A nurse is caring for an 18-month-old infant. Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation & Rationale
Condition: Intussusception Actions to Take: Place child on NPO status - The child should not receive oral intake to prevent aspiration and to prepare for potential surgical intervention or a procedure like an air enema, which is commonly used to treat intussusception. Prepare child for air enema - An air enema is the preferred non-surgical treatment for intussusception. It may help reduce the telescoping of the bowel and restore normal bowel function. Parameters to Monitor: Stool patterns - Red, jelly-like stools are a key characteristic of intussusception, which is caused by the telescoping of the intestines. Monitoring stool patterns helps assess the progression and resolution of the condition. Abdominal pain - The child is already experiencing severe abdominal pain, often associated with intussusception. Ongoing monitoring of pain will help gauge the effectiveness of treatment and any changes in the condition. Rationale Intussusception is a condition where one part of the intestine slides into another, leading to obstruction. It is a common cause of abdominal pain and is characterized by red, jelly-like stools due to the presence of blood and mucus. The child's symptoms, including abdominal pain, crying, and the palpable mass, strongly suggest this condition. Air enema is a non-invasive treatment that can reduce the telescoped segment of the intestine, often resolving the issue without the need for surgery. Stool patterns and abdominal pain are both critical indicators of the condition's progress, and careful monitoring will help guide further interventions.