Avolvulus is a mechanical obstruction of the bowel that occurs when the intestine twists at least 180 degrees on itself. Although it can occur in either the large or the small bowel, the most common areas in adults are the sigmoid and ileocecal areas. Compression of the blood vessels occurs, and an obstruction both proximal and distal to the volvulus also occurs. The direction of the chyme flow is obstructed, but the secretions of bile, pancreatic juices, and gastric juices continue. The internal pressure of the bowel rises when fluids and gases accumulate, thus causing a temporary stimulation of peristalsis that increases the distension of the bowel and causes colicky pain. The bowel wall becomes edematous and capillary permeability increases, causing fluid and electrolytes to enter the peritoneal cavity.
These changes place the patient at risk for severe electrolyte imbalance, decreased circulating blood volume, and development of peritonitis. When the volvulus is near or within the ileum, regurgitation and vomiting increase fluid, electrolyte, and acid-base imbalances. Blockage within the cecum or large intestine leads to bowel distension and eventual perforation. Reflux can occur if the ileocecal valve is incompetent. Perforation of the bowel releases bacteria and endotoxins into the peritoneal cavity, causing endotoxic shock and even death.
In some patients, the cause of a volvulus is never discovered. In most cases, however, the condition occurs at the site of an anomaly, tumor, diverticulum, foreign body (dietary fiber, fruit pits), or surgical adhesion.
Nursing care plan assessment and physical examination
Take a complete history of the patient’s eating patterns, bowel patterns, onset of symptoms, and distension. Elicit a gastrointestinal history from the patient, with particular attention to those with a history of constipation and Meckel’s diverticulum (a blind pouch found in the lower portion of the ileum). Ask if the patient has had abdominal surgery because adhesions make the patient at risk for a volvulus. Ask the patient to describe any symptoms, which may include abdominal distension, thirst, and abdominal pain. Patients may also report anorexia and food intolerance, with vomiting after eating. Late signs include colicky abdominal pain of sudden onset and vomiting with sediment and a fecal odor. The patient may also describe chronic constipation with no passage of gas or feces, or when a stool is passed, there may be blood in it.
The patient usually appears in acute distress from abdominal pain and pressure. The patient’s abdomen appears distended, and the patient may show signs of dehydration such as poor skin turgor and dry mucous membranes. Measure the abdominal girth to identify the amount of distension. When you auscultate the abdomen, you may hear no bowel sounds at all, indicating a paralytic ileus, or you may hear high-pitched peristaltic rushes with high metallic tinkling sounds, indicating intestinal obstruction. You may be able to palpate an abdominal mass, although the patient experiences pain and guarding on palpation.
The patient may have lived with constipation for a long time and may be embarrassed to discuss the issue of bowel movements or may hold certain beliefs about the frequency and consistency of bowel movements. Assess the patient’s self-image and the patient’s ability to cope with possible body disfigurement from surgical correction. If the patient is an adult, determine the patient’s ability to provide self-care.
Nursing care plan primary nursing diagnosis: Pain (acute) related to inflammation.
Nursing care plan intervention and treatment plan
A tube that is inserted into the small intestine (such as a Miller-Abbott) may be used to decompress the bowel and relieve the volvulus. If a lower bowel volvulus is suspected, a proctoscopy is performed to check for an infarcted bowel, followed by a sigmoidoscopy with a flexible scope to deflate the bowel. If these procedures are successful, the patient immediately expels gas and receives relief from abdominal pain.
Children with small bowel volvulus generally require immediate surgery. In adults, when nonsurgical treatments fail to resolve the volvulus, surgery is performed. The objective of treatment is to relieve the obstruction, although the cause is not always apparent and sometimes is discovered only during surgery. Vascular and mechanical obstructions are relieved by the surgeon, who excises the affected bowel. Depending on the location and extent of the bowel resection, a colostomy or bypass procedure may be performed.
The collaborative postoperative management often includes intravenous analgesia with narcotic agents or patient-controlled analgesia, antibiotic therapy, nasogastric drainage to low continuous or intermittent suction, and intravenous fluids. Monitor the patient for complications such as wound infection (fever, wound drainage, poor wound healing), pneumonia (lung congestion, shallow breathing, fever, productive cough), and bleeding at the surgical site.
When the patient is first admitted to the hospital, she or he is in acute discomfort. Usually, strategies are initiated immediately to correct the underlying condition rather than provide analgesia to minimize the discomfort. Explain to the patient that large doses of analgesics mask the symptoms of volvulus and may place the patient at risk for perforation. Remain with the patient as much as possible until the decision is made to use surgical or nonsurgical treatment to correct the volvulus. If the patient receives successful nonsurgical treatment, the symptoms subside immediately. At that time, provide teaching about strategies to limit constipation, such as diet, adequate fluid intake, and appropriate exercise.
If the patient requires surgery, provide a brief explanation of the procedures and what the patient can expect postoperatively. Have the patient practice coughing and deep breathing, and reassure the patient that postoperative analgesia will be available to manage pain. When the patient returns from surgery, use pillows to splint the abdomen during coughing and deepbreathing exercises. Get the patient out of bed for chair rest and ambulation as soon as the patient can tolerate activity. Notify the physician when bowel sounds resume, and gradually advance the patient from a clear liquid diet to solid food. If the patient experiences any food intolerance at all (nausea, vomiting, pain), notify the surgeon immediately.
If a colostomy or other surgical diversion is needed, work with the patient to accept the change in body image and body function. Allow the patient to verbalize his or her feelings about the ostomy and begin a gradual program to assist the patient to assume self-care. Be honest and explain whether the ostomy is temporary or permanent. If the patient or significant other is going to care for the ostomy at home and is having problems coping, contact the enterostomal therapist or clinical nurse specialist to consult with the patient.
Nursing care plan discharge and home health care guidelines
Teach the patient about strategies to maintain healthy bowel function, such as diet, exercise, drinking fluids, and avoiding laxatives. Provide phone numbers and agencies that can be supportive, such as colostomy and ileostomy groups. Encourage the patient to report any recurrence of symptoms immediately, particularly if the patient has been treated nonsurgically. Encourage patients who have had surgery to avoid strenuous activity for up to 6 weeks.
I have been dishcargef from Hospital having received non sugical concervative treatment for Jejunal Volvulus.
ReplyDeleteUnfortunately without a Home Care Management Plan. Having contacted GP, 111, and the Hospital Ward.
How can I obtain a Home Care Plan ? My carer is 89 years of age with a terminal diagnosis.