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Pathophysiology

Paralytic ileus is the impairment of normal bowel movement and the development of an obstruction without a structural basis. This condition is as a result of an impairment of the autonomic nerves system, which is expected to control the contractions of the intestines (Harnsberger et al., 2019). Some physical attribute include surgeries on the Abdomen, especially the GIT since this brings inflammation that paralyzes bowel movement. It has also been attributed to trauma, severe infections, peritonitis, pancreatitis, and metabolic disturbances including hypokalemia. Some other drugs that can alter the functions of the nerves in the intestines include the opioids, anticholinergics, and the anesthetics can also lead to paralytic ileus.

Clinical signs of Paralytic ileus include abdominal pain, distension, nausea and vomiting with absence of bowel movement due to luminal obstruction. They may also present with no bowel sounds or reduced and infrequent bowel sounds which is an indication of the poor peristalsis process going on in the body. Some of the symptoms of gastritis include stomach discomfort and/or pain, bloating, passing gas, constipation, and the urge to pass gas. This fluid and electrolyte imbalance may cause severe dehydration if the intestine persists in malfunctioning for long. Possible causes of paralytic ileus are post operative inflammation, use of certain drugs, disturbances in electrolyte balance, minimal mobility and other diseases like sepsis, metabolic diseases.

In gerontological patients, the risk of paralytic ileus is heightened. Ageing leads to a natural decline in gastrointestinal motility, making older adults more vulnerable to disruptions in bowel function (Dickinson & Leo, 2014). They are also more likely to have multiple comorbidity conditions, to undergo surgeries, and to be on medications that alter bowel movement. Combined with this, their level of physiological reserve is not as high, which complicates recovery from the diseases mentioned above and their consequences. Paralytic ileus, if not treated, could lead to bowel ischemia, perforation, sepsis, and acute renal failure due to dehydration. Consequently, early detection and treatment are vital to avoid adverse complications and achieve bowel regularity.

Significant Diagnostic test

Abdominal X-ray

• Nursing Interventions

  • Patient Education: Explain the procedure to reduce anxiety and ensure the patient understands the importance of remaining still during the test for accurate imaging (Jotterand et al., 2016).

  • Positioning: Assist the patient lying flat on their back for the X-ray to capture a clear view of the Abdomen.

  • Remove Metal Objects: Remove jewelry, belts, or metal objects from the patient to prevent artifacts on the X-ray.

  • Pregnancy Check: For female patients of childbearing age, assess pregnancy status to avoid unnecessary radiation exposure.

  • Monitor for Discomfort: Observe the patient for any discomfort during the procedure, particularly if they have pain due to abdominal distension.

• Explanation: An abdominal X-ray helps visualize the intestines and identify air-fluid levels or dilated bowel loops indicative of paralytic ileus (Singh & Patel, 2019). It is often used to differentiate between functional obstruction (ileus) and mechanical obstruction (e.g., tumor or blockage).

CT scan of the Abdomen

• Nursing Interventions:

  • Assess for Allergies: Check for allergies to contrast dye, iodine, or shellfish if a contrast-enhanced CT scan is ordered.

  • Hydration: Ensure the patient is adequately hydrated to help flush the contrast dye from the kidneys post-procedure.

  • IV Access: Establish an IV line for the administration of contrast dye if needed.

  • Monitor for Reactions: Observe the patient for any signs of allergic reactions, such as itching, rash, or difficulty breathing, during and after the scan.

  • Provide Comfort: Comfort the patient and offer them a warm blanket, as they will have to remain as still as possible during the scan.

• Explanation: The CT scan delivers cross-sectional images of the abdominal organs to enable the assessment of bowel dilation and the presence of gas, together with the identification of any mechanical obstacles. These images are important in verifying paralytic ileus and excluding other abdominal disorders.

Electrolyte Panel

• Nursing Interventions:

  • Explain the Procedure: Inform the patient about the blood draw process to ease anxiety and ensure cooperation.

  • Blood Sample Collection: Follow aseptic techniques to draw blood and prevent contamination.

  • Monitor Site: Observe the venipuncture site for signs of bleeding or hematoma post-procedure.

  • Patient Positioning: Have the patient in a comfortable sitting or lying position to prevent dizziness or fainting during the blood draw.

  • Review and Report Results: Monitor abnormal electrolyte levels, such as hypokalemia, and report critical values to the healthcare team for prompt management.

• Explanation: The electrolyte panel shows the potassium, sodium, and calcium abnormalities that can influence gastrointestinal peristalsis. Alleviating these dysfunctions is another crucial step towards combating paralytic ileus.

Complete Blood Count (CBC)

• Nursing Interventions:

  • Explain the Purpose: Educate the patient about the importance of the test in evaluating infection or anemia, which may be linked to their symptoms (Wittink & Oosterhaven, 2018).

  • Standard Precautions: Use gloves and aseptic techniques while collecting the blood sample to prevent infection.

  • Sample Labeling: Properly label the blood sample to avoid misidentification and ensure accurate results.

  • Apply Pressure: Apply pressure to the venipuncture site to prevent bleeding or bruising after the blood draw.

  • Monitor Results: Observe the patient for signs of infection, such as fever, if an elevated white blood cell count is found.

• Explanation: A CBC reveals leukocytosis, indicating the presence of infection or the potential for systemic effects or complications of paralytic ileus.

Medical Management

NPO (Nothing by Mouth) Status

• Explanation: The patient is placed on NPO status to rest the gastrointestinal (GI) tract and prevent further accumulation of gas and fluids in the intestines. This approach allows the bowel to recover and helps prevent complications such as vomiting and aspiration. Collaborating with dietitians is essential to plan alternative nutritional support if the NPO status is prolonged.

Nasogastric (NG) Tube Decompression

• Explanation: Inserting an NG tube helps relieve abdominal distension by removing accumulated gas, fluids, and stomach contents, which reduces pressure on the intestines (Smart & Lau, 2023). Nurses pay attention to the content of the passed tube and the comfort of the patient, while physicians evaluate the need for the decompression and its duration. This collective intervention can mitigate symptoms and possible adverse effects, such as bowel rupture.

Intravenous (IV) Fluid and Electrolyte Replacement

• Explanation: The patient is given IV fluids to replace lost fluids and electrolyte imbalances like hypokalemia to help regulate bowel movement in patients with constipation. The nurses work with the physicians to check fluids and electrolytes balance and fine-tune IV replacement when oral intake is limited.

Pharmacological Interventions

• Explanation: Medication that may be administered include prokinetic (e.g., metoclopramide) or antiemetic (e.g., ondansetron) to facilitate bowel movement or prevent nausea, respectively. Close cooperation between nurses, pharmacists, and physicians is crucial when choosing specific medications, evaluating their efficacy, and modifying doses according to a patient's reaction. Gastric motility is also affected and should be regulated, whereby opioids should be given judiciously due to the risk of worsening ileus.

Surgical Consultation

• Explanation: In severe cases or when the paralytic ileus is superimposed by other conditions such as bowel ischemia or perforation, surgery may be required. Concerning surgery, the decision maker is the surgeon, together with the medical team, who examines the need for surgery. Nurses have an essential responsibility to plan the patient for the possible surgery, give pre-operative care, and assist in recovery and early detection of complications after surgery.

Early Ambulation and Physical Therapy

• Explanation: The patient should be encouraged to start walking as soon as possible, together with physical therapists, to help increase bowel movements and facilitate healing. Nurses help with mobility measures, evaluate the patient's tolerance level towards these procedures, and offer advice on safe mobilization. Getting out of bed is another simple intervention that has a great impact on bowel movement and looks at the potential adverse effects of bedridden patients.

Patient and Family Education

• Explanation: Patient and family teaching about the condition, its treatment, and possible complications are essential for recovery and future management of the condition (Wittink & Oosterhaven, 2018). The patient and the healthcare team, including the nurses, consult to ensure that the patient receives all the necessary details on the changes in the diet, the medication schedule, and the lifestyle changes that are required to ensure that the cancer does not reoccur. Such education engages the patients and their families in the care plan and also improves the health of the patients.

Nursing Diagnosis: Acute Pain related to Abdominal Distension 2nd paralytic ileus

• Supporting Data:

  • The patient reports severe abdominal discomfort and cramping.

  • Physical examination reveals abdominal distension and tenderness.

  • Decreased bowel sounds were noted on auscultation.

• Goal:

  • The patient will report a reduction in abdominal pain to a manageable level within 48 hours, as measured by a pain scale of 3 or less.

Nursing Plan/Interventions:

• Provide analgesics as prescribed while avoiding opioids, if possible, to reduce pain without exacerbating ileus.

• Assess the severity of the patient’s pain using a certain pain scale and make necessary changes to the pain management plan (Czarnecki et al., 2011).

• It is advisable that one should avoid the taking of pains relievers and instead go for other kinds of pains relieving methods such as the use of heat pads, or even practicing on how to relax.

• Assist the patient in finding comfortable positions that could help in the reduction or management of pain, including sitting or lying down on one side.

• Consult with the healthcare provider regarding pain management practices and outcomes and inform the employer about substantial improvements or intensification of pain (Czarnecki et al., 2011).

• Assist the patient with gradual movement and ambulation as tolerated to help stimulate bowel motility and relieve discomfort.

• Frequently assess the abdomen for changes in distension and listen to bowel sounds to identify signs of improvement or worsening.

• Maintain NPO (nothing by mouth) status to rest the gastrointestinal tract, potentially reducing pain associated with bowel movement and distension.

• If the patient experiences nausea, provide prescribed antiemetics to manage symptoms and potentially reduce abdominal discomfort.

Nursing Diagnosis: Risk for Fluid Volume Deficit related to Nausea and Vomiting 2nd paralytic ileus

• Supporting Data:

  • Patient exhibits signs of dehydration, including dry mucous membranes and decreased urine output.

  • The patient reports persistent nausea and vomiting.

  • Laboratory results indicate electrolyte imbalances.

• Goal:

  • The patient will maintain adequate hydration as evidenced by stable vital signs, normal urine output, and improved electrolyte levels within 24-48 hours.

Nursing Plan/Interventions:

Provide intravenous fluids as prescribed to replenish lost fluids and electrolytes.

• Regularly check blood pressure, heart rate, and other vital signs to detect early signs of fluid volume deficit.

• Make sure to assess the fluids that the patient is receiving and losing to avoid signs of dehydration.

• Teach the patient about the necessity of liquids and what symptoms to look for when one is already dehydrated (Wittink & Oosterhaven, 2018).

• Monitor electrolyte concentrations and modify the treatment based on laboratory tests and clinical outcomes.

• Assess for signs of fluid overload, such as peripheral edema or increased lung sounds, to adjust IV fluid therapy as necessary.

• Encourage oral care to keep the mouth moist and prevent discomfort, especially if the patient is NPO.

• If the patient is no longer NPO, encourage small, frequent sips of water or oral rehydration solutions as tolerated.

• Elevate the head of the bed to reduce nausea and prevent aspiration if vomiting occurs.

Nursing Diagnosis : Anxiety related to Uncertainty about Health Status and Potential Complications

• Supporting Data:

  • Patient expresses fear and concern about their condition and potential need for surgery.

  • Due to anxiety, the patient experiences problems like restlessness, tachycardia, and insomnia.

  • The patient has poor insight into the severity of the condition and its management plan.

• Goal:

  • The patient will demonstrate reduced anxiety and increased understanding of their condition and treatment plan, as evidenced by improved verbal expression of concerns and calm demeanor within 48 hours.

Nursing Plan/Interventions:

• To help minimize confusion and anxiety, provide straightforward details concerning the disease, available therapies, and possible results.

• Provide reassurance and active listening to address the patient’s concerns and anxieties.

• Engage the patient in the planning process to minimize feelings of powerlessness and confusion.

• Teach relaxation techniques like deep breathing or guided imagery to help manage anxiety (Wittink & Oosterhaven, 2018).

• Refer the patient to counseling or support groups if needed and coordinate with mental health professionals to address persistent anxiety.

• Minimize environmental stressors, such as noise and bright lights, to promote a sense of calm for the patient.

• Include family members in discussions about the patient’s condition and care plan to provide a support network and alleviate patient anxiety.

• Use an anxiety scale to monitor the patient's anxiety level and adjust interventions as necessary.

• Create a predictable daily routine for the patient to reduce uncertainty and help them feel more secure in their care environment.