Paralytic ileus is a temporary cessation of normal bowel motility that occurs without mechanical obstruction. This comprehensive guide explores the essential nursing diagnoses, interventions, and care plans necessary for effective patient care. Understanding these elements is crucial for nurses managing patients with this condition.
Understanding Paralytic Ileus
Paralytic ileus represents a significant challenge in patient care, characterized by the temporary paralysis of intestinal muscles that normally move digestive contents through the gastrointestinal tract. This condition requires careful nursing assessment and intervention to prevent complications and promote recovery.
Clinical Manifestations
The primary symptoms of paralytic ileus include:
- Abdominal distention and bloating
- Nausea and vomiting
- Absence of bowel movements
- Decreased or absent bowel sounds
- Loss of appetite
- Abdominal tenderness
- Inability to pass gas
Nursing Assessment
Subjective Assessment
During the initial evaluation, nurses should gather the following information:
Medical History
- Recent surgeries, particularly abdominal procedures
- Current medications, especially opioids
- History of gastrointestinal disorders
- Previous episodes of paralytic ileus
Symptom Assessment
- Onset and progression of symptoms
- Character and severity of abdominal discomfort
- Changes in bowel habits
- Presence of nausea or vomiting
Objective Assessment
Physical examination should include:
Abdominal Assessment
- Inspection for distention
- Auscultation of bowel sounds
- Gentle palpation for tenderness
- Percussion to identify tympanic areas
Vital Signs Monitoring
- Blood pressure and heart rate
- Temperature
- Respiratory rate
- Oxygen saturation
Nursing Care Plans
1. Impaired Gastrointestinal Motility
Nursing Diagnosis Statement:
Impaired Gastrointestinal Motility related to neuromuscular dysfunction as evidenced by absent bowel sounds, abdominal distention, and inability to pass stool or gas.
Related Factors:
- Operative procedures
- Medication side effects
- Electrolyte imbalances
- Neurological impairment
Nursing Interventions and Rationales:
- Monitor bowel sounds every 4 hours
Rationale: Provides baseline data and tracks return of peristalsis - Maintain NPO status as ordered
Rationale: Prevents further gastric distention and allows bowel rest - Implement early mobilization
Rationale: Promotes return of peristalsis - Monitor fluid and electrolyte balance
Rationale: Prevents complications and supports normal bowel function
Desired Outcomes:
- The patient will demonstrate a return of normal bowel sounds
- The patient will pass flatus and stool within 72 hours
- The patient will maintain adequate hydration status
2. Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to abdominal distention as evidenced by verbal reports of discomfort, guarding behavior, and facial grimacing.
Related Factors:
- Increased intestinal pressure
- Gas accumulation
- Abdominal distention
- Inflammation
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Enables appropriate pain management strategies - Position patient for comfort
Rationale: Reduces pressure on the distended abdomen - Administer prescribed pain medications
Rationale: Provides comfort while avoiding opioids when possible - Apply warm compresses as appropriate
Rationale: Promotes comfort and may help stimulate peristalsis
Desired Outcomes:
- The patient will report pain at acceptable levels (≤3 on a 0-10 scale)
- The patient will demonstrate improved comfort through normal rest patterns
- The patient will utilize effective non-pharmacological pain management techniques
3. Risk for Fluid Volume Deficit
Nursing Diagnosis Statement:
Risk for Fluid Volume Deficit related to decreased oral intake and gastric losses.
Related Factors:
- Nausea and vomiting
- NPO status
- Nasogastric drainage
- Decreased fluid intake
Nursing Interventions and Rationales:
- Monitor intake and output strictly
Rationale: Early detection of fluid imbalance - Assess for signs of dehydration
Rationale: Enables prompt intervention - Administer IV fluids as ordered
Rationale: Maintains adequate hydration - Monitor lab values
Rationale: Identifies electrolyte imbalances requiring correction
Desired Outcomes:
- The patient will maintain adequate hydration
- The patient will demonstrate stable vital signs
- The patient will maintain normal skin turgor and moist mucous membranes
4. Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis Statement:
Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients as evidenced by weight loss and poor intake.
Related Factors:
- NPO status
- Decreased absorption of nutrients
- Nausea and vomiting
- Prolonged illness
Nursing Interventions and Rationales:
- Monitor nutritional status daily
Rationale: Identifies nutritional deficits - Implement parenteral nutrition as ordered
Rationale: Provides essential nutrients when oral intake is contraindicated - Monitor weight trends
Rationale: Tracks nutritional status - Collaborate with dietary services
Rationale: Ensures appropriate nutrition plan upon resumption of oral intake
Desired Outcomes:
- The patient will maintain a stable weight
- The patient will demonstrate adequate nutritional intake
- The patient will show no signs of malnutrition
5. Anxiety
Nursing Diagnosis Statement:
Anxiety related to illness and hospitalization as evidenced by expressed concerns and restlessness.
Related Factors:
- Uncertainty about condition
- Hospitalization stress
- Physical discomfort
- Changes in health status
Nursing Interventions and Rationales:
- Provide clear information about the condition
Rationale: Reduces fear of the unknown - Implement relaxation techniques
Rationale: Helps manage anxiety - Maintain consistent communication
Rationale: Builds trust and reduces anxiety - Include family in care planning
Rationale: Provides support system and reduces isolation
Desired Outcomes:
- The patient will verbalize decreased anxiety
- Patient will demonstrate the use of coping mechanisms
- The patient will express understanding of condition and treatment plan
Patient Education
Successful management of paralytic ileus requires comprehensive patient education, including:
- Recognition of symptoms requiring medical attention
- Importance of early mobilization
- Dietary modifications upon recovery
- Medication management
- Follow-up care requirements
Discharge Planning
Prepare patients for discharge by:
- Providing written instructions
- Reviewing medication requirements
- Scheduling follow-up appointments
- Discussing lifestyle modifications
- Explaining warning signs requiring medical attention
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Khawaja ZH, Gendia A, Adnan N, Ahmed J. Prevention and Management of Postoperative Ileus: A Review of Current Practice. Cureus. 2022 Feb 27;14(2):e22652. doi: 10.7759/cureus.22652. PMID: 35371753; PMCID: PMC8963477.
- Saclarides TJ. Current choices–good or bad–for the proactive management of postoperative ileus: A surgeon’s view. J Perianesth Nurs. 2006 Apr;21(2A Suppl):S7-15. doi: 10.1016/j.jopan.2006.01.008. PMID: 16597534.
- Sanfilippo F, Spoletini G. Perspectives on the importance of postoperative ileus. Curr Med Res Opin. 2015 Apr;31(4):675-6. doi: 10.1185/03007995.2015.1027184. PMID: 25753356.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
