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 is most commonly occur 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 increases 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 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
Nursing Diagnosis
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
- 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 Interventions | Rationale |
---|---|
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. |
Assess fluid intake and output. | Measurement of fluid intake and output is an important indicator of child’s fluid status. |
Monitor vital signs as frequently as possible. | Vital sign changes such as hypotension, tachycardia and increased temperature reveals hypovolemia. |
Monitor characteristic 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. |
Suggest and offer infant the use of a pacifier. | Sucking on a pacifier may promote peristaltic movement and passage of gas. |
Administer IV fluids as ordered. | Post-operatively, intravenous fluids are continued to re-established electrolyte imbalance and to promote adequate fluid intake. |
Instruct parents that they may offer clear liquids then gradually advanced diet as tolerated. | A clear liquid diet, then progressing to soft diet is given until normal bowel function is established. |
Provide frequent oral hygiene. | Deficient fluid intake can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces discomfort of dry mucous membranes. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023Â (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
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 | 6 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.