Bowel Perforation

A bowel perforation occurs when a hole is formed somewhere within the gastrointestinal (GI)  tract: the stomach, the small intestine, or the large intestine.  This hole allows bile and digestive contents into the peritoneal cavity.  This causes inflammation of the peritoneal cavity, also known as peritonitis. This is a life threatening condition and needs to be treated immediately. 

Causes

There are numerous medical causes which can make a bowel perforation occur:

  • appendicitis or ruptured appendix
  • peptic ulcer disease
  • Crohn's disease
  • diverticulitis
  • gallbladder disease
  • inflammatory bowel diseases
  • ulcerative colitis
  • cancer in the gastrointestinal tract

There are also surgical or trauma-related causes which can cause a bowel perforation to occur:

  • stab or gunshot wounds to the abdomen 
  • abdominal surgery complications
  • ingestion of foreign objects
  • blunt force trauma to the abdomen

How to Diagnose a "Perfed" Bowel

The most definitive way to diagnose a perforated bowel is to physically look at it during surgery.  One of the most definitive non-invasive tests is an abdominal x-ray; this would show "free air" meaning air from the bowels that has gone through the perforation into the abdominal cavity.  In conjunction with this, patients can have severe abdominal pain, an elevated white blood cell count (due to infection), fever, nausea, noticeable blood loss, and hemodynamic instability (septic shock).

Treatment

Treatment usually involves surgery to repair the hole in the GI tract. If this occurs in the small or large intestine, surgery sometimes involves a removal of a portion of the intestine and creation of an ostomy.  An ostomy allows GI contents (stool, bile, etc.) from the intestine to drain through a hole in the skin into a bag attached to the abdominal wall. 

If a patient's peritonitis is very severe, they may remain "open" after surgery, meaning their surgical incision is not closed with staples or sutures.  It literally remains an open incision usually covered with a wound vacuum.  This allows for excess drainage to be removed from the abdominal cavity and for increasing abdominal pressure to be relieved. 

Nursing Care Plans and Interventions

1.  Risk for infection.  Assess vital signs making note of trends showing signs of sepsis (increased HR, decreased BP, fever). Assess neuro status including changes in level of consciousness or new onset confusion.  Observe output from drains to include color, clarity, and smell. Administer antibiotics as ordered.

2. Risk for anemia/blood loss.  Monitor hemoglobin and hematocrit (H&H) on complete blood count (CBC).  Administer blood products as needed to keep H&H up.  Labs and blood products are orders to be placed by a doctor; if they are not ordered, maybe suggest to the doctor that a recheck might be needed?  Look for signs of active bleeding such as change in VS (increased HR, decreased BP), flank bruising, frank blood coming from ostomy or NG tube, etc.

3. Acute pain.  Monitor pain based off a scale of 0-10.  Find out the patient's tolerable pain level and administer pain medications to keep within that threshold.  Keep patient in the semi-Fowler's position to relieve pressure on abdominal surgical wounds. Educate patient on the importance of splinting the surgical site with a pillow or soft object to lessen pain with movement. 

4. Risk for imbalanced nutrition.  Assess bowel sounds for frequency.  Monitor NG tube output.  Administer TPN or tube feeds as ordered.  Monitor abdominal girth size and be aware of trends in this measurement.  Notify provider of critical lab values including albumin, pre-albumin, BUN, creatinine, protein, glucose and nitrogen balance.

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AuthorCourtney Tracy