00196 Dysfunctional Gastrointestinal Motility

Domain 3: elimination and exchange
Class 2: gastrointestinal function
Diagnostic Code: 00196
Nanda label: gastrointestinal motility dysfunctional
Diagnostic focus: gastrointestinal motility
Approved 2008 • Revised 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « gastrointestinal motility dysfunctional ” is defined as: increase, decrease, inefficiency or lack of peristaltic activity in the gastrointestinal tract.

Definite characteristics

  • Abdominal colic
  • Abdominal pain
  • ABSENCE OF VENTOSITIES
  • Acceleration of gastric emptying
  • Alteration of intestinal sounds
  • Bilious color gastric residue
  • Diarrhea
  • Difficulty defecating
  • Abdominal distension
  • Hard feces, formed
  • Increase in gastric residue
  • Nausea
  • Regurgitation
  • Vomiting

Related factors

  • Altered water source
  • Anxiety
  • Changes in eating habits
  • deterioration of physical mobility
  • Malnutrition
  • Sedentary lifestyle
  • Stressors
  • Non -hygienic food preparation

Risk population

  • People who have ingested contaminated material
  • Older adults
  • Premature infants

Associated problems

  • Decrease in gastrointestinal circulation
  • Diabetes mellitus
  • Enteral nutrition
  • Food intolerance
  • Gastroesophageal reflux
  • Infections
  • Pharmacological preparations
  • Therapeutic regime

Suggestions of use

  • This broad diagnosis can be used to describe an increase or decrease in motility. However, diagnosis diarrhea describes an increase in motility, and the label constipation describes a reduction in motility. It seems that these diagnoses should be used when their defining characteristics are present.
  • Dysfunctional gastrointestinal motility can also represent some collaboration problems (such as gastrointestinal complications:
  • Paralytic ileus). If the only independent nursing activities for the patient are the surveillance of gastrointestinal complications and notify the main provider of care, a collaboration problem should be used.

Suggested alternative diagnostics

  • Diarrhea
  • Constipation
  • Constipation, risk of
  • Fecal incontinence

NOC Results

  • Intestinal elimination: Formation and evacuation of feces
  • Gastrointestinal function: process in which food (ingested or administered by probe) goes from ingestion to excretion

Evaluation objectives and criteria

Examples with the use of terms no c

  • Gastrointestinal motility within normal limits, which is manifested by intestinal elimination and gastrointestinal function within the expected range for the patient
  • Demonstrates-nastinal elimination, as the following indicators reveal (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Elimination pattern
    • Soft and formed stool
    • Easy step of the feces
    • Intestinal sounds
  • It demonstrates intestinal elimination, as the following indicators reveal (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Constipation
    • Diarrhea

Other examples

  • Amount of feces appropriate for the amount of food ingested
  • Amount of gastric waste within the expected limits
  • absence of abdominal distension
  • Absence of regurgitation
  • Peristalsis is not observed

NIC Interventions

  • Probe care: Gastrointestinal: Management of a patient with a gastrointestinal probe
  • Gastrointestinal Intubation: Introduction of a tube in the gastrointestinal tract
  • Diarrhea management: control and relief of diarrhea
  • Intestinal elimination management: establishment and maintenance of a regular habit of fecal evacuation
  • Building/impact management: prevention and improvement of constipation and impact
  • Vomit management: prevention and relief of vomiting

Nursing Activities

Note : If it is necessary to use this diagnosis, also consult the constipation and diarrhea labels, since these diagnoses require the same nursing activities. For that reason, these activities in great detail are not described here.

Valuations

  • Watch the intestinal sounds regularly
  • Observe and perceive to detect abdominal distension; Measure the abdominal circumference daily
  • Register the frequency and consistency of intestinal movements
  • Monitor the intake and expenditure of liquids
  • (If the patient has a gastrointestinal probe) monitor the placement of the probe, according to institutional policies

Patient and family education

  • Teach the importance of an adequate fiber and liquid intake to avoid constipation
  • Indicate patients to consult their doctor in case of intense abdominal pain, blood in the stool, involuntary weight loss or lack of improvement in constipation after following medical treatment
  • Teach patients to wash their hands frequently to prevent the spread of pathogenic agents causing diarrhea
  • Provide information about foods that can cause diarrhea (for example, very seasoned or high foods)

Collaboration activities

  • Manage medications to increase or reduce gastrointestinal motility, depending on which one is present
  • Administer antibiotics in case of infectious diarrhea

Others

  • Promote prompt ambulation after surgery
  • Promote the usual exercise, as to be tolerated