Introduction

Intussusception is defined as: “invagination or telescoping of proximal loop of intestine (intussusceptum) into a distal segment (intussuscipiens) and leads to bowel
obstruction” (Rogers and Robb, 2010). This leads to impaired venous return, incarceration and finally necrosis of the trapped segment (Nylund et al, 2010). It is the
most common surgical emergency in infants and young children. Patients may present with the classic triad of symptoms – abdominal pain, vomiting and blood in
stools – although 75% of children present with only two symptoms (Paul et al, 2010). Intussusception has a male preponderance (four males to every one female)
and is most common in children under two years of age, with a peak incidence between four to nine months (Paul et al, 2010). Aetiology remains idiopathic in
younger children and may be preceded by a viral upper respiratory tract infection or gastroenteritis-like illness (Rogers and Robb, 2010). Bacterial enteritis has
been identified as a significant risk factor for developing intussusception (Nylund et al, 2010). Intussusception most often occurs in the ileocolic region (80% of
cases) but can appear in any part of the intestine (Rogers and Robb, 2010). Ultrasound is usually used to diagnose the condition, and treatment by radiological
reduction (air or contrast enema) is successful in most cases (Paul et al, 2010).
Intussusception (in-tuh-suh-SEP-shun) is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often
blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that is affected. This can lead to a tear in the
bowel (perforation), infection and death of bowel tissue.
It is the most common cause of intestinal obstruction in children younger than 3 years old. The cause of most cases of intussusception in children is unknown.
Though intussusception is rare in adults, most cases of adult intussusception are the result of an underlying medical condition, such as a tumor.
In children, the intestines can usually be pushed back into position with a minor procedure. In adults, surgery is often required to correct the problem.
Your intestine is shaped like a long tube. In intussusception, one part of your intestine — usually the small intestine — slides inside an adjacent part. This is
sometimes called telescoping because it's similar to the way a collapsible telescope slide together.
In some cases, in adults, the telescoping is caused by an abnormal growth in the intestine, such as a polyp or a tumor (called a lead point). The normal wavelike
contractions of the intestine grab this lead point and pull it and the lining of the intestine into the bowel ahead of it. In most cases, however, no cause can be
identified for intussusception.
Objectives
GENERAL OBJECTIVES
This case study on Intussusception aims to look into indispensable information regarding the disease. It also aims to develop our skills, knowledge and attitude in
providing proper nursing care needed to have an effective nursing management.

SPECIFIC OBJECTIVES

Knowledge
 Define Intussusception
 Enumerate the clinical manifestations of the disease
 Discuss the different diagnostic exam as well as the planned surgical procedure.

Skills
 Perform thorough physical assessment in a cephalocaudal manner.
 Apply a necessary care plan to prioritize the immediate problem of the patient.
 Record and document accurately the past and present medical history.
 Evaluate the effectiveness of the nursing care implemented.

ATTITUDE
 Establish rapport with other significant others to gain good relationship and cooperation.
 Recognize client’s needs using a holistic approach.
 Exhibit positive attitude in caring.
Nursing Health History
Nursing Health History
A. Biography Data
● Patient’s Name: N/A
● Age: 18 months old
● Sex: Male
● Source of Information: Mother
● Relationship: Son

B. Chief Complaint
Six hours of stomach pain

C. History of Present Illness

Upon waking up in the morning he complained of stomach pain. He was crying and was cuddled by his mother. After a few minutes he was able to
sleep. Over the next few hours he was intermittently crying and irritable. He has less appetite since the onset of signs and symptoms. He is able to walk but prefers
to be carried by mother most of the time. He is less playful than usual and sometimes bend down crying. No fever, cough, runny nose, vomiting nor diarrhea and
his last stool yesterday.
No history of abdominal trauma. The mother brought the child to the hospital due to persistent stomach pain, thus advised for admission.

D. Past Health History

● N/A

E. Family Medical History

● N/A

F. Lifestyle

He has less appetite since the onset of the signs and symptoms. He is usually playful and is able to walk by himself when he feels better. He is cuddled by
his mother when he’s crying and irritable.

Physical Examination
Vital signs
Temperature: 37.6 °C
Head - normocephalic
- hard and smooth without lesions and bumps
Eye - symmetrical
Ears - normal tympanic membranes Pulse rate: 118 beats/minute
- mobile, firm, and not tender; pinna recoils after it is folded Respiratory rate: 24 breaths/minute
Nose - with pinkish nasal mucosa BP: 85/55 mmHg
- no discharge or flaring Weight: 11 kg
Mouth - pink and moist oral mucosa Level of Consciousness: awake, alert, responds to mom appropriately
Pharynx - no ulcers in the posterior pharynx
Neck - trachea in midline
- no tenderness and lumps noted
Lung/chest - with clear lungs
- with good aeration
Heart - regular heart rhythm
- normal heart rate
Abdomen - colicky abdominal pain
- with soft abdomen; no distension
- with normoactive bowel sounds
- no masses noted
- abdominal tenderness may be present
Genitalia - no scrotal/testicular swelling or tenderness
Upper/Lower - warm distal extremities
Extremities
- with strong distal pulses
Skin - with slight poor skin turgor
- slightly warm to touch
Nails - brisk capillary refill
Anatomy and Physiology
ANATOMY AND PATHOPHYSIOLOGY

The small intestine is the longest part of the digestive system. It extends from the stomach (pylorus) to the large intestine (cecum) and consists of three
parts: duodenum, jejunum and ileum. The main functions of the small intestine are to complete digestion of food and to absorb nutrients.

The small intestine is divided into the duodenum, jejunum, and ileum. Together these can extend up to six meters in length. All three parts are covered
with the greater omentum anteriorly. The duodenum has both intraperitoneal and retroperitoneal parts, while the jejunum and ileum are entirely intraperitoneal
organs. As the small intestine is the main site for the final stages of food digestion and its absorption, its gross and microanatomy are adjusted to that function.

Duodenum

The duodenum by definition is the first part of the small intestine. It extends from the pyloric sphincter of the stomach, wraps around the head of the
pancreas in a C-shape and ends at duodenojejunal flexure. This flexure is attached to the posterior abdominal wall by a peritoneal fold called the suspensory
muscle (ligament) of duodenum, also called the ligament of Treitz.
Jejunum

The jejunum is the second part of the small intestine. It begins at the duodenojejunal flexure and is found in the upper left quadrant of the abdomen. The
jejunum is entirely intraperitoneal as the mesentery proper attaches it to the posterior abdominal wall.

Ileum

The ileum is the last and longest part of the small intestine. It is found in the lower right quadrant of the abdomen, although the terminal ileum can extend
into the pelvic cavity. The ileum terminates at the ileal orifice (ileocecal junction) where the cecum of the large intestine begins.

At the ileocecal junction, the lamina muscularis of the ileum protrudes into the lumen of the cecum forming a structure called the ileocecal fold. These
muscular fibers form a muscular ring within the fold called the ileocecal sphincter which controls the emptying of ileal content into the large intestine.

The main functions of the small intestine are secretion and absorption. The epithelial cells of the small intestine secrete enzymes which digest chyme into
the smallest particles, making them available for absorption. Concurrently the duodenum functions to mix food with bile and pancreatic enzymes to continue the
digestion of carbohydrates, fats, and proteins.

Concerning absorption, carbohydrates and proteins are absorbed in the duodenum and jejunum respectively. The jejunum also functions to absorb most fats. The
ileum function involves absorption of vitamin B12, bile salts and all digestion products which were not absorbed in duodenum and jejunum. All three small
intestine segments absorb water and electrolytes.
Diagnostic and Laboratory
Patients with a typical presentation of sudden onset of intermittent severe abdominal pain with or without rectal bleeding or characteristic findings on radiography,
may proceed directly to non-operative reduction using hydrostatic (contrast and saline) or pneumatic (air) enema, performed under either sonographic or
fluoroscopic guidance. In this case, the procedure is both diagnostic and therapeutic.

If diagnosis is unclear at presentation, initial workup may include abdominal ultrasound or abdominal plain films. If these support the diagnosis of intussusception,
non-operative reduction is then performed. Reduction is complete only when a good portion of the distal ileum is filled with contrast.

Water Soluble Contrast Enema

- A procedure performed to examine the large intestine for abnormalities. A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of
organs so that they will show up on an X-ray) is given into the rectum as an enema.
- An Intussusception is identified at the hepatic Flexure. The ileocolic Intussusception is successfully reduced. There was a reflux of the contrast into ileum.
- On some occasions, the pressure exerted on the intestine while inserting barium will help the intestine to unfold, correcting the intussusception.

Abdominal X-ray
- A diagnostic test that may show intestinal blockage.
- An abdominal x-ray will reveal a “Crescent sign” or a “Bull's eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen.
- Absence of air in right lower quadrant and right upper quadrant, soft tissue density in right upper quadrant in 25-60% of patients, and normal in 60% of
cases.

Ultrasound
- The presence of mesenteric lymph nodes within the lumen of the intusscipiens is a highly specific ultrasound finding. A typical ileocolic intussusception,
which occurs in more than 80% of patients, has the appearance of a peripheral hypoechoic ring (the “target sign”) with central echogenicity (the
pseudokidney sign)
CT scan
- CT cannot be used to reduce the intussusception and can be time-consuming in children who may require sedation. Thus, CT generally is reserved for
patients in whom the other imaging modalities are unrevealing, or to characterize pathological lead points for intussusception detected by ultrasound.

Drug Study
Nursing Care Plan
Discharge Plan/ Health Teaching
Discharged in an improved condition cuddled by mother after barium enema was done. Going home instructions given to mother.
1. Advise the mother to observe untoward signs and symptoms for further complications such as increase of fever, respiratory distress, and poor sucking
reflex.
Report to attending physician as soon as possible.
2. Measure abdominal girth and weigh patient regularly
3. Instruct mother to gradually introduce oral fluid and milk formula
4. Observe for aspirations
5. Increase intake of dietary fiber
6. Have a regular follow up for assessment with the Pediatrician
7. Observe high standard of personal hygiene at home and environmental sanitation