Page 978 - Saunders Comprehensive Review For NCLEX-RN

breakdown (stoma should be red and moist).
5. Assess the anal area for the presence of stool, redness,
or discharge.
6. Maintain NPO status as prescribed and until bowel
sounds return or flatus is passed, usually within 48 to
72 hours.
7. Maintain nasogastric tube to allow intermittent suction
until peristalsis returns.
8. Maintain IV fluids until the child tolerates appropriate
oral intake, advancing the diet from clear liquids to
regular as tolerated and as prescribed.
9. Assess for dehydration and fluid overload.
10. Monitor strict intake and output.
11. Obtain daily weight.
12. Assess for pain and provide comfort measures as
required.
13. Provide the parents with instructions regarding
colostomy care and skin care.
14. Teach the parents about the appropriate diet and the
need for adequate fluid intake.
XI. Intussusception (Fig. 33-5)
A. Description
1. Telescoping of one portion of the bowel into another
portion
2. The condition results in obstruction to the passage of
intestinal contents.
B. Assessment
1. Colicky abdominal pain that causes the child to
scream and draw the knees to the abdomen, similar to
the fetal position
2. Vomiting of gastric contents
3. Bile-stained fecal emesis

4. Currant jelly–like stools containing blood and

mucus
5. Hypoactive or hyperactive bowel sounds
6. Tender distended abdomen, possibly with a palpable
sausage-shaped mass in the upper right quadrant
C. Interventions

1. Monitor for signs of perforation and shock as

evidenced by fever, increased heart rate, changes in
level of consciousness or blood pressure, and
respiratory distress, and report immediately.
2. Antibiotics, IV fluids, and decompression via
nasogastric tube may be prescribed.

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