intestinal obstruction cs anp file .docx

ytr

1. 1

SISTER NIVEDITA GOVERNMENT
COLLEGE OF NURSING
IGMC, SHIMLA

SUBJECT: ADVANCED NURSING PRACTISE
CASE STUDY ON: INTESTINAL OBSTRUCTION
SUBMITTED TO: SUBMITTED BY:
Mrs. Pooja Sood Sheetanshu Patiyal
Lecturer (Obstetrics and Gynaecological Nursing) MSc(N)1
st
Year
SNGNC, IGMC SNGNC, IGMC
Shimla Shimla
SUBMITTED ON:

2. 2

 HISTORY TAKING
 Biographic data/ Identification data
Name: Smt. Anjana Devi
CR.NO: 20230849800
Age: 44 years
Sex: Female Adult
Ward no.: HDU (high density unit)
Bed no.: 2
Language known: Pahari, hindi
Marital Status: Married
Religion: Hindu
Nationality: Indian
Educational Status: BSc B.Ed
Occupation: Housewife
Monthly family income: Rs 70,000/-

3. 3

Informant: Husband
Address: Vill. Ghiyana P.O. Brahampukar Teh. Sadar Distt. Bilaspur
Contact number: 6230876212
Date of admission: 30
th
November, 2023 at 4:15pm
Diagnosis: Intestinal Obstruction
Surgery performed: Laproscopic Bowel Resection done under epidural anesthesia.
Post operative day: 2
nd
day
Duration of care: 2 days
Doctor’s Name: Dr. Ashish
 CHIEF COMPLAINTS: Smt. Anjana Devi, aged 44 years was admitted in IGMC Hospital Shimla with the chief complaints of:
 Abdominal pain since last 3 days
 Abdominal discomfort since last 5 days
 Episodes of vomiting since last 2 days
 HISTORY OF PRESENT ILLNESS :
 Present Medical History: The patient was apparently well 2 days before the date of admission when she developed pain and discomfort
in her abdomen which was acute in onset, non radiating, severe in intensity over the entire abdomen. The patient also had episodes of
vomiting.

4. 4

 Vitals on admission:
Sr. no. Vitals Name Patient value Normal value
1. Temperature 97.8
0
F 98.6
0
F
2. Blood pressure 128/76mm Hg 120/80mm Hg
3. Respiration 16b/min 12-20b/min
4. Pulse rate 78b/min 60-100b/min

 Present surgical history: The client underwent laproscopic bowel resection surgery for intestinal obstruction under epidural anesthesia.
 HISTORY OF PAST ILLNESS:
 Past medical history: Nothing significant
 Past surgical history: Nothing significant
 History of any chronic illness in the family: There is no such history of illness in the family.
 History of any communicable and hereditary disease: There is no such history of communicable and hereditary disease.
 PERSONAL HISTORY:
 Habits: The patient has a habit of reading newspapers and watching spiritual shows.
 Sleep pattern: The patient has a sound sleep pattern.
 Exercise pattern: The patient does not do any exercise at all.
 Nutritional pattern: Patient is vegetarian and has a poor nutritional status
 Bowel and bladder habits: Regular bowel and bladder habits
 Personal Hygiene: The client has good personal hygiene.
 Sexual history: There is no sex related problems

5. 5

 Contraceptive history: The patient has had tubectomy after her 2
nd
child.
 Psychological history: The patient has good and sound relations with the family members and relatives. She also has good relations with
her society.
 Nutritional History: The patient is vegetarian. Her appetite is good.
 Menstrual History: Her menstruation is normal and has a cycle of 28 days. The flow is normal. She has complaints of dysmenorrheal.
 FAMILY HISTORY:
 Type of family: Nuclear family
 Head of the family: Sh. Rakesh Singh
 Any medical history in the family- Nothing significant
 Any surgical history in the family- Nothing significant
 IMMUNIZATION HISTORY: The patient has been immunized with all the vaccines. Her immunization schedule is complete.
 FAMILY TREE: KEY

Sh. Rakesh Singh,48 years Smt. Anjana Devi,44 years


Aashray,18 years(Son) Gunjan,15years(Daughter)

Patient
Male
Female

6. 6

 FAMILY COMPOSITION:
Sr.
No.
Name of family
member
Age Sex Relationship
with the
client
Educational Status Occupational Status Health Status
1. Sh. Rakesh
Singh
48
years
Male Adult Husband MSc. M.Ed Teacher Healthy
2. Smt. Anjana
Devi
44
years
Female
Adult
Patient BSc B.Ed Housewife Intestinal obstruction
3. Aashray 18
years
Male Adult Son 12
th
class Student Healthy
4. Gunjan 15
years
Female Adult Daughter 9
th
class Student Healthy

 SOCIOECONOMIC STATUS
 House: The patient stays in a pucca house
 Ventilation: There is proper ventilation
 Social relationship: The patient has sound and healthy relationships with the society
 Monthly Income: Rs 70,000/-
 Environmental hygiene: Good environmental hygiene
 Drinking water: Tap water and ground water supply
 Environmental pollution: No environmental pollution

7. 7

 Social support system: Social support system is provided
 Any psychological stressors: No psychological stressors present in day to day life
 Spouse general health: Spouse is healthy
 Number of children: Two children, one son and one daughter
 PHYSICAL ASSESSMENT:
1. General Appearance-
 Sensorium: Alert and conscious
 Emotional State: Anxious
 Activity: Active
 Foul body odor: Not present
 Foul breath: Not present
 Body built: Thin
 Grooming: Well groomed
 Nourishment: Well nourished
 Posture: Normal
 Gait: Normal
2. Anthropometric Assessment:
 Height: 5 feet 3 inches or 160 cm
 Weight: 52 kg
 Body mass index(BMI): weight(kg)/height(m)
2

=52kg/1.6
2

8. 8


= 20.3kg/m
2

3. VITAL SIGNS on post operative days
DATE TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE
01-12-2023 97.6
0
F 78/min 18/min 86/66mm/hg
02-12-2023 100.4
0
F

78/min 18/min 82/62mm/hg

4. HEAD TO TOE EXAMINATION:
ORGAN ASSESSMENT FINDINGS

GENERAL APPERANCE Health
Built
Behavior pattern
Mental alertness
Looks pale
Weakened and lethargic
Listens carefully but moaning in pain
Alert
SKIN AND MUCUS
MEMBRANES
Color
Temperature
Lesions
Scars
Edema
Birthmark
Looks pale, no cyanosis present
The patient has no fever
No lesions in skin
No scars on skin membranes
No edema
No birthmark present
HEAD Size, shape and position Normal

9. 9

Symmetry
Skull deformities
Nodules and masses
Symmetrical in shape
Absent
Absent
HAIR AND SCALP Hair color
Distribution of hair
Texture
Dandruff/Parasites
Sclap lesions
Brown
Normal and symmetrical distribution of hair
No alopecia present
No dandruff present
Absent
NAILS Shape
Color
Clubbing
Normal
Slightly pink
No clubbing present
FACE Symmetry
Appearance
Lesions
Facial hair
Peri orbital edema
Symmetrical
Pale
No lesions present
Absent
Absent
EYES Shape
Color
Movements
Eyelids
Eyelashes
Normal
Black color
Symmetrical and normal eye movements
Normal scaling
Sticky eyelashes, equal distribution of hair

10. 10

Conjunctiva
Sclera
Pupil
Vision
Normal, no inflammation
White
Normal reaction to light and accommodation
Normal 6/6
EARS Alignment
Discharge
Swelling
Wax
Hearing
Normal
No discharge
Not present
Present
Normal hearing
NOSE AND SINUSES Symmetry
Discharge
Septum
Mucus
Nasal flaring
Normal
No discharge
Normal, no DNS
Intact
Not present
THROAT AND NECK Neck movements
Lymph nodes
Neck muscles
Gag reflex
Thyroid gland
Normal movements in both right and left side
No enlargement
Symmetrical neck muscles, normal ROM
Present
Normal, no enlargement
MOUTH AND PHARYNX Lips
Teeth
Dehydrated
30 in number

11. 11

Tongue
Gums
Palate
Buccal mucosa
Color of teeth
Trauma
Slightly pink and no coating
Pinkish, no complaints of bleeding
No coating, flat arch
Soft, pink and no lesions present
Slightly yellow
No trauma
AXILLA Lymph nodes
Distribution of hair
Excessive perspiration
no lymph nodes present
Sparse
No excessive perspiration
CHEST AND BACK Symmetry
Breath sounds
Any deformity
Respiration
Symmetrical in shape
Normal S1 and S2 sounds
No deformity present
Normal respiration
BREAST Size and symmetry
Contour or shape
Color
Nipple and areola
Breast tissue
Lymph nodes
Normal symmetry
No masses, retraction or dimpling present
No redness present
No discharge present, nipple and areola normal
No masses present
Absent
UPPER EXTREMITIES Inspection
Range of motion
Normal upper extremities
Normal ROM on both sides

12. 12

Lesions
Any deformity
No lesions present
No deformity present
ABDOMEN Inspection
Auscultation
Palpation
Percussion
Surgical scar present
Normal bowel sounds
No enlargement of liver
No extra sounds of accumulated fluid or air
GENITALIA External genitalia
Discharge
Vulva
Any deformity
Normal
No discharge
Normal, no inflammation
No deformity present
ANUS AND RECTUM Skin
Bowel habit
Malena
Any scar/ fistula
Valsalva maneuver
Intact
Not normal
Not present
No scar or fisula present
Not recommended
LOWER EXTREMITIES Inspection
Range of motion
Lesions
Any deformity
Lower extremities normal
Normal ROM
No lesions present
No deformity present

13. 13

5. SYSTEMATIC EXAMINATION
SYSTEM ASSESSMENT FINDINGS

RESPIRATORY SYSTEM Inspection
Auscultation
Palpation
Percussion
Any respiratory disease
Respiratory depth, rhythm
Use of accessory muscles
Lumps/ nodules
Breath sounds
Symmetrical bilateral chest
Respiratory rate- 16b/min
No abnormal mass, no tenderness present
No air or fluid accumulation in lungs
No respiratory disease
Normal
Diaphragm is used for breathing
No lumps or nodules present
Normal sounds heard, no abnormal sounds
CARDIOVASCULAR SYSTEM Pulse rate
Heart sounds
Abnormal sounds
Any cardiovascular disease
Edema
Murmur
78b/min
S1 and S2 sounds present
No abnormal sounds heard
The patient has hypertension since last 6 years
No edema present
No murmur sound heard
GASTRO INTESTINAL SYSTEM Any family history of GI diseases
INSPECTION-
Skin color
No family history of GI diseases

Normal skin color

14. 14

Edema
Lesions
Distension
Scars
Masses or nodules
PALPATION
Light palpation
Tenderness
Rebound tenderness
Palpable mass
Deep palpation
Enlarged organs

PERCUSSION
Direct percussion
Indirect percussion
AUSCULTATION
Bowel sounds
Renal bruits
Liver bruits
Aorta
No edema present
No lesions present
Abdominal distension present
Scars of surgery present
No masses or nodules present


Present
Absent
Absent

No enlargement is seen in liver, spleen, kidneys, gall
bladder. The organs are normal

Flat sounds present in all 4 quadrants
Flat sounds present in all 4 quadrants

Sluggish bowel sounds present
Absent
Absent
Present

15. 15

MUSCULOSKELETAL SYSYEM Body gait
Spine curvature
Muscle strength
Homan’s sign
Upper limbs
Lower limbs
Limpy gait
Normal
Active and passive ROM
Negative
Normal movements, normal shape, ROM performed
No arch deviation, gait limpy, flexion and extension
normal
NERVOUS SYSTEM Level of consciousness
Awareness of place/person/time
Verbal response
Ability to follow commands
Intellectual activity
Language
Memory and judgement
Long and short term memory
Reflexes
Semi conscious
Oriented to place, person and time
Normal
Follows the commands
Intact
Normal
Intact
Intact
Normal
ENDOCRINE SYSTEM No investigations are done to rule out the hormone level
INTEGUMENTARY SYSTEM Inspection
Skin turgor
Texture
Color
Normal color
Good
Soft and hydrated
Normal color

16. 16

Skin temperature
Moisture level
Pressure injuries
Lesions, rashes and bruises
Capillary refill
Edema
No temperature
The skin is hydrated
No pressure injuries present
No lesions, rashes and bruises
Capillary refill time -2 to 3 sec
No edema present
GENITO URINARY SYSTEM Urinary output
Voiding pattern
Color of urine
Urinary pattern
Bowel pattern
1200ml/day
Normal
Dark color
Passes urine 3-4 times per day
Abnormal pattern
REPRODUCTIVE SYSTEM External genitalia
Urethral orifice
Vaginal introitus
Internal genitalia
Cervical examination
Cervical test

No polyps present
No lesions, edema, inflammation, tenderness present

Normal
Normal

17. 17

LAB INVESTIGATIONS:+
Sr. No. Investigations Patient’s value Normal value Remarks
1. Haemoglobin 9.7gm% 12-14gm% Low
2. Platelets 2.8lakh/mm
3
1.5-4.5lakh/mm
3
Normal
3. TLC 5.3x1000/ml 4.5-11x1000/ml Normal
4. Polymorphs 45% 40-65% Normal
5. Lymphocytes 1140/ml 1000-4800/ml Normal
6. Eosinophils 170/ml 30-350/ml Normal
7. Monocytes 4% 2-8% Normal
8. Urea 12mg/dl 6-21mg/dl Normal
9. Creatinine 0.68mg/dl 0.6-1.1mg/dl Normal
10. Potassium 5.2mEq/L 3.5-5.5mEq/L Normal
11. Sodium 138mEq/L 135-145mEq/L Normal

6. RADIOLOGICAL INVESTIGATIONS:
 Chest radiograph PA view: NAD
 Abdomen radiograph standing: Multiple air fluid levels present in jejunum
 Ultrasound: Multiple dilated gaseous and content filled bowel loops noted with too and fro peristalsis, with maximum small
bowel diameter of 3.4cm.
7. MANAGEMENT:
 Patient was kept NBM.

18. 18

 Ryle’s tube aspiration was done half hourly.
 Foley’s catheterization was done
 Injectable IV fluid support, antibiotics, antiemetics and analgesics were started soon after admission
 Patient was taken for laprotomy with diagnosis of intestinal obstruction
8. MEDICAL MANAGEMENT:
Sr .no. Name of the drug, route,
dose
and frequency
Indications Contra
indications
Mechanism
of action
Side effects Nurses responsibility
1. IV 0.9 NS 500ml
aggressively rush
-Extracellular fluid
replacement
-Metabolic alkalosis
-Mild sodium
depletion

-Edema
-Heart disease
-Cardiac
decomposition
-Primary or
secondary
aldosteronism
It is capable
of inducing
diocese
depending on
the clinical
condition of
the patient
-Febrile
response
-Infection at
the site of
injection
-Venous
thrombosis
-Phlebitis
-Assessing the IV site
-Hanging the primary IV bag
-Calculating IV rates
-Ensuring the correct dosage
-Monitoring the I/O of the
patient
-Preparing the fluid
-Safely administering the drug
-Avoiding potential
complications
2. IV RL 500ml aggressively
rush

-Low blood pressure
-Low blood volume
-Blood loss
-Metabolic
acidosis
-Metabolic
It alkanizes
via its
consumption
-Allergic
reactions
-Hives
Assessing the IV site
-Hanging the primary IV bag
-Calculating IV rates

19. 19

-Burn injuries alkalosis
-Severe liver
disease
-Anoxic states
-Renal failure
in the Citric
acid cycle the
generation of
a molecule of
carbon
dioxide which
is an excreted
by the lungs
-Cardiac issues
-Breathing
issues
-Back pain,
chest pain,
discomfort
-Ensuring the correct dosage
-Monitoring the I/O of the
patient
-Preparing the fluid
-Safely administering the drug
-Avoiding potential
complications
3. Inj. Dexamethasone 20mg/dl
TDS
-Inflammation
-Severe allergies
-Adrenal problems
-Arthritis
-Asthma
-Multiple sclerosis
-Infections
-Hypersensitivity
-Cerebral malaria
-Systemic fungal
infection

Suppress the
migration of
neutrophils
and
decreasing
lymphocyte
colony
proliferation
-Headache
-Blurred vision
-Insomnia
-Muscle
weakness
-Sore throat
-Increased hair
growth
-Observe for signs of adverse
reactions
-Monitor blood pressure two to
three times daily
-Test for Glycosuria daily
-If urine is positive for sugar
check each urine

4. Inj. Hyosine butylbromide
40mg/dl TDS
-Abdominal pain
-Abdominal cramps
-Renal colic


-Myasthenia
gravis
-Mega colon
-Glaucoma
-Hypersensitivity
Acts as
smooth
muscle
relaxing/
spasmolytic
-Dry mouth
-Feeling sleepy
or dizziness
-Constipation
-Tachycardia
-Be alert for adverse reactions
and drug interactions
-Assess for eye pain
-Assess for urinary hesitancy
-Monitor urine output

20. 20





effect -Blurred vision
-Problems in
urination
-Encourage patient to void
-Monitor BP for possible
hypertension
-Monitor cervical effacement
and dilatation in case of
pregnant women
5. Inj. Metaclopramide 40mg/dl
every 4 hrly
-Nausea
-Vomiting
-Heartburn
-Feeling of fullness
-Loss of appetite
-Hypersensitivity
-GI Bleeding
-Perforation
-GI obstruction
-Haemorrhage
Acts by
increasing the
movements or
contractions
of the
stomach and
intestines
-Syncope
-Dark urine
-Chills
-Dysphagia
-Heart
arrhythmia
-Muscle pain
-Insomnia
-Assess for extra pyramidal
symptoms and tardive
dyskinesia
-Assess for gastrointestinal
complaints such as nausea
vomiting and Constipation
-In oral administration, for
better absorption allow 30
minutes to one hour before
eating
6. Inj. Ondansetron 4mg/2ml
BD

-Nausea
-Vomiting
-Hypersensitivity Acts as anti
emetic drug
-Decreased or
irregular
heartbeat
-Diarrhea
-Dizziness
-Assess for nausea, vomiting
abdominal distension and
bowel sounds
-Do not chew the film
-Monitor EKG, potassium and

21. 21

-Itching
-Painful
urination
magnesium level in case of
giving ondensetron.
7. Inj. PCM 100ml TDS

-Pains
-Aches
-Fever
-Severe liver
disease
-Active liver
disease
Acts as an
anti pyretic
-Headache
-Itching
-Anxiety
-Stomach pain
-Insomnia
-It should not not be taken as a
substitute
-It should not be taken with
other medications especially
those that we also affect the
liver
8. Inj. Amikacin 300mg BD

-Hospital
acquired/ventilator
associated/healthcare
associated
pneumonia
-Endophthalmitis
-Meningitis
-Wound infections
-UTI
-Hypersensitivity
-Pregnancy
-Renal toxicity
-Auditory
toxicity
-Infants and
small children
Acts as
antibiotic
-Dizziness
-Parasthesia
-Diarrhea
-Twitching
-Hearing loss
-Balance
disorder
-Chest pain
-Renal function should be
checked twice weekly if stable
or according to guidelines
-Auditory and vestibular
functions should also be
monitored during treatment
9. Inj. Pantoprazole 20mg OD -GERD
-Esophageal varices
-Esophagitis
Hypersensitivity Acts as a
proton pump
inhibitor
-Headache
-Vomiting
-Joint pain
-Assess the patient’s medical
history
-Monitor for side effects

22. 22

-Acid peptic disease
-Helicobacter pylori
eradication
-Diarrhea
-Dizziness
-Monitor for drug interactions
-Assess for signs of
gastrointestinal bleeding.

ANATOMY AND PHYSIOLOGY OF GASTROINTESTINAL TRACT
The gastrointestinal tract or GI Tract is a set of organs beginning in the mouth and ending in the anus that processes the food we eat from its
intake till its eventual expulsion after digestion. The GI tract us present in all multi cellular animals however it can differ drastically from an
animal to animal.
The GI tract in humans begins in the mouth, continuing through oesophagus, stomach, small and large intestines. Taken as a whole, the GI tract
is 9 meters long. There are many supporting organs as well, such as liver which help by secreting enzymes that are necessary for the digestion of
food.
The human GI tract is divided into two halves, namely, the upper GI tract and the lower GI tract.
The organs of upper GI tract are:
 Mouth/oral cavity
 Pharynx
 Esophagus
 Stomach
Mouth: Food enters the digestive tract through the mouth or oral cavity.

23. 23

Pharynx: From the mouth, food passes posteriorly into the oropharynx and laryngopharynx
Esophagus: It is a muscular tube that carries food from mouth to the stomach. Once the food reaches the esophagus, the action of swallowing
becomes involuntary and is controlled by esophagus.
Stomach: This is where most of the digestion takes place. The stomach is J shaped bag like organ that stores the food temporarily, breaks it
down, mixes and churns with the enzymes and other digestive fluids and finally passes it along to the small intestine.
The organs of lower GI tract are:
 Small intestine
 Large intestine
 Anal canal
Small intestine: The small intestine is a coiled thin tube, about 6 meters in length, where most of the absorption of nutrients takes place. Food is
mixed with enzymes in liver and the pancreas in small intestine. The walls of small intestine absorbs the nutrients from the food into the
bloodstream, which carries them to the rest of the body.
Large intestine: The large intestine also known as colon, is a thick tubular organ wrapped around the small intestine. The primary function of
the large intestine is to process the waste products and absorbs any remaining nutrient and water back into the system. The remaining waste is
then sent to the rectum and discharged from the body as stool.

24. 24



FOUR LAYERS OF GI TRACT:
 Mucosa
 Sub mucosa
 Muscularis externa
 Serosa/Mesentry

25. 25


DISEASE CONDITION
INTESTINAL OBSTRUCTION :
Introduction:
Intestinal obstruction is a blockage that keeps food and liquid from passing through the small intestine or large intestine. Causes of intestinal
obstruction may include fibrous bands of tissue (adhesions) in the abdomen that after the surgery, an inflamed intestine (Crohn’s Disease),
infected pouches in the intestine (diverticulitis), hernias and colon cancer.
Without treatment, the blocked part of the intestine can die leading to serious problems. However, with prompt medical care,intestinal
obstruction often can be successfully treated.

26. 26

Types of intestinal obstruction:
 TYPE I: The Complete Intestinal Obstruction:
In a complete obstruction, the colon will be completely kinked, twisted or blocked off from blood supply. This condition mandates
immediate surgery.
 TYPE II: Partial Intestinal Obstruction:
A bowel obstruction may also be partial in which case the intestine is not completely blocked off, but only partially obstructed. This
condition might also be treated with a few days of bowel rest.
Re-booting the bowel with bowel rest
In the hospital, the technique of bowel rest requires that any food in the stomach is drained. The patient is NPO means he or she does not
eat. Intravenous fluids are given to stay hydrated. Sometimes, within few days things cab open up and start moving along. Thus no
surgery is needed.
When bowel rest fails
However, if the bowel rest is ineffective, or bowel tissue starts to die because of the blockage, then surgery to untwist the kinked bowel
or remove blockage is the only source. During the surgery the surgeon will remove the affected part of the bowel depending upon the
disease condition, the patient might have an ileostomy or colostomy. In bowel surgery, after the dead part is removed, sometimes the end
parts are sewn and the bowel pinks up nicely.
 TYPE III: Pseudo obstruction:
At times, a patient will exhibit bowel obstruction symptoms but X rays reveal no true blockages. This is called intestinal pseudo
obstruction. In such cases, nerves or muscles fail to move food properly.
 OTHER TYPES:

27. 27

 Mechanical obstruction: An intra luminal obstruction or a mural obstruction from pressure on the abdominal wall. The lumen of the
bowel is blocked due to incarceration, strangulation, neoplasm or volvulus, intussesceptions, polpyoid tumors,stenosis, strictures,
adhesions, hernias and abscesses, Crampy abdominal pain is typical, inability to pass stool is always noted. Vomiting is usually present.
The abdomen is distended with hyperactive peristalsis.
 Functional obstruction: The intestinal musculature cannot propel the content along the bowel. The blockage can be temporary and the
result of manipulation of the bowel during surgery. Paralytic ileus, obstruction is due to inhibition of intestinal motility. Vomiting and
intractable constipation are common symptoms. Peristalsis is markedly diminished or absent. The abdomen is distended and may or may
not be tender.
 Vascular obstruction: The most common causes are mesenteric artery occlusion and mesenteric wall thrombosis. Patients are usually
elderly. There is an onset of sudden severe abdominal pain, vomiting, diarrhea, shock and blood in stools. The abdomen is tender,
peristalsis diminished or absent. The obstruction can be partial or complete. Its severity depends upon their bowel being affected, the
degree to which lumen is obstructed and specially the degree to which the vascular supply to the bowel wall is destroyed.
Etiology
BOOK PICTURE PATIENT PICTURE
Intestinal adhesions Present
Colon cancer Absent
Hernias Absent
Inflammatory bowel disease Absent
Crohn’s disease Absent
Diverticulitis Absent

28. 28

Volvulous Absent
Impacted feces Absent
Abdominal or pelvic surgery Absent
Infection Present
Muscle or nerve disorders Absent
Certain medications Absent

Risk factors
BOOK PICTURE PATIENT PICTURE
Abdominal or pelvic surgery Absent
Abdominal adhesions Present
Crohn’s disease Absent
Infection Present

Pathophysiology
Due to etiological factors viz. infection and abdominal adhesions

Blockage in the large intestine

29. 29

Accumulation of intestinal contents, fluid and gas proximal to the obstruction

Bowel distension

Secretory and absorptive Venous obstruction
functions of the mucosa and
are depressed arterial occlusion

Dehydration Infarction

Diagnostic Evaluation
BOOK PICTURE PATIENT PICTURE
History taking Done
Physical examination Done
X Rays Done
USG Done
CT Scan Not done
Air or barium enema Not done

30. 30

Signs and Symptoms
BOOK PICTURE PATIENT PICTURE
Severe bloating Absent
Abdominal pain Present
Decreased appetite Absent
Nausea Absent
Vomiting Present
Inability to pass gas or stool Absent
Constipation Absent
Diarrehea Absent
Severe abdominal cramps Present
Abdominal swelling Absent

Management
BOOK PICTURE PATIENT PICTURE
PHARMACOLOGICAL
Antibiotics Inj. Dexamethasone,
inj.Amikacin
Antacids Inj. Pantoprazole
Anti emetics Inj. Ondansetron

31. 31

Anti pyretics Inj. PCM
NON PHARMACOLOGICAL
Patient is kept NPO Done
IV Therapy Done
Nasogastric tube insertion Done
Position of the patient Fowler or semi fowler position
Monitor I/O Chart Done
Monitor vitals Done
Diet and nutrition Patient takes soft diet
Regular exercise Patient does exercise daily
SURGICAL
Surgical decompression Not done
Exporatory laprotomy not one
Caecostomy and caecopaxy Not done
Young elective sigmoid colostomy Not done
Laproscopic bowel resection Done

NURSING MANAGEMENT
 NURSING ASSESSMENT
 Gather information about patient’s symptoms.

32. 32

 Assess patient’s risk factors.
 Assess patient’s family understanding about the diagnose.
 Identify patient’s and family level of anxiety and use of appropriate coping mechanisms
 Check vital signs
 Evaluate patient’s medical history for condition

 NURSING DIAGNOSIS
 Acute pain related to surgical incision as evidenced by pain scale.
 Fluid volume deficit related to surgical intervention and NPO status as evidenced by intake output chart
 Risk of infection related to altered immunity
 Disturbed sleeping pattern related to pain at incision site as evidenced by fatigue during daytime
 Anxiety related to hospitalization as evidenced by facial expressions

 SHORT AND LONG TERM GOALS
SHORT TERM GOALS LONG TERM GOALS

To reduce pain

To improve the sleeping pattern
To maintain fluid and electrolyte imbalance

To reduce anxiety
To reduce risk of infection

To improve the knowledge regarding disease

33. 33

 NURSING CARE PLAN
NURSING
ASSESSMENT
NURSING
DIAGNOSE
GOAL PLANNING IMPLEMENTATON RATIONALE EVALUATION
Subjective Data-
The patient says
that she is having
pain at the
incision site

Objective Data-
The nurse
observed that the
patient looks
irritable and
restless
















Acute pain
related to surgical
incision as
evidenced by
pain scale























To reduce the
level of pain


























To assess the post
operative pain in
the patient using
pain scale



To check the
nature frequency
and quality of
pain

To provide the
diversional
therapy

To provide
comfortable
position

To administer
pain medication

To encourage
early ambulation



Assessed the post
operative pain in the
patient using pain
scale. The scale score
was 6


Paine was intense and
radiating in nature



Provided emotional
and social support


Provided Supine
position


Inj. PCM 100ml IV
TDS provided

Early ambulation is
encouraged



Proper
assessment helps
in quantifying
pain and
providing pain
medication

Helps in
prescribing
appropriate
medication

Provide
distraction from
the pain

Helps in reducing
pain


Helps in relieving
pain

Helps in early
recovery



The pain of the
patient has been
reduced to some
extent.

34. 34

NURSING
ASSESSMENT
NURSING
DIAGNOSE
GOAL PLANNING IMPLEMENTATON RATIONALE EVALUATION
Subjective Data-
The patient tells
that her lips are
dry And she feels
like vomiting

Objective Data-
The nurse
observed that the
patient looks dull
lethargic and have
poor skin turgor.


















Fluid volume
deficit related to
surgical
intervention and
NPO status as
evidenced by
intake output
chart






















To maintain
adequate fluid
balance



























To assess the
blood pressure
and pulse of the
patient


To inspect mucus
membrane skin
turgor and
capillary fill time


To maintain
intake output
chart hourly


To administer IV
fluids and
electrolytes


To provide clear
liquids when oral
intake is resumed





Blood pressure-
82/64mm Hg
Pulse- 68b/min



Capillary refill time
was 2.4 sec




I/O – 15ml/hr




IV NS and IV RL
aggressively rushed



Homemade and fresh
juices provided






Helps in checking
the status of the
patient



To know the
degree of fluid
and electrolyte
imbalance


Assess the
amount of fluid
loss


Helps in
maintaining fluid
level


Helps in starting
normal diet






The fluid volume of
the patient has been
restored to some
extent

35. 35

NURSING
ASSESSMENT
NURSING
DIAGNOSE
GOAL PLANNING IMPLEMENTATON RATIONALE EVALUATION
Subjective Data-
The patient says
that he is feeling
warm

Objective Data-
The nurse
observed that the
patient is having
fever.
Fever= 100.7
0
F













Risk of infection
related to altars
immunity
To reduce the
chances of
infection in the
patient and
prevent
complications
To practice and
instruct good
Habits




Inspect incision
site and dressing




To monitor vital
signs





To administer
antibiotics




To teach the use
of aseptic
technique during
dressing
Hand washing is put
into action and steps
of hand washing are
demonstrated to the
patient and her family


Inspected incision site
and dressing. There is
no sign of pus or
cyanosis present.


Temp. 100.7
0
F
Pulse- 78b/min
Respiration-22b/min




Inj. Amikacin
300mg/dl BD and inj.
Dexamethasone
20mg/dl TDS given


Aseptic technique is
used for dressing

Prevent
transmission of
infection




To check any
wound infection




Tell about the
condition of the
patient and
provide baseline
data


It treats and fights
against infection




It prevents
transmission of
diseases and
infection
The risk of infection
of the patient has
been reduced to
some extent

36. 36

HEALTH EDUCATION
 Rest-
 To take at least 10 hours of sleep a day
 To prevent from fatigue ness
 Have plenty of rest in a day
 Avoid doing sternous activities that make you feel tired
 Decrease emotional stress
 Nutrition-
 Give high protein diet like chicken, egg, cereal, milk
 Take more liquids in diet.
 Eat smaller meals more frequently throughout the day instead of three large meals
 Chew your food well ideally until its liquid
 Drink plenty of water to stay hydrated up to 64 ounces per day
 Slowly add new foods back into your diet
 If you had partial obstruction the doctor may recommend a special low fiber diet that is easier for the intestine to process
 Advice to avoid carbonate beverages in case of sudden pain
 Medication-
 Prevent cessation of medication in between
 Continue medication in prescription
 Take medications as prescribed
 Do not take any medication without prescription
 Hygiene-
 Maintain eye care
 Cut nails and maintain moisture of skin
 Demonstrate ostomy care including wound cleaning if colostomy is done
 High standard of personal hygiene at home and environmental is required

37. 37

 Medical help-
 Approach hospital whenever needed
 Early treatment help in survival
 In case of any pain or complication do consult the doctor
 In case of any abnormality at incision site or wound dressing immediately referred to hospital and consult doctor
 Follow up-
 Advise for routinely follow up
 In case of any emergency consult the doctor
 Activity-
 Allow the patient for the ROM exercises.
 Exercise regularly
 The surgeon may ask the patient to limit sternness activity for four to six weeks

38. 38

SUMMERIZATION
 My patient Mrs. Anjana was admitted in for the treatment of abdominal pain and the surgical treatment i.e., Laprotomy at IGMC
Shimla on 30-11-2023.

 She was admitted in HDU with the chief complaints of abdominal pain, abdominal discomfort and episodes of vomiting.

 After history collection, I assessed the patient by physical examination, noted down her lab investigations and advised to take rest
and protein rich diet.

 Then I made the nursing care plan based on her condition.

 I gave the patient and her family members health education on various aspects like rest, medication, nutrition, hygiene, medical help,
follow up and activity.

 Now the condition of the patient has been improved up to some extent.

39. 39

BIBLIOGRAPHY
 BOOK REFERENCES :
 Jacob and Singh “PediatricNursing”2
nd
edition.N.R.publishers.page.no.301-308.
 Suddharth and Brunner “MedicalSurgicalNursing”2
nd
edition.Jaypee.publishers.page.no.308-309


 INTERNET REFERENCES:
 http://www.sbribd.com/document/454854849/1585564206708-case-study-intestinal-obstruction-docx
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860489
 http://www.youtube.com/live/wek9TA_3pFY?si=90-zxX-5o6pTRONm
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007228