Bowel Perforation Nursing Diagnosis & Care Plan

Bowel perforation, a serious medical condition requiring emergency medical care, occurs when a hole develops in the bowel wall. This can cause leakage of gastric acid or stool into the peritoneal cavity. If left untreated, it can result in internal bleeding, peritonitis, permanent damage to the intestines, sepsis, and death.

This condition can be caused by injury, trauma, or an underlying health condition, including:

It is vital to seek medical care when clinical signs of bowel perforation occur. Signs and symptoms include:

  • Severe abdominal pain or cramping
  • Abdominal tenderness
  • Bloating or distended abdomen 
  • Fever or chills
  • Nausea and vomiting

After a physical examination, diagnostic procedures like blood tests, x-rays, abdominal CT scans, upper endoscopy, or a colonoscopy may be performed to confirm the condition. 

Nursing Process

Immediate medical care must be provided to patients with bowel perforation to prevent complications. Nursing care for bowel perforation includes treating the underlying condition, hemodynamic stabilization, preparing the patient before and after surgical and medical intervention, promoting comfort, patient education, and preventing complications such as abscesses or fistulas. 

Nursing Care Plans Related to Bowel Perforation

Acute Pain

One of the first symptoms of bowel perforation is severe abdominal pain that occurs gradually, along with abdominal tenderness and bloating. Pain will become constant and worsen with movement or when increased pressure is placed on the abdomen.

Nursing Diagnosis: Acute Pain

Related to:

  • Disease process
  • Inflammatory process
  • Peritoneal tissue trauma or injury
  • Chemical irritation of the peritoneal cavity
  • Abdominal distention

As evidenced by:

  • Expressive behavior
  • Guarding behavior
  • Facial expression of pain
  • Protective behavior

Expected outcomes:

  • Patient will verbalize pain relief.
  • Patient will demonstrate interventions that can improve symptoms and promote comfort.

Assessment:

1. Assess the patient’s level of pain and pain characteristics.
Patients typically describe a worsening of abdominal pain and distention with bowel perforation. In some cases, there may be a pain-free period followed by worsening pain due to decompression just after perforation.

2. Assess imaging and laboratory studies.
Imaging studies like colonoscopy, CT scan, and x-ray can help confirm the diagnosis, locate the perforated site, and plan appropriate interventions to manage the extent of bowel perforation. Complete blood count, basic metabolic panel, and inflammatory markers should also be reviewed to assess signs of infection and determine liver and kidney function.

Interventions:

1. Administer medications for pain control.
Providing analgesics once the diagnosis has been established can help reduce metabolic rate, minimize peritoneal irritation, and promote comfort in patients with bowel perforation.

2. Keep NPO and consider a nasogastric tube.
The patient should be kept NPO and may require nasogastric decompression.

3. Prepare and assist in surgery.
Surgery is indicated in patients with bowel perforation to help repair the perforated area and prevent complications like peritonitis and sepsis.

4. Encourage the patient to use abdominal splints.
Splinting the abdomen can help reduce abdominal pressure before and after surgery when moving.


Risk for Infection

Patients with bowel perforation have a very high risk of developing an infection. When the bowel becomes perforated, stool and other gastric contents may spill into the abdomen and the peritoneum, causing peritonitis and sepsis.

Nursing Diagnosis: Risk for Infection

Related to:

  • Inadequate primary defenses
  • Disease process
  • Traumatized/broken skin/tissues
  • Invasive procedure or surgical intervention
  • Leakage of bowel contents into the peritoneum

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions will be directed at the prevention of signs and symptoms.

Expected outcomes:

  • Patient will be free from any signs of infection or further complications. 
  • Patient will verbalize understanding of the condition and its complications and alert the nurse or provider to signs of infection such as fever or wound drainage.

Assessment:

1. Evaluate for any signs of systemic infection or sepsis.
Alterations in the patient’s vital signs, including a decrease in blood pressure, increased heart rate, tachypnea, fever, and reduced pulse pressure, can indicate septic shock, leading to vasodilation, fluid shifting, and reduced cardiac output.

2. Assess laboratory values.
Alterations in laboratory values like white blood count can indicate infection.

3. Assess wound healing.
Following surgical intervention, the nurse should monitor incisions for any redness, warmth, pus, swelling, or foul odor that signals an abscess or delayed wound healing.

Interventions:

1. Monitor the patient’s skin moisture, color, and temperature.
Warm, dry, and flushed skin are early signs of sepsis. When the patient develops cyanotic, cold, and clammy skin, this can indicate septic shock from peritoneal infection.

2. Administer antibiotics as indicated.
Antibiotics can help prevent and treat infection in patients with bowel perforation.

3. Dress surgical wounds aseptically.
Surgical wounds can increase the risk of infection due to compromised skin or tissues. The nurse must closely monitor the wound and perform dressing changes as instructed.

4. Ensure infection control precautions are followed.
Interventions that can help reduce infection in patients with bowel perforation include meticulous hand hygiene before and after handling the patient, the surgical site, and IV sites or catheters.


Deficient Knowledge

It is important to provide proper patient education about the condition, prognosis, treatment options, and complications to ensure adherence with the treatment regimen.

Nursing Diagnosis: Deficient Knowledge

Related to:

  • Misinformation
  • Misinterpretation of information
  • Inadequate access to resources 
  • Inadequate commitment to learning 
  • Inadequate awareness of resources 
  • Inadequate information
  • Lack of a support system
  • Inadequate participation in care planning

As evidenced by:

  • Nonadherence with the treatment regimen
  • Inaccurate follow-through of instructions 
  • Inaccurate statements about a topic 
  • Development of a preventable complication

Expected outcomes:

  • Patient will verbalize understanding of the condition, its complications, and the treatment regimen.
  • Patient will participate in care planning and follow-up appointments.

Assessment:

1. Assess the patient’s understanding of the current condition.
This will help determine the need to provide more information about the patient’s condition and the topics that need to be addressed.

2. Evaluate the patient’s support system.
Patients who undergo serious abdominal surgery will likely require support in the hospital and at discharge. Provide instructions to a dependable support person.

Interventions:

1. Discuss diet and comorbidities.
Since bowel obstructions, impaction, and diverticulitis can all lead to bowel perforations, the patient should be instructed on consuming a proper diet, such as increased fiber intake and plenty of fluids if not contraindicated.

2. Discuss symptoms that require immediate medical attention.
Signs and symptoms like worsening abdominal pain and discomfort, chills, fever, nausea and vomiting, and purulent drainage with edema and erythema around the surgical site must be reported, as this can indicate developing complications.

3. Prepare the patient for surgery.
Bowel perforation may be treated through a laparoscopic procedure, or endoscopy, or if severe, may result in a colostomy. Prepare the patient for what to expect with their procedure by encouraging and answering questions.

4. Encourage the patient to follow up with care.
Monitoring after surgical intervention for bowel perforation is essential to avoid complications like a fistula or hernia.


References

  1. ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
  2. Bowel Perforation. Jones MW, Kashyap S, Zabbo CP. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537224/
  3. Gastrointestinal Perforation. Cleveland Clinic. Reviewed: July 11, 2022. From: https://my.clevelandclinic.org/health/diseases/23478-gastrointestinal-perforation
  4. Gastrointestinal Perforation. Healthline. Updated October 6, 2018. From: https://www.healthline.com/health/gastrointestinal-perforation
  5. Intestinal Perforation. Hafner J, Tuma F, Hoilat GJ, et al. [Updated 2022 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538191/
  6. Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.