Nursing Care Plan Dysfunctional Gastrointestinal Motility

stomach colon small bowel 195x300 Nursing Care Plan Dysfunctional  Gastrointestinal MotilityNursing Care Plan Dysfunctional  Gastrointestinal Motility Definition:Increased, decreased,ineffective, or lack of peristaltic activity within the gastrointestinal system Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common. Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6  months.Nursing Diagnosis:Acute Pain Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.Nursing Care Plan Dysfunctional  Gastrointestinal Motility

Defining Characteristics

  • Nausea
  • Abdominal pain
  • Vomiting
  • Absence of flatus
  • Abdominal distension
  • Hard, dry stool
  • Change in bowel sounds
  • Difficulty passing stool(e.g., absent, hypoactive,hyperactive)
  • Diarrhea
  • Abdominal cramping
  • Increased gastric residual
  • Accelerated gastric emptying

Related Factors

  • Anxiety
  • Malnutrition
  • Surgery
  • Food intolerance (e.g., lactose,
  • Immobility gluten)
  • Pharmacological agents (e.g.,
  • Ingestion of contaminants narcotics, laxatives, antibiotics,anesthesia) (e.g., food, water)
  • Enteral feedings
  • Aging
  • Inactive lifestyle

Assessment Focus

  • Elimination
  • Fluid and electrolytes
  • Physical regulation

Expected Outcomes The Patient Wil

  • Verbalize strategies to promote healthy bowel function.
  • Acknowledge the importance of seeking medical help for persistent alteration in GI motility
  • Not experience any fluid and electrolyte imbalance as a result of altered motility.
  • Understand the need for early ambulation following abdominal surgery.

Suggested Noc Outcomes

Bowel Elimination, Electrolyte and Acid–Base Balance, Gastrointesti-nal Function

Interventions And Rationales

Determine: Assess abdomen including auscultation in all four quad-rants noting character and frequency to determine increased or decreased motility.Assess current manifestations of altered GI motility to help iden-tify the cause of the alteration and guide development of nursing interventions.151 Monitor intake and output to identify need for restoration of fluid balance.Perform: Collect and evaluate laboratory electrolyte specimens. Some altered motility states may require electrolyte replacement therapy.Insert nasogastric tube as prescribed for patients with absent bowel sounds to relieve the pressures caused by accumulation of air and fluid.Inform: Educate patients regarding importance of maintaining diet high in natural fiber and adequate fluid intake. Fiber increases stool bulk and softens the stool. Fluid will promote normal bowel elimi-nation pattern.Attend: Encourage activities such as walking as tolerated for patients with decreased GI motility. Increased activity will stimulate peristal-sis and facilitate elimination.Manage: Coordinate with dietitian and other healthcare professionals as needed to meet the unique needs of each individual patient.

Suggested Nic Interventions

Fluid/Electrolyte Management; Gastrointestinal Intubation; Tube Care: Gastrointestinal

Reference

Sabol, V. K., & Carlson, K. K. (2007). Diarrhea: Applying research to bedside practice. AACN Advanced Critical Care, 18, 32–44.

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