[ANSWERED 2023] Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10 years ago for third-degree heart block.

Written By: Dan Palmer, RN

Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10 years ago for third-degree heart block.

CC: “I have stomach pain.”

HPI: Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10 years ago for third-degree heart block. He presents today with a complaint of abdominal pain.

You suspect a bowel obstruction in Max, an 80-year-old patient with complaints of cramping abdominal pain, nausea, and vomiting for 4 days.

Describe six (6) ROS questions you would explore further with him to determine the location, severity, and timing of his pain.

PE: On exam, the abdomen appears distended, Max has generalized tenderness over the epigastric region on palpation. He is guarding so the exam is limited. Bowel sounds are decreased.

His vital signs are normal. He describes his abdominal pain as 7/10.

As the APRN, you order an abdominal x-ray.

Test results:

The abdominal x-ray is indeterminate. What are your next diagnostic choices to determine a bowel obstruction in this patient?

List at least three differential diagnoses for abdominal pain.

The CT scan shows that Max has a small bowel obstruction. What is your next step?

Max is an 80-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and a pacemaker placed 10 years ago for third-degree heart block.

Max is an 80-year-old male with a history of gastroesophageal reflux


Expert Answer and Explanation

Focused SOAP Note Small Intestine Obstruction

Patient Information:

Max, 80 years, male, African American


CC: “I have stomach pain.”

HPI: Max is an 80-year-old male of African American origin who came to the health clinic complaining of abdominal pain. The pain is located in the abdominal area. It started four days ago. The character of pain is cramping and intermittent. Associated signs include nausea and vomiting. The patient notes that the severity of the pain is 7/10.

Current Medications: No medications.

Allergies: No food, dug, or environmental allergies.

PMHx: Past major illnesses include hypertension (HTN), gastroesophageal reflux disease (GERD), and a pacemaker placed 10 years ago for third-degree heart block. He does not remember when he took tetanus or pneumonia shots.

Soc and Substance Hx: He took alcohol in his thirties and quit over 45 years ago. He comes from a working family. No history of illicit drug or tobacco use. He says that he has smoke detectors in his house and wears seat belts while driving. His support system is his son and two daughters.

Fam Hx: His father died from colon cancer. His mother died from type II diabetes. His older son died in an accident at the age of 28. His second child has type two diabetes. His grandchildren are healthy.

Surgical Hx: He reports a knee operation at 33 years old.

Mental Hx: No mental health disorder diagnosis and treatment. No history of self-harm.

Violence Hx: No history of violence.

Reproductive Hx: He is sexually inactive and has no reproductive health.


  • GENERAL: He reports fatigue and weakness. No fever or chills.
  • HEENT: Eyes: No visual loss. Ears, Nose, Throat: No congestion, sneezing, hearing loss, sore throat, or runny nose.
  • SKIN: No rash or itching.
  • CARDIOVASCULAR: No chest discomfort, pressure, pain, or edema.
  • RESPIRATORY: No shortness of breath.
  • GASTROINTESTINAL: No diarrhea or anorexia.
  • GENITOURINARY: No burning on urination.
  • NEUROLOGICAL: No dizziness, headache, paralysis, or syncope.
  • MUSCULOSKELETAL: No joint or muscle pain.
  • HEMATOLOGIC: No anemia.
  • LYMPHATICS: No enlarged nodes.


Physical exam:

  • Vitals: BP 139/92, Temp 35, P 78, Ht. 5’9, Wt. 87kgs.
  • Cardiovascular: No cracks in the chest. No edema.
  • Respiratory: No breathing distress. No wheezes or crackles. No fluids in the lungs.
  • Genitourinary: No urinary retention. No renal angle tenderness. No tender bowel loops. No abdominal masses.
  • Gastrointestinal: Bowel sounds absent on inspection. Distension of the abdomen on auscultation.

Diagnostic results:

The abdominal x-ray is indeterminate. Since an x-ray is indeterminate, a CT scan should be ordered.

A CT scan combined with X-ray images. Dou et al. (2022) noted that a CT scan combined with multiple X-ray images will show intestinal obstructions.

Blood test: A blood test will be used to identify whether the patient has intestinal infections.


Differential diagnoses: 

  • Small intestine obstruction: The primary diagnosis for this case is small intestine obstructions. According to Jackson and Cruz (2018), the symptoms of small intestine obstructions include vomiting, crampy abdominal pain and comes and goes, constipation, loss of appetite, swelling of the abdomen, and inability to pass gas or have a bowel movement.

Small intestine obstruction is the main diagnosis because the patient complains of crampy abdominal pain, nausea, and vomiting which are major symptoms of the disease (Jackson & Cruz, 2018). Physical exam results (bowel sounds absent on inspection, distension of the abdomen on auscultation) also show that the patient has a small intestine obstruction.

  • Appendicitis: The second diagnosis is appendicitis. The symptoms of appendicitis include flatulence, loss of appetite, vomiting and nausea, sudden pain that starts in the lower abdomen, pain that worsens when one coughs, diarrhea and constipation, low-grade fever and might increase if the illness progresses, and abdominal bloating (Talan & Di Saverio, 2021).

The disease has been included because the patient reports abdominal pain, nausea, and vomiting which are part of the clinical manifestations of appendicitis. However, it is a secondary diagnosis because the patient does not have a low-grade fever, diarrhea, or pain in the lower abdomen.

  • Intestinal Infection: The last diagnosis is an intestinal infection. The symptoms of intestinal infection include headache, vomiting, nausea, diarrhea, crampy abdominal pain, and fever (Guo et al., 2021). The disease has been ruled out because the patient does not have a headache or fever.


The patient will be recommended to undergo a CT scan combined with a series of X-ray images of the small intestine. The patient will also undergo blood tests. These tests will help identify the actual disease affecting the patient. Since it is suspected that the patient has small intestine obstructions, he should be hospitalized (Ten Broek et al., 2018)).

The pain should be stabilized by placing an intravenous (IV) line into the patient’s arm so that he can be given fluids. Abdominal swelling should be relieved by putting a nasogastric tube inside the patient’s nose into his stomach to suck out fluids and air. A catheter should be put into his bladder to drain urine. Pain medications should be given to the patient through IV to help relieve pain (Ten Broek et al., 2018). If the patient has partial small bowel obstruction, further treatment is needed after the patient has been stabilized.

A low-fibre diet should be recommended to make it easy for the partially blocked intestine to process. The patient should be referred to a gastroenterologist for surgery if the patient has complete obstruction (Ten Broek et al., 2018)). If the patient has appendicitis, he can also be referred to a gastroenterologist for laparoscopic appendectomy to remove the appendix (Talan & Di Saverio, 2021). The patient can be disposed of two days after surgery. The patient can be educated on how to cope after surgery.

If the patient has intestinal infections, antibiotics should be recommended to help fight the infections. The patient should be educated to eat a low-fiber diet to make it easy for the stomach to digest. The patient should be educated to take small amounts of food frequently instead of having huge meals at once. For instance, he should have five to six meals throughout the day. The patient should be educated to chew food well about 20 times.


I have learned a lot from this case. One of the things I have learned from the case is that abdominal pain is caused by various health problems. Healthcare professionals need to conduct a thorough assessment to determine the exact cause of the pain. Another thing I have learned is that patients should be provided proper education after hospitalization to prevent any readmissions.

The following are the review of systems questions that the patient should be asked to determine the severity, location, and timing of this pain. The first question is what are other associated symptoms? The second question is where do you feel the pain? The patient’s answer will help me identify the exact location of the pain. The third question is apart from cramping, what are other characteristics of the pain? This question will help me understand if the pain comes and goes.

The fourth question is can you do your daily chores with the pain? This question will help me rate the severity of the pain. The fifth question is, can you explain your bowel movements? The last question is what aggravates the pain?


Dou, C., Li, K., & Wang, L. (2022). Computed tomography image segmentation of the proximal colon by u-net for the clinical study of somatostatin combined with intestinal obstruction catheter. Computational and Mathematical Methods in Medicine, 2022. https://doi.org/10.1155/2022/6868483

Guo, M., Tao, W., Flavell, R. A., & Zhu, S. (2021). Potential intestinal infection and faecal–oral transmission of SARS-CoV-2. Nature reviews Gastroenterology & hepatology, 18(4), 269-283. https://doi.org/10.1038/s41575-021-00416-6

Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American Family Physician, 98(6), 362-367. http://dispatcher1.ds.aafp.org/content/brand/aafp/pubs/afp/issues/2018/0915/p362/

Talan, D. A., & Di Saverio, S. (2021). Treatment of acute uncomplicated appendicitis. New England Journal of Medicine, 385(12), 1116-1123. https://www.nejm.org/doi/full/10.1056/NEJMcp2107675

Ten Broek, R. P., Krielen, P., Di Saverio, S., Coccolini, F., Biffl, W. L., Ansaloni, L., & van Goor, H. (2018). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery, 13(1), 1-13. https://link.springer.com/article/10.1186/s13017-018-0185-2

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How to Loosen a Bowel Blockage at Home: Natural Remedies for Quick Relief


Dealing with a bowel blockage can be an uncomfortable and distressing experience. Bowel blockages occur when there is an obstruction in the digestive system, preventing the smooth passage of stool. While it is essential to seek medical attention for severe cases, there are some effective home remedies that can help alleviate mild bowel blockages. In this article, we will explore various natural methods to loosen a bowel blockage at home, providing you with relief and comfort.

Stay Hydrated

Proper hydration is crucial when dealing with a bowel blockage. Drinking plenty of water can help soften the stool and facilitate its movement through the intestines. Aim to drink at least 8 to 10 glasses of water throughout the day. You can also include herbal teas and clear soups to enhance hydration levels.

Fiber-Rich Diet

Including fiber-rich foods in your diet can help promote regular bowel movements and prevent blockages. Foods such as fruits, vegetables, whole grains, and legumes are excellent sources of dietary fiber. However, if you are currently experiencing a blockage, it’s best to avoid insoluble fiber temporarily, as it may worsen the condition. Stick to soluble fiber sources like oatmeal and bananas for now.

Physical Activity

Engaging in light physical activities can help stimulate bowel movement and relieve constipation. Try going for a short walk or doing gentle exercises to encourage the natural peristaltic movement of the intestines. Physical activity can also reduce bloating and discomfort associated with bowel blockages.

Abdominal Massage

Massaging your abdomen in a clockwise direction can help alleviate bowel blockages. Use gentle, circular motions and apply slight pressure to promote movement in the digestive tract. This technique can assist in breaking down the blockage and easing the passage of stool.

Warm Compress

A warm compress applied to your abdomen can provide relief from pain and discomfort caused by a bowel blockage. The heat helps to relax the muscles and may assist in loosening the obstruction. Ensure the compress is not too hot to avoid burns.

Lemon Water

Lemon water is known for its natural laxative properties. Squeeze the juice of half a lemon into a glass of warm water and drink it in the morning on an empty stomach. Lemon water can help stimulate bowel contractions and soften the stool.

Prune Juice

Prune juice has been used for generations as a home remedy for constipation. It contains sorbitol, which acts as a natural laxative. Drinking a small glass of prune juice daily may help in loosening a bowel blockage.

Epsom Salt Solution

An Epsom salt solution can be an effective way to relieve bowel blockages. Mix one teaspoon of Epsom salt in a glass of water and drink it. Epsom salt has magnesium sulfate, which can promote bowel contractions and facilitate bowel movement.

Castor Oil

Castor oil has been used as a traditional remedy for constipation. It works by stimulating the intestines and promoting bowel movements. However, it should be used with caution and only in small quantities, as excessive use can lead to dehydration.

Avoid Dairy Products

Dairy products can contribute to constipation in some individuals. If you suspect that dairy might be causing or exacerbating your bowel blockage, consider reducing or eliminating its intake for a few days.

Aloe Vera Juice

Aloe vera juice is known for its soothing properties on the digestive system. It can help reduce inflammation and irritation in the intestines, which might be beneficial for bowel blockages.

Herbal Laxatives

Certain herbal laxatives, such as senna and cascara sagrada, can help provide relief from constipation and promote bowel movements. However, it’s essential to use them cautiously and consult a healthcare professional before use.


Probiotics are beneficial bacteria that support digestive health. Consuming probiotic-rich foods like yogurt or taking probiotic supplements may help regulate bowel movements and ease blockages.

Apple Cider Vinegar

Apple cider vinegar has been suggested to improve digestion and support bowel movements. Mix one tablespoon of apple cider vinegar with water and drink it before meals to potentially aid in relieving constipation.


While bowel blockages can be distressing, these natural remedies can often provide relief and promote bowel movement. However, if your symptoms persist or worsen, it is essential to consult a healthcare professional for a proper diagnosis and treatment.


  1. Can I use laxatives for bowel blockage? It is best to avoid over-the-counter laxatives for bowel blockages. Natural remedies are safer and more suitable for initial relief.
  2. How long should I try these home remedies before seeking medical attention? If your symptoms persist for more than two to three days, it’s time to consult a healthcare professional.
  3. Are bowel blockages a serious medical condition? Bowel blockages can be severe and may require immediate medical attention. Don’t hesitate to seek help if you experience severe pain or vomiting.
  4. Can stress contribute to bowel blockages? Yes, stress can affect digestion and contribute to constipation and bowel blockages.
  5. Is it safe to use abdominal massage for bowel blockages? Gentle abdominal massage is generally safe and can provide relief. However, avoid excessive pressure or forceful manipulation.

Signs a Bowel Obstruction is Clearing

Dealing with a bowel obstruction can be a challenging and uncomfortable experience. However, as the obstruction begins to clear, certain signs and symptoms may indicate that you are on the path to relief and recovery. It’s crucial to pay attention to these signs to ensure that your condition is improving. Here are some common indicators that a bowel obstruction is clearing:

Passing Gas: One of the positive signs that a bowel obstruction is clearing is the ability to pass gas. The release of gas indicates that the intestines are starting to function again, and the blockage is gradually resolving.

Decreased Abdominal Distension: As the obstruction starts to clear, you may notice a reduction in abdominal bloating and distension. The decrease in swelling indicates that the intestines are becoming less obstructed.

Resumption of Bowel Movements: When a bowel obstruction is clearing, you will likely start to have bowel movements again. The stool may be small in quantity initially, but it’s a positive sign of progress.

Decreased Nausea and Vomiting: As the blockage clears, the feeling of nausea and the urge to vomit should subside. This is a reassuring indication that the intestines are no longer as obstructed.

Relief from Abdominal Pain: Gradually, the intense abdominal pain associated with a bowel obstruction should ease as the obstruction clears. You may still experience some discomfort, but it should be less severe.

Improved Appetite: A clearing bowel obstruction often leads to an improvement in appetite. You may find yourself feeling hungry again as your digestive system starts functioning more normally.

Increased Energy Levels: As your digestive system begins to recover, you may experience a boost in energy levels. The body is no longer expending excessive energy trying to cope with the obstruction.

Partial Bowel Obstruction Symptoms

A partial bowel obstruction occurs when there is a partial blockage in the intestine, which hinders the smooth passage of stool and gas. This condition can be uncomfortable and may require medical attention. Recognizing the symptoms of a partial bowel obstruction is crucial for early detection and appropriate management. Here are some common symptoms to watch out for:

Abdominal Pain: Persistent, cramp-like abdominal pain is a hallmark symptom of a partial bowel obstruction. The pain may be intermittent or constant and is often felt in the lower abdomen.

Bloating and Distension: Individuals with a partial bowel obstruction may experience abdominal bloating and distension. The belly may feel swollen or full due to the accumulation of gas and fluid above the blockage.

Changes in Bowel Movements: A partial obstruction can cause changes in bowel habits. You may experience diarrhea or constipation, depending on the location and severity of the blockage.

Inability to Pass Gas: Difficulty passing gas is a common symptom of a partial bowel obstruction. The trapped gas cannot move through the intestines freely, leading to discomfort and bloating.

Vomiting: Partial bowel obstructions can cause episodes of vomiting. The vomit may be clear or contain partially digested food.

Nausea and Loss of Appetite: Feelings of nausea and a reduced appetite are often present in individuals with a partial bowel obstruction.

Cramping Sensation: Some people may experience cramping sensations in the abdomen as the intestines try to overcome the partial blockage.

Visible Peristaltic Waves: In severe cases, you may notice visible peristaltic waves on the abdomen. These are visible movements of the intestine attempting to propel the contents past the obstruction.

Tender Abdomen: The abdomen may become tender to touch, especially in the area near the site of the blockage.

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Types of Intestinal Obstruction

Intestinal obstruction refers to a condition where there is a partial or complete blockage in the intestines, which hampers the normal movement of stool and gas through the digestive tract. This obstruction can occur in different parts of the intestine and may have various underlying causes. Here are the common types of intestinal obstruction:

Mechanical Obstruction: This type of obstruction occurs when there is a physical blockage in the intestine, hindering the passage of contents. Mechanical obstructions can be caused by various factors such as adhesions (scar tissues), hernias, tumors, impacted feces, foreign objects, and strictures (narrowing of the intestine).

Functional Obstruction: In functional obstruction, there is no physical blockage, but the intestines fail to function correctly due to muscle or nerve problems. This type of obstruction is often caused by conditions like paralytic ileus, where the intestines are temporarily paralyzed and unable to propel contents forward.

Small Bowel Obstruction: Small bowel obstruction occurs when the blockage is in the small intestine. It is a common type of obstruction and can result from various causes such as adhesions, hernias, Crohn’s disease, tumors, and intussusception (telescoping of the intestine into itself).

Large Bowel Obstruction: Large bowel obstruction refers to a blockage in the large intestine or colon. Common causes include colorectal cancer, diverticular disease, volvulus (twisting of the intestine), and impacted feces.

Incarcerated Hernia: An incarcerated hernia is a type of mechanical obstruction where a hernia becomes trapped and cannot be pushed back into its normal position. This can lead to a complete bowel obstruction if not promptly treated.

Volvulus: Volvulus occurs when a portion of the intestine twists upon itself, causing a blockage. It is more common in the large intestine and can lead to a life-threatening condition if not treated promptly.

Intussusception: Intussusception happens when one segment of the intestine slides into the adjacent segment, causing a blockage. It is more common in children but can also occur in adults.

Gallstone Ileus: This type of obstruction occurs when a gallstone passes into the intestinal tract through a fistula (abnormal connection) and causes a blockage.

Bezoar: A bezoar is a mass of undigested material, such as hair, vegetable fibers, or medications, that can accumulate in the stomach or intestines and cause an obstruction.

Colonic Pseudo-obstruction: Also known as Ogilvie syndrome, this condition mimics the symptoms of a bowel obstruction but does not involve a physical blockage. Instead, it is caused by abnormal colon motility.

Types of Intestinal Obstruction

A blocked small intestine, also known as small bowel obstruction, requires prompt medical attention as it can be a serious and potentially life-threatening condition. The treatment approach depends on the cause and severity of the obstruction. Here are the common methods used to treat a blocked small intestine:

Hospitalization: If you suspect a small bowel obstruction or are diagnosed with one, you will likely need to be hospitalized for close monitoring and treatment.

Nasogastric Tube (NG Tube): A nasogastric tube may be inserted through your nose and down into your stomach to help decompress the intestines. This tube helps remove excess air and fluid from the stomach and intestines, relieving pressure and reducing bloating.

Intravenous (IV) Fluids: You will receive fluids through an IV to prevent dehydration and maintain electrolyte balance. Since you won’t be able to eat or drink anything orally during treatment, IV fluids are essential.

Pain Management: Medications may be prescribed to manage pain and discomfort associated with the obstruction.

Observation and Bowel Rest: In some cases, a partial small bowel obstruction can be managed with observation and bowel rest. This means refraining from eating or drinking for a period to allow the intestines to rest and potentially resolve the obstruction.

Surgery: In more severe cases or if the obstruction does not improve with conservative measures, surgery may be necessary. The type of surgery will depend on the cause and location of the obstruction. The surgeon may remove the blockage, repair damaged tissues, or address any underlying issues contributing to the obstruction.

Lysis of Adhesions: If adhesions (scar tissues) are causing the obstruction, a surgical procedure called “lysis of adhesions” may be performed to separate and remove the adhesions, thereby restoring normal bowel function.

Treatment of Underlying Conditions: If the small bowel obstruction is caused by an underlying condition, such as Crohn’s disease or tumors, the primary focus will be on treating that condition in addition to managing the obstruction.

Post-Surgery Care: After surgery, you will receive post-operative care, which may include pain management, wound care, and monitoring for any complications.

Small Bowel Obstruction Complications

A small bowel obstruction is a serious medical condition that requires prompt attention and appropriate treatment. If left untreated or if the obstruction is severe, it can lead to various complications that can be life-threatening. Here are some potential complications associated with a small bowel obstruction:

Bowel Perforation: In cases of severe or prolonged obstruction, the pressure inside the intestine can become too high, leading to bowel perforation. This is when a hole or tear forms in the intestinal wall, allowing the contents of the intestine to leak into the abdominal cavity. Bowel perforation is a medical emergency and requires immediate surgical intervention to repair the damage and prevent infection.

Ischemia (Reduced Blood Flow): The blockage in the small intestine can compromise blood flow to the affected area. Ischemia, or reduced blood flow, can lead to tissue damage and necrosis (death of tissue). If not addressed promptly, ischemia can cause the intestine to become gangrenous, which necessitates surgical removal of the affected segment.

Infection (Peritonitis): If a bowel perforation occurs, bacteria from the intestine can spill into the abdominal cavity, causing peritonitis. Peritonitis is a severe and potentially life-threatening infection that requires immediate medical attention and intravenous antibiotics.

Dehydration and Electrolyte Imbalance: Persistent vomiting and the inability to eat or drink can lead to dehydration and electrolyte imbalances. These imbalances can affect the normal functioning of the body and may require intravenous fluid and electrolyte replacement.

Septicemia: In severe cases of infection, bacteria can enter the bloodstream, causing septicemia (blood poisoning). This is a life-threatening condition that requires aggressive treatment with antibiotics and supportive care.

Organ Dysfunction: Complications from a small bowel obstruction can lead to organ dysfunction, particularly affecting the kidneys and liver. These organs may struggle to filter waste and toxins from the body, leading to further complications.

Short Bowel Syndrome: In cases where a large portion of the small intestine is removed due to severe damage or gangrene, the remaining intestine may not be sufficient for proper nutrient absorption.



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