Pyloric Stenosis- Clinical PDF

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Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable  Scenario Mr. and Mrs. B. arrive in the emergency department (ED) with their 6-week-old

infant, S.B. As the triage nurse, you ask the couple why they have brought S.B. to the ED. Mrs. B. states, “My baby breastfed well for the first couple of weeks but has recently been throwing up all the time, sometimes a lot and really forcefully. He looks skinny and is hungry and fussy all the time.” You determine that the couple is homeless and has been living out of their car for the past month. S.B. has had no primary care since discharge after delivery.

1. What additional information will you need to obtain from Mr. and Mrs. B.? ●

The patient’s symptoms are very general like “fussy, hungry, and vomiting” which would definately prompt me to ask many more questions like: ○ Did he have a fever at home? ○ Mom, Are you taking any medications? (meds can pass to breastmilk) ○ Does he have all his vaccines up to date? ○ Does the baby have any health conditions? ○ Does the baby show any red bumps on skin ?(can be an allergy) ○ Are you feeding him anything different besides breast milk like gallon milk? ○ has he been exposed to extreme hot or cold temperatures while living in your car? ○ what other symptoms?

Case Study Progress Your primary assessment of the infant reveals the following: S.B is alert and fussy and consoles with a bottle of Pedialyte (per physician orders). His anterior fontanel is slightly depressed and posterior fontanel cannot be palpated. You auscultate regular breath sounds at a rate of 18 breaths/min. No adventitious sounds. Pulse oximetry is 98% on room air. Heart rate is 140 beats/min with regular rate and rhythm. Brachial and pedal pulses are +3 and equal. Abdomen is round and nontender to palpation. Positive bowel sounds. Diaper is dry. S.B. moves all extremities and there are no rashes noted. Rectal temperature is 98.9° F (37.2° C). There is a quarter-sized flat red area on occiput that “has been there since he was born” according to the mother. Slight “tenting” noted. You transport S.B. to radiology and he vomits a large amount of clear fluid. Patient returns to the room in his mother's arms, awake and alert. The mother appears anxious and states, “I don't know what's wrong with my baby! Why can't you people tell me anything?”

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

2. Your institution uses electronic charting. Based on the assessment described which of the following systems would you mark as abnormal as you document your findings? Mark abnormal findings with an "X" and provide a brief narrative note.

฀Neurologic:

alert but fussy, anterior fontanelle sunken/depressed and posterior fontanel cannot be palpated which can signify dehydration

฀ Respiratory:

regular breath sounds but RR is low at 18 breaths per minute

98% o2sat on room air

☐ Cardiovascular: normal, brachial and pedal pulse 2+ and heart rate 140/bpm is normal rate and rhythm is normal

฀ Gastrointestinal: appears as if there are no bowel movements, dry diaper maybe dehydrated or blockage positive bowel sound in abdomen, increased bowel activity

฀ Genitourinary: no signs of micturition- dry diapers may be dehydration ☐ Musculoskeletal: normal; moves all extremities

☐ Skin: normal;no rashes, no bruising

☐ Psychosocial: very fussy but reacting to pedialyte

฀Pain:

looks like 7 on the FLACC scale

and/or blockage

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

3. The emergency physician orders a complete blood count, complete metabolic profile, urinalysis, blood pH, and x-rays. The physician suspects dehydration and metabolic alkalosis secondary to hypertrophic pyloric stenosis. Which of these laboratory findings would you expect with metabolic alkalosis? a. Na: 128mEq/L, K: 2.6mEq/L, Cl: 90mEq/L, HCO3 : 28mEq/L b. Na: 130mEq/L, K: 5.7mEq/L, Cl: 94mEq/L, HCO3 : 22mEq/L c. Na: 130mEq/L, K: 3.9mEq/L, Cl: 98mEq/L, HCO3 : 17mEq/L d. Na: 148mEq/LK: 4.1mEq/L, Cl: 108mEq/L, HCO3 : 13mEq/L

4. What is the underlying cause of S.B.'s diagnosis of metabolic alkalosis?

Metabolic alkalosis is caused by loss of the hydrogen ions in the blood, in the patient's cause it could be due to dehydration

5. Which of these clinical manifestations might you find with metabolic alkalosis? Select all that apply.  b.c.d.

a. Increased respiratory rate b. Tetany c. Increased risk for seizures d. Hyperthermia e. Neuromuscular irritability

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

6. What additional assessment findings might reflect the consequences of frequent prolonged vomiting in the infant? Tenting when doing Skin turgor test and also sunken fontanelle can show dehydration which is a consequence of prolonged vomiting

Case Study Progress S.B. is diagnosed with hypertrophic pyloric stenosis, admitted to the pediatric unit, and scheduled for surgery 7. S.B.'s parents are concerned that their living situation contributed to S.B.'s diagnosis. How would you respond to their concerns?

I would reassure her that their living situation(living in a car and being homeless) didn’t have anything to do with it because this is a condition that happens due to birth defects or environmental factors like using antibiotics.

8. Mr. and Mrs. B. have questions about the necessity of surgery and question what is going to be done next. What are your responsibilities as you respond to Mr. and Mrs. B.'s concerns? I would be truthful but him a generalized response because the Doctor is the one that would make that determination. As a nurse I am not allowed to determine what will be done next or discuss surgery options and risks. I will be general and I would say, “ With this condition , surgery intervention is usually needed because the pyloric sphincter that sends food to the small intestine is narrowed, and the only way to reasonably open it is with surgery. But to be sure, The Doctor will come in to further discuss with you surgery options” and then if the Doctor talks to the patient about the risks and benefits I can reinforce that afterwards.

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

9. Which of these preoperative orders would you question? ● I wouldn’t give anymore pedialyte because the patient will throw it back out and just make them choke during surgery. ● NG tube is not needed, because suction during general anesthesia can cause choking ● IV is ok, it bypasses the GI tract and gets excreted through the kidneys

Chart View Preoperative Orders Vital signs q4h Strict intake and output (I&O) 30mL Pedialyte q3h PO Place IV and begin D5 ⅓NS at 50mL/hr Nasogastric (NG) tube placed to low continuous wall suction Daily weights 10. Which of these interventions can be delegated to nursing assistive personnel (NAP)? Select all that apply. a. Teaching parents the rationale for NG tube insertion b. Reminding parents to save diapers to be weighed c. Obtaining VS every 4 hours and reporting any abnormal findings to the RN d. Assisting parents in holding infant without removing NG tube e. Assessing for NG tube placement every shift

11. You note that your patient was hypokalemic and the fluids you hung per orders do not include potassium. You contact the surgeon to clarify. You receive the following order: “Discontinue D5 1 ⁄3NS at maintenance and hang D5 1 ⁄3NS with 20mEq KCl at maintenance.” You obtain the new fluids and hang per orders. True or False: This is an appropriate nursing action. Explain your answer.

false, you first discontinue the old bag then you hang new and I also need more information like the IV flow rate before I administer.

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

Case Study Progress S.B. returns to your unit after a pyloromyotomy. Mrs. B. is concerned about when she will be able to resume breastfeeding and what they need to do for their baby.

12. What postoperative teaching would you provide to them? You will need to hold off on breastfeeding your baby, because due to surgery he can only consume clear liquids within 24 hours. After that you can start feeding your baby breast milk. Rest assured within 4-6 hours post surgery will will feed him baby formula and gradually increase to see tolerance, also he is being given fluids and electrolytes for hydration.

Case Study Outcome S.B. progresses well and is tolerating normal breastfeeding within 48 hours with minimal vomiting. He is discharged with follow-up in 2 weeks with the parents' new primary care provider. A social worker has helped Mr. and Mrs. B. obtain temporary housing and apply for available insurance.

Complete a discharge care plan with two actual problems for S.B. Imbalanced nutrition related to inability to retain food as evidenced by vomiting after surgery Plan: Patient will not vomit the baby formula by the end of the day Intervention: Patient education about giving little amounts of baby formula,sitting baby up with a pillow to prevent aspiration to lungs and vomiting, also to monitor her baby at all times Evaluation: Baby is no longer vomiting and is well nourished with baby formula

Pyloric Stenosis 1). Complete the Case study. 2). List the pertinent data from the case introduction. 3). Complete a growth chart for the child if applicable. 4). Plot the labs on fishbones if applicable

Deficient fluid volume related to frequent vomiting  as evidenced by tenting in skin turgor Plan: Baby will be hydrated with IV within 4 hours Intervention: Tell mother to feed baby baby formula because it contains more concentration of water just for now because his pyloric sphincter is so inflamed due to surgery that baby formula contains more concentration of water and will allow it to pass better through Evaluation: Patient looks more hydrated and skin turgor does not tent anymore...