Content Reviewers:Antonella Melani, MD, Lisa Miklush, PhD, RNC, CNS, Jodi Berndt, PhD, RN, CCRN-K, PCCN-K, CNE, CHSE
Contributors:Ursula Florjanczyk, MScBMC, Alaina Mueller, Jake Ryan, Filip Vasiljević, MD, Katherine May, BSN, RN
In the emergency department, a mother brings in her 3-week-old male infant named Owen Tamm.
She says that Owen started vomiting with every feeding since two weeks of age, and occasionally he would vomit so forcefully that it sprayed her face.
Over the past week, he’s been increasingly irritable and fussy, especially after vomiting. But in the last two days, he’s become much more sleepy, and today has been difficult to awaken.
Diagnostic labs and screenings confirm hypertrophic pyloric stenosis, and Owen is admitted to the Neonatal Intensive Care Unit pending pyloromyotomy.
First, let’s review hypertrophic pyloric stenosis, or HPS.
This is a gastric outlet obstruction that is the second most common condition requiring surgery in newborns.
In HPS, babies are born with a normal pylorus, which is the last part of the stomach that consists of a thickened band of smooth muscle.
This band can contract or relax to allow food to exit the stomach and enter the small intestine.
But within a few weeks after birth, the pyloric muscle begins to undergo hypertrophy, which is an increase in the size of each cell, and hyperplasia, which is an increase in the overall number of cells.
Its cause is unknown, but it is more likely due to a combination of genetic and environmental factors, and is about 4 to 5 times more common in males than females, especially first-born males.
As the smooth muscle of the pylorus undergoes thickening and elongation, the pylorus nearly doubles in size, producing an olive-shaped mass felt in the epigastrium just right of the umbilicus.
This narrows the passageway between the stomach and small intestine.
If food can’t pass through the pylorus, it quickly starts to build-up, causing gastric distention.
Eventually, this leads to vomiting that may get more intense over time until it leads to projectile vomiting, where the vomit literally launches out of the infant’s mouth.
The vomit is non-bilious, meaning it doesn’t contain bile, and in babies, it consists primarily of milk and stomach acid. The non-bilious projectile vomiting is a classic sign of HPS.
This can lead to long-term complications such as weight loss and failure to thrive.
HPS also impairs peristalsis, the normal process where the smooth muscle of the digestive tract moves in a series of waves to push food through the digestive system.
In HPS, the obstruction makes the stomach’s smooth muscle work much harder to push food through.
This leads to visible peristaltic waves that can be seen moving left to right across the abdomen.
Treatment typically involves maintaining fluid and electrolyte balance, but the definitive treatment is a pyloromyotomy, also known as Ramstedt’s procedure, where the muscle of the pylorus is cut and separated, allowing food to pass through more easily.
Now that we understand hypertrophic pyloric stenosis, let’s meet Owen and his mother, and begin to collect objective and subjective assessment data.
You introduce yourself as the nurse caring for Owen, confirm Owen’s identity, then obtain a history of Owen’s feeding behaviors and illness progression by first asking his mother how Owen is feeling today.
She shares with you he barely moved when she went to rouse him this morning, and he has become increasingly sleepy and lethargic since yesterday.
When asked to describe the vomiting episodes in detail, she explains that Owen vomits near the end or shortly after every feeding.
The vomit is often white or cream-colored, and sometimes appears watery or resembles curdled milk.
At times, the vomit would spray across her shoulder or face.
She expresses that he is often very eager to eat, continually sucking, especially after vomiting.
Next, you wash your hands, and speaking softly to Owen and using a gentle touch, you assess his hydration status and development patterns.
You notice he is pale, and his anterior fontanelle and eyes appear sunken.
On closer inspection, his diaper looks and feels dry.
His mother comments that she only changes his diaper two or three times a day, and the last time she changed his diaper was this morning.
He appears tired but can turn his head from side to side and demonstrates a strong grasp reflex.
You observe abdominal distension and visible peristaltic waves moving from left to right across his abdomen.
Next, you auscultate hyperactive bowel sounds.
Through gentle palpation, you feel an olive-shaped mass in the upper right quadrant of his abdomen.
Using the FLACC scale, which looks at the face, legs, activity, cry, and consolability to assess pain, you notice Owen grimaces and appears withdrawn and tense, occasionally shifting his legs and moaning.
You notice that softly speaking and gentle touching do little to console him.
Assessment of his vital signs show he is slightly tachycardic with a heart rate of 172, tachypneic with respirations of 70, hypotensive with a blood pressure of 50/30, and feverish with a temperature of 99.9°F or, 37.7°C.
You document vital signs and assessment findings and then review Owen’s recent laboratory results which shows the following: sodium 130 mEq/L, potassium 3.6 mEq/L, and chloride 81 mEq/L with an decreased carbon dioxide level of 28 mEq/L, indicating hypochloremic metabolic alkalosis.
Additional lab values include blood pH 7.5, hemoglobin 18.5 g/dL, BUN 15 mg/dL, and creatinine 0.5 mg/dL.
Next, let’s create our problem-solving strategy by first identifying problems based on your assessment findings.
These identified problems are our nursing diagnoses which will help you to know what to anticipate, what to monitor as you provide care, and what client education may be needed.
Other nursing diagnoses include imbalanced nutrition less than body requirements related to excessive vomiting secondary to gastric outlet obstruction, acute pain possibly related to abdominal distension, forceful vomiting, or abdominal cramping; risk of infection due to the planned surgical procedure; and deficient parental knowledge and anxiety related to the illness, hospitalization, and postoperative care of their child.
Now that we’ve identified the nursing diagnoses, the next step involves developing goals or desired outcomes for each one.
These goals are the solutions to the problems we’ve identified, and they need to be specific, measurable, attainable, results-oriented, and time-based; in other words, SMART.
Working together with Owen’s interdisciplinary team, you share your nursing diagnoses and collaborate to develop goals that match Owen’s needs.
The goal for the nursing diagnosis of deficient fluid volume is to improve Owen’s hydration status by ensuring adequate fluid intake and urinary output, along with evidence of adequate hydration such as a flat fontanelle and eyes that are no longer sunken by the time of surgery.
Other goals include tolerating oral feedings, absence of vomiting, a non-distended abdomen, maintaining a stable weight, and being comfortable and relaxed by hospital discharge.
Goals for his family involve recognizing signs of deficient fluid volume, understanding the importance of monitoring intake and output, following a feeding schedule, positioning correctly during and after feedings, and recognizing when to contact a healthcare provider.