Intussusception NCLEX Review Care Plans
Nursing Study Guide for Intussusception
Intussusception is a medical condition wherein a part of the intestine goes into another part of the intestine that is adjacent to it, quite like how a telescope looks.
Intussusception causes blockage of fluid and food, disabling them to go through the intestine smoothly. In addition to this, blood supply can be cut off from the affected intestinal area.
This may lead to bowel perforation or a tear in the intestine, which can further result to tissue infection and death.
This form of intestinal obstruction can happen in children age 3 and below and can be corrected through an X-ray method. Intussusception is considered rare in adults.
Tumor is the underlying condition that leads to adult intussusception, and this requires surgical intervention.
Signs and Symptoms of Intussusception
- Currant jelly-like stool
- Stool with mucus and blood
- Abdominal lump
- Acute abdominal pain – on and off; initially has about 20-minute intervals
- Nausea and Vomiting
- Lethargy or tiredness
- Sudden loud crying – especially in healthy infants
Causes and Risk Factors for Intussusception
Telescoping in intussusception can be caused by a “lead point”, which is commonly an abnormal tissue growth in the bowel, such as a polyp or a tumor.
It is usually the small intestine that slides into an adjacent portion of the bowel.
The root cause of most intussusception cases remains unknown. Aside from tumor or polyp, adhesions or scar-like tissues, as well as inflammatory bowel disease, and weight loss surgery can lead to intussusception.
Children age 3 and below are more likely to experience intussusception. Fall and winter are the common times of increased cases of intussusception, which can make us question whether a viral infection has a play to role on its development.
Boys seem to be more affected than girls. Having a family history (especially siblings) of this condition increases a person’s risk for having it. Intestinal malrotation, or an abnormal formation of intestine at birth can lead to intussusception.
Complications of Intussusception
- Bowel Perforation. If the blood supply is cut off in the affected part of the intestine, that tissues in that area may die. This can cause a tear in the wall of the intestine, also known as bowel perforation.
- Peritonitis and Shock. If left untreated, bowel perforation can cause the infection of the peritoneum, or the lining of the abdominal cavity. This can trigger a more severe abdominal pain, swelling, and fever. Peritonitis is a fatal condition that can lead to shock.
Diagnosis of Intussusception
- Imaging – X-ray, ultrasound or CT scan of the abdomen can help visualize the intestinal obstruction; there can be coiling of the intestine and bowel perforation found using imaging studies
- Enema – air or barium enema is inserted to the rectum, which helps visualize the colon
Treatment for Intussusception
- Air or barium enema. This is a common diagnosis and treatment and can successfully cure intussusception in 9 out of 10 children. If there is recurrence of intussusception, the enema can be done again.
- Surgery. The surgeon can treat the intestinal obstruction and correct the telescoped position of the affected intestine. If there is an evidence of tissue death, the surgeon will remove such dead portion of the intestinal wall.
Nursing Care Plans for Intussusception
- Nursing Diagnosis: Fluid Volume Deficit related to excessive losses through normal routes secondary to intussusception, as evidenced by vomiting, diarrhea, decreased urine output, dry mucous membranes, poor skin turgor, irritability, and reduced oral fluid intake
Desired Outcome: The child will have a balanced electrolyte, input and output status, accompanied with the absence of vomiting and diarrhea, as well as normal appearance of mucous membranes (such as the lips and tongue).
|Assess vital signs, particularly blood pressure level and heart rate. Assess the child for signs of dehydration.||Dehydration can result from vomiting due to intussusception. The appearance of mucous membranes, the quality of skin turgor, and the any increase in heart rate and decrease in blood pressure levels should be assessed.|
|Commence a strict fluid balance chart, monitoring the input and output of the patient. Monitor the stool characteristics using a stool chart.||To monitor patient’s fluid volume accurately. To check for any worsening of intestinal blockage, such as presence of blood in the stool.|
|Collect daily bloods, as ordered by the physician.||To monitor any decrease in serum electrolytes due to vomiting.|
|Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Encourage oral fluid intake as recommended by the pediatrician.||To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body.|
|Educate the child’s guardian on how to fill out a fluid balance chart at bedside. Inform the guardian the need to start with clear fluids and gradually going to soft diet.||To help the guardian take ownership of the patient’s care, encouraging them to help the child drink more clear fluids and then gradually improving to soft diet. This will also empower them to report any changes to the nursing team.|
- Nursing Diagnosis: Acute Pain related to intestinal obstruction secondary to intussusception as evidenced by pain score of 10 out of 10, verbalization of abdominal pain, guarding sign on the chest or abdomen, and irritability
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Prepare the patient for air/barium enema or surgery, usually by putting him/her in a nothing per orem / nothing by mouth status.||To help the patient prepare for the treatment of intussusception using the most appropriate method of treatment.|
|Post-operative care: Administer pain medication as prescribed.||Weight-adjusted morphine is administered intravenously post abdominal surgery. Once the patient is suited for an oral diet, oral opioid analgesics can be given as prescribed.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of post-operative pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Teach the patient on how to perform non-pharmacological pain relief methods such as deep breathing, massage, acupressure, biofeedback, distraction, music therapy, and guided imagery.||To reduce stress levels, thereby relieving the acute post-operative pain.|
|Gradually introduce oral fluids and food as recommended by the surgeon post-operatively.||To allow the patient’s abdomen to heal post-operatively, as the normal bowel function gradually becomes established.|
Other Nursing Diagnoses:
- Risk for Injury
- Deficient Knowledge
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
Please follow your facilities guidelines and policies and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.
This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.