Watch More! Unlock the full videos with a FREE trial
Add to Study plan
Master
Included In This Lesson
Study Tools
Intussusception Pathochart (Cheat Sheet)
Example Care Plan_Intussusception (Cheat Sheet)
Blank Nursing Care Plan_CS (Cheat Sheet)
Intussusception (Picmonic)
Access More! View the full outline and transcript with a FREE trial
Transcript
We're going to work on the care plan for intussusception. So the pathophysiology behind intussusception is a telescoping movement where part of the intestine slides over itself, making the intestines shorter almost as if closing a telescope. When this happens, the intestine begins to swell from inflammation, food can't pass through, and the blood supply is cut off. So what are the nursing considerations? Well, we want to assess the abdomen. We want to palpate; you may feel a lump. We want to also assess for the stool you want to assess for bloody stool. We also want to listen to the heart sounds and manage the pain. The desired outcome is to make sure that the patient has optimal pain management. Also, the patient will have adequate fluid balance.
So intussusception. This is primarily seen in pediatric patients, usually under the age of two. So what are some things that they will either present with or show complaint? What would the parents let us know? Well, there'll be some colicky, abdominal pain. Also, there will be some lethargy - they’d be tired. What are some things that we'll see, or some objective data that we can gather from the patient? Whether there'll be crying, there'll be some crying or fussiness. Also, blood or mucus in the store. This is often described as a red currant jelly.
I know it's not the most appealing thing, but if you could just put in your mind, a red currant jelly, that's what they call it. Red currant, jelly, stools, vomiting, diarrhea, fever, and also a palpable lump in the abdomen. Okay. So our first nursing intervention, ADPIEI, we're going to start with assessment. We're going to assess that abdomen. We're going to do a good abdominal assessment. Okay. We're going to look for any type of abdominal distension. We're going to look for abdominal distention. We're going to listen for the bowel sounds and we're going to also feel or palpate for any lumps or tenderness. They may complain of pain. So we're going to do that assessment. We're going to initiate IV fluids. Children are dehydrated quickly, and vomiting and diarrhea can cause significant fluid loss.
So we are going to want to just take a look at their vitals. We're going to take a look at fluid and electrolytes, because their electrolytes can be thrown off because of vomiting and diarrhea. So we want to keep those patients hydrated. We're going to monitor again for a bloody stool or bloody diarrhea. The red currant jelly stools are common and it consists of blood mucus in the stool. This is the most common symptom in the hallmark sign of intussusception. So if you don't remember anything, remember the red currant stool. Okay, next we're going to monitor their T’s and O’s. We're going to take note of watery stools, emesis, and urine output. Very important to look at their fluid balance. Okay.
We're going to perform or assist with the therapeutic enema. Oftentimes intussusception can be monitored and treated without surgery. So we can use enemas. We can use barium enemas that are water-soluble. And a lot of times the provider would just instill air so we can use air enemas. And we want to, again, assess vitals; fever is an accompaniment. Isn't an accompanying symptom, and it can be a sign of infection. So anybody with increased temp or fever, which could be anything over 100.4 degrees, it's something that we want to monitor. Okay. So now let's take a look at the keynotes. Okay. A key point first, the pathophysiology just remember that this telescoping movement or intussusception is where part of the intestine slides over itself. It makes the intestine shorter. So when you think about the function of the intestine, the function of the intestine is absorption.
It absorbs; you get a lot of your fluids and hydration from your intestine. So if your intestine is shorter, it has less contact with the water. So you're not going to absorb as much water. Okay. We are going to assess the patient. We're going to get some subjective data. We're going to get some chest pain, colicky, abdominal pain, and lethargy. We're going to also look at the patient. We're going to observe the patient, get some objective data. We're going to see fussiness. We're going to also see some red currant jelly stools, and we're going to have a palpable abdominal lump. This patient is at risk for bowel perforation. So, we want to assess pain and prepare the patient for surgery. They may require surgical intervention. Okay. Also we want to assess for dehydration. So that's why we want to look at the heart because IV fluids and electrolytes from diarrhea are lost a lot. Dehydration is very common in these patients. We love you guys; go out and be your best self today. And, as always, happy nursing.
So intussusception. This is primarily seen in pediatric patients, usually under the age of two. So what are some things that they will either present with or show complaint? What would the parents let us know? Well, there'll be some colicky, abdominal pain. Also, there will be some lethargy - they’d be tired. What are some things that we'll see, or some objective data that we can gather from the patient? Whether there'll be crying, there'll be some crying or fussiness. Also, blood or mucus in the store. This is often described as a red currant jelly.
I know it's not the most appealing thing, but if you could just put in your mind, a red currant jelly, that's what they call it. Red currant, jelly, stools, vomiting, diarrhea, fever, and also a palpable lump in the abdomen. Okay. So our first nursing intervention, ADPIEI, we're going to start with assessment. We're going to assess that abdomen. We're going to do a good abdominal assessment. Okay. We're going to look for any type of abdominal distension. We're going to look for abdominal distention. We're going to listen for the bowel sounds and we're going to also feel or palpate for any lumps or tenderness. They may complain of pain. So we're going to do that assessment. We're going to initiate IV fluids. Children are dehydrated quickly, and vomiting and diarrhea can cause significant fluid loss.
So we are going to want to just take a look at their vitals. We're going to take a look at fluid and electrolytes, because their electrolytes can be thrown off because of vomiting and diarrhea. So we want to keep those patients hydrated. We're going to monitor again for a bloody stool or bloody diarrhea. The red currant jelly stools are common and it consists of blood mucus in the stool. This is the most common symptom in the hallmark sign of intussusception. So if you don't remember anything, remember the red currant stool. Okay, next we're going to monitor their T’s and O’s. We're going to take note of watery stools, emesis, and urine output. Very important to look at their fluid balance. Okay.
We're going to perform or assist with the therapeutic enema. Oftentimes intussusception can be monitored and treated without surgery. So we can use enemas. We can use barium enemas that are water-soluble. And a lot of times the provider would just instill air so we can use air enemas. And we want to, again, assess vitals; fever is an accompaniment. Isn't an accompanying symptom, and it can be a sign of infection. So anybody with increased temp or fever, which could be anything over 100.4 degrees, it's something that we want to monitor. Okay. So now let's take a look at the keynotes. Okay. A key point first, the pathophysiology just remember that this telescoping movement or intussusception is where part of the intestine slides over itself. It makes the intestine shorter. So when you think about the function of the intestine, the function of the intestine is absorption.
It absorbs; you get a lot of your fluids and hydration from your intestine. So if your intestine is shorter, it has less contact with the water. So you're not going to absorb as much water. Okay. We are going to assess the patient. We're going to get some subjective data. We're going to get some chest pain, colicky, abdominal pain, and lethargy. We're going to also look at the patient. We're going to observe the patient, get some objective data. We're going to see fussiness. We're going to also see some red currant jelly stools, and we're going to have a palpable abdominal lump. This patient is at risk for bowel perforation. So, we want to assess pain and prepare the patient for surgery. They may require surgical intervention. Okay. Also we want to assess for dehydration. So that's why we want to look at the heart because IV fluids and electrolytes from diarrhea are lost a lot. Dehydration is very common in these patients. We love you guys; go out and be your best self today. And, as always, happy nursing.
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
“Would suggest to all nursing students . . . Guaranteed to ease the stress!”
