Intussusception Nursing Care
Jumat, 13 Januari 2023
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A. Intussusception Disease
1. Understanding.
Intussusception is the entry of a portion of the intestine (Intussuseptum) into a more distal portion (Intussuscipien) (Ian Roberts & Pincus Catzel, Kapita Selekta, 1990.
Intussusception is a condition in which the proximal segment of the intestine enters the more distal segment of the intestine and generally causes symptoms of intestinal obstruction (Markum, Pediatrics, 1991)
Intussusception is intestinal obstruction caused by the presence of a part of the intestine that has invaginated (telescoping) into the surrounding area (Susan Martin Tuncker et al, Standard of Patient Care, 1998).
From the three definitions above, it can be concluded that intussusception is a condition where a part of the proximal intestine (intussusceptum) enters into a more distal part (intussuscipient) which generally causes symptoms of intestinal obstruction.
2. Incidence Number.
Intussusception (invagination) is the most common cause of intestinal obstruction in children between the ages of 3 months and 5 years. Half of cases occur in children less than 1 year of age. Usually occurs at the age of 3-12 months. And it occurs more often in boys than girls. More often in children with cystic fibrosis. Although specific intestinal lesions may be found in a few cases in children, the cause is generally unknown. >90% of intussusceptions have no pathological clues.
3. Etiology.
Causes are generally unknown. However, there are predisposing factors for intussusception, namely:
a. Meckel's diverticulum is a duct arising from the ileum, which closes at the end of the umbilical cord but does not open at the end of the intestine, or polyps/cysts in the intestine.
b. Intestinal polyps are epithelial plants of the mucous membranes in the intestine.
c. Duplication of the intestine, namely the doubling of the intestinal structure.
d. Ileal granuloma is the presence of granulation tissue in the ileum area.
e. Lymphosarcoma is a malignant tumor that is in the lymph area.
Also in young children the greatest incidence is between the 4th and 8th months, when there is an opportunity for a more dense diet which can alter intestinal peristalsis. With increased peristaltic activity, it can initiate intussusception (Rosa M Sacharin, Principles of Pediatric Nursing, 1993).
4. Classification.
Classification by location.
a. Ileocaecal : the ileum invaginates into the ascending colon at the ileocaecal valve.
b. Ileocolic : the ileum invaginates into the colon
c. Colocolic : the colon invaginates into the colon
d. Ileo-ileo : the small intestine invaginates into the small intestine (Rosa M Sacharin, 1993)
Combined types like ilio-ilio-kolika & ilio – kolo – colic. What is often found is the type of iliokolika & ilio - ilio - colika. (AH Markum, Pediatrics, 1991).
5. Pathophysiology.
Intussusception is an invagination or one portion of the intestine on another. Usually ileocecal valve (ileocolic inflow). Where the ileum enters the cecum and then enters the colon. Or ileoileal (part of the ileum enters into part of the ileum) and colocolic (one part of the colon enters another part of the colon), usually in the area of the liver or splenic flexure or part of the transverse colon.
The result of invagination is obstruction of the intestinal contents that will complicate defecation. In addition, the 2 intestinal walls press against each other causing inflammation, edema and eventually reduced blood flow. Ischemia, perforation, peritonitis and shock are serious complications of intussusception.
6. Clinical Features.
ü The child is usually healthy and the onset of illness is sudden.
ü The child screams loudly suddenly, covering the knees like there is something severe abdominal pain.
ü Attacks are repeated after varying lengths of time.
ü If the attack is severe or prolonged, the child will be pale, restless, and sweat profusely.
ü Vomiting is not conspicuous but he does not vomit after an attack of colic.
ü Rectal examination found traces of blood on finger examination.
ü The pulse is fast and gentle and the body temperature is subnormal.
(Rosa M Sacharin, 1993)
In atypical cases, lethargy may be the first visible symptom (Hickey, Sodhi and Johnson, 1990)
The child may have a fever with a temperature of up to 106˚F (41.1˚C) and signs of shock such as sweating, weak and shallow pulse, grunting breath. Stiff abdomen (Thompson's Pediatric Nursing an Introductory text, 1997)
7. Radiological Examination.
a. A plain photo of the abdomen shows an uneven distribution of air (no air in the right lower abdomen & large intestine).
b. Advanced cases, there are signs of obstruction such as "AIR FLUID LEVEL" in the dilated small intestine & empty large intestine.
c. Barium enema examination shows a "Filling defect"/"cupping" at the end of the contrast. Contrast is seen in a straight line in the area of the intestinal lumen that is pinched and the appearance of thin circles in the intussusceptum.
d. Ultrasound examination, looks like a cow's eye.
8. Complications.
Complications from intussusception include:
a. Inflammatory reaction.
Occurs due to pressure / clamping of blood vessels in the tissue which causes a pain response due to the occurrence of an inflammatory reaction.
b. Ederna.
The entry of the proximal intestine into the distal part results in the blood vessels passing through this intestinal area being pinched. So that the blood that should pass smoothly will be blocked and gather in one place and eventually become ederna.
c. ischemic.
Due to the presence of pinched blood vessels which results in obstructed blood flow in these tissues which will eventually cause ischemia.
d. Corporation.
With the implantation reaction will result in necrosis. If the necrosis lasts a long time it will result in tissue perforation.
e. Peritonitis.
From an intractable inflammatory process. So, will cause peritonitis.
f. Shock.
As a result of frequent vomiting, the baby will lack fluids and electrolytes which will eventually lead to dehydration. Immediately treated dehydration will cause shock.
9. Principles of Treatment and Care Management.
Ø In many cases the initial treatment of choice is non-surgical hydrostative reduction using a barium enema. The force exerted by the barium flow is usually sufficient to push the invaginated portion of the bowel into its original position (Wong & Waley). The use of barium as a contrast agent is not a frequent alternative. Today a high percentage of radiologists use water-soluble contrast and air pressure to reduce intussusception (Mayer, 1992). Applying air pressure to reduce intussusception has been successful and more rapid than barium, without the risk of peritonitis. IV fluids, NG decompression and antibiotic therapy may be given before hydrostatic reduction trials are performed. Since this procedure is not always successful, the child is advised to have surgery (Wong & Whaley). Reduction of intussusception can be done by injecting saline, air/barium into the colon. This method is rarely used as long as there is a risk of perforation, however small, and there is no guarantee of successful reduction (AH Markum, Pediatrics, 1991).
o Surgical reduction.
a. Preoperative Care
a.) Rutin.
b.) Naso-gastric tube.
c) Correct dehydration if present.
b. Direct visual reduction of intussusception, keeping bowel warm with saline. It also helps reduce edema.
c. IV plasma should be available in cases of collapse.
d. If the intussusception cannot be reduced, resection and primary anastomosis are required.
o Postoperative management.
a. routine.
b. Incubator care for small babies.
c. Administration of O2.
d. Followed by IV fluids.
e. Antibiotics.
f. If an ileostomy is performed, suction drainage is applied to the tubaileostomy until continuation of the stomach is restored.
g. Observation of vital functions.
h. Treatment of wounds and drains.
o Routine maintenance.
1. Feeding should be resumed as soon as possible, ie if vomiting has disappeared and peristaltic activity is satisfactory.
2. Bathing and handling.
Ø Parental/Family support.
Since hospitalization may be the first time a child is separated from their parents, it is very important to maintain the parent-child relationship by encouraging rooming in/visit. And maybe it's also their first experience, their child receiving hospital treatment which might require them to prepare everything.
Ø Support from parents.
The amount of support needed depends on the general status of the child and the surgical procedures performed. The child's condition must be fully explained and reassured. Once the child's general condition improves, parents can participate in child care.
Ø Prognosis.
ð Non-operative reduction was successful > 75% of cases.
ð Surgery is recommended in patients who are not successful with contrast enemas. If left untreated, approximately 10% of children will suffer complications such as peritonitis, perforation, and sepsis.
B. Intussusception Nursing Care Concept.
1.) Assessment.
a. Demographic Data.
1. Client Identity: includes name, age and gender
(Intussusception (invagination) is more common in children between the ages of 3 months and 5 years. Half of cases occur in children less than one year old, usually between 3-12 months of age. And it occurs more frequently in boys than girls.) residence.
2. Identity of person in charge: includes name, gender, education, address, relationship with client.
b. Main complaint.
Nurses can find out the client's main complaints by getting explanations from their parents regarding the child's physique and symptoms of changes in behavior.
c. Current Client Health History.
The symptoms that arise so that the client is treated.
d. History of Past Diseases.
Meckel's diverticulum, intestinal polyps, intestinal duplication, ileal granulomas, lymphosarcoma which are predisposing factors for intesusception.
e. Daily Habit Patterns.
Assess habits in fulfilling nutrition (where there is an opportunity for a more dense diet that can change intestinal peristalsis), activity.
f. Physical examination.
1. General Circumstances.
General appearance of the client.
2. Vital Signs.
Found pulse fast and gentle, sushu sometimes increased, increased frequency of respiration.
3. Respiratory System.
Assess the frequency and pattern of breathing, regular or not, whether the client uses additional muscles such as external retractions and nostrils.
4. Gastrointestinal System.
Assess the client's weight, abdominal pain, incoming nutrition, there is an increase in bowel sounds, the abdomen is soft, tender and distended, palpation of the right upper abdomen feels a mass (like a sausage), the lower right abdomen feels empty.
5. Nervous System There is an increase in bowel sounds.
Assess level of consciousness, lethargy occasionally occurs.
6. Integumentary System.
Possible pale skin, profuse sweating, check skin turgor to check for dehydration.
2.) Nursing Diagnosis
Possible diagnoses:
Pre-Operation
a. Pain associated with intestinal obstruction.
b. Disturbance of fluid balance related to vomiting.
c. Impaired nutritional fulfillment related to inadequate nutritional intake due to vomiting.
d. Anxiety for parents due to lack of knowledge about their child's illness.
e. An increase in body temperature associated with an implantation reaction.
Post Operations
a. Potential for ineffective breathing patterns s / d anesthesia, postoperative immobilization, pain.
b. Pain s / d surgical intervention.
c. Impaired skin integrity s/d surgical intervention.
Intervention | Rationalization |
1. Give parental nutrition according to the program. 2. Weigh yourself every day. 3. Resume formula and breastfeeding as soon as possible. | To meet the nutritional needs of clients. To monitor the client's nutritional status. To meet the nutritional needs of clients. |
3.) Nursing Diagnosis Purpose Results Criteria | : Worried about the parents' lack of knowledge about their child's illness. : reduce or overcome parental anxiety : parents look more calm in facing the reality of their child's illness. |
Intervention | Rationalization |
1. Give health education to parents about intussusception. 2. Listen to every complaint expressed by parents. 3. Convince parents that taking their child to a health service is appropriate. | So that parents get information about intussusception so that it can reduce parents' anxiety. In order for parents to be more calm in facing the fact that their child is sick. It is the initial process of creating the hospitalization process. |
4.) Nursing Diagnosis Purpose Yield criteria | : : : | Increase in body temperature until the implantation reaction. Body temperature returns to normal. Body temperature drops. |
4. Planning
Pre operation
1. Nursing diagnosis : pain to intestinal obstruction.
Goal : relieve pain.
Outcome criteria : the child shows a sense of comfort.
Intervention | Rationalization |
1. Assess pain scale. 2. Perform compressing action on the painful part. 3. Perform distraction techniques by giving toys. | To determine the degree of pain so that further action can be taken that is more appropriate. By doing this action it is hoped that the tense blood vessels can be relieved again so that the pain can be reduced. It is hoped that the child is not concentrated with what he feels. |
2. Nursing Diagnosis Purpose Results Criteria | : : : | Disturbance of fluid balance to vomiting. So that normal body fluids return. Clients look fresh, good skin turgor. |
Intervention | Rationalization |
1. Give IV fluid therapy 2. Monitor fluid intake and output | To restore lost body fluids. As a basis for maintaining fluid balance. |
3. Nursing Diagnosis Purpose Yield criteria | : : : | Impaired fulfillment of nutrition related to malnutrition due to vomiting. The client's nutritional needs are met The client is no longer vomiting. |
Intervention | Rationalization |
1. Give parental nutrition according to the program 2. Weigh yourself every day 3. Resume formula and breastfeeding as soon as possible | To meet the nutritional needs of clients. To monitor the client's nutritional status To meet the nutritional needs of clients. |
5.) Nursing diagnosis Purpose Yield criteria | : : : | Increase in body temperature due to implantation reaction. Body temperature returns to normal Body temperature drops |
Intervention | Rationalization |
1. Monitor vital signs 2. Give compress 3. Provision of antipyretics according to the program | To know the progress of the condition Client. By compressing it is hoped that it will reduce the heat. If the heat does not go down with compresses, then give antipyretics according to the program. |
Post Operations
1.) Nursing Diagnosis Purpose Yield criteria | : : : | Potential for ineffective breathing pattern to anesthesia, pain. Breathing pattern returns to normal. Respiratory frequency according to age level. |
Intervention | Rationalization |
1. Monitor vital signs every 4 hours. 2. Ambulate at least three/four times per day as tolerated. 3. Give pain medication according to the program if necessary before ambulation and action, to facilitate breathing. 4. Position the patient in a comfortable position | To know the progress of the client Changing positions helps to expand the lungs and facilitate exhalation Helps to reduce pain. The right position, easier breathing position. |
2.) Nursing diagnosis Purpose Yield criteria | : : : | Pain related to surgical intervention. pain resolved. The patient is free of pain or minimal pain before going home. |
Intervention | Rationalization |
1. Assess for symptoms and pain 2. Give analgesic drugs according to the treatment program 3. Perform acts of comfort and pain control a. Relaxation. b. Dress the wound with a bandage 4. Perform distraction techniques (gives a toy) | To determine the degree of pain. Administration of analgesics to reduce pain. To relax tense muscles. So that the surgical wound can be maintained By giving toys to distract children from the pain they feel. |
3.) Nursing diagnosis Purpose Yield criteria | : : : | Impaired skin integrity until surgical intervention. Reconnection of the former incision The surgical incision heals |
Intervention | Rationalization |
1. Monitor for signs of wound infection. 2. Give care to the incision according to the treatment program. 3. Advise proper feeding or nutrition. | To find out if there is an infection process. Wound care to speed up the incision process Provision of adequate nutrition to accelerate the wound healing process, |
4. Implementation/Implementation.
Is the realization of the plan that has been set.
5. Evaluation.
Done continuously and refers to the goal.
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