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Student Name Sarah Rosa

Nursing Diagnosis: Ineffective gastrointestinal perfusion

Kapi’olani Community College
Associate Degree Nursing Program
Nurs320 Nursing Care Plan
Date of Care: 12/3/15

Date Submitted: 12/8/15

Related to: small bowel obstruction secondary to adhesions from previous multiple abdominal surgeries
As manifested by: ischemia and necrosis of bowel leading to fistula formation (3) with 124 mL bilious drainage
Scientific Rationale: Intestinal obstructions occur in 1 in 1500 live births and should be suspected in any child with persistent vomiting, distention, and
abdominal pain, because delayed diagnosis and treatment can lead to devastating consequences. Undiagnosed or improperly managed obstructions can
progress to vascular compromise, which causes bowel ischemia, perforation, sepsis, and death. Only about 6-7% of children with adhesive small bowel
obstruction require immediate laparotomy (Pediatric small bowel obstruction, 2014).
Outcomes (measurable)
Short Term
Patient will have decreased drainage
from fistula during my shift

Interventions
1. Monitor vital signs

Rationale
1. Vital signs can increase with
perforation

Evaluation
1. Pt remained afebrile during shift,
VSS.

2. Maintain and administer continuous
isotonic IV fluids

2. Isotonic fluids such as ½ NS will
allow the electrolytes to remain in the
vascular system

2. Pt was initially on D5 ½ NS at 70
mL/hr continuous because his PICC was
not patent. Pt was on continuous ½ NS
at 30 mL/hr with working PICC.

3. Administer broad-spectrum
antibiotics

3. Broad spectrum antibiotics will
reduce infection caused by perforation
and other infections in the bowel

3. Patient was on merepenem 540 mg
IV syringe TID

4. Administer prophylactic gastric acid
reducer

4. Acid reducers will reduce the amount
of gastric acids, which decreases the
risk of gastric and duodenal ulcers

4. Patient was on pantoprazole 15 mg
IV syringe BID

5. Assess bowel sounds, tenderness,
distention, flatus, and stool

5. Assessment of bowel sounds, flatus,
and stool indicates working bowels.
Distention and tenderness indicates
continued bowel problems

5. Patient had normoactive bowel
sounds, no flatus or distention, but
tenderness on palpation. Per mother,
last BM was one day ago.

6. Assess capillary refill, pulses, provide
O2; warm, dry skin

6. Indicates perfusion to extremities,
which hopefully translates to perfusion
to bowel. Providing O2 will increase
oxygen to perfused sites

6. Capillary refill < 3 sec; radial, brachial
and dorsal pedalis pulses 2+, equal, and
symmetric bilaterally

Long Term
Patient will have no evidence of future
fistulas by discharge

7. Monitor electrolytes, skin turgor,

mucous membranes, daily weight,
edema

8. Provide wound care, assessment of
wounds, drainage, and maintenance
fluids for drainage

9. Keep client NPO and provide proper
nutrition

10. Monitor strict I&O. Replace
stoma/fistula output 1:1 Q4H.

11. Assess pain and administer pain
medications

7. Fever, perforation, and NPO may
cause dehydration

7. Patient’s electrolytes were all winthin
normal limits, skin turgor was elastic,
and with no edema. Patient’s weight
was not taken daily, order were for once
upon admission

8. Assessment of the wound and
drainage determines if the fistulas are
healing

8. Malecot catheter had no drainage to
ostomy bag. Previous superior fistula
without drainage, dressing CDI. Right
abdominal fistula dressing CDI with
output of 124 mL bilious fluid during
shift. Maintenance fluids (½ NS)
administered 1:1.

9. Keeping client NPO will allow the
bowels to rest. Proper parenteral
nutrition will allow the bowels to rest
while providing nutrition needed to aid in
wound/fistula healing

9. The client was kept NPO, except for
2 oz ice chips or popsicle every 3 hours.
TPN held d/t non-patency of PICC. D5
½ NS administered at 70 mL/hr. Once
PICC became patent, TPN administered
at 75 mL/hr continuous

10. Monitoring I&O helps regulate the
fluid and electrolyte balance needed for
patients with fistula drainage

10. Patient had a total of 578 mL intake.
324 mL output, 200 mL of which was
urine. Replaced 90 mL of fistula output
at 0900, and 34 mL from fistula output at
1300 with NaCl 0.45%. Reinforced strict
I&O to mother because she was not
having the patient collect urine in the
urinal to be measured

11. Pain management will promote
proper healing, ambulation to reduce
infection, and comfort

11. The patient had a morphine PCA
and PRN ibuprofen. However, refused
to use PCA when in pain. Did parent
teaching (because the patient did not
speak or understand English) about pain
management and preventing having to
“chase the pain” and that pain
management can reduce stress, which
can promote healing and comfort. The
mother stated, “You did not see him
previously. He was in much more pain
than this. This is good compared to the
past couple weeks”

12. Monitor CBC, electrolytes and other
lab results.

13. Prepare client and family for
surgical exploratory laparotomy and
provide general post-operative care
 Early ambulation
 Cough and deep breath
 Frequent positional changes
 ROM

12. WBC indicates inflammation and
infection; RBC and H&H indicates
possible bleeding and anemia;
electrolytes indication imbalance;
albumin and calcium indicates nutrition
status
13. Proper postoperative care will
reduce the risk for infection and
postoperative complications

12. The patient’s WBC were elevated;
RBC, H&H were decreased; electrolytes
were all within normal limits; albumin
and calcium were decreased.

13. Encouraged ambulation to the
playroom. PT came into the playroom
and incorporated ambulation into play
by having the patient walk to get the
craft items he needed. The patient was
able to ambulate the whole way to the
play room after reopening in the
afternoon. The patient can
independently reposition and has full
ROM in all extremities

Reference:
Ball, J., Bindler, R., & Cowen, K. (2015). Principles of Pediatric Nursing: Caring for Children (6th
ed.). Upper Saddle River, New Jersey: Pearson.
Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses, interventions and outcomes, (7th ed.). St Louis: Mosby.

Pediatric small bowel obstruction. (2014). In Medscape. Retrieved from http://emedicine.medscape.com/article/930411-overview#a3