). Keeping the patient and family in the loop with the plan of care will enable to have input on what is happening and play a more active role in the recovery too.

Risk, Incidence, and Mortality

With any medical condition, there presents dangers, especially in small bowel obstructions. With knowing the cause of obstruction, the physician has to weigh the options out of whether to do surgery, take conservative measures, and also abide by what the patient wishes. Small bowel obstructions tend to occur more in the elderly population, it is best if surgical intervention is needed to take into consideration the overall health of the elderly patient (Ekin, O., et al, 2018). The physician is more than likely going to get an echo to examine heart function pre-operatively, as well as a complete blood count, and review ongoing medical history of the patient to ensure the patient will make it through the abdominal surgery.

These tests are obtained for any patient facing abdominal surgery for a bowel obstruction (Ekin, O., et al, 2018). According to Ekin, O’s study on small bowel obstruction in the elderly, “approximately 70% to 90% of small bowel obstructions in all ages are handled without surgical intervention and about 30% have to undergo surgery (2018).” Also, according to Ekin O’s research when there’s a delay in surgical approach there was documented to be a 17% mortality rate (2018). With any type of surgery there is always risks, these are also made aware to the patient by the surgeon previously and the patient has to sign a consent for the operation, noting the benefits outweigh the risks.

TMS Floor Management

On the telemetry medical-surgical unit there are policy and procedures in place for each scenario we encounter, such as nasogastric insertion and maintenance. When there is a patient presenting with abdominal pain that has a CT scan showing small bowel obstruction versus ileus, we want to provide gut rest. As a nurse, administering intravenous fluids for the patient to stay hydrated is crucial, monitoring nausea and if patient vomits is beneficial. If the patient’s abdominal pain worsens, making the physician aware, the doctor may want to try intravenous nausea medications, if this fails then insertion of a nasogastric tube would be the next step.

The attending nurse would measure from the tip of the nare, around the ear and to the xyphoid process, and mark that on the tubing. This gives the nurse a measurement of how far to insert the nasogastric tube as the patient holds their head downward while sipping on water. Once the tube is inserted an x-ray is needed to confirm placement. It is very easy for this tube to get lodged in the lungs and if used before correct placement is confirmed it can do damage (Ekin, O, et al, 2018). The physician will order for the patient to be on low intermittent suction at all times, the nurse is to flush the tube every four hours with water as well as check for placement and residual. If the nasogastric tube presents with more then 20cc residual then it is best to notify the physician because the suction may need to be increased due to a lot of sludge in the intestines (Ekin, O, et al, 2018).

The recommendation is to clamp the tube after administering medications for about 30 minutes for the medication to process and the hook the patient back up to suction. While the patient is on suction, the nurse is to assess for bowel sounds, if the patient is passing gas, the color and consistency of the drainage that the suction is getting out, and how the patient is feeling overall (Baui, I, et al 2018). There are some surgeons that will do a repeat abdominal x-ray of the abdomen to see if there is any improvement in the area the blockage is at. If there is improvement and a lessening of fluid coming out from being suctioned, then some physicians like to clamp the nasogastric tube for four to six hours. This is a controversial method between physicians and healthcare staff due to the risk of the obstruction not being resolved and being off of the continuous low intermittent suction.

Suggested Implementations for Precise Care

As a nurse who sees small bowel obstructions quite frequently on the TMS unit, I propose not to do a clamping trial with nasogastric tubes in place due to putting the patient at a higher risk of aspiration and sending the body into shock (Ekin, O., et al 2018). If the bowel obstruction is not resolving, without the continuous low intermittent suction then the gastrointestinal contents are still sitting in the abdominal cavity and will continue to seep into the surrounding tissues. As the seeping occurs this minimizes the oxygen flow to the abdominal cavity which causes increased abdominal distension and can cause the patient’s blood pressure to drop (Hasundugan, A., 2016).

While the gastric contents are just sitting in the bowels not being suctioned out it increases the chances for the patient to aspirate because the tip of the nasogastric tube is keeping the lower esophageal sphincter open (Alley, R., 2019). As well as being high risk for aspiration, the aspiration can quickly turn into pneumonia, and these are complications that could be avoided by not doing clamping trials. In order to determine if the nasogastric tube needs to be removed, the nurse and physician can assess return of bowel function, output color of bilous content, and if there is a decrease in output amount (Alley, R., 2019). There still proves to be different viewpoints within the healthcare team on whether to clamp or not with a nasogastric tube in place.

With the different viewpoints, I was able to discuss with doctor Huber who oversees a lot of bowel obstructions and performs many surgeries to correct obstructions. Discussing the matter with her, she is in favor to not clamp the nasogastric tube mainly because of the risk for aspiration, especially if the blockage is not resolved. Overtime doctor Huber stated, “not only can the patient aspirate, having the gastrointestinal contents just sitting there can cause further erosion to the bowels.” I thoroughly appreciated the talk with doctor Huber and having her input. There are very limited definitive studies out there at this time that say not to clamp the nasogastric tube so this is something still that could be researched out more definitively.

As a nurse who actively works with patients presenting with small bowel obstructions, standing my ground with the healthcare team to prove there is greater benefit to not doing a clamping trial will aide in further exploration of the matter to come to a common ground among the healthcare team.

References

1. Baiu, I., & Hawn, M. (2018). Small bowel obstruction. Jama: Journal of the American Medical Association, 319(20).
2. Ekin, O., Marianne, V., Martijn, M., Yvonne, S., Richard, R., & Harry, V. (2018). Small bowel obstruction in the elderly: A plea for comprehensive acute geriatric care. World Journal of Emergency Surgery, 13(1), 1-8. doi:10.1186/s13017-018-0208-z
3. Alley, R. (2019, June 28). Nasogastric Tube Clamping Trial vs. Immediate Removal- Full Text View. Retrieved from https://clinicaltrails.gov/ct2/show/NCT04001985
4. Hasudungan, A. (2016, April 5). Retrieved February 9, 2020, from https://youtu.be/sBm12CkNtAo
5. Story, L. (2015). Pathophysiology: a practical approach (2nd). Burlington, MA: Jones & Bartlett Learning.

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