Nursing diagnosis – RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

RISK  FOR  DYSFUNCTIONAL

GASTROINTESTINAL  MOTILITY

DEFINITION

Risk for increased, decreased, ineffective, or lack of peristaltic activity

within the gastrointestinal system

RISK FACTORS

• Abdominal surgery

• Gastroesophageal reflux

• Diabetes

disease (GERD)

• Prematurity

• Unsanitary food preparation

• Decreased gastrointestinal

• Anxiety

circulation

• Lifestyle

• Pharmaceutical agents (e.g.,

• Immobility

narcotics, antibiotics, proton
pump inhibitors, and laxatives)

• Food intolerance (e.g., gluten,
lactose)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Fluid and electrolytes

• Elimination

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain adequate fluid and electrolyte balance.

• Identify diet selections and lifestyle changes that would promote

healthy GI function.

• Not experience altered GI motility related to prescribed

medications.

• Recognize chronic conditions that may contribute to altered GI

motility, for example, diabetes, GERD.

SUGGESTED NOC OUTCOMES

Electrolyte and Acid–Base Balance; Fluid Balance; Bowel Elimination

INTERVENTIONS AND RATIONALES

Determine: Assess patient for signs of fluid or electrolyte imbalance

related to increased or decreased GI motility. Fluid and electrolyte

alterations can result from either increased or decreased

gastrointestinal motility.

Assess patient for positive risk factors for altered GI motility. This

will allow for timely interventions to prevent complications associ-

ated with GI dysfunction.

Perform: Assist patients taking prescribed medications that affect

motility with strategies to avoid GI complications. Awareness of pre-

ventive measures will decrease GI complications.

Encourage early ambulation for postoperative patients receiving

opioids for pain control. Early ambulation will reduce the risk of

narcotic-related constipation.

Inform: Educate patient regarding the risk factors related to altered

GI motility, including certain food choices, fluid intake, medications,

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and activity. Promotion of healthy lifestyle choices will contribute to

positive patient outcomes.

Attend: Provide encouragement and support for behaviors that

enhance gastrointestinal health. Positive reinforcement results in

improved confidence in self-management of health behaviors.

Manage: Coordinate care with other disciplines as needed to

reinforce positive behaviors or to assist with complex situations.

SUGGESTED NIC INTERVENTIONS

Diarrhea Management; Electrolyte Monitoring; Fluid Management;

Nutrition Management

Reference

Mazumdar, A., Mishra, S., Bhatnagar, S., & Gupta, D. (2008). Intravenous

morphine can avoid distressing constipation associated with oral morphine:
A retrospective analysis of our experience in 11 patients in the palliative
care in-patient unit. The American Journal of Hospice & Palliative Care,
25, 282–284.

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.