Paralytic Ileus Nursing Care Plans Diagnosis and Interventions
Paralytic Ileus NCLEX Review and Nursing Care Plans
Paralytic ileus is the paralysis or occlusion of the intestines, inhibiting peristalsis or the forward pushing of intestinal contents.
This may result to the accumulation of intestinal contents and eventual blockage of the intestines.
Four out of five cases of paralytic ileus occur in the small intestines.
Cases reported in the large bowel are commonly related to cancer. The prevalence of paralytic ileus is unknown.
However, reports show that it is commonly seen in patients undergoing surgeries.
In post-operative settings, paralytic ileus is known to last for up to three days.
Paralytic ileus can occur at any age and equally in both men and women.
Signs and Symptoms of Paralytic Ileus
Gastrointestinal symptoms are the most common manifestation of paralytic ileus.
The severity depends on the site and degree of blockage.
If any of the following symptoms is experienced post-surgery, it is important for the patient to report them to the health care team.
- Extreme abdominal discomfort or pain
- Abdominal cramps
- Loss of appetite
- Bloated feeling
- Constipation
- Inability to pass gas
- Stomach swelling
- Nausea
- Vomiting
- Watery stools
Causes of Paralytic Ileus
In general, paralytic ileus can have functional or mechanical causes.
Mechanical paralytic ileus occurs when there is obstruction in the lumen of the bowel, impeding passage of its contents.
The most common causes of mechanical ileus are as follows:
- External compression caused by surgical adhesions and hernia
- Changes in the bowel wall from tumor, inflammation, or infection
- Blockage of the lumen of the bowel from coprostasis (fecal impaction) or intussusception
Functional ileus, on the other hand, is related to the reduced contraction of the smooth muscles of the bowel wall. The most common causes are as follows:
- Reflectory ileus. This form of paralytic ileus is related to having abdominal or retroperitoneal surgery or lesions. The presence of a tumor, hemorrhage, and infection are the most common examples.
- Drug-induced ileus. Opioids and neuroleptic drugs can both cause reduced muscle contractions in the bowels.
- Metabolic ileus. Potassium plays a role on muscle contractions. Hypokalemia can affect the smooth muscles in the bowel wall. Diabetes, on the other hand, can also cause slowing of the muscle contractions in the bowel due to ketoacidosis.
- Vascular ileus. Hypoperfusion of the bowel due to vascular causes can reduce muscular contraction affecting the bowel walls.
Complications of Paralytic Ileus
If left untreated or if treatment is inadequate, paralytic ileus can lead to serious complications, such as:
- Necrosis of the intestines. Necrosis refers to cellular death. Necrosis can occur anywhere in the body including the bowel. It happens when the blood supply is cut off, therefore stopping oxygen supply leading to the death of cells and tissues. Necrosis can make it easier for the bowel to tear and leak also known as bowel perforation.
- Peritonitis. Peritonitis is the inflammation of the abdominal cavity commonly caused by bacteria or fungi. It usually results from bowel perforation. The body has naturally occurring bacteria in the intestines. They are part of the body’s normal flora and do not cause any harm unless they leak into body cavities. When bacteria leak into the peritoneum, infection may happen which can further lead to sepsis.
Diagnosis of Paralytic Ileus
A detailed history and physical examination will be conducted by the doctor.
This will include history of previous surgeries, list of medications, and the presence of signs and symptoms.
An assessment of your bowel sounds will be made through auscultation. In addition to these, the following diagnostic procedures may be requested to support the diagnosis:
- Plain film X-ray- though X-ray films are not always conclusive, they can show signs of trapped air and possible obstructions in the bowel.
- CT Scan – often give the clinician a better view of the bowels. A contrast dye is typically given either intravenously or orally to give better quality images.
- Ultrasound – commonly used imaging technique in children suspected of having paralytic ileus
- Barium Enema – a procedure that includes the use of radiopaque barium inserted in the patient’s rectum. X-ray images are then taken while the barium makes its way through to the bowel. Images will show if there is any obstruction.
Treatment of Paralytic Ileus
In some cases of paralytic ileus, treatment may not be needed. However, depending on the severity of the condition, the following may need to be performed:
- Nothing by mouth (NBM or NPO) status. Taking no food and fluids orally for 24 to 72 hours. Giving the intestines time to relax can help solve the problem.
- Stopping the medication that induced ileus. In cases of paralytic ileus being caused by certain medications, the doctor may recommend that to stop the medication and replace with an alternative as needed.
- Intravenous fluids. IV fluids are often prescribed to prevent further electrolyte imbalance. The lack of calcium and potassium may cause paralytic ileus, hence improving their levels can help correct the problem.
- Gastric lavage. This procedure involves the insertion of a small tube to the stomach through the person’s nose with the aim to decompress the stomach and intestines.
- Electrical stimulation. In cases of functional paralytic ileus, electrical stimulation is done to encourage the intestinal muscles to “restart” or to improve their contractions.
- Surgery. Some cases of paralytic ileus may require surgery. This is particularly applicable when the paralytic ileus is caused by cancer or in the presence of complete blockage.
Nursing Diagnosis Paralytic Ileus
Paralytic Ileus Nursing Care Plan 1
Nursing Diagnosis: Constipation related to paralytic ileus as evidenced by type 1-2 stools on Bristol stool chart, inability to open bowels in the last 3 days, irritability
Desired Outcome: The patient will be able to re-establish normal bowel elimination.
| Paralytic Ileus Nursing Interventions | Rationales |
| Commence a stool chart. Use a standardized stool assessment tool such as Bristol stool chart. | To monitor the patient’s bowel pattern. |
| Administer laxatives as prescribed. | To help evacuate stools, the following laxatives can be used as prescribed: •Stimulant laxatives •Stool softeners, especially for the elderly patients •Bulk laxatives |
| Encourage to increase oral fluid intake as tolerated, ideally at least 2L per day. Check if the patient is in any fluid restriction before doing so. | To help soften the stool and make it easier to pass. |
| Encourage physical mobility and exercise as tolerated. | To increase bowel peristaltic movement. |
| Encourage fiber intake of at least 25 grams per day for women and 38 grams per day for men, as recommended by the dietitian. | To help the food move through the intestines. Examples of good dietary fiber include artichokes, carrots, and spinach. |
Paralytic Ileus Nursing Care Plan 2
Nursing Diagnosis: Acute Pain related to paralytic ileus as evidenced by pain score of 6 out of 10, verbalization of abdominal pain and cramping, guarding sign on the abdomen, abdominal rigidity, and restlessness
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.
| Paralytic Ileus Nursing Interventions | Rationale |
| Administer prescribed pain medications. | To alleviate the symptoms of acute abdominal pain. Pain medications may include narcotics, anticholinergics, or smooth muscle relaxants. |
| 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 abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered. |
| Elevate the head of the bed and position the patient in semi Fowler’s. | To increase the oxygen level by allowing optimal lung expansion. |
| Place the patient in complete bed rest during severe episodes of pain | To reduce gastrointestinal stimulations thereby decreasing GI activity. |
| Perform non-pharmacological pain relief methods: relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio. | To provide optimal comfort to the patient. |
| Place the patient on nothing by mouth (NBM or NPO) status or 24 to 72 hours. | Giving the intestines time to relax can help solve the problem. |
| Administer IV fluids as prescribed. | To prevent further electrolyte imbalance. The lack of calcium and potassium may cause paralytic ileus, hence improving their levels can help correct the problem. |
| Prepare the patient for gastric lavage. | This procedure involves the insertion of a small tube to the stomach through the person’s nose with the aim to decompress the stomach and intestines. |
| Prepare the patient for surgery as ordered. | Severe acute pain due to obstruction from paralytic ileus may require immediate surgical intervention. |
Paralytic Ileus Nursing Care Plan 3
Nursing Diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements
Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.
| Paralytic Ileus Nursing Interventions | Rationale |
| Ask the patient’s preferences regarding food and drinks. Discuss with the patient the short term and long-term nutritional goals. | To help the patient gain a sense of control in his/her nutritional intake and meal planning. |
| Create a daily weight chart and a food and fluid chart. Calculate caloric intake. | To effectively monitor the patient’s daily nutritional intake and progress in nutritional goals. |
| Help the patient to select appropriate dietary choices to follow a low-fat high fiber diet. | Low-fat high fiber diet is ideal for patients with paralytic ileus. |
| Refer the patient to the dietitian. | To provide a more specialized care for the patient in terms of nutrition and diet in relation to post-surgical status. |
Paralytic Ileus Nursing Care Plan 4
Nursing Diagnosis: Ineffective Tissue Perfusion related to insufficient blood flow or blood flow interactions to organs and tissues secondary to paralytic ileus, as evidenced by sudden sharp abdominal pain, nausea, vomiting, abdominal distension, and bloating.
Desired Outcomes:
- The patient will demonstrate signs of improved gastrointestinal perfusion including, normal blood pressure, tolerating the suggested food, having regular bowel movements, and remaining free of abdominal pain and distention.
- The patient will demonstrate relief of pain with a pain score of 0 out of 10.
| Paralytic Ileus Nursing Interventions | Rationale |
| Determine the patient’s complete medical history. | Examine for other causative factors such as blood clots, myocardial infarction, congestive heart failure, diabetes, vascular disorders, and organ failure, all of which can impact perfusion. Consider how the perfusion of several body systems can be affected by certain conditions. |
| Assess the patient’s bowel sounds. | Peristalsis and intestinal digestion can be slowed by insufficient blood supply. Bowel noises are likely to be weak or non-existent. |
| Control the patient’s vomiting and nausea. | Dehydration can occur in vomiting patients. Antiemetics should be given to control vomiting, and IV fluids and supplements should be given to replace lost fluid and electrolytes. |
| Encourage the patient to eat small, readily digestible meals. | Start with watery or bland diets when people recover from bowel procedures or other diseases to avoid overwhelming the gastric system. |
| Monitor the patient’s vital signs regularly. | The first indicators of decreased blood volume in the circulatory system are hypotension and tachycardia. When blood volume is low, the body prioritizes perfusing essential organs like the brain and heart. As a result, blood is directed first to those organs, leaving the gastrointestinal tract and renal system to perfuse last. Those organs will receive the brunt of the “punch” and are at the greatest risk of poor perfusion. |
| Monitor the patient’s serum lactate levels. | When the body doesn’t have enough oxygen, glucose breaks down into lactate, which can be used as an energy source. As a result, a spike in lactate levels may signal a lack of oxygen in the body. |
| Regularly check the patient’s mean arterial pressure (MAP). | The average pressure in the arteries for one complete cycle of a heartbeat is known as mean arterial pressure. To appropriately perfuse all of the body’s important organs, the MAP should be at least 60 mmHg. |
| Assess the patient for pain and take note of characteristics such as onset, location, nature, duration, and factors that help or hurt the pain. | Ischemic abdominal discomfort that might occur suddenly. With the sudden start of stomach pain, and mesenteric ischemia should be considered. |
| Administer IV fluids as ordered. | The patient may need to have fluids, electrolytes, and nutrients replaced through intravenous fluid therapy (IVF). |
| Encourage the patient to walk or do mild exercise as tolerated | Helps in increasing the bowel peristaltic movement. |
| Encourage the patient to increase the fiber intake such as carrots, spinach, and artichokes, as recommended by the dietician. | To help the food move through the intestines. |
| Elevate the head of the patient’s bed and put the patient in Semi Fowler’s position. | To increase the oxygen level by allowing optimal lung expansion. |
| Insert the nasogastric tube into the patient as needed and be ordered by the physician | A nasogastric tube may be required for patients who require bowel rest or decompression. Check stomach output for signs of improved bowel function. |
| Observe the changes in the patient’s stool. | Delay in digestion might cause constipation. Ischemic colitis, which is caused by a reduction in blood supply to the large intestine, can be detected by blood in the stool. A GI bleed might be identified by bright blood or black stools. |
| Monitor the patient’s hemoglobin levels. | The lower the oxygen saturation, the lower the affinity for hemoglobin, resulting in less oxygen intake. As a result, less oxygen circulates throughout the body. |
| Provide the patient with warm blankets and advise them to wear socks and slippers to keep the extremities warm. | The cold causes vasoconstriction, which restricts blood flow. |
Paralytic Ileus Nursing Care Plan 5
Nursing Diagnosis: Deficient Knowledge related to misinterpretation of data, inability to recall, and unawareness of available resources regarding the disease secondary to paralytic ileus, as evidenced by asking related questions, verbal requests for more information, assertions of misunderstandings, and the inability to follow instructions.
Desired Outcomes:
- The patient will be able to explain the disease process and any potential problems.
- The patient will be able to identify stressful situations and the appropriate actions to take.
- The patient will be able to explain the therapeutic regimen to others.
- The patient will be able to take part in the therapy program.
- The patient will be able to make the appropriate lifestyle adjustments.
| Paralytic Ileus Nursing Interventions | Rationale |
| Determine how the patient views the disease process. | Establishes a foundation of knowledge and provides some insight into individual learning requirements. |
| Review with the patient the disease process, the causes and effects of the factors that create symptoms, and identify approaches to eliminate contributing elements. Allow time for the patient to ask questions. | Individual circumstances can trigger or aggravate symptoms; thus the patient should be aware of what meals, fluids, and lifestyle factors can trigger symptoms. Patients can make informed decisions and choices regarding their chronic disease’s future and manage it with an accurate knowledge base. Although most patients are aware of their own disease process, they may be misinformed or have outdated information. |
| Educate the patient regarding the medications, including their purpose, frequency, dosage, and potential side effects. | Improves understanding and participation in the treatment plan. |
| Emphasize to the patient the significance of regular skin care such as proper handwashing techniques and perineal skin care. | Reduces bacterial spread and the danger of skin irritation or breakdown, as well as infection. |
| Advise the patient to stop smoking, if applicable. | Smoking may worsen the current symptoms and may interact with the patient’s treatment regimen. |
| Emphasize the need to adhere to follow-ups and long-term reevaluation of the condition. | Regular check-ups with the healthcare provider will aid in the early detection and prevention of developing complications. |
| Explain any possible diagnostic procedures to the patient. | Allows the patient to understand how the procedure will work and will help the patient to relieve anxiety before the procedure. |
| Assess the patient’s capacity to learn or provide required healthcare services. | Cognitive limitations must be identified in order to develop an effective teaching strategy. |
| Examine the patient’s drive and readiness to learn about the current condition. | Learning takes effort. Patients must see a reason or need to learn. They also have the option of declining educational services. |
| Consider the patient’s learning style, particularly if the patient has previously learned and retained new material when giving instructions on the medication schedule. | Every person has a unique learning style, which must be considered while developing an educational program. Some people prefer textual materials to visual materials, and others prefer group sessions to one-on-one training. Matching the learner’s preferred learning style to the educational approach will aid in knowledge mastery. |
| Provide the patient with physical comfort. | According to Maslow’s philosophy, basic physiological requirements must be met before patient education can begin. Keeping the patient comfortable allows them to focus on what is being discussed or displayed. |
| Allow for an uninterrupted calm and tranquil environment when educating the patient. | The patient can concentrate and focus more fully in a tranquil setting. |
| Explanation and demonstration of the treatment plan to the patient should be clear, detailed, and understandable. | When patients have a basic understanding of what to expect, they are more equipped to ask questions. |
| Encourage the patient to ask questions and clarifications when giving instructions. | Questions allow for open dialogue between patients and health care providers, as well as verification of understanding of the information provided. |
| Encourage the patient to have adequate sleep and allow for optimal rest and recovery. | The patient needs to regain energy in order to fully recover. |
Paralytic Ileus Nursing Care Plan 6
Nursing Diagnosis: Impaired comfort related to abdominal pain, anxiety, nausea, and vomiting secondary to paralytic ileus, as evidenced by grimacing, guarding behavior, Irritability or restlessness, tachycardia, and expression of feeling stressed and worried.
Desired Outcomes:
- The patient will be able to display a calm and relaxed state with vital signs within normal range.
- The patient will be able to show relief from pain with a pain score of 3 or less out of 10.
- The patient will be able to learn methods to control the stress and worry.
| Paralytic Ileus Nursing Interventions | Rationale |
| Determine the patient’s physical sources of pain. | Pain, nausea, exhaustion, and medical equipment like IV lines and catheters can all contribute to a lack of comfort. |
| Monitor the patient’s level of pain. | Using a pain scale, keep a close eye on the pain level such as verbal or nonverbal. |
| Assess the patient for any mental or emotional distress. | Outward indicators of distress, such as restlessness or tears, may be observed by the nurse, but the patient may be dealing with an emotional issue. |
| Inquire about the patient’s comfort objectives. | In other cases, the nurse may be powerless to intervene, or the patient may lack real knowledge of the situation. |
| Be kind and approach the patient in a calm manner. | Being polite to patients is the easiest and most important thing a nurse can do. Smile, speak in a pleasant tone and convey competence and concern. Patients must feel secure in order to be at ease. |
| Administer pain relief medications as ordered, to help in alleviating the pain. | To aid comfort, rest, and recovery, pain medicines, antiemetics, and antianxiety drugs are required. |
| Educate the patient on some nonpharmacological approaches that may help in reducing the pain. | Warm blankets might help the patient relax. Cool towels can help with nausea and overheating. Physical discomfort can be avoided with pillows and repositioning. |
| Explain the procedure to the patient before implementing it and ask the patient if there are some questions or clarifications. | When unwell and hospitalized, patients frequently can feel vulnerable. Before doing anything, the nurse should always explain the procedure. When a patient knows what to expect, fear and discomfort are greatly reduced. |
| Offer the patient alternative relaxation and soothing strategies. | A calming voice may be needed to reassure a patient who is feeling overwhelmed or nervous. Teach meditation and breathing exercises. |
| Maintain a clean and stress-free environment for the patient. | After obtaining permission, assist the patient in cleaning up their surroundings. Cluttered tables, strewn papers, and stale food can be overpowering. Reduce stimulation by turning down the volume outside, lowering the lights, and keeping the door shut. |
| Provide the patient with hygiene products or cleaning supplies and encourage the patient to perform self-care. | Unclean feelings have a significant impact on comfort. Offer a bed bath with skincare and oral care if the patient is unable to clean themselves. Provide supplies such as a toothbrush, comb, and deodorant if the patient is self-sufficient. |
| Provide the patient with spiritual distress chaplain services, as needed. | If the patient’s distress is due to a spiritual issue, the chaplain may be called. |
| Encourage the patient’s family and friends to visit if the patient permits. | Encourage the patient to invite relatives and friends to come in order to lift their spirits. If they are not feeling well enough to receive guests, suggest calling them. |
| Provide some distractions if the patient is feeling anxious. | A frightened or anxious patient may require distraction. It can be beneficial to draw, listen to relaxing music, or read books. |
| Respect the patient’s cultural values by respecting their privacy, asking permission before touching them, and avoiding bringing up things with which they are uncomfortable. | Being in the hospital can be isolating, and the patient may feel out of their comfort zone. |
| Recognize the patient’s feelings. | The nurse should calmly listen to the patient and reassure them that their feelings and opinions are valid. The nurse does not always have to provide a solution; often all that is required is for the patient to express their worries. |
| Provide proactive support on the patient’s long-term needs. | The patient may be concerned about the financial situation or how they will deal with their disease once they return home. To alleviate the patient’s uncertainty, the nurse can enlist the help of a case manager and begin discussing support at home before the patient is discharged. |
More Nursing Diagnosis for Paralytic Ileus
Nursing References
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. (2022). 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. (2020). 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
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