This article explores the nursing diagnosis of intussusception, including its definition, causes, symptoms, and interventions. Learn more here.
What is Intussusception?
Intussusception is a telescoping of one portion of the bowel into another portion which results in obstruction to the passage of the intestinal contents and inflammation and impaired blood flow to the parts of the intestinal walls that are pressing against one another. If not treated, tissue necrosis, intestinal perforation, and peritonitis may occur. The symptoms of intussusception include colicky abdominal pain, nausea, vomiting, lethargy, and blood or mucus in the stools (sometimes referred to as “currant jelly” stool).
It most commonly occurs in infants ages 3 to 12 months or in children 12 to 24 months of age. The cause of intussusception is unknown but children with Meckel’s diverticulum, celiac disease, cystic fibrosis, diarrhea, or constipation increase the likelihood of incurring this condition. Surgical correction is done if the obstruction of the involved segment does not resolve through manual reduction or by hydrostatic pressure or if the bowel becomes necrotic.
Nursing Care Plans
Nursing care planning goals of a child with intussusception revolve toward providing appropriate information about the child’s condition, restoring fluid volume and preventing dehydration, and observing resolution or improvement (relief of abdominal pain, return of normal bowel sounds).
Here are three (3) nursing care plans (NCP) and nursing diagnosis (NDx) for intussusception:
Deficient Fluid Volume
Intussusception is a medical condition where a portion of the intestine folds into another section of the intestine. This can cause obstruction of the bowel, leading to vomiting, abdominal pain, and diarrhea, which can result in a loss of fluids and electrolytes, ultimately leading to deficient fluid volume.
Nursing Diagnosis
- Deficient Fluid Volume
May be related to
- Excessive losses through normal routes
Possibly evidenced by
- Vomiting
- Decreased urine output
- Inadequate fluid intake
- Signs and symptoms of dehydration or electrolyte imbalance
Desired Outcomes
- The child will be able to tolerate age-appropriate foods and fluids without vomiting or recurrence of symptoms and will be free from fluid and electrolyte imbalances.
Nursing Assessment and Rationales
1. Assess for signs and symptoms of dehydration such as poor skin turgor, dry mucous membranes, irritability, and delayed capillary refill.
Repeated vomiting and insufficient fluid intake may lead to dehydration.
2. Assess fluid intake and output.
Measurement of fluid intake and output is an important indicator of a child’s fluid status.
3. Monitor vital signs as frequently as possible.
Vital sign changes such as hypotension, tachycardia, and increased temperature reveal hypovolemia.
4. Monitor characteristics of stool (consistency and color).
Initially, a child with intussusception may pass a normal stool, but later on, a mucus, blood-filled or jelly-like stool is observed.
Nursing Interventions and Rationales
1. Suggest and offer the infant the use of a pacifier.
Sucking on a pacifier may promote peristaltic movement and passage of gas.
2. Provide frequent oral hygiene.
Deficient fluid intake can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes.
3. Administer IV fluids as ordered.
Post-operatively, intravenous fluids are continued to re-established electrolyte imbalance and to promote adequate fluid intake.
4. Instruct parents that they may offer clear liquids and then gradually advance diet as tolerated.
A clear liquid diet, then progressing to a soft diet is given until normal bowel function is established.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for pediatric conditions and diseases:
- Acute Glomerulonephritis | 4 Care Plans
- Acute Rheumatic Fever | 4 Care Plans
- Apnea | 4 Care Plans
- Brain Tumor | 3 Care Plans
- Bronchiolitis | 5 Care Plans
- Cardiac Catheterization | 4 Care Plans
- Cerebral Palsy | 7 Care Plans
- Child Abuse | 4 Care Plans
- Cleft Lip and Cleft Palate | 7 Care Plans
- Congenital Heart Disease | 5 Care Plans
- Congenital Hip Dysplasia | 4 Care Plans
- Croup Syndrome | 5 Care Plans
- Cryptorchidism (Undescended Testes) | 3 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Dying Child | 4 Care Plans
- Epiglottitis | 5 Care Plans
- Febrile Seizure | 4 Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Hospitalized Child | 5 Care Plans
- Hydrocephalus | 5 Care Plans
- Hypospadias and Epispadias | 4 Care Plans
- Intussusception | 3 Care Plans
- Juvenile Rheumatoid Arthritis | 4 Care Plans
- Kawasaki Disease | 6 Care Plans
- Meningitis | 7 Care Plans
- Nephrotic Syndrome | 5 Care Plans
- Osteogenic Sarcoma (Osteosarcoma) | 4 Care Plans
- Otitis Media | 4 Care Plans
- Scoliosis | 4 Care Plans
- Spina Bifida | 7 Care Plans
- Tonsillitis and Adenoiditis | 4 Care Plans
- Umbilical and Inguinal Hernia | 4 Care Plans
- Vesicoureteral Reflux (VUR) | 5 Care Plans
- Wilms Tumor (Nephroblastoma) | 4 Care Plans
Thank you for the content, It is clear even a lay person would not need explanations. Clear and concise.