Intussusception Nursing Diagnosis and Nursing Interventions
Intussusception
(Also Called 'Bowel Obstruction')
Intussusception is when one segment of intestine "telescopes" inside of another causing an intestinal obstruction. Although it can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestine. The obstruction can cause swelling & inflammation that can lead to tearing of the intestines.
Intussusception’s cause is unknown, but is usually preceded by a virus that produces swelling of the lining of the intestine, which then prolapses into the downstream intestine. In some children, it is caused by a congenital anomaly of the intestine such as a polyp or diverticulum.
What are the symptoms of intussusception?
The characteristic signs and symptoms of intussusception are episodic, severe, crampy abdominal pain alternating with periods of lethargy. Small children may draw their knees up to their chest. Other possible symptoms of intussusception include:
Nausea and vomiting
Rectal bleeding (red jelly-like stools) sometimes mixed with mucus
These symptoms begin abruptly, usually one week after a non-specific viral illness.
Intussusception Nursing Diagnosis and Nursing Interventions
Nursing Diagnosis :1. Hypovolemic shock related to vomiting, bleeding and accumulation of fluid and electrolytes in the lumen.
Purpose: circulating volume (fluid and electrolyte balance) can be maintained.
Results Criteria : signs of hypovolemic shock does not occur.
Intervention:
2. Acute pain related to surgical incision
Goal: reduction in pain according to the tolerance in children.
Results Criteria : The child shows no signs of pain or discomfort to a minimum.
Intervention:
3. Anxiety related to a lack of knowledge, foreign environment.
Purpose: anxiety in children can be reduced
Results Criteria : children can rest and do the procedure without worry.
Intervention:
(Also Called 'Bowel Obstruction')
Intussusception is when one segment of intestine "telescopes" inside of another causing an intestinal obstruction. Although it can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestine. The obstruction can cause swelling & inflammation that can lead to tearing of the intestines.
Intussusception’s cause is unknown, but is usually preceded by a virus that produces swelling of the lining of the intestine, which then prolapses into the downstream intestine. In some children, it is caused by a congenital anomaly of the intestine such as a polyp or diverticulum.
What are the symptoms of intussusception?
The characteristic signs and symptoms of intussusception are episodic, severe, crampy abdominal pain alternating with periods of lethargy. Small children may draw their knees up to their chest. Other possible symptoms of intussusception include:
Nausea and vomiting
Rectal bleeding (red jelly-like stools) sometimes mixed with mucus
These symptoms begin abruptly, usually one week after a non-specific viral illness.
Intussusception Nursing Diagnosis and Nursing Interventions
Nursing Diagnosis :1. Hypovolemic shock related to vomiting, bleeding and accumulation of fluid and electrolytes in the lumen.
Purpose: circulating volume (fluid and electrolyte balance) can be maintained.
Results Criteria : signs of hypovolemic shock does not occur.
Intervention:
- Monitor vital signs, note the presence of hypotension, tachycardia, tachypnea, fever.
- Monitor input and output.
- Note the presence of snoring or breathing fast and shallow if it is in a state of shock.
- Monitor the pulse frequency with pulse cernat and know the exact range for the child's age.
- Report indicating the presence of tachycardia shock.
- Reduce the temperature of the fever increases metabolism and oxygenation during anesthesia becomes more difficult.
- collaboration:
- Perform laboratory tests: hemoglobin / hematocrit, electrolytes, protein, albumin, BUN, creatinine.
- Give the plasma / blood, fluids, electrolytes, diuretics as indicated to maintain circulating blood volume.
2. Acute pain related to surgical incision
Goal: reduction in pain according to the tolerance in children.
Results Criteria : The child shows no signs of pain or discomfort to a minimum.
Intervention:
- Avoid palpation operating area when not needed.
- Insert rectal tube if indicated, to free air.
- Push for waste water to prevent distention of urinary vesicles.
- Give oral care to provide comfort.
- Lubrication of the nostrils to reduce irritation.
- Provide a comfortable position on the child if there are no contraindications.
- collaboration:
- Give an analgesic to treat pain.
- Give antiemetics to order for nausea and vomiting.
3. Anxiety related to a lack of knowledge, foreign environment.
Purpose: anxiety in children can be reduced
Results Criteria : children can rest and do the procedure without worry.
Intervention:
- Give health education prior to surgery to reduce anxiety.
- Orient the client with an unfamiliar environment.
- Defend someone who always accompany clients to improve safety.
- Explain the reasons following surgery.
- Explain all surgical procedures to be performed.
