Patient Scenario, Chapter 45, Nursing Care of a Family When a Child Has a Gastrointestinal Disorder AN INFANT WITH PYLOR

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Patient Scenario, Chapter 45, Nursing Care of a Family When a
Child Has a Gastrointestinal Disorder AN INFANT WITH PYLORIC
STENOSIS Jack Weintraub is a 6-week-old infant brought to the
hospital emergency room. CHIEF CONCERN: “He throws up after every
feeding.” HISTORY OF CHIEF CONCERN: The child was born preterm at
34 weeks. He was hospitalized in NICU for 4 weeks because he
developed necrotizing enterocolitis shortly after birth. He has
been well since discharge until 2 days ago. The child was breastfed
until 1 week ago when he was changed to formula because his mother
was hospitalized because of an auto accident. Almost immediately,
he began vomiting at least half of each feeding. Vomitus is sour,
but no mucus or blood is present. Vomiting was projectile this
afternoon accompanied by a loose bowel movement. The father thinks
that the child has lost weight. Voices concern child could have a
peptic ulcer (as father has) or celiac disease (which a maternal
aunt has). FAMILY PROFILE: The family lives in a two-bedroom
apartment. The father is having difficulty caring for infant and
working and visiting wife in hospital. He admits to “feeding in a
hurry” to “get it over with” so he can take child to babysitter.
The father works as a chemist; he says finances are “about to be
ruined” because of hospital bills. HISTORY OF PAST ILLNESSES: The
child had skin tag in front of left ear removed by ligation at 1
week of age; there is no sequelae. An IVP done at birth was normal.
The child was seated in infant seat in back seat of mother’s car a
week ago when car was struck by a taxi cab. The infant was seen in
the emergency room and discharged as uninjured. His weight at visit
is 4.5 kg. PREGNANCY HISTORY: Pregnancy was intended. The mother
was diagnosed as having hydramnios, mild hypertension, chronic back
pain, and mild placenta previa at 20 weeks by sonogram; these
persisted throughout pregnancy so infant was born by cesarean
birth. Apgar scores are 7 and 9; the child breathed spontaneously.
HISTORY OF FAMILY ILLNESSES: A paternal grandmother has Raynaud
disease. A maternal aunt has celiac disease. The father has
gastrointestinal reflux disease since adolescence and peptic ulcer.
A mother has allergy to house dust. DAY HISTORY: Nutrition: Infant
is breastfed until 1 week ago; now he is on formula without iron (4
oz, six times per day). Sleep: Infant wakes once during night and
at every 4 hours during day for feedings. Play: Infant holds
rattle; he plays “so big.” Growth and development: Social smile: 6
weeks; lifts up head when on abdomen REVIEW OF SYSTEMS: Slight
diaper rash; otherwise, negative except for chief concern PHYSICAL
EXAMINATION: Weight: 4.0 kg (50th percentile); height: 57 cm (50th
percentile) General appearance: Rangy-appearing; crying, 6-week-old
male Head: Normocephalic; anterior fontanelle palpated at 3 cm × 3
cm; slightly sunken; posterior: barely palpable Eyes: Red reflex
present; child follows right and left; not past midline Ears:
Normal alignment; TMs pink; landmarks identified; no cer¬umen;
attunes to examiner’s voice Nose: Midline septum; no discharge;
mucous membrane pink; nares patent Mouth and throat: No teeth;
mucous membrane dry; hard and soft palate intact; gag reflex
present Neck: Full range of motion; no palpable lymph nodes Lungs:
Respiratory rate: 22 breaths/min; clear to percussion and
aus¬cultation Heart: Rate: 132 beats/min; no murmurs Abdomen: Skin
turgor poor; rapid bowel sounds all quadrants; liver and spleen
both palpable 1 cm below costal margins; palpable olive-sized mass
in right epigastric region; when fed a bottle of glucose water,
visible peristaltic waves left to right were visible on abdomen.
Child vomited feeding with force. Genitalia: Circumcised male;
testes descended; midline meatus Extremities: Full range of motion;
skin turgor on thighs poor Back: Midline vertebrae; no tufts or
dimples on spinal column Neurologic: Moro, sucking, parachute, step
in place tested and intact; Babinski flaring Jack was diagnosed by
ultrasound as having pyloric stenosis and was scheduled for
immediate surgery. STUDY QUESTIONS: 1. When Jack was seen in the
emergency room a week ago, he weighed 4.5 kg. Today, he weighs 4.0
kg. When planning his care, how should you interpret his weight
loss? a. It is not problematic because it is only 500 g. b. It is
not problematic because it is less than 20% of his weight. c. It is
problematic because it is 12% of his weight. d. It is problematic
but likely to resolve spontaneously. 2. Jack was diagnosed as
having pyloric stenosis. When explaining this diagnosis to Jack’s
family, you should describe which of the following pathophysiologic
phenomena? a. Constriction of the valve between the stomach and
duodenum b. Enlargement of the valve between the stomach and
esophagus c. Inflammation of the duodenum from an allergy to milk
d. Necrotic patches forming on the lining of the stomach 3. You are
reviewing Jack’s electronic health record since his admission.
Which of the signs from Jack’s health history is most clearly
representative of pyloric stenosis? a. Refusing feedings b. Intense
crying 2 to 3 hours after feeding c. Diarrhea for 2 or more days d.
Vomiting immediately after feeding 4. You are also reviewing Jack’s
family history and health history in his electronic record. Which
of the factors from Jack’s health history constitutes a known risk
factor for pyloric stenosis? a. He is a first-born, male infant. b.
He lives in an inner-city setting. c. His mother has an extensive
allergy history. d. His father’s work involves contact with
chemicals. 5. Jack’s father asks you what the usual therapy is for
pyloric stenosis. You encourage to discuss specifics with the
pediatrician but should also describe what typical intervention? a.
Rest for the duodenum for 24 hours and supplementation by IV fluids
b. Small, frequent feedings administered orally or by nasogastric
tube c. Surgery to free the pyloric valve and allow better passage
of milk d. Surgery to remove the lower half of the stomach, which
is often ulcerated 6. Thinking of the QSEN competency for safety,
when changing Jack’s diaper following surgery, which approach would
be best to use? a. Fold diapers high so the incision line is well
covered. b. Fold diapers low so the incision will not be
contaminated. c. Temporarily avoid using diapers because they could
cause abdominal bloating. d. Use sterile diapers to prevent
infection in the incision. 7. Vomiting is a danger in children
because it can lead to fluid, electrolyte, and acid–base
imbalances. The nurse who is caring for a child who has been
vomiting should prioritize assessments related to what problem? a.
Hypocalcemia b. Hypernatremia c. Alkalosis d. Acidosis 8. Because
of vomiting, in which electrolyte is a baby with pyloric stenosis
most apt to be deficient? a. Iron b. Phosphorus c. Potassium d.
Zinc 9. Jack is prescribed an IV of D5W with potassium added.
Before hanging the IV fluid containing potassium, which would be
the most important assessment to make? a. If his head circumference
is normal b. If his deep tendon reflexes are normal c. If he is
voiding sufficiently d. If he has consistent bowel sounds present
10. Jack has a past history of necrotizing enterocolitis. Because
of this health problem, which of the following occurred? a. A
volvulus of his intestine led to death of tissue. b. A congenital
short bowel syndrome limited his digestion. c. A lack of pancreatic
enzymes limited his digestion of fats. d. Necrotic patches of the
intestine interfered with absorption. 11. When the nurse was
assessing Jack for one of the first symptoms of necrotizing
enterocolitis, he or she would have documented the presence of
which of the following? a. Fresh blood in stools b. Pain under the
sternum c. Sweating and liver pain d. Abdominal distention 12.
Jack’s father was concerned his son might have gastric reflux or a
peptic ulcer. A child with suspected peptic ulcer disease should be
assessed for which of the following? a. An H. pylori bacterial
infection b. Stress from psychological trauma c. An allergy to milk
or milk products d. Irritation from a foreign body 13. In addition
to an antibiotic, the plan of care for a child with a peptic ulcer
should include which of the following interventions? a. Surgery to
remove the offending ulcer b. Administration of a proton pump
inhibitor c. Ethacrynic acid to reduce acid content d. Whole milk
to neutralize excessive stomach acid 14. Jack’s father is also
concerned Jack may be developing celiac disease because a maternal
aunt has this. If Jack were developing this, you would assess the
child specifically for symptoms of what health problem? a. Rickets
b. Polycythemia c. Obesity d. Blindness 15. If Jack were diagnosed
with celiac disease, you would eventually anticipate the need to
educate his father about what dietary modification? a. A low-fat,
low-carbohydrate diet b. A diet free of wheat, rye, and barley c. A
diet free of dairy and dairy products d. A diet high in simple
carbohydrates 16. Jack had a loose bowel movement this morning. It
is important to teach new parents which of the following facts
about diarrhea in infants? a. It usually resolved quickly because
of infants’ high fluid content and intake. b. It is more serious in
infants than in adults because of fluid shifts. c. It is not likely
to cause dehydration unless it occurs over several days. d. It is
not apt to be serious unless it is associated with a high fever.
17. Jack’s father reports his son was constipated until this
morning’s diarrhea. Hirschsprung disease can be a potential cause
of constipation in infants. Children with this disease reveal what
assessment finding? a. A form of volvulus that leads to obstruction
b. Lack of nerve endings in the sigmoid colon c. Lack of pancreatic
enzymes d. Necrotic patches that form in the large intestine 18. An
infant with Hirschsprung disease may need a daily enema to promote
bowel evacuation. When giving parents’ instructions for this, which
solution would you recommend they use? a. An isotonic saline
solution b. Warmed (not hot) tap water c. Tap water with a
prescribed amount of baking soda added d. A concentrated glucose
solution 19. Both of Jack’s parents had an appendectomy when they
were school-age. Suppose you see a 10-year-old who has symptoms of
appendicitis in an emergency room. When assessing for rebound
tenderness, you should do which of the following? a. Palpate the
child’s right lower quadrant, quickly release your hand, and ask
him if he has increased pain. b. Palpate first the left lower
quadrant and then the right and ask the child to compare the levels
of pain he feels. c. Ask the child to use a Valsalva maneuver and
note if pain is increased after the maneuver or not increased. d.
Tell the child to bend forward and ask him if he notices bounding
pain in his abdomen or in his thighs. 20. Suppose a child’s
appendix ruptured before he could have surgery. Which position
would you encourage for him postoperatively? a. Prone b. Supine c.
Semi-Fowler’s d. Right side-lying OPEN-ENDED QUESTIONS: 21. What if
an adolescent has recovered from both a peptic ulcer and ulcerative
colitis? What are preventive measures you should discuss with him
to help present relapses of these disorders? 22. What if the mother
of a child with celiac disease tells you she’s angry because many
people are reducing their intake of gluten but few appreciate how
hard it is to prepare true gluten-free meals? What advice could you
give her? FILL IN THE BLANK QUESTIONS: 23. The type of vomiting
that occurs with pyloric stenosis is usually _____________. 24. The
stools of a child with aganglionic megacolon are usually described
as being ________________. MULTIPLE RESPONSE QUESTION: 25. Children
with celiac disease are said to have a “celiac syndrome.” Which of
the following assessment findings are consistent with this
diagnosis? (Select all that apply.) a. Malnutrition b. Protuberant
abdomen c. Red, flushed face d. Deficit of fat-soluble vitamins e.
Large, fat-filled stools