Feature

Urgent treatment of patients

withintestinal obstruction
Beatrice Harold outlines the assessments and
interventions needed in acutely ill patients with blocked
intestines who present to emergency departments
Summary
This article reviews the management in emergency
departments of acutely unwell patients with
intestinal obstruction. It describes the diagnostic
tests and management required for patients with
this condition, suggests that reflecting on practice
can help practitioners evaluate the quality of the
care they gave and presents a case study involving
awoman with intestinal obstruction.
Keywords
Abdominal pain, intestinal obstruction, pain relief
Intestinal obstruction is defined as a blockageof
the intestines or a slowing down of the normal
flow of intestinal contents (Jackson and Raiji2011).
Suchobstructions can result in generalised abdominal
pain, vomiting and dehydration, perforation of the
bowel, peritonitis and sepsis, or even organ failure and
death (Hughes2005, Bader et al 2009).
If patients who show signs and symptoms
of intestinal obstruction present to emergency
departments (EDs), they should be assessed
immediately. Practitioners should assess vital
signs: pain, including where appropriate pain
withgynaecological causes, and consciousness;
and blood and urine. In addition, patients should
undergo electrocardiography, and chest and
abdominal radiography, before interventions are
made (Cole et al 2006).
This article outlines these assessments and
interventions, discusses the need for reflection,.
It alsopresents a relevant case study, opposite,
concerning the management in a London ED of a
woman with an intestinal obstruction. To maintain
her privacy, her name has been changed.
28 April 2011 | Volume 19 | Number 1

Vital signs
Temperature and pulsePatients with bowel
obstruction are usually normothermic, but pulse is
an excellent marker of physiological abnormality.
Patients with bowel obstruction can become
hypovolaemic due to vomiting, poor fluid intake
or the leaking of fluid into the bowel lumen that
is not re-absorbed. When combined with low
blood pressure, this can prevent the heart from
maintaining adequate cardiac output, leading to
tachycardia (Patel and Burnard 2009). Meanwhile,
excretion of urinary sodium and water is usually
reduced to maintain plasma volume, resulting in
oliguria (Macutkiewicz and Carlson 2005).
Oxygen saturationThis refers to the percentage
saturation of oxygen in haemoglobin rather than
thepartial pressure of oxygen in the blood (Docherty
2002). Measuring oxygen saturation with saturation
probes is less invasive and painful, is cheaper,
and involves less risk of infection than frequent
measuring of arterial blood gas samples (Department
of Health 2008).
HydrationThis is one of the first signs of
hypovolaemia (Kadlec et al 2008) and is indicated
bylack of skin turgor, dry tongue or, in extreme
cases, sunken eyes. To test patients hydration
status, nurses can ask them if they are thirsty.

Pain and consciousness

PainThere are various pain assessment tools,
but numerical scales are commonly used in EDs.
Asimple, verbal pain scale of zero to ten, in
which zero indicates no pain and ten indicates
excruciating pain, can provide enough information
to plan interventions and prescribe in the short
EMERGENCY NURSE

Feature
term (Davis 2000). Patients with bowel obstruction
are given analgesia according to the World Health
Organizations (2011) pain ladder, originally devised
for pain from cancer. This means using paracetamol
if pain is mild and progressing through non-steroidal
anti-inflammatory drug and opiates as pain becomes
more severe. Analgesia is usually given in intravenous
(IV) form inpatients who are nil bymouth.
ConsciousnessIn patients with bowel obstruction,
Glasgow Coma Scale (GCS) parameters remain
unaltered. In patients with sepsis, perfusion of
the brain may be inadequate. This can lead to
perforation or shock, and affect patients mental
state (Gilkes and Whitfield 2009).

Blood and urine

BloodSamples are taken: full blood count, urea and
electrolytes, and serum amylase. High haemoglobin
concentration usually indicates dehydration, while
low haemoglobin concentration indicates acute or
chronic blood loss. Leukocytosis, or raised white
cell count (WCC), usually indicates inflammation or
infection. Leukopenia, or lowered WCC, suggests
overwhelming inflammation or lack of immune
response to inflammation. Thrombocythaemia, or
raised platelet count, occurs in active inflammatory
bowel disease, while thrombocytopaenia, or lowered
platelet count, is a manifestation of overwhelming
sepsis (Nunes and Lobo 2005).
Renal functionBlood tests can reveal acute renal
dysfunction or electrolyte abnormalities, including
hyponatraemia and hypokalaemia associated
with profound vomiting (Nunes and Lobo 2005).
This is particularly important in patients with
intestinalobstruction.
Blood glucoseThis helps detect hyperglycaemia
or hypoglycaemia and is particularly important
inpatients with diabetes who might require an
insulin sliding scale.
Serum amylaseThis blood test can help rule out
pancreatitis. The accepted upper limit of normal
serum amylase is 80 unit/L. High concentrations can
occur in almost any acute abdominal condition, but
a fourfold increase in concentration suggests acute
pancreatitis (Vissers et al1999).
Liver functionThese tests of the amount of liver
enzymes in the blood are essential in patients with
bowel obstruction, being more useful for detecting
hepatobiliary causes of abdominal pain such as
obstructive jaundice and acute injury of the liver.
30 April 2011 | Volume 19 | Number 1

However, these conditions can be found in patients

with sepsis. In cases of bowel obstruction secondary
to gallstones, or gallstone ileus, enzyme levels are
elevated (Kirchmayr et al2005).
Arterial gas testBlood can be taken from the
arteries and analysed to determine carbon dioxide
and oxygen levels to interpret patients acid base
balance (Kelly 2010). Abnormalities in pH and acidosis
or metabolic disruption can also be detected.
Urinalysis and urine microscopyIn patients with
acute abdominal pain, urinalysis is an essential
investigation to help rule out differential diagnoses.
It can detect urinary calculi or urinary tract infection,
while urine microscopy can reveal micro-organisms,
blood, pus, sugar or ketones in the urine. Urine
output should be measured hourly to check for
dehydration (Ramos-Fernndez and Serrano 2009).
Menstrual period and pregnancyIn women who
have passed the menarche, but have not completed
the menopause, with abdominal pain, the date
at which the most recent menstrual period took
place should be noted and pregnancy tests should
be carried out to rule out gynaecological causes
of abdominal pain. Ensure that their consent to
pregnancy testing is clearly documented.

Electrocardiography and radiography

ElectrocardiographyThis should be undertaken
to rule out cardiac causes of abdominal pain, such
as inferior myocardial infarction, and arrhythmias.
Patients with bowel obstruction can manifest
electrocardiographic abnormalities secondary
to electrolyte disturbances. Electrocardiographs
are also required in pre-surgical preparation
(Webster et al2002).
RadiologyPlain radiographs rarely show features
that enable a specific diagnosis but where
obstructions have been complicated by perforation,
erect x-rays of the chest or lateral decubitus x-rays
of the abdomen can reveal intraperitoneal gas
(Chiu et al 2009). The features of abdominal x-rays
that are associated with bowel obstruction vary with
the sites of obstruction, but dilated, gas-filled loops
of bowel can usually be seen (Maglinte et al 1997).

Interventions
Fluid managementFluid resuscitation is an essential
first step when managing intestinal obstruction.
After prolonged vomiting, patients fluids and
electrolytes can be seriously depleted (Burkitt and
Quick 2002) and there may be excessive fluid in the
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Feature
upper gastrointestinal tract, so oral intake of fluids
should be discontinued and IV intake introduced.
The volume and type of fluid depends on patients
hydration status, the duration of the obstruction
and serum electrolyte abnormalities. Over a 24-hour
period, up to 8L of gastrointestinal secretions
from the stomach, pancreas, gall bladder and
small intestine can accumulate in the bowel due to
obstruction (Shelton 1999). Nasogastric tubes (NGTs)
drain the gastro-intestinal fluids, reducing fluid
accumulation at the site of obstruction and the risk
of perforation (Shelton 1999).
AntiemeticsManaging the symptoms of intestinal
obstruction is extremely important and the use
of appropriate antiemetics is essential. In surgical
settings, metoclopramide is commonly used in
patients who experience nausea and vomiting. It is
contraindicated in patients with bowel obstruction,
however, because it stimulates gastric emptying and
further distends the bowel, as stomach contents
pass into an area of the gut where there is no
possible outlet. Cyclizine and prochlorperazine,
which act centrally on the chemoreceptor trigger
zone and the vomiting centre, can be used instead
(Bader et al2009).
AnalgesiaChoice of analgesia is usually based on
each patients pain type, intensity, duration and
constancy. It is also based on each patients age,

diagnosis, functional or performance state, hepatic

or renal insufficiency and ability to take medication
orally, and the potential interactions of the analgesia
with other medications.
MonitoringPatients with bowel obstruction are
likelyto exhibit signs of hypovolaemic shock
asvomiting dehydrates them, fluid shifts into
their bowel and maintaining homeostasis becomes
increasingly difficult.
Nurses must monitor such patients vital signs
half-hourly or hourly (Kenward et al 2001) and
should assess theirurine hourly to detect changes in
their condition early on and ensure that treatment
is instigated quickly to prevent deterioration
(Hughes2005).

Reflection
Emergency care staff see patients with a wide range
of medical, surgical, psychological, gynaecological
and traumatic conditions, and it is vital that they
are skilled to treat all such conditions effectively
andcompetently.
Reflection enables practitioners to explore,
understand and develop meaning and highlights
contradictions between theory and practice.
Byreflecting on the care given to patients it is
possible to learn what could have been done
differently and what to do if the situation
occursagain.

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This article has been subject
to double-blind review and
has been checked using
antiplagiarismsoftware
Beatrice Harold is a
senior straff nurse at the
emergency department at
HillingdonHospital, London

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