Kapiolani Community College

Associate Degree Nursing Program

Nurs320 Nursing Care Plan
Student Name Bradley Keown
Nursing Diagnosis: Dysfunctional gastrointestinal motility.

Date of Care: 11/13/15

Date Submitted: 11/16/15

Related to: Decreases in peristaltic activity from alteration of diet, post-surgery, and immobility.
As manifested by: Vomiting, absence of flatus and abdominal distension/pain.
Scientific Rationale: State of decreased, ineffective or lack of peristaltic activity within the gastrointestinal system.
Reference: http://nandanursingdiagnosis.org/nursing-diagnosis-dysfunctional-gastrointestinal-motility/

Outcomes (measurable)
Short Term
Pt will be free of any abdominal distress,
nausea, and/or vomiting as a result of
altered GI motility.

Interventions
1. Assess for the signs and symptoms
altered motility (nausea, vomiting,
absence of flatus, constipation, and
abdominal pain).
2. Assess abdomen for distension,
bowel sounds, tenderness, and
firmness.
3. Monitor I & O.
4. Monitor weights daily
5. Use the FLACC scale to assess
pain.
6. Administer laxatives.
7. Vent flatus build up via G-Tube
and/or Red Robinson catheter.

Rationale
1. Signs and symptoms currently
exhibited by altered motility can be
indications of change in condition.
2. Distension, firmness, lack of bowel
sounds, or pain can be an indication
of a backup of feces or flatus.
3. Alterations in motility can lead to
fluid and electrolyte imbalances.
4. Alterations in motility can lead to
inadequate nutrition and decreased
growth.
5. Pain can be a symptom of altered
motility.
6. Laxatives can help promote GI
motility and prevent constipation.
7. Venting flatus can help relieve
bloating, distention, pain, and
nausea associated with alter GI
motility.

Evaluation
1. Patient was difficult to determine if
any signs and symptoms were
present due to developmental delay,
other than not having BM
throughout shift. However, patient
appeared calm, quiet and at ease.
2. Patients abdomen was soft and
non-tender with normoactive bowel
present in all four quadrants.
3. Patient was on special ketogenic
continuous J-tube feeding running
at 40 mL/hr. 240 mL formula + 40
mL flush + 15.5 mL medications=
295.5 mL Intake/ 82 mL Output
4. Patients weight remained constant
from admission to date of care.
16.54kg
5. Patient did not exhibit pain using the
FLACC scale (0 of 10).
6. Administered Miralax 2.13 g at
0900.
7. Opened G-Tube to act as a vent

from 1200 to 1400. End was

covered in diaper to collect any
possible discharge. Tube was
clamped at end of time, no
discharge to note.

Long Term

Pt will continue to gain weight and

meet acceptable developmental
growth rates.

Reference: Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.). Philadelphia, PA: Elsevier.