Nursing diagnosis – DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

DYSFUNCTIONAL  GASTROINTESTINAL

MOTILITY

DEFINITION

Increased, decreased, ineffective, or lack of peristaltic activity within

the gastrointestinal system

DEFINING CHARACTERISTICS

• Nausea

• Abdominal pain

• Vomiting

• Absence of flatus

• Abdominal distension

• Hard, dry stool

• Change in bowel sounds

• Difficulty passing stool

(e.g., absent, hypoactive,
hyperactive)

• Diarrhea
• Abdominal cramping

• Increased gastric residual

• Accelerated gastric emptying

RELATED FACTORS

• Anxiety

• Malnutrition

• Surgery

• Food intolerance (e.g., lactose,

• Immobility

gluten)

• Pharmacological agents (e.g.,

• Ingestion of contaminants

narcotics, laxatives, antibiotics,
anesthesia)

(e.g., food, water)
• Enteral feedings

• Aging

• Inactive lifestyle

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Verbalize strategies to promote healthy bowel function.

• Acknowledge the importance of seeking medical help for persistent

alteration in GI motility.

• Not experience any fluid and electrolyte imbalance as a result of

altered motility.

• Understand the need for early ambulation following abdominal

surgery.

SUGGESTED NOC OUTCOMES

Bowel Elimination, Electrolyte and Acid–Base Balance, Gastrointesti-

nal Function

INTERVENTIONS AND RATIONALES

Determine: Assess abdomen including auscultation in all four quad-

rants noting character and frequency to determine increased or

decreased motility.

Assess current manifestations of altered GI motility to help iden-

tify the cause of the alteration and guide development of nursing

interventions.

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Monitor intake and output to identify need for restoration of fluid

balance.

Perform: Collect and evaluate laboratory electrolyte specimens. Some

altered motility states may require electrolyte replacement therapy.

Insert nasogastric tube as prescribed for patients with absent

bowel sounds to relieve the pressures caused by accumulation of air

and fluid.

Inform: Educate patients regarding importance of maintaining diet

high in natural fiber and adequate fluid intake. Fiber increases stool

bulk and softens the stool. Fluid will promote normal bowel elimi-

nation pattern.

Attend: Encourage activities such as walking as tolerated for patients

with decreased GI motility. Increased activity will stimulate peristal-

sis and facilitate elimination.

Manage: Coordinate with dietitian and other healthcare professionals

as needed to meet the unique needs of each individual patient.

SUGGESTED NIC INTERVENTIONS

Fluid/Electrolyte Management; Gastrointestinal Intubation; Tube

Care: Gastrointestinal

Reference

Sabol, V. K., & Carlson, K. K. (2007). Diarrhea: Applying research to bedside

practice. AACN Advanced Critical Care, 18, 32–44.

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