Carlson, Dorothy S. DEd, RN; Pfadt, Ellen MSN, RN
Associate Professors Edinboro University Edinboro, Pa.
MADELINE MARTIN, 50, arrives at the ED complaining of intermittent nausea and crampy, midabdominal pain. She states that her pain seems to occur in cycles, and that she's relatively comfortable between the pain episodes. She rates her current pain intensity as a 6 on a scale of 0 (no pain) to 10 (worst possible pain). While you perform a focused physical assessment, she vomits a large amount of fluid; the vomitus contains bile and mucus. You also note abdominal distension and hyperactive bowel sounds. Her oral temperature is 99° F (37.2° C); pulse, 118; respirations, 28; BP, 112/70; and SpO2, 95% on room air.
What's the situation?
Two weeks ago, Ms. Martin had an abdominal hysterectomy for uterine fibroids. Her medical history includes hypertension, obesity, and dyslipidemia, and her postoperative course was uneventful until now. You notify the ED physician and her surgeon of your assessment findings, and administer analgesia and an antiemetic as prescribed.
What's your assessment?
Based on your assessment findings and Ms. Martin's history, you suspect a postoperative intestinal obstruction.
In 75% of patients, acute intestinal obstruction is caused by adhesions or internal or external hernias secondary to recent abdominal surgery. About 25% of these patients develop intestinal obstruction within a few weeks postoperatively. Of those patients, 10% to 50% need surgery.
Complications of acute intestinal obstruction include electrolyte depletion and fluid losses, which can lead to hypovolemia, renal insufficiency, and shock. Strangulation, an especially dangerous complication, is a surgical emergency. A strangulated obstruction impairs blood supply to the bowel and causes ischemia, which can progress to gangrene. Perforation of the bowel, another potential complication, can lead to peritonitis and sepsis.
What must you do immediately?
Provide supplemental oxygen via nasal cannula as prescribed, initiate cardiac monitoring, obtain peripheral vascular access, and infuse an isotonic crystalloid such as 0.9% sodium chloride solution or lactated Ringer's solution, as prescribed. Keep Ms. Martin N.P.O. and insert a nasogastric tube for decompression, as prescribed. Obtain specimens for a complete blood cell (CBC) count; comprehensive metabolic panel (CMP) including serum electrolytes, blood urea nitrogen, creatinine, glucose, amylase, and liver function tests; type and crossmatch; and urinalysis.
A 12-lead ECG shows sinus tachycardia without evidence of myocardial ischemia. The CBC count is within normal limits, but the CMP results indicate dehydration, which is treated with I.V. fluids, and hypokalemia, which is treated with I.V. potassium supplementation. A computed tomography scan of the abdomen demonstrates a partial small-bowel obstruction.
The surgeon opts for a trial of nonoperative management and you prepare Ms. Martin for admission to a medical-surgical unit for continued monitoring, fluid and electrolyte replacement, and bowel rest.
What should be done later?
Ms. Martin's obstruction responds to medical treatment and resolves within 72 hours. The remainder of her hospital stay is uneventful, and she's discharged home with surgical follow-up.
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