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.
In this article:
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 Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to bowel perforation.
Subjective Data
Review of health history and complaints
1. Ask about the patient’s general symptoms.
It is vital to seek medical care when clinical signs of bowel perforation occur. Signs and symptoms include:
- Change in bowel habits
- Severe abdominal pain or cramping
- Abdominal tenderness
- Bloating or distended abdomen
- Fever or chills
- Nausea and vomiting
2. Investigate the pain further.
The patient is likely to report worsening abdominal pain, cramping, and distention. The pain may be sudden or gradual but will progress in severity. The decompression of an irritated or wounded area after the perforation may offer a pain-free period before worsening again. The abdomen will be tender on palpation.
3. Assess causative factors.
This condition can be caused by injury, trauma, or an underlying health condition, including:
- Accidental ingestion of harmful objects or substances like batteries, magnets, sharp objects, or any corrosive chemicals
- Injury from a traumatic event like a motor vehicle accident
- Bowel impaction
- Forceful vomiting
- Complications from surgery
- Appendicitis
- Cancer in the gastrointestinal tract
- Diverticulitis
- Bowel obstruction
- Hernias
- Inflammatory bowel disease
- Peptic ulcer disease
4. Inquire about recent invasive procedures.
Pain in the chest or abdomen following recent surgical or diagnostic procedures like endoscopy, colonoscopy, or laparoscopic, may suggest bowel perforation.
5. Review medical, surgical, and social history.
The patient’s past and present medical, surgical, and social history should be reviewed. This information should cover any prior hernias, bowel obstructions, cancer, foreign body insertions or ingestions, abdominal trauma, and regular medication use (NSAIDs, corticosteroids, and chemotherapy).
Objective Data
Physical assessment:
1. Monitor vital signs.
Although vital signs might be normal, sepsis symptoms such as tachycardia, tachypnea, and fever will likely emerge.
2. Perform a thorough abdominal examination.
Bowel sounds are sluggish or absent in bowel perforation due to the hole in the bowel wall. Diffuse air and intestinal leakage may make it difficult to localize the pain, but palpation can reveal tenderness. Abdominal guarding and rigidity may develop.
Diagnostic procedures:
1. Obtain samples for blood tests.
Laboratory tests include:
- Complete blood count
- Basic metabolic panel
- Liver function tests
- Lipase
- Amylase
- Inflammatory indicators like C-reactive protein (CRP)
For diagnostic purposes, however, common signs like leukocytosis (increased WBC), increased amylase (an enzyme that digests carbohydrates), or elevated CRP levels are non-specific.
2. Visualize the presence of air in the abdomen.
It is possible to see free intraperitoneal air below the diaphragm that may indicate bowel perforation through a chest x-ray. If the patient sits upright for at least 15 minutes before the film, the likelihood of diagnosing free air increases.
3. Further investigate the perforation.
- Ultrasounds may locate gas collections that could indicate a perforation.
- Abdominal CT scan is the procedure of choice for determining the location of the perforation and for diagnosing free air
- Upper GI endoscopy or colonoscopy visualizes perforation in the bowel.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with bowel perforation.
Manage Fluid and Hemodynamic Status
1. Treat sepsis or shock.
Intravenous (IV) access and initial hemodynamic care are necessary for treating a patient with bowel perforation, especially if the patient exhibits any signs or symptoms of sepsis or shock.
2. Initiate antibiotics early.
Using broad-spectrum antibiotics early on is crucial to combat gram-negative and anaerobic pathogens. Administration of antibiotics is usually accompanied by decontamination of the bowel through lavage.
3. Decompress the GI tract.
Nasogastric suction is necessary to empty the gut. Ensure the patient remains NPO.
4. Insert a urinary catheter.
Fluid replenishment and urine flow are evaluated by urinary catheterization, especially since bowel perforation increases the risk of fluid volume deficit.
Repair the Perforation
1. Prepare for surgery.
Surgical treatment to repair the hole is used to treat the majority of bowel perforations. Hemodynamically stable patients without concerns for peritonitis may only require antibiotics and observation.
2. Mend the perforation.
Urgent surgery may be necessary to fix the perforation. The procedure will depend on the perforation’s severity and location.
- An endoscopic procedure places endoscopic clips to halt bleeding. The size of the perforation determines how many clips are needed.
- Laparoscopic procedure outcomes are comparable to open surgery. Laparoscopy has several advantages in terms of post-operative results. Reduced paralytic ileus, a quicker recovery to normal bowel function, less pain, and a shorter hospital stay than open surgery.
- Traditional open surgery necessitates deeper abdominal incisions. It can lead to the creation of a stoma (opening on the abdomen) and colostomy (opening from the bowel through the abdomen).
3. Rest the colon.
The patient may need a temporary colostomy so that the colon can recover. This procedure includes:
- Stoma creation of a tiny hole in the abdomen.
- Connection of a section of the colon or small intestine to the stoma.
- Placement of a colostomy bag (a pouch attached to the stoma outside).
Nursing Care Plans
Once the nurse identifies nursing diagnoses for bowel perforation, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for 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.
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.
Ineffective Breathing Pattern
Clinical manifestations of bowel perforation include fatigue, oliguria, decreased peristalsis, and shortness of breath due to abdominal distention and swelling.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Disease process
- Abdominal distention
- Abdominal tenderness
- Increased abdominal pressure
- Abdominal pain or discomfort
- Inflammatory process
- Infection
As evidenced by:
- Shortness of breath
- Bradypnea
- Tachypnea
- Cyanosis
- Hyperventilation
- Hypoventilation
- Hypoxemia
- Hypoxia
Expected outcomes:
- Patient will demonstrate a normal breathing pattern and show no signs of respiratory distress.
- Patient will exhibit ABGs within acceptable limits.
Assessment:
1. Assess the patient’s respiratory status.
Patients with bowel perforation often experience respiratory distress due to increased abdominal pressure from intestinal content leakage into the abdomen, which places pressure on the lungs and disrupts the patient’s respiratory status.
2. Determine potential causes that aren’t physiologic.
Dyspnea and tachypnea can occur due to psychological reasons like anxiety due to the prognosis of the condition or physical reasons due to the increasing intra-abdominal pressure, distention, and pain.
3. Conduct an abdominal assessment.
Abdominal distention and pain associated with bowel perforation can significantly affect the patient’s vital signs, particularly the patient’s breathing pattern. It is crucial to inspect the abdomen for dehiscence, hernias, distention, or rigidity that contribute to alterations in breathing.
Interventions:
1. Monitor the patient’s oxygen saturation continuously.
Dyspnea and other alterations in breathing patterns associated with bowel perforation and increased intra-abdominal pressure can cause hypoxia. Normal oxygen saturation is between 95% to 100%. SpO2 less than 90% can indicate significant oxygenation problems.
2. Monitor and evaluate blood gas values.
Blood gas values can indicate imbalances in carbon dioxide, oxygenation, and pH levels of the blood and can signify developing complications for patients with bowel perforation. Normal blood gas values include PaO2 80-100 mmHg, PaCO2 35-45 mmHg, HCO3 22-26 mEq/L, and pH 7.35-7.45.
3. Administer supplemental oxygenation.
Initial management for bowel perforation includes aggressive resuscitation, including oxygen therapy, intravenous fluids, and administration of broad-spectrum antibiotics. Oxygen supplementation can help correct hypoxemia or hypoxia.
4. Administer medications as indicated.
Pain medications can help relieve abdominal pain and reduce dyspneic episodes caused by bowel perforation and abdominal discomfort.
Ineffective Tissue Perfusion
Bowel perforation is characterized by loss of continuity of the bowel wall, resulting in ineffective tissue perfusion complications like leakage of intestinal contents into the peritoneal cavity, peritonitis, bleeding, multiple organ failure, and shock.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Inflammatory process
- Infection
- Ischemia
- Obstruction
As evidenced by:
- Abdominal distension
- Abdominal discomfort
- Abdominal tenderness
- Nausea and vomiting
- Hypoactive or absent bowel sounds
- Nausea and vomiting
Expected outcomes:
- Patient will remain free from abdominal distention and discomfort.
- Patient will remain free from gastrointestinal tissue perfusion complications like peritonitis, bleeding, and septic shock.
Assessment:
1. Conduct a thorough history and physical evaluation.
This will help determine the etiology of the perforation, as almost all patients experience abdominal pain, nausea and vomiting, fever, and decreased bowel function. Assessment will entail a detailed history of medical conditions, family history of cancers, inflammatory bowel diseases, and recent medical procedures or surgical interventions that may have caused the perforation.
2. Assess vital signs and blood tests.
Laboratory studies can determine signs of infection and declining liver and kidney functions associated with leakage of bowel contents into the peritoneum. Since bowel perforation increases the patient’s risk for shock and compromised tissue perfusion, vital signs must be assessed and monitored.
3. Assess results of diagnostic imaging studies.
Diagnostic tests like colonoscopy, x-rays, and CT scans can help diagnose bowel perforation, determine its extent and location, and confirm the need for surgical interventions.
Interventions:
1. Administer intravenous fluid replacement.
Initial management of bowel perforation involves establishing hemodynamic stability and preventing complications like septic shock.
2. Administer medications as indicated.
Early initiation of antibiotic therapy is essential in preventing infection, reducing inflammation, and promoting adequate gastrointestinal tissue perfusion.
3. Prepare the patient and assist in surgical intervention.
In severe cases, laparoscopic or traditional open surgery may be indicated to remove the perforated part of the bowel and reconnect it.
4. Perform proper stoma care.
In some cases, bowel perforation surgeries will require the creation of the stoma to allow the resected bowel to rest and heal before it will be reattached. The nurse will monitor the stoma following surgery for complications such as bleeding, necrosis, retraction, and prolapse that inhibit perfusion.
5. Monitor for any signs of complications.
The nurse should monitor the patient for signs of complications like bowel obstruction, fistula formation, and hernias. Symptoms such as absent bowel sounds, increased pain, and changes in vital signs signal abnormalities in perfusion.
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.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- 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/
- Cleveland Clinic. (2022, July 11). Gastrointestinal perforation: Symptoms, surgery, causes & treatment. Retrieved March 2023, from https://my.clevelandclinic.org/health/diseases/23478-gastrointestinal-perforation
- de Bakker, J., & Bruin, S. (2012). Successful laparoscopic repair of a large traumatic sigmoid perforation. Journal of Surgical Case Reports, 2012(2), 3-3. https://doi.org/10.1093/jscr/2012.2.3
- Gastrointestinal Perforation. Cleveland Clinic. Reviewed: July 11, 2022. From: https://my.clevelandclinic.org/health/diseases/23478-gastrointestinal-perforation
- Gastrointestinal Perforation. Healthline. Updated October 6, 2018. From: https://www.healthline.com/health/gastrointestinal-perforation
- 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/
- Jones, M. W., Kashyap, S., & Zabbo, C. P. (2022, June 5). Bowel perforation – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved March 2023, from https://www.ncbi.nlm.nih.gov/books/NBK537224/
- Lee, S. (2022, June). Bowel perforation. Canadian Cancer Society. Retrieved March 2023, from https://cancer.ca/en/treatments/side-effects/bowel-perforation
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
- Medscape. (2022, September 29). Intestinal perforation treatment & management: Approach considerations, medical therapy, surgical therapy. Diseases & Conditions – Medscape Reference. Retrieved March 2023, from https://emedicine.medscape.com/article/195537-treatment#d10
- Wilkinson, J. (2022, October 2). Perforated bowel: Symptoms, causes, complications. Verywell Health. Retrieved March 2023, from https://www.verywellhealth.com/whats-a-bowel-perforation-797590
