Patient Scenario, Chapter 45, Nursing Care of a Family When a Child…

Patient Scenario, Chapter 45, Nursing Care of a Family When a Child… Patient Scenario, Chapter 45, Nursing Care of a Family When a Child Has a Gastrointestinal Disorder AN INFANT WITH PYLORIC STENOSIJack 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. 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 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 concernPHYSICAL 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 palpableEyes: Red reflex present; child follows right and left; not past midlineEars: Normal alignment; tympanic membranes pink; landmarks identified; no cer­umen; attunes to examiner’s voiceNose: Midline septum; no discharge; mucous membrane pink; nares patentMouth and throat: No teeth; mucous membrane dry; hard and soft palate intact; gag reflex presentNeck: Full range of motion; no palpable lymph nodesLungs: Respiratory rate: 22 breaths/min; clear to percussion and aus­cultationHeart: Rate: 132 beats/min; no murmursAbdomen: 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 meatusExtremities: Full range of motion; skin turgor on thighs poorBack: Midline vertebrae; no tufts or dimples on spinal columnNeurologic: 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 duodenumb. Enlargement of the valve between the stomach and esophagusc. Inflammation of the duodenum from an allergy to milkd. 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 feedingsb. Intense crying 2 to 3 hours after feedingc. Diarrhea for 2 or more daysd. 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 fluidsb. Small, frequent feedings administered orally or by nasogastric tubec. Surgery to free the pyloric valve and allow better passage of milkd. Surgery to remove the lower half of the stomach, which is often ulcerated  6. 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. Hypocalcemiab. Hypernatremiac. Alkalosisd. Acidosis 7. Because of vomiting, in which electrolyte is a baby with pyloric stenosis most apt to be deficient?a. Ironb. Phosphorusc. Potassiumd. Zinc 8. 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 normalb. If his deep tendon reflexes are normalc. If he is voiding sufficientlyd. If he has consistent bowel sounds present 9. 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. 10. 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 sternumc. Sweating and liver paind. Abdominal distention 11. 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 infectionb. Stress from psychological traumac. An allergy to milk or milk productsd. Irritation from a foreign body 12. 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 ulcerb. Administration of a proton pump inhibitorc. Ethacrynic acid to reduce acid contentd. Whole milk to neutralize excessive stomach acid 13. 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. Ricketsb. Polycythemiac. Obesityd. Blindness 14. 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 dietb. A diet free of wheat, rye, and barleyc. A diet free of dairy and dairy productsd. A diet high in simple carbohydrates 15. 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.  16. 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 obstructionb. Lack of nerve endings in the sigmoid colonc. Lack of pancreatic enzymesd. Necrotic patches that form in the large intestine 17. 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. FILL IN THE BLANK QUESTION:18. The type of vomiting that occurs with pyloric stenosis is usually _____________.      Health Science Science NursingShare QuestionEmailCopy linkComments (0)

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