Notes
Description
Intussusception usually appears in healthy babies without any demonstrable cause.
- Intussusception is a process in which a segment of intestine invaginates or telescopes into the adjoining intestinal lumen, causing bowel obstruction.
- It occurs most commonly at the juncture of the ileum and the colon, although it can appear elsewhere in the intestinal tract.
- The invagination is from above downward, the upper portion slipping over the lower portion pulling the mesentery along with it.
Pathophysiology
The pathogenesis of intussusception is not well established.
- It is believed to be secondary to an imbalance in the longitudinal forces along the intestinal wall.
- As a result of an imbalance in the forces of the intestinal wall, an area of the intestine invaginates into the lumen of the adjacent bowel.
- The invaginating portion of the intestine (ie, the intussusceptum) completely “telescopes” into the receiving portion of the intestine (ie, the intussuscipiens); this process continues and more proximal areas follow, allowing the intussusceptum to proceed along the lumen of the intussuscipiens.
- If the mesentery of the intussusceptum is lax and the progression is rapid, the intussusceptum can proceed to the distal colon or sigmoid and even prolapse out the anus.
- The mesentery of the intussusceptum is invaginated with the intestine, leading to the classic pathophysiologic process of any bowel obstruction.
Statistics and Incidences
A wide geographic variation in the incidence of intussusception among countries and cities within countries make determining a true prevalence of the disease difficult.
- Its estimated incidence is approximately 1 case per 2000 live births.
- In Great Britain, incidence varies from 1.6-4 cases per 1000 live births.
- Overall, the male-to-female ratio is approximately 3:1.
- With advancing age, gender difference becomes marked; in patients older than 4 years, the male-to-female ratio is 8:1.
- Two-thirds of children with intussusception are younger than 1 year; most commonly, intussusception occurs in infants aged 5-10 months.
- Intussusception is the most common cause of intestinal obstruction in patients aged 5 months to 3 years.
- Intussusception can account for as many as 25% of abdominal surgical emergencies in children younger than 5 years, exceeding the incidence of appendicitis.
Causes
In most cases, however, no cause can be identified for intussusception.
- Hyperperistalsis. The normal wave-like contractions of the intestine grab this lead point and pull it and the lining of the intestine into the bowel ahead of it.
- Digestive system activities. The unusual mobility of the cecum and ileum normally present in early life may also cause intussusception.
Clinical Manifestations
The constellation of signs and symptoms of intussusception represents one of the most classic presentations of any pediatric illness; however, the classic triad of vomiting, abdominal pain, and passage of blood per rectum occurs in only one-third of patients.
- Abdominal pain. In rare circumstances, the parents report 1 or more previous attacks of abdominal pain within 10 days to 6 months prior to the current episode; pain in intussusception is colicky, severe, and intermittent.
- Vomiting. Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious.
- Currant jelly stool. Parents also report the passage of stools that look like currant jelly; this is a mixture of mucus, sloughed mucosa, and shed blood.
- Lethargy. Lethargy is a relatively common presenting symptom with intussusception; the reason lethargy occurs is unknown because lethargy has not been described with other forms of intestinal obstruction.
Assessment and Diagnostic Findings
The care provider usually can make a diagnosis from:
- Rectal examination. The healthcare provider may perform a rectal examination during a calm interval.
- Palpation. A baby is often unwilling to tolerate palpation, and sedation may be ordered; a sausage-shaped mass can be often felt through the abdominal wall.
- Radiographs. Plain abdominal radiography reveals signs that suggest intussusception in only 60% of cases; as the disease progresses, the earliest radiographic evidence includes an absence of air in the right lower and upper quadrants and a right upper quadrant soft tissue density present in 25-60% of patients.
- Ultrasonography. One study reported that the overall sensitivity and specificity of ultrasonography for detecting ileocolic intussusception was 97.9% and 97.8%, respectively; the authors concluded that ultrasonography should be used as a first-line examination for the assessment of possible pediatric intussusception.
- CT scanning. Computed tomography (CT) scanning has also been proposed as a useful tool to diagnose intussusception; however, CT scan findings are unreliable, and CT scanning carries risks associated with intravenous contrast administration, radiation exposure, and sedation.
- Contrast enema. The traditional and most reliable way to make the diagnosis of intussusception in children is to obtain a contrast enema (either barium or air); contrast enema is quick and reliable and has the potential to be therapeutic.
Palpable sausage mass in the right upper quadrant.
Medical Management
Unlike pyloric stenosis, intussusception is an emergency in the sense that prolonged delay is dangerous.
- Intravenous fluid. For all children, start intravenous fluid resuscitation and nasogastric decompression as soon as possible.
- Therapeutic enema. Therapeutic enemas can be hydrostatic, with either barium or water-soluble contrast, or pneumatic, with air insufflation; therapeutic enemas can be performed under fluoroscopic or ultrasonographic guidance; the technique chosen is not important as long as the radiologist performing the enema is comfortable with the method.
- Surgical reduction. If a nonoperative reduction is unsuccessful or if obvious perforation is present, promptly refer the infant for surgical care; risk of recurrence of the intussusception after operative reduction is less than 5%.
- Laparoscopy. Laparoscopy has been added to the surgical armamentarium in the treatment of intussusception; laparoscopy can be performed in all cases of intussusception; reduction of the intussusception, confirmation of radiologic reduction, and detection of lead points have all been reported.
Pharmacologic Management
Drug therapy is not currently a component of the standard of care for intussusception. Medications are limited to those used for pain control after surgery. In the immediate postoperative period, weight-adjusted intravenous morphine is usually administered.
Nursing Management
Nursing management of a child with intussusception includes:
Nursing Assessment
Assessment of a child with intussusception includes:
- Physical examination. The hallmark physical findings in intussusception are a right hypochondrium sausage-shaped mass and emptiness in the right lower quadrant (Dance sign).
- History. The patient with intussusception is usually an infant, often one who has had an upper respiratory infection, who presents with vomiting, abdominal pain, passage of blood and mucus, lethargy, and palpable abdominal mass.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
- Acute pain related to bowel invagination.
- Deficient fluid volume related to vomiting, nausea, fever, and diaphoresis.
- Ineffective breathing pattern related to abdominal distention and rigidity.
- Anxiety related to change in health status.
Nursing Interventions
Nursing interventions appropriate for the infant are:
- Intravenous fluids. Administer IV fluids as ordered; if the patient is in shock, give blood or plasma as ordered.
- Decompression. A nasogastric tube is inserted to decompress the bowel.
- Monitor I&O. Replace volume lost as ordered, and monitor the intake and output accordingly.
- Education. Educate the family caregivers on what happens during intussusception and about the surgery, and answer questions to reduce the anxiety.
Evaluation
Goals are met as evidenced by:
- The patient shows stable vital signs.
- The patient exhibits balanced intake and output.
- The patient’s pain decreases and is comfortable.
- The patient’s pattern of breathing is effective.
- The caregiver’s anxiety is resolved.
Documentation Guidelines
Documentation in a child with intussusception include:
- Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
- Intake and output.
- Characteristics of vomitus.
- Cultural and religious beliefs, and expectations.
- Plan of care.
- Teaching plan.
- Responses to interventions, teaching, and actions performed.
- Attainment or progress toward desired outcome.
Practice Exam
[mtouchquiz 796 title=off]
Nursing Care Plan
Deficient Fluid Volume
Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.
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. |
Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- Lack of information about condition
Possibly evidenced by
- Request for information about causes of condition, postoperative or postprocedural care
Desired Outcomes
- Parents verbalize understanding of intussusception, the need for a barium enema, and possibility of surgical intervention.
| Nursing Interventions | Rationale |
|---|---|
| Assess parent’s knowledge of the condition, signs and symptoms, therapeutic regimen following procedures. | Promotes the development of an effective plan of instruction. |
| Offer parents with clear and brief information; May utilize teaching aids and encourage questions. | Ensures understanding of care needs based on ability to learn. |
| Teach parents of signs and symptoms of infection in the incision area and demonstrate and allow for return demonstration of dressing change. |
Raises awareness of signs and symptoms of wound infection to facilitate an immediate intervention. |
| Instruct parents to monitor any blood in stool, change in stool characteristics or diarrhea or constipation or absence of stools. | Reveals gastrointestinal bleeding and possible recurrence or chronicity of condition. |
| Instruct parents about preparation procedures for reduction by barium enema or surgery and antibiotic and postoperative care given to the child. | Provides information regarding care to expect during hospitalization. |
| Teach parents that a nothing-per-orem (NPO) status will be ordered initially and will be offered clear fluids and slowly progress to usual diet once advised. |
Prevents vomiting or abdominal distention until condition resolved. |
| Educate parents about activity restrictions. | Allows condition and/or wound to heal and resolve itself without complications. |
| Inform parents that bowel elimination of brown stools indicate that condition has been improved. | Provides parents with baseline expected with successful resolution of the problem. |
Risk for Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
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. |