Bowel Perforation Nursing Diagnosis and Nursing Care Plan

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Bowel Perforation Nursing Care Plans Diagnosis and Interventions

Bowel Perforation NCLEX Review and Nursing Care Plans

Bowel perforation occurs when the intestinal wall mucosa is injured due to a violation of the closed system. As a result, organs enclosed within the peritoneal cavity are exposed to digestive fluids, forming a hole through the wall of the organ.

The most frequent secondary causes of bowel perforation are inflammation, infection, blockage, trauma, and invasive procedures.

Patients who present with abdominal pain and distension, especially in the right historical context, must be assessed for this entity because a delayed diagnosis increases the risk of developing infections like peritonitis, which can be fatal.

Stabilizing the patient is a part of the management while seeking surgical advice. Bowel perforation can increase morbidity and mortality even when treated properly because of post-repair problems such as adhesions and fistula formation.

Signs and Symptoms of Bowel Perforation

Symptoms of bowel perforation may include the following:

When peritonitis occurs secondary to bowel perforation, the abdomen becomes tender and painful on palpation or when the patient moves.  The abdomen may also feel rigid and stick outward farther than usual. In general, putting the patient in a supine position alleviates the pain.

In addition to the typical symptoms of a bowel perforation, symptoms of peritonitis might include:

Cause of Bowel Perforation

The underlying causes of bowel perforation can be categorized based on their anatomic location, however many etiologies are overlapping, and these may include:

  • Small Bowel Perforation
    • Infection or abscess
    • Tumor
    • Erosion from duodenal ulcerations
    • Meckel diverticulum
    • Mesenteric ischemia
    • Inflammatory bowel disease/colitis
    • Presence of foreign body
    • Obstruction
    • Medication/radiation-related
    • Blunt or penetrating abdominal trauma
    • Iatrogenic
  • Large Bowel Perforation
    • Tumor
    • Infection or abscess
    • Colitis
    • Foreign body
    • Obstruction
    • Volvulus
    • Blunt or penetrating abdominal trauma
    • Iatrogenic

Bowel perforation can also be caused by medical procedures involving the abdomen which may include:

  • Enema
  • Bowel preparation for colonoscopy
  • Colonoscopy
  • Sigmoidoscopy
  • Abdominal or pelvic surgery

Bowel perforation in children is most likely to occur after abdominal trauma. In juvenile trauma patients, intestinal perforation occurs somewhere between 1% and 7% of the time.

Duodenal ulcers cause bowel perforation at a rate that is 2- to 3-times higher than stomach ulcers do, making ulcerative disease the most common cause of bowel perforation in adults. Up to 15% of occurrences of perforation are related to diverticular illness.

The most frequent cause of perforation in the elderly population is perforated appendicitis. Around 2% of colonoscopies are reported to result in perforations generally, with greater rates during the procedure necessitating therapeutic measures.

Risk Factors to Bowel Perforation

A number of risk factors may increase the risk of developing bowel perforation including:

  • Abdominal surgery recently or in the past
  • Previous or recent pelvic surgery
  • Age more than 75 years old
  • History of multiple comorbidities
  • Trauma to the pelvis or abdomen, such as from an accident
  • History of diverticular disease
  • History of Inflammatory Bowel Disease
  • Colon cancer
  • Scar tissue formation, typically from a prior operation, in the pelvic area
  • Being assigned female at birth because a surgery can more readily injure the colon

Complications of Bowel Perforation

The abdominal cavity, which encloses a number of internal organs, is normally sterile. However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. 

The abdominal cavity can get contaminated by stomach acids, bacteria, and food particles, thereby predisposing it to infection and inflammation. These contents can range from feces from a more distal location of perforation to extremely acidic gastric contents in more proximal bowel perforation.

Over time, partial erosion might progress to full-thickness tears, or a particular lesion can prompt a spontaneous rupture. This means that while pain may come on suddenly or gradually, its severity typically increases.

The leaked bowel contents may also cause abscess formation leading to an excruciating infection called peritonitis. If left untreated, this may further develop to sepsis or worse, death.

Complications of bowel perforation may include:

  • Early Complications
    • Hemodynamic instability leading to hypoperfusion
    • Multi-organ system failure
    • Infection such as peritonitis, local abscess formation, or systemic bacteremia
  • Late Complications
    • Delayed wound healing
    • Fistula formation, bowel obstruction, and hernia formation secondary to postoperative adhesions

Diagnosis of Bowel Perforation

Diagnostic tests for bowel perforation should usually include:

  • A comprehensive history taking and physical examination.  A comprehensive history and physical examination is vital in evaluating a patient with a suspected intestinal perforation. When determining the diagnosis of intestinal perforation, historical variables are incredibly helpful. After recent instrumentation from an endoscopy, colonoscopy, or laparoscopic or open surgical treatment, lower chest or abdominal pain should generate a high suspicion for this diagnosis. The patient’s previous medical, surgical, and social history should be elicited. This information should cover any prior hernias, bowel obstructions, known or suspected malignancies, foreign body insertions or ingestions, abdominal trauma, and regular medication use (NSAIDs, corticosteroids, and chemotherapy are the most typical). The patient is likely to express worsening abdominal pain and distension in complaints. Patients may mention a pain-free interval prior to their discomfort getting worse; this may be the decompression of an irritated or wounded area just after the perforation. During a focused abdominal examination, diffuse leakage of air and intestinal contents may make it difficult to localize the pain, but palpation is likely to reveal tenderness.  Peritoneal symptoms like guarding and rigidity may appear as the disease progresses. Vital signs may be normal, especially at the time of an early presentation, but symptoms of sepsis such tachycardia, tachypnea, fever, and others are likely to appear later.
  • Laboratory workup. A complete blood count, a basic metabolic panel, liver function tests, lipase, amylase, and inflammatory indicators like C-reactive protein are examples of possible laboratory tests. For diagnostic purposes, however, common signs like leukocytosis, increased amylase, or elevated CRP levels are non-specific.
  • Upright chest radiography. A bowel perforation may be indicated by the presence of free intraperitoneal air below the diaphragm, which is detectable by upright chest radiography (50–70% sensitive). If the patient has been sitting upright for at least 15 minutes before the film, the likelihood of diagnosing free air is increased. In the event that a patient is unable to sit up straight, lateral decubitus films may be employed.
  • Computer tomography (CT) scan. The preferred method for locating the perforation location and diagnosing free air is a CT scan. It can also be used to evaluate whether the area has walled off on its own, whether an abscess has developed, or whether nearby tissues are being affected by inflammation.
  • Ultrasound. Localizing gas collections that may indicate perforation is made possible using ultrasound. However, this modality is particularly reliant on the operator’s level of experience.

Treatment for Bowel Perforation

Treatment for bowel perforation should usually include the following:

  • Hemodynamic management. Establishing intravenous (IV) access and initial hemodynamic management are necessary for the treatment of a patient with a suspected intestinal perforation, particularly if the patient exhibits any signs or symptoms of sepsis or shock.
  • Antibiotics and observation. It is crucial to start using broad-spectrum antibiotics early on to combat gram-negative and anaerobic pathogens. In the event that the patient’s hemodynamics are stable and there is no risk of peritonitis, as would be the case with a spontaneously confined perforation, the surgical team may decide to pursue the non-surgical therapy option of antibiotics and observation.
  • Nasogastric decompression. When an intestinal distal perforation is suspected, nasogastric decompression should be carried out and the patient put on NPO (nothing by mouth).
  • Abscess drainage. Interventional radiology could be used to drain a localized abscess.
  • Direct investigation via laparoscopy or open (laparotomy) exploration. In the majority of cases, direct investigation via laparoscopic or open (laparotomy) exploration is required. This enables both primary repair and infection control measures. Minimally invasive procedures are frequently successful. However, it should be highlighted that the preferred surgical procedure for any indications of clinical deterioration or hemodynamic instability is an exploratory laparotomy.

Bowel Perforation Nursing Diagnosis

Nursing Care Plan for Bowel Perforation 1

Risk for Infection

Nursing Diagnosis: Risk for Infection related to inadequate primary defenses invasive procedures, and immunosuppression secondary to bowel perforation

Desired Outcomes

  • The patient will achieve timely healing and be free of fever and purulent drainage or erythema
  • The patient will verbalize an understanding of the individual risk factor(s).
Nursing Interventions for Perforated BowelRationale
Evaluate the patient’s vital signs and take note of any patterns that indicate sepsis (increased heart rate, progressing decreased blood pressure, fever, tachypnea, reduced pulse pressure).These are warning signs of septic shock. Endotoxins in the bloodstream eventually cause vasodilation, a fluid shift, and a reduced cardiac output state.
Assess the patient’s neurological status, taking into account any changes in consciousness or newly developed confusion.Deteriorating mental status can be brought on by hypoxemia, hypotension, and acidosis.
Examine the color, clarity, and smell of drain outflow.This can provide information with regards to the patient’s infection status.
Give antibiotics as directed.Gram-negative aerobic bacteria and anaerobic bacteria are the targets of treatment. Lavage can be utilized to treat poorly localized or distributed inflammation as well as remove necrotic waste.
Assess and monitor the patient’s urine output. Reduced renal perfusion, circulating toxins, and the effects of antibiotics all contribute to the development of oliguria.
Evaluate the patient’s skin color, moisture and temperature.Early signs of septicemia include warm, flushed, and dry skin. As shock becomes refractory, later symptoms include chilly, clammy, pale skin and cyanosis.
Identify the individual risk factors.Common risk factors include abdominal trauma, acute appendicitis, and peritoneal dialysis. It is important to identify risk factors as it may influence the choice of medical intervention.
Keep all abdominal drains, incisions, open wounds, dressings, and invasive sites sterile at all times. Use the appropriate solution to clean these sites.This restricts or prevents access to infectious agents and cross-contamination.  

Nursing Care Plan for Bowel Perforation 2

Acute Pain

Nursing Diagnosis: Acute Pain related to tissue trauma, chemical irritation of the parietal peritoneum, and abdominal distension secondary to bowel perforation as evidenced by muscle guarding, rebound tenderness, verbalization of pain, distraction behavior, facial mask of pain, and autonomic or emotional responses (anxiety).

Desired Outcomes: 

  • The patient will verbalize that the pain is alleviated or managed.
  • The patient will demonstrate employment of relaxation skills and other methods to encourage comfort.
Nursing Interventions for Perforated BowelRationale
Observe and assess the patient’s level of pain on a scale of 0-10. Characterize the pain according to onset, quality (dull, sharp, constant), location, and radiation.Although not unusual, changes in location or intensity could signal developing complications. As the inflammatory process accelerates, pain usually spreads across the entire abdomen and tends to become continuous, more acute, and localized if an abscess forms.
Determine the patient’s threshold for bearable pain and give them painkillers to stay within it.Reducing the metabolic rate and intestinal irritation caused by circulating or local toxins promotes healing and helps to relieve pain. Pain is typically very bad, and narcotic painkillers may be necessary. Since analgesics can conceal symptoms and indications, they may be withheld throughout the first diagnostic process.
To reduce pressure on abdominal surgery wounds, keep the patient in a semi-Fowler position.This lessens abdominal tension and/or diaphragmatic irritation, which in turn lessens pain by facilitating fluid or wound drainage by gravity.
Inform the patient about the necessity of using a pillow or other soft object to splint the surgical site in order to reduce pain when moving.This reduces guarding and muscle tension, which might reduce movement-related pain.
Provide comforting techniques such as massages and deep breathing. Teach the patient breathing and visualization techniques and offer diversionary pursuits.  This helps the patient unwind and could improve their coping skills by refocusing their attention.
Give regular oral care. Eliminate unpleasant environmental stimuli.This decreases vomiting and nausea, which can worsen pain and increase intra-abdominal pressure.
Administer antiemetics or antipyretics as indicated. Antiemetics reduce nausea and vomiting which may worsen abdominal pain. Antipyretics lessen the discomfort brought on by a fever.

Nursing Care Plan for Bowel Perforation 3

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume related to fever/hypermetabolic state and fluid shifting into intestines and/or peritoneal space from extracellular secondary to bowel perforation as evidenced by hypotension, tachycardia, decreased urine output, concentrated urine, poor skin turgor, delayed capillary refill, dry mucous membrane, and weak peripheral pulses.

Nursing Stat Facts
Nursing Stat Facts

Desired Outcome:  The patient will demonstrate improved fluid balance as evidenced by stable vital signs, adequate urinary output with normal specific gravity, moist mucous membranes, prompt capillary refill, good skin turgor, and weight within normal range.

Nursing Interventions for Perforated BowelRationale
Monitor the patient’s complete blood count (CBC), hemoglobin and hematocrit (H&H) levels, serum electrolyte, BUN, creatinine, albumin levels.This provides information about organ function and hydration. Fluid changes, hypovolemia, hypoxia, circulating toxins, and necrotic tissue products can all have an impact on how well the body functions.
Measure the patient’s urine specific gravity.This shows abnormalities in renal function and the status of hydration, which may signal the onset of acute renal failure in response to hypovolemia and the effects of toxins. Numerous antibiotics also have nephrotoxic side effects that may worsen kidney damage and urine production.
To maintain H&H, administer blood products as necessary.This restores the electrolyte balance and circulation volume. Colloids (plasma, blood) increase the osmotic pressure gradient, which aids in the movement of water back into the intravascular compartment. To help in the excretion of toxins and to improve renal function, diuretics may be taken.
Keep an eye out for any indications of active bleeding, such as changes in the vital signs (increased heart rate, lowered blood pressure), bruises on the flanks, frank blood coming through an ostomy or NG tube, etc.This helps determine the degree of fluid deficiency, the efficacy of fluid replacement therapy, and the responsiveness to drugs.
Maintain accurate input and output measurements and correlate it with the patient’s daily weights. Include also measured losses. For the third spacing of fluid, take measurements from the following: stomach suction, drains, dressings, Hemovacs, diaphoresis, and abdominal circumference.This reflects the patient’s state of total hydration. Hypovolemia and reduced renal perfusion may reduce urine production, yet weight gain due to ascites accumulation or tissue edema may still occur. Large gastric suction losses may occur, and the intestine and peritoneal space may sequester a significant amount of fluid (ascites).
Remove unpleasant sights and odors from the environment. Limit the patient’s intake of ice chips.This reduces the patient’s urge to vomit and gastrointestinal stimulation. Electrolyte washout from the stomach during gastric aspiration may increase if there is an excessive use of ice chips.
Frequently change the patient’s position. Provide the patient with frequent skin care and maintain a dry and wrinkle-free bedding.It is easy for edematous tissue with poor circulation to break down.
Maintain NPO by intestinal or nasogastric aspiration.This reduces diarrhea losses and bowel hyperactivity.

Nursing Care Plan for Bowel Perforation 4

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to metabolic abnormalities (increased metabolic needs) and intestinal dysfunction secondary to bowel perforation

Desired Outcome: The patient will maintain a normal weight and a positive nitrogen balance.

Nursing Interventions for Perforated BowelRationale
Check the patient’s frequency of bowel movements. Auscultate the bowels for irregular, absent, or hyperactive bowel sounds.Even though bowel sounds are typically absent, intestinal inflammation and irritation can also cause diarrhea, decreased water absorption, and intestinal hyperactivity.
Assess and monitor the patient’s NG tube output. Take note if the patient is experiencing vomiting or diarrhea.Vomiting, diarrhea, and large volumes of gastric aspirate are signs of intestinal obstruction that need additional investigation.
As directed, administer total parenteral nutrition (TPN) or tube feeds.This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally.
Measure the patient’s abdominal circumference and be mindful of any trends.This demonstrates changes in stomach or intestinal distension and/or ascites buildup quantitatively.
Critical lab values such albumin, prealbumin, BUN, creatinine, protein, glucose, and nitrogen balance should be communicated to the provider.This reflects nutrient requirements, condition, and organ function.
Evaluate the patient’s abdomen periodically for softening, the resumption of regular bowel noises, and the passing of flatus.This indicates the capacity to resume oral intake and the resumption of regular bowel function.
As tolerated, advance the patient’s diet. Advance the diet from clear liquids to soft meals.When intake is restarted, the risk of stomach irritation is reduced by a careful diet progression.  
Measure the patient’s weight regularly.Initial gains or losses reflect hydration changes, while persistent losses imply nutritional deficiency.

Nursing Care Plan for Bowel Perforation 5

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to misinterpretation of information, lack of recall/exposure, and unfamiliarity with information sources secondary to bowel perforation as evidenced by statement of misconception, questioning, inaccurate follow-through of instruction, and request for information

Desired Outcomes: 

  • The patient will verbalize an understanding of the disease process and its potential complications.
  • The patient will identify the relationship of signs/symptoms to the disease process and associate these symptoms with causative factors.
  • The patient will verbalize an understanding of pharmacological intervention and therapeutic needs.
  • The patient will accurately perform necessary procedures and explain reasons for these actions.
Nursing Interventions for Perforated BowelRationale
Review with the patient the underlying disease process and anticipated recovery.This provides baseline knowledge to allow the patient to make educated decisions.
Identify the signs and symptoms that necessitates prompt medical evaluation: persistent abdominal pain and discomfort, nausea, vomiting, fever, chills, or purulent drainage, edema, or erythema around a surgical incision (if present).Early detection and treatment of developing complications can help prevent progression to severe illness and injury.
Discuss with the patient the dosage, frequency, and potential negative effects of the medications.Depending on the length of the stay, antibiotics may be continued after release.
Recommend resuming regular activities gradually as tolerated, allowing for enough rest.This prevents weariness and improves wellbeing.
Examine any constraints or limitations on the patient’s activity (e.g., avoid heavy lifting, constipation).This prevents needless muscle stress and intra-abdominal pressure buildup.    
Teach the patient how to change the dressing aseptically and wound care.This lowers the danger of contamination and gives the chance to assess the healing process.
Emphasize the value of medical follow-up.Monitoring the clearance of the infection and the return to regular activities is essential.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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