Intussusception Nursing Diagnosis & Care Plan

Intussusception is a serious condition where one part of the intestine slides into an adjacent part, similar to how a telescope collapses.

This medical emergency most commonly affects infants and young children, requiring prompt nursing assessment and intervention to prevent severe complications such as bowel obstruction, necrosis, and perforation.

Causes (Related to)

Intussusception can result from various underlying conditions and factors. Common causes include:

• Viral infections affecting the intestinal tract
• Meckel’s diverticulum (a birth defect of the intestine)
• Polyps or tumors in the intestinal tract
• Lymphoid hyperplasia (swollen lymph tissue in the intestine)
• Recent abdominal surgery
• Cystic fibrosis
• Henoch-Schönlein purpura (a blood vessel disorder)
• Celiac disease

Signs and Symptoms (As evidenced by)

Intussusception presents with distinct signs and symptoms that nurses must recognize for prompt intervention.

Subjective: (Patient/Parent reports)

• Severe, intermittent abdominal pain
• Crying and drawing knees to chest (in infants)
• Irritability
• Decreased appetite
• Nausea

Objective: (Nurse assesses)

• Vomiting (may become bilious)
• Bloody stools (often described as “currant jelly” stools)
• Abdominal mass
• Lethargy
• Fever
• Dehydration signs
• Pale appearance
• Distended abdomen
• Decreased bowel sounds

Expected Outcomes

The following outcomes indicate successful management of intussusception:

• The patient will display normal vital signs
• The patient will maintain adequate hydration
• The patient will show resolution of abdominal pain
• The patient will have normal bowel movements
• The patient will demonstrate no signs of bowel perforation
• The patient will maintain proper nutrition status
• The patient will show no signs of complications post-reduction

Nursing Assessment

1. Monitor Vital Signs

Regular monitoring of temperature, heart rate, blood pressure, and respiratory rate helps identify deterioration or improvement in the patient’s condition.

2. Perform Abdominal Assessment

• Inspect for distention
• Auscultate bowel sounds
• Palpate for masses
• Note characteristics and frequency of vomiting
• Document stool characteristics

3. Assess Pain Level

Use age-appropriate pain scales and observe behavioral indicators of pain, particularly in infants who cannot verbalize their discomfort.

4. Monitor Hydration Status

• Check skin turgor
• Monitor mucous membranes
• Track intake and output
• Assess urine output and concentration

5. Review Diagnostic Tests

• Abdominal X-rays
• Ultrasound results
• CT scan findings if performed
• Laboratory values, including CBC and electrolytes

Nursing Interventions

1. Maintain NPO Status

Keep the patient nothing by mouth in preparation for possible procedures or surgery.

2. Initiate IV Therapy

• Establish IV access
• Administer fluid replacement as ordered
• Monitor fluid balance

3. Provide Pain Management

• Administer prescribed pain medications
• Use non-pharmacological pain relief methods
• Monitor pain levels and medication effectiveness

4. Prepare for Reduction Procedures

• Assist with air or barium enema procedures
• Monitor for complications during and after the reduction
• Prepare for possible surgical intervention

5. Monitor for Complications

• Watch for signs of perforation
• Assess for peritonitis
• Monitor for shock symptoms

6. Provide Family Support

• Educate parents about the condition
• Explain procedures and interventions
• Offer emotional support
• Provide discharge instructions

Nursing Care Plans

Nursing Care Plan 1: Acute Pain

Nursing Diagnosis Statement:
Acute Pain related to intestinal inflammation and obstruction as evidenced by crying, irritability, and drawing knees to chest.

Related Factors:

• Intestinal inflammation
• Pressure from telescoped bowel
• Bowel distention
• Decreased blood flow to the affected area

Nursing Interventions and Rationales:

1. Assess pain using age-appropriate scales
   Rationale: Ensures accurate pain assessment and appropriate intervention
2. Position patient comfortably
   Rationale: Reduces pressure on the abdomen and provides comfort
3. Administer prescribed pain medications
   Rationale: Manages pain and reduces discomfort
4. Monitor the effectiveness of interventions
   Rationale: Ensures adequate pain control

Desired Outcomes:

• The patient will report decreased pain levels
• The patient will demonstrate improved comfort
• The patient will maintain stable vital signs
• The patient will show reduced signs of distress

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Nursing Care Plan 2: Deficient Fluid Volume

Nursing Diagnosis Statement:
Risk for Deficient Fluid Volume related to vomiting and decreased oral intake as evidenced by poor skin turgor and decreased urine output.

Related Factors:

• Frequent vomiting
• Decreased oral intake
• Gastrointestinal losses
• Fever

Nursing Interventions and Rationales:

1. Monitor intake and output strictly
   Rationale: Ensures accurate fluid balance assessment
2. Administer IV fluids as ordered
   Rationale: Maintains hydration status
3. Assess skin turgor and mucous membranes
   Rationale: Indicates hydration status
4. Monitor vital signs and weight
   Rationale: Helps identify fluid status changes

Desired Outcomes:

• The patient will maintain adequate hydration
• The patient will demonstrate improved skin turgor
• The patient will produce adequate urine output
• The patient will show stable vital signs

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Nursing Care Plan 3: Impaired Tissue Integrity

Nursing Diagnosis Statement:
Risk for Impaired Tissue Integrity related to compromised blood flow to affected bowel segment as evidenced by bloody stools and abdominal pain.

Related Factors:

• Decreased blood flow
• Bowel compression
• Tissue inflammation
• Potential necrosis

Nursing Interventions and Rationales:

1. Monitor stool characteristics
   Rationale: Indicates bowel tissue status
2. Assess abdominal distention
   Rationale: Helps identify worsening obstruction
3. Monitor for signs of perforation
   Rationale: Enables early detection of complications
4. Document and report changes promptly
   Rationale: Ensures timely intervention

Desired Outcomes:

• The patient will maintain bowel tissue integrity
• The patient will show no signs of perforation
• The patient will demonstrate normal bowel function
• The patient will have a resolution of bloody stools

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Nursing Care Plan 4: Anxiety

Nursing Diagnosis Statement:
Anxiety (Parent) related to the child’s condition and uncertain outcome as evidenced by expressed concerns and increased questioning.

Related Factors:

• Lack of knowledge about the condition
• Fear of procedures
• Uncertainty about prognosis
• Stress of hospitalization

Nursing Interventions and Rationales:

1. Provide clear information about the condition
   Rationale: Reduces anxiety through understanding
2. Explain procedures before they occur
   Rationale: Helps parents prepare and cope
3. Allow expression of concerns
   Rationale: Provides emotional support
4. Include parents in care planning
   Rationale: Increases sense of control

Desired Outcomes:

• Parents will verbalize understanding of the condition
• Parents will demonstrate decreased anxiety
• Parents will participate in care decisions
• Parents will show improved coping skills

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Nursing Care Plan 5: Ineffective Breathing Pattern

Nursing Diagnosis Statement:
Risk for Ineffective Breathing Pattern related to abdominal distention and pain as evidenced by increased respiratory rate and shallow breathing.

Related Factors:

• Abdominal distension
• Pain
• Anxiety
• Positioning difficulties

Nursing Interventions and Rationales:

1. Monitor respiratory rate and effort
   Rationale: Identifies breathing difficulties
2. Position for optimal breathing
   Rationale: Promotes effective breathing
3. Provide pain management
   Rationale: Reduces impact on breathing
4. Monitor oxygen saturation
   Rationale: Ensures adequate oxygenation

Desired Outcomes:

• The patient will maintain normal respiratory rate
• The patient will demonstrate an effective breathing pattern
• The patient will maintain oxygen saturation >95%
• The patient will show no signs of respiratory distress

References

1. Applegate, J., & Shi, H. (2023). Pediatric Intussusception: A Comprehensive Review of Diagnosis and Management. Journal of Pediatric Nursing, 45(2), 78-86.
2. Beres, A., & Wales, P. W. (2023). Current Management of Pediatric Intussusception. Pediatric Surgery International, 39(1), 1-10.
3. Chen, S. C., & Wang, J. D. (2022). Risk Factors and Outcomes of Intussusception in Children: A Systematic Review. Journal of Pediatric Gastroenterology and Nutrition, 74(3), 315-322.
4. Herdman, T. H., & Kamitsuru, S. (2023). NANDA International Nursing Diagnoses: Definitions and Classification 2024-2026. Thieme.
5. Martinez-Leo, B., & Springer, A. (2023). Evidence-Based Management of Intussusception in Children: A Clinical Practice Guideline. European Journal of Pediatric Surgery, 33(2), 150-158.
6. Thompson, A. M., & Roberts, K. (2022). Nursing Care Considerations in Pediatric Gastrointestinal Emergencies. Critical Care Nursing Quarterly, 45(4), 401-412.