Nursing Care Plan (NCP) for Intussusception

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Outline

Pathophysiology

The most common cause of bowel obstruction in children is intussusception. This is a telescoping movement where part of the intestine slides over itself making the intestine shorter, 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. Tissue death, bowel perforation and infection may occur. This most often affects children between 3 months and 3 years of age and can be a serious, life-threatening emergency.

Etiology

The cause is not known exactly. It is believed that oftentimes, the normal contraction movement of the intestine causes a portion to become stuck over the diverticulum, pulling the segment of intestine inside itself. Others suspect that a virus may be the cause.   

Desired Outcome

Patient will have optimal pain management; patient will have adequate fluid balance

Intussusception Nursing Care Plan

Subjective Data:

  • Colicky abdominal pain
  • Lethargy

Objective Data:

  • Crying or fussiness
  • Blood and mucus in stool (red currant jelly stools)
  • Vomiting
  • Diarrhea
  • Fever
  • Palpable lump in abdomen

Nursing Interventions and Rationales

  • Assess vitals

 

Fever is an accompanying symptom and can be a sign of infection

 

  • Assess abdomen
    • Look for distention or abnormal shape
    • Listen for bowel sounds
    • Feel / palpate for lumps and tenderness

 

A hallmark sign of this condition is an obvious lump of bowel that is distended and tender to touch.

 

  • Assess for pain (including verbal and non-verbal cues)

 

Abdominal pain is associated with this condition but may not be initially present or constant.

Depending on the age of the patient, they may be guarding the abdomen, or may appear colicky with bouts of inconsolable crying or fussiness

 

  • Initiate IV fluids

 

Children dehydrate quickly and easily. Vomiting and diarrhea can cause a significant fluid loss and dehydration.

 

  • Monitor stool for bloody diarrhea

 

“Red currant jelly” stools are common and consist of blood, mucus and stool. This is one of the most common symptoms and a hallmark sign of intussusception

 

  • Monitor intake and output

 

Take note of watery stools, emesis, urine output.

 

  • Insert nasogastric tube and perform gastric decompression

 

Reduces bowel stress and promotes bowel rest.

 

  • Perform or assist with therapeutic enema

 

Enemas may be given with barium, water-soluble solution or air.

While most often used as a diagnostic test, this procedure may help the intestine correct itself so the child can avoid surgery.

 

  • Prepare patient for surgery

 

In cases where there is tissue necrosis or perforation of the bowel, or where the intestine doesn’t self-correct, surgical repair will be necessary.

 

  • Provide education and support for patient and family members

 

Provide information and support for the parents and family members of patients. Answer questions, give resource information based on the child’s discharge needs.

Provide education on post-operative dietary requirements.

Writing a Nursing Care Plan (NCP) for Intussusception

A Nursing Care Plan (NCP) for Intussusception starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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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.

 

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