New Severe Pain in a Patient with Small Bowel Obstruction
A 58-year-old woman is admitted with 3 days of vomiting and abdominal distention. She has a nasogastric tube to low intermittent suction, IV fluids at 125 mL/h, and a urinary catheter. Six hours after admission, she reports a new constant, severe mid-abdominal pain. Vital signs: temperature 38.4°C, heart rate 126, blood pressure 92/54, respirations 28, SpO2 94% on room air. Abdomen is distended and firm; bowel sounds are absent. The NG tube has drained 400 mL in the last hour and is now dark. Urine output is 20 mL over the last 2 hours. Lactate is 4.2 mmol/L. The surgical resident orders “increase IV fluids and reassess in 2 hours.” The patient is restless and asks for more pain medication.
1. What complication do you suspect, and which findings most strongly support it?
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The cluster suggests strangulated or ischemic small bowel obstruction, not simple dehydration. Severe constant pain that changes from colicky to constant, fever, tachycardia, hypotension, abdominal firmness, absent bowel sounds, dark NG drainage, oliguria, and lactate 4.2 all point to bowel ischemia or perforation. The dark drainage may be old blood or ischemic mucosa. A 2-hour delay is dangerous because infarction and perforation can progress. The restlessness and request for pain medication may be pain or early shock; I would not dismiss it. I would explicitly state my concern to the resident.
2. What are your immediate actions and how do you escalate?
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Immediate actions: call rapid response and the surgeon now; stay with the patient; apply oxygen to keep SpO2 ≥94%; ensure two large-bore IVs; give ordered crystalloids cautiously while monitoring for worsening hypotension; continuous cardiac and pulse oximetry; strict intake and output; keep NG to low intermittent suction and report character; draw lactate, CBC, coagulation, type and crossmatch; prepare for OR. I would not give additional opioid before assessing and informing the provider, because it may mask deterioration, but pain should be treated once the surgical plan is clear. I would place the patient NPO and document. If the patient becomes more hypotensive or confused, I would call the surgeon and rapid response again.
3. How do you communicate with the resident who wants to wait 2 hours?
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Use SBAR: “This is a 58-year-old with SBO; in the last hour she has new constant severe pain, fever 38.4, HR 126, BP 92/54, dark NG drainage, urine 20 mL/2 h, lactate 4.2, abdomen firm and silent. I am concerned about strangulation. You ordered fluids and reassessment in 2 hours; I am requesting bedside evaluation now.” If the resident refuses, I would ask for the attending surgeon, notify the charge nurse, and document the request and response. I would not simply wait; the nurse’s concern plus objective data justifies escalation. I would also prepare the family for possible surgery.