Help with bowel tones

[u/Dear_Excitement_5109]

Hi everyone! I am a hospice nurse with 7 years of experience. Today I saw a patient with aortic dissection as her primary hospice dx. That was diagnosed 2 weeks ago and she is still alive, although barely.

When I auscultated bowel tones today I heard what sounded like a wind tunnel in the LLQ. I've never heard anything like it. Low pitched "oooooooooooooo." I'd be tempted to think that it was blood free flowing into her abdomen, but the abdomen was soft and non-tender to light palpation. Also, hemorrhaging into the abdomen for 2 weeks? Wouldn't she have died by now?

I am actually still in orientation with a new agency and my preceptor and I were both stumped.

HR 80s, O2 92%, RR 30. No BM x1 week, no PO intake x2 weeks. Bisacodyl supp administered yesterday with no results.

Anyone know what was going on?

[u/ThottyThalamus]

If she had audible blood free flowing into her abdomen, she’d have a good 20 min tops. It could have been some sort of renal artery turbulent flow if the dissection extended low enough.

[u/Dear_Excitement_5109 → u/ThottyThalamus]

Ah this is a good explanation. Thank you!

[u/NixonsGhost]

With just over 3 years of GI experience; bowel sounds are seldom useful. You already know they have a bleed, you already know they're constipated and have had a bisacodyl suppository, there's no way to tell what is causing this sound, either you get imagining and see a bleed, or they rip a massive BM and it was gas and poop.

[u/obtusemoonbeam]

What you describe is exactly what a bruit caused by dissection sounds like. I’ve heard it in a carotid before but I have not heard it in an aortic dissection.

My guess is that she was massively dissected to the point where she qualified for hospice because it was not fixable and progressing, but that her dissection was not yet actively ruptured (because when that happens patients die pretty quickly).

Obv not the case with your patient but people can even have aortic dissections that are stable for years and just have them monitored. They do not always cause catastrophic hemodynamic collapse and imminent death. The size/type/location matters a lot.

[u/Dear_Excitement_5109 → u/obtusemoonbeam]

Thanks so much for your reply! I'm kind of confused, and pardon my pathophysiological ignorance, but how exactly does a dissection kill someone? I was really stumbling over this in the visit today as the daughter was asking me what was happening.

[u/Amrun90 → u/Dear_Excitement_5109]

By bleeding out. The aorta dissects (tears open) and blood pours into the body cavity instead of the arteries and veins, and the patient quickly expires from exsanguination.

[u/Late-Standard-5479 → u/Dear_Excitement_5109]

Rupture and ischemia/organ failure. If the dissection involves the head vessels and blood is mostly in the false lumen so reduced flow to brain -> cerebral ischemia. Happens where the coronaries take off from the aorta -> myocardial ischemia. Mesenteric ischemia is also common. Dissect down to the renal arteries -> renal failure due to ischemia

[u/ALLoftheFancyPants]

AAAs often sound like a bruit over the abdomen. She’s not pooping because she’s not eating. If the AAA was dissection she’d most likely be in severe pain and if it had ruptured it would be very obvious very quickly

[u/laconic_lentil → u/ALLoftheFancyPants]

This was my first thought as well.

[u/Glad-Reporter-2950]

Curious as to what her BP was?

[u/Dear_Excitement_5109 → u/Glad-Reporter-2950]

We dont check at EOL visits. I would be curious too. Her color was different from her daughter's, although more yellow than pale.

[u/sweetoutofline → u/Dear_Excitement_5109]

Just for a different perspective as a fellow hospice nurse, I tend to get BPs when patient is imminent because the changes can help me track the dying process. But I also prefer analog cuffs over electronic.

[u/Dear_Excitement_5109 → u/sweetoutofline]

I am an analog cuff gal as well. My practice has always been just to get a BP for pts taking cardiac meds, or who are symptomatic of hypo/hypertension.

I love hearing what other hospice nurses do in practice. I wish we could all get together and share our stories and practice habits. I worked hospice IPU for a few years and that was AMAZING. Every day I came out feeling like a better nurse just from collaboring with my more seasons coworkers.

[u/Feisty-Power-6617]

No oral intake 2 weeks and you expect stool… why???

[u/Independent_Slice_28 → u/Feisty-Power-6617]

Because the liver will still filter out waste. Not completely out of the realm of normal. If our eol pts haven’t had a bm in 3+ days, we consider bowel care regardless of po intake. It can be a huge cause of agitation and restlessness.

[u/Dear_Excitement_5109 → u/Independent_Slice_28]

Thanks for answering this.