DEVIATION
INTUSSUSCEPTION
NORMAL
Idiopathic, UTI,
Tumor/Polyps, Meckel's
Diverticula, Lympoid
Hyperplasia, Virus
ILEOCECAL VALVE
Risk factors: Had
one previously;
Intestinal
Malrotation
JUNCTION BETWEEN
COMMON SITE OF
INTUSSUSCEPTION
ILEUM of
Small
Intestine
CECUM of
Large
Intestine
Prevent food and
fluid from passing
through
Large Mass on
RLQ
Obstruction
Complete bowel
obstruction
NURSING INTERVENTIONS:
DX:
1. Monitor VS
2. Assess skin turgor
3. Monitor intake and output
as ordered
TX:
1. Give oral hygiene
2. Administer IV fluid as
ordered
3. Provide fluids
EDX:
1. Encourage to replenish fluid
loss by increasing fluid intake
Abdominal
distention
Vomiting
DEFICIENT FLUID
VOLUME R/T ACTIVE
FLUID LOSS
Portion of intestinal
bowel invaginates or
'telescopes' into
Distal adjacent loop
(Cecum)
Impaired lymphatic drainage
and increasing pressure in
intussusceptum bowel wall
Venous Impairment
& congestion
Mesenteric vessels
are congested
Presence of blood
in stool; blood per
rectum
INTUSSUSCEPTUM
INTUSSUSCIPIENS
Sepsis and
Fever
HYPERTHERMIA
R/T ONGOING
INFECTION
Release of
bacteria
Intestinal tearing
RED CURRANT
JELLY STOOL
Infarction (death
of tissue)
Ischemia (lack of
blood flow)
HEMATOCHEZIA
NURSING INTERVENTIONS:
DX:
1. Monitor VS especially
temperature
TX:
1. Eliminate excess clothing or
covers
2. Administer antipyretic as
ordered
3. Tepid sponge bath
EDX:
1. Encourage to hydrate with
ample amount of fluid as
tolerated
Bowel mucosa slough off:
BLOOD, INTESTINAL
MUCOSA, MUCUS
TRANSMURAL
NECROSIS &
PERFORATION
WITH PROLONGED
ISCHEMIA
References:
Wayne, G. (2017). Hyperthermia. Retrieved from nurselabs.com
Wayne, G. (2019). Deficient fluid volume. Retrieved from
nurselabs.com
Intussuception. (n.d.). Retrieved from amboss.com