Nanda Books

Paralytic Ileus is a paralysis of the intestine. It is a complicated medical condition that is characterized by partial or total non-mechanical obstruction of the large or small intestine. This blockage occurs when the intestinal muscles suffer a paralysis. Even a partial paralysis that makes the intestinal muscles inactive is enough to cause this disorder. Such a state of inactivity makes it difficult for food to pass through the intestine. It creates an intestinal blockage and gives rise to serious complications.

Paralytic ileus can affect any part of the intestine. Causes can include:

• Abdominal surgery
• Pelvic surgery
• Infection
• Certain medications, including antidepressants and pain medications that affect muscles and nerves
• Muscle and nerve disorders, such as Parkinson's disease

Nursing Diagnosis for Paralytic Ileus : Risk for Hypovolemic Shock
related to: the lack of body fluid volume.

Goal: hypovolemic shock does not occur.

Expected outcomes:

• Vital signs are within normal limits,
• volume of body fluid balance,
• fluid intake met.

Interventions:

1. Monitor general condition
Rationale: Establish baseline data to determine the patient's deviation from normal condition.

2. Observations of vital signs
Rationale: It is a reference to determine the patient's general condition.

3. Assess fluid intake and output
Rationale: To determine the body's fluid balance.

4. Collaboration in the provision of intravenous fluids
Rationale: To meet the water balance.


Nursing Diagnosis for Paralytic Ileus : Impaired Bowel Elimination
related to: constipation

Goal: Impaired elimination pattern does not occur

Expected outcomes: Patterns of normal bowel elimination

Interventions:

1. Assess and record the frequency, color and consistency of stool
Rationale: To determine the presence or absence of abnormalities that occur in fecal elimination.

2. Auscultation of bowel sounds
Rationale: To determine whether or not normal bowel movements.

3. Encourage clients to drink plenty
Rationale: To stimulate spending feces.

4. Collaboration in the provision of laxative therapy
Rationale: To provide ease of elimination needs.