Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Gastro-intestinal Module
• Acute Abdomen

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Acute Abdomen Classification

• The term Acute Abdomen refers to abdominal
  acute conditions requiring emergency surgery
• The main conditions are
• Perforation (gastric or intestinal)
• Mesenteric Thrombosis
• Intestinal Obstruction
• Severe cases of haematemesis/ malaena
  unresponsive to medical treatment

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Acute AbdomenPerforation

• Perforation of the stomach or intestine ?
  peritonitis. It includes perforation from
• Peptic ulcer
• Inflammatory bowel disease Crohns disease or
  ulcerative colitis
• Perforated appendix (appendicitis)
• Diverticular disease
• Requires urgent surgical intervention to save
  life

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Acute Abdomen Mesenteric Thrombosis

• A thrombus or embolus obstructing the blood flow
  in the mesenteric arteries (supplying the
  intestines)
• ? necrosis of the intestinal segment supplied
• ? peritonitis
• Requires urgent surgical intervention to save
  life

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Acute Abdomen Intestinal Obstruction

• Either the small or large intestine may obstruct.
  (Large bowel obstruction develops more slowly,
  therefore is less of an emergency)
• Main causes are
• Adhesions (fibrous strictures following
  inflammation and scarring)
• Strangulated hernia (inguinal or femoral)
• Tumours
• Volvulus or intussusception (children mainly)
• Most require urgent surgical intervention to
  save life (partial obstruction may resolve)

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Acute Abdomen

• Peritonitis

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Acute Abdomen Peritonitis

• Peritonitis inflammation of the usually sterile
  peritoneal membranes and cavity
• May be one or both of
• Chemical (inflammation from acid gastric contents
  as with perforated peptic ulcer)
• Infective (micro-organisms from the bowel
  entering the sterile peritoneum)

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Peritonitis Pathophysiology

• An inflammatory process
• Accumulation of fluid (serous or purulent) in the
  peritoneal cavity leads to-
• Shock (hypovolaemic and neurogenic)
• Paralytic Ileus (? peristalsis with accumulation
  of fluid and gas in the intestine)
• Septicaemia (septic shock)
• Abscess formation (pelvic sub-phrenic)

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PeritonitisClinical Manifestations

• Extreme abdominal pain and tenderness ? shock
• Rigid board-like abdomen with distension
• Hypotension, cold and clammy skin
• Tachycardia, weak, thready pulse
• Pyrexia
• Nausea, vomiting, dehydration, electrolyte
  imbalance
• Restlessness (? oxygenation to brain)

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Intestinal Obstruction

• Pathophysiology

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Intestinal Obstruction Pathophysiology

• An accumulation of intestinal contents, fluid and
  gas above the obstruction ? abdominal distension
  (the lower the obstruction, the more the
  distension)
• ? absorption of fluids,? gastric secretions and
  secretions of inflammatory response
• ? peristalsis and reverse peristalsis above the
  obstruction (silent bowel below the obstruction)

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Intestinal Obstruction Pathophysiology (cont)

• Vomiting leads to fluid, potassium and chloride
  loss
• ? dehydration and electrolyte imbalance
• ? hypovolaemic shock
• Increased pressure within the lumen affects blood
  supply ? oedema, ischaemia, necrosis
• Perforation of intestinal wall ? peritonitis

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Intestinal Obstruction Clinical Manifestations

• Abdominal distension and discomfort
• Colicky abdominal pain
• Vomiting initially undigested food ? bile. May
  eventually become faecal vomit if low obstruction
  (reverse peristalsis)
• Silent abdomen no bowel movement and no flatus
  passed
• Dehydration thirst, dryness of skin/ mouth,
  malaise, drowsiness ? signs of hypovolaemic shock
  (fluid and electrolyte imbalance)

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Acute Abdomen

• Diagnosis

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Acute Abdomen (all categories) Diagnosis

• History and clinical condition
• Ultrasound scan to exclude differential diagnosis
  of ruptured ovarian cyst
• Abdominal Xray (supine and erect)
• Shows peritoneal fluid levels in cases of
  peritonitis
• Shows fluid levels/ gas in distended loops of
  bowel in intestinal obstruction/ paralytic ileus
• Blood CBC, urea and electrolytes, serum amylase
  (differential diagnosis of pancreatitis), random
  blood sugar, blood culture

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Acute Abdomen

• Management

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Acute Abdomen (all categories) Medical Management

• Stabilise (IV colloids and crystalloids)
• Blood group and cross-match pre-op
• Transfer to OR (emergency) once stable for a
  Laparotomy and appropriate surgery
• Repair of perforation
• Resection of the affected bowel and end-to- end
  anastomosis
• Resection of affected bowel and ileostomy or
  colostomy (temporary or permanent)

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Acute Abdomen

• Nursing Care

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Acute Abdomen Nursing Care (pre-op)

• Support the patient and family (pain relief)
• Monitor vital signs, IV fluids, urine output,
  fluid balance, O2 therapy/ pulse oximetry
• Insert NG tube and aspirations (decompression of
  intestine)
• Accompany to Xray for diagnosis
• Take blood samples and ensure blood available for
  transfusion prior to OR
• Prepare for OR. NO bowel preparation.

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Acute Abdomen Nursing Care (post-op)

• Pain relief
• Monitor vital signs, IV fluids, urine output,
  fluid balance, O2 therapy/ pulse oximetry,
  medication including IV antibiotics
• Nil by mouth (later graduated oral intake)
• NG aspirations
• Listen for bowel sounds and report
• Wound care, drains, stoma care if applicable
• Semi-sitting position. Encourage deep breathing
  and leg exercises (TED stockings/ Heparin).
  Gradual mobilisation