NURSING CARE PLAN FOR A CLIENT WITH INTUSSUSCEPTION

18 months old male presents to the emergency department with six hours of stomach pain. He awoke at 4 am crying. His mother carried him and settled
down after a few minutes and then fell back asleep. Over the next few hours, he woke up intermittently crying. His appetite has been poor since the onset of these
symptoms. He is able to walk but prefers to be carried by his mom this morning. He is less playful than usual. He would sometimes bend down crying. There is no
vomiting or diarrhea. His last stool yesterday was normal. There is no fever, cough or runny nose. Abdominal series reveals a soft tissue density in the right lower
quadrant. Intussusception is suspected.
EXAM VS, T: 37.6, P: 118, R: 24, BP: 85/55, Weight: 11kg

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute Pain related to After 1 hour of  Administer  Administer IV After 1 hour of
 Experiencing bowel invagination nursing intervention, Intravenous fluid fluids as nursing intervention,
stomach pain. evidenced by stomach the patient’s pain will ordered; if the the goal is partially
 Had poor pain. decrease and will be patient is in met as evidenced by,
appetite and less comfortable. shock, give the patient’s pain has
playful than  Provide measures to blood plasma as slightly decrease and
usual since relieve pain before it ordered. has been
onset of becomes severe such  Relive or reduce comfortable.
symptoms as paracetamol, pain
according to ibuprofen, aspirin or
mother diclofenac

Objective:  Decompression
 T: 37.6
 P: 118  A nasogastric
 R: 24 tube is inserted
 BP: 85/55  Monitor I&O to decompress
 Weight: 11kg the bowel

 Replace volume
lost as ordered,
and monitor the
 Perform a intake and
comprehensive output
assessment of pain. accordingly
Such as
Numerical Rating
Scales (NRS),  Assessment of
Verbal Rating the pain helps in
Scales (VRS), Visua planning
 l Analog optimal pain
Scales (VAS), and management
the Faces Pain strategies.
Scale-Revised (FPS-
R)

 Education

 Educate the
family care
givers on what
happens during
intussusception
and about the
surgery, and
answer question
to reduce the
anxiety.
ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
 Subjective: Fluid volume deficit No signs of -Assess for the signs and -Insufficient fluid intake The goal is met,
 Had poor related to excessive dehydration will be symptoms of dehydration. and continuous there are no signs of
appetite and less losses through normal noted and patient vomiting may lead to dehydration and
routes evidenced by  Dry mucus dehydration.
playful than will be free from patient is free from
membrane
usual since inadequate fluid electrolyte and fluid electrolyte and fluid
 Poor skin turgor
onset of intake imbalances.  Delayed capillary imbalances.
symptoms refill
according to  Irritability
mother
-Assess fluid intake and
output. -Fluid intake and output
 Objective:
is an indicator of child’s
 T: 37.6
fluid status.
 P: 118
 R: 24 -Instruct parent to offer their - Clear liquid diet then
 BP: 85/55 child a clear liquid then progression to soft diet
 Weight: 11kg slowly advanced diet. can be used to
 Pale skin color normalize bowel
 Clammy skin movement.
 profound -Administer IV fluid
listlessness
 Inadequate fluid -IV fluids promote
intake adequate fluid intake
and re-establishes
-Frequently monitor vital electrolyte imbalance.
signs
-Abnormal changes in
vital signs such as
tachycardia, increases in
temperature and
hypotension shows
-Monitor the consistency and
hypovolemia.
color of the stool.
-A mucus, blood-filled
or jelly-like stool may
 observed in a child with
intussusception.
-Offer toddler the use of
pacifier.

-Sucking promotes
peristaltic movement
-Provide oral hygiene and passage of gas.

-Attention to mouth care

reduces discomfort of
dry mucous membranes
and promotes interest in
drinking.
 ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Imbalance nutrition  After the  Nasogastric  Feeding this  Patient ingests an
less than body nursing tube is inserted way helps the adequate diet of
• Had poor appetite requirements related intervention, for feeding. patient get 50 kcal/lb. (110
since the onset of the patient will enough kcal/kg) in 24
to poor appetite
symptoms. maintain the nutrition. hours; weight is
nutritional  Provide liquid  It is crucial for maintained within
status and diet rich in healthy growth 10% of birth
Objective: patient’s protein and and weight.
weight remains high caloric development
within 10% of diet. and influence
birth weight major functions
• T: 37.6 of the body.
• P: 118  To know the
• R: 24 patient’s proper
• BP: 85/55  Monitor intake intake of
• Weight: 11kg and output. nutrients and to
monitor
patients
adequate output
of urine and
stool.
 Wet patients’
lips with a
moisturizing
cream or jelly if
they appear to
be dry or offer
them a pacifier
to suck if this
seems to
comfort the
 Encourage patient.
patient’s parent
in doing oral
care
 ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Sleep deprivation After the nursing  Position client in a  To alleviate After the nursing
 He woke up at 4 due to pain and intervention, the comfortable position discomfort and intervention, the
am crying and severe crying patient will improve promote sleep patient showed
fell back asleep his sleeping patterns improvements with
after his mother
and will shows regards to his
carried him and  Provide comfort  To distract
settle down, absence of sleeping patterns and
measures such as attention on
then over a few restlessness. quiet environment showed absence of
pain, reduce
hours, he woke and dim light tension and to restlessness.
up again and promote non
intermittently -pharmacologic
crying due to al management
stomach pain

 Assess sleep pattern  To provide

comparative
baseline

 Investigate anxious  To help

feelings determine basis
and appropriate
anxiety
reduction
techniques
 ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Activity intolerance After the nursing Encourage physical Helps promote a sense After the nursing
 He is less playful related to Abdominal intervention, the patient activity consistent with of autonomy while intervention, goal was
than usual pain will be able to maintain the patient’s energy being realistic about met as the patient
Objective: activity level within levels. capabilities. maintains the activity
capabilities. level within capabilities
• T: 37.6 -Gradually progress -To see improvement to as evidenced by being
• P: 118 patient activity like the child ability to do playful.
• R: 24 asking the SO do play activity
• BP: 85/55 with the child.
• Weight: 11kg
-Encourage adequate - Rest between
rest periods activities provides time
for energy conservation
.
-Have the patient - Helps in increasing
perform the activity the tolerance for the
more slowly, in a activity.
longer time with more
rest or pauses, or with
assistance if necessary.

-Evaluate the need for - Coordinated efforts

additional help. are more meaningful
and effective in
assisting the patient in
conserving energy.