The nurse assesses a child with intussusception. Which assessment findings require priority intervention?

Question

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Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. (Option B) Absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently. (Option C) A classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. (Option D) A "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition. Educational objective: Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency.

The Nurse Assesses a Child with Intussusception