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IntestInal obstructIon is defined as a blockage of the intestines or a slowing down of the normal flow of intestinal contents (Jackson and raiji 2011). such obstructions can result in generalised abdominal pain, vomiting and dehydration, perforation of the bowel, peritonitis and sepsis, or even organ failure and death (Hughes 2005, 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 with gynaecological 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 also presents 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.

Vital signsTemperature and pulse Patients 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 saturation this refers to the percentage saturation of oxygen in haemoglobin rather than the partial 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).

Hydration this is one of the first signs of hypovolaemia (Kadlec et al 2008) and is indicated by lack 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 consciousnessPain there are various pain assessment tools, but numerical scales are commonly used in eDs. a simple, 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

Beatrice Harold outlines the assessments and interventions needed in acutely ill patients with blocked intestines who present to emergency departments

urgent treatment of patients with intestinal obstruction

summaryThis 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 a woman with intestinal obstruction.

KeywordsAbdominal pain, intestinal obstruction, pain relief

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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 in patients who are nil by mouth.

Consciousness In 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 urineBlood samples 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 function blood 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 intestinal obstruction.

Blood glucose this helps detect hyperglycaemia or hypoglycaemia and is particularly important in patients with diabetes who might require an insulin sliding scale.

Serum amylase this 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 al 1999).

Liver function these 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.

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 al 2005).

Arterial gas test blood 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 microscopy In 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 pregnancy In 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 radiographyElectrocardiography this 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 al 2002).

Radiology Plain 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).

InterventionsFluid management Fluid 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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This article has been subject to double-blind review and has been checked using antiplagiarism software

Beatrice Harold is a senior straff nurse at the emergency department at Hillingdon Hospital, London

online archiveFor related information, visit our online archive of more than 6,000 articles and search using the keywords

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).

Antiemetics Managing 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 al 2009).

Analgesia choice 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.

Monitoring Patients with bowel obstruction are likely to exhibit signs of hypovolaemic shock as vomiting 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 their urine hourly to detect changes in their condition early on and ensure that treatment is instigated quickly to prevent deterioration (Hughes 2005).

Reflectionemergency 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 and competently.

reflection enables practitioners to explore, understand and develop meaning and highlights contradictions between theory and practice. by reflecting on the care given to patients it is possible to learn what could have been done differently and what to do if the situation occurs again.

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References

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