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:
Risk for Injury
Nursing Diagnosis
- Risk for Injury
May be related to
- Bowel dysfunction
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Intussusception will be reduced by hydrostatic pressure.
- Client will pass a normal brown stool.
Nursing Interventions | Rationale |
---|---|
Assess presence of acute abdominal pain accompanied by loud crying and drawing knees up to chest which may be episodic, vomiting, passage of a brown stool followed by red, currant jelly-like stool, pallor, irritability. | Provides information that intussusception is present which may result in obstruction and if left untreated, will lead to peritonitis. |
Monitor older child for presence of diarrhea, constipation, and vomiting episodes. | Reveals presence of intussusception and a further assessment is needed. |
Observe bowel elimination and characteristics of stool and ability to eliminate barium following the procedure. | Signifies that the procedure in reducing the affected bowel is successful as the condition may recur within 36 hours. |
Provide NG tube attached to suction, IV fluids to decompress bowel and maintain hydration status and maintain patency of therapy as ordered. | Avoids episodes of vomiting and dehydration and prepares the child for barium enema procedure to diagnose and reduce the invagination. |
Provide information on the therapeutic regimen and allow for an opportunity to inquire questions about procedures. | Decreases anxiety and helps eliminate the fear of the unknown. |
Provide reassurance to parents and allow to accompany the child during the procedure. | Promotes trust and reduces anxiety. |
Inform parents on the purpose for IV and NG tube, NPO status. | Provides information about treatments for understanding and lessening of anxiety. |
Inform parents that surgical reduction may be needed if barium enema fail to reduce the invagination. | Prepares parents for a possibility of surgical correction. |
Reinforce information given by the physician. | Provides information about surgical intervention if barium enema reduction is unsuccessful or if bowel obstruction and necrosis is present. |
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:
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- Croup Syndrome | 5 Care Plans
- Cryptorchidism (Undescended Testes) | 3 Care Plans
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- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Dying Child | 4 Care Plans
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- 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
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