Nursing Care Plan (NCP) for Intussusception
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Lesson Objectives for Nursing Care Plan for Intussusception
- Understanding Intussusception:
- Comprehend the pathophysiology and etiology of intussusception, including the telescoping of one part of the intestine into another and the common causes in pediatric patients.
- Recognizing Clinical Signs and Symptoms:
- Identify the clinical manifestations of intussusception, such as severe abdominal pain, vomiting, and the presence of a palpable abdominal mass. Understand the importance of prompt recognition for timely intervention.
- Diagnostic Assessment:
- Learn about the diagnostic procedures used to confirm intussusception, including imaging studies like ultrasound or air enema. Understand the significance of accurate and timely diagnosis for effective treatment.
- Nursing Assessment Skills:
- Develop skills in conducting a focused nursing assessment for a child suspected of or diagnosed with intussusception. This includes monitoring vital signs, assessing abdominal pain, and recognizing signs of potential complications.
- Nursing Interventions and Care:
- Acquire knowledge about nursing interventions and care strategies for children with intussusception, including preparation for diagnostic procedures, administration of prescribed medications, and post-procedural monitoring.
Pathophysiology of Intussusception
- Telescoping of the Intestine:
- Intussusception involves the telescoping or invagination of one segment of the intestine into an adjacent segment. This process can obstruct the normal flow of intestinal contents.
- Lead Point Mechanism:
- In many cases, intussusception is triggered by a lead point, which can be a part of the intestine with altered peristalsis or a pathological condition. This lead point initiates the telescoping process.
- Obstruction and Ischemia:
- The telescoped intestine can cause obstruction, leading to impaired blood flow to the affected segment. Ischemia can result in tissue damage and, if left untreated, progress to necrosis.
- Lymphatic and Venous Compromise:
- Intussusception can compromise lymphatic and venous drainage, contributing to edema and congestion. This further exacerbates the ischemic damage to the affected intestinal segment.
- Potential for Complications:
- If not promptly addressed, intussusception can lead to complications such as perforation, peritonitis, and sepsis. These complications significantly increase the morbidity and mortality associated with the condition.
Etiology of Intussusception
- Idiopathic Causes:
- In many cases, intussusception occurs spontaneously without an identifiable cause. This idiopathic form is more common in children and often lacks a specific triggering factor.
- Lead Points:
- Intussusception can be associated with lead points, which are pathological conditions that serve as a trigger for the telescoping of the intestine. Examples of lead points include Meckel’s diverticulum, polyps, tumors, or areas of inflammation.
- Viral Infections:
- Certain viral infections, particularly those affecting the gastrointestinal tract, have been implicated in the development of intussusception. Rotavirus, adenovirus, and other viral agents have been associated with an increased risk, especially in infants.
- Congenital Predisposition:
- Some children may have a congenital predisposition to intussusception due to factors such as abnormalities in the shape or structure of the intestine. These congenital factors can make the intestine more susceptible to telescoping.
- Postoperative Intussusception:
- In rare cases, intussusception can occur as a complication following abdominal surgery. Postoperative adhesions or changes in bowel motility may contribute to the development of intussusception in these situations.
Desired Outcome for Intussusception
- Resolution of Telescoping:
- The primary goal is the successful reduction or resolution of the intussusception, restoring normal bowel anatomy and function.
- Relief of Symptoms:
- Achieve relief from symptoms such as abdominal pain, vomiting, and bloody stools, indicating the alleviation of the obstructive process.
- Prevention of Complications:
- Minimize or prevent complications associated with intussusception, including bowel ischemia, perforation, and peritonitis.
- Normalization of Bowel Function:
- Restore normal bowel function and prevent long-term sequelae, ensuring the resumption of regular bowel movements and proper absorption of nutrients.
- Prevention of Recurrence:
- Take measures to prevent the recurrence of intussusception, especially in cases where identifiable factors such as lead points contribute to the condition.
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 Assessment for Intussusception
- Clinical History:
- Obtain a detailed history, including the onset and duration of symptoms, presence of abdominal pain, vomiting, and characteristics of bowel movements.
- Physical Examination:
- Perform a thorough abdominal examination to assess for signs of tenderness, distension, and palpable masses. Pay attention to the presence of a sausage-shaped mass, which may indicate intussusception.
- Vital Signs Monitoring:
- Monitor vital signs, especially assessing for signs of shock such as tachycardia and hypotension, which may indicate complications like bowel ischemia.
- Assessment of Bowel Sounds:
- Auscultate bowel sounds to identify changes in motility and potential bowel obstruction.
- Assessment of Stool:
- Examine stools for the presence of blood or currant jelly-like consistency, which can be indicative of intestinal ischemia.
- Diagnostic Tests:
- Assist in coordinating diagnostic tests such as ultrasound or imaging studies to confirm the diagnosis and assess the extent of the intussusception.
- Fluid Balance:
- Monitor fluid balance, especially in cases of persistent vomiting or diarrhea, to prevent dehydration and electrolyte imbalance.
- Pain Assessment:
- Assess the intensity and location of abdominal pain using a pain scale to guide pain management interventions.
Implementation for Intussusception
- Immediate Medical Intervention:
- Collaborate with the healthcare team to ensure prompt medical intervention, which may involve attempts at non-surgical reduction using procedures like air enema or, if necessary, surgical intervention.
- Pain Management:
- Administer prescribed pain medications as ordered to alleviate abdominal pain and discomfort. Monitor the patient’s response and adjust interventions as needed.
- Fluid and Electrolyte Management:
- Monitor and manage fluid and electrolyte balance closely, especially in cases of vomiting and diarrhea. Administer intravenous fluids as prescribed to prevent dehydration.
- Preparation for Procedures:
- If the patient requires a procedure such as an air enema, ensure proper preparation, including explaining the procedure to the patient and family, obtaining informed consent, and providing emotional support.
- Postoperative Care (if applicable):
- If surgical intervention is necessary, collaborate with the surgical team to provide postoperative care. Monitor for signs of complications, such as infection or bowel perforation, and implement appropriate nursing interventions.
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.
Evaluation for Intussusception
- Relief of Symptoms:
- Evaluate the patient’s response to medical or surgical interventions by assessing the relief of symptoms, particularly abdominal pain, vomiting, and changes in bowel movements.
- Stability of Vital Signs:
- Monitor and assess the stability of vital signs, including heart rate, blood pressure, respiratory rate, and temperature, to ensure that the patient is responding positively to treatment and is not experiencing complications.
- Resolution of Intussusception:
- Determine if the intussusception has resolved by reviewing imaging studies (such as ultrasound or contrast enema) and collaborating with the medical team. Resolution should be evident on imaging studies, confirming the success of the intervention.
- Fluid and Electrolyte Balance:
- Evaluate the patient’s fluid and electrolyte balance to ensure that any deficits or imbalances have been corrected. This is crucial in cases where vomiting, diarrhea, or dehydration were present.
- Patient and Family Education:
- Assess the patient’s and family’s understanding of the condition, its treatment, and the importance of follow-up care. Provide additional education and support as needed, ensuring they are well-informed about signs of recurrence and when to seek medical attention.
References
- https://www.mayoclinic.org/diseases-conditions/intussusception/diagnosis-treatment/drc-20351457
- https://my.clevelandclinic.org/health/diseases/10793-intussusception/management-and-treatment
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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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