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due Oct 7, 2018
Week 5: Discussion Part Two
22 22 unread replies. 75 75 replies. A three-month-old baby boy comes into your clinic with the main complaint that he frequently vomits after eating. He often has a swollen upper belly after feeding and acts fussy all the time. According to his parents, the vomiting has become more frequent this past week and he is beginning to lose weight. After careful history taking, a thorough physical exam and diagnostic work-up, the patient is diagnosed with pyloric stenosis.
- What is the etiology of pyloric stenosis?
- Describe in detail the pathophysiological process of pyloric stenosis.
- Identify hallmark signs identified from the physical exam and presenting symptoms. What diagnostic tests would help to confirm the diagnosis of pyloric stenosis?
- Describe the pathophysiology of complications of pyloric stenosis.
- What teaching would you provide this patient/parents regarding pyloric stenosis? In addition to the textbook, utilize at least one peer-reviewed, evidence based resource to develop your post. Search entries or author Filter replies by unread Unread Collapse replies Expand replies Subscribed
Collapse SubdiscussionTiffani Pendleton
Tiffani Pendleton
Sep 30, 2018Sep 30, 2018 at 5:03pm Manage Discussion Entry Dr. Schwindenhammer and Classmates, Etiology of Pyloric Stenosis According to McCance and Huether (2014), pyloric stenosis is a blockage of the pyloric sphincter due to enlargement of the sphincter muscle. A common issue for infants that affects more males than females. As with this infant, it usually presents with vomiting right after eating as the main symptom. According to McCance and Huether (2014), the exact cause is unknown, but has been attributed to increased gastrin secretion by the mother during the final trimester of pregnancy,
administration of prostaglandin E, and even genetic predisposition with family history. Pathophysiological Process of Pyloric Stenosis According to Ndongo, Tolefac, Tambo, Abanda, Ngowe, Fola, Dzekem, Weledji, Sosso and Minkande (2018), the enlargement and overproduction of the smooth muscle cells of the pylorus causes narrowing and encroachment by the pyloric sphincter muscle which makes it difficult for adequate movement of food through the pylorus. With the extra work being done to try and move the food through the pylorus, it becomes even more enlarged exacerbating the problem. Hallmark Signs and Diagnostic Tests The main sign of pyloric stenosis would be the sudden, projectile vomiting after eating. According to McCance and Huether (2014), along with the projectile vomiting that usually starts around 2-3 weeks of age, the infant usually wants to eat again immediately after vomiting and constipation is always an issue because the food never reaches the intestines as it should. If the infant continues to vomit with feedings, then dehydration and electrolyte issues are soon to follow as well. Since food never actually reaches the intestines, these infants will have infrequent stools and will likely be fussy and lethargic from lack of intake. Although diagnosis is usually made from the symptomatology stated above, there are also a couple of diagnostic tests that can be performed. According to McCance and Huether (2014), in most cases, a small, moveable mass in the right upper quadrant can be palpated during examination and an ultrasound can also be performed that shows the enlarged pyloric muscles and narrowed pyloric channel. Complications of Pyloric Stenosis Most of the complications of pyloric stenosis result after non-treatment/late diagnosis of the issue. As stated above, if the infant continues to vomit then dehydration and electrolyte imbalances such as hypokalemia will result. If the child continues along this path then malnutrition will result and according to McCance and Huether (2014), because of the delicate nature of their systems, the subsequent weight loss can be fatal. It is important to diagnosis and treat quickly to avoid these more severe complications. Teaching About Pyloric Stenosis The main symptom of pyloric stenosis is a sudden onset of projectile vomiting after eating. If a parent notices that the infant is vomiting after every feeding and wanting to eat again immediately I would encourage them to seek a
identify if the infant could be dehydrated. I remember back to when my child was sick, and I was trying to tell the doctor that he had this many wet diapers and ate that much. I realized I couldn’t keep track of it all in my head. I started to make journal of when my child was sick. It helped me track when medication was due and provided an exact timeline of his illness. This is something I will recommend to the parents as well. Trying to remember everything as a new parent is hard when everything goes smooth, so I can imagine how hard it would be in this situation. In our profession it is very important to have a strong team to bounce idea’s off for this very reason. Without you and your post, I would have never educated the patients on how to monitor for dehydration. So again, thanks for allowing me to be a better educator for my patients. Heather (1 like)
Joy Sladek Joy Sladek Oct 2, 2018Oct 2, 2018 at 8:39am Manage Discussion Entry Heather and Tiffani, Great posts ladies about pyloric stenosis. Your discussions have really added to my knowledge of this disorder. We do know that this is the most common condition that requires a surgical intervention usually within the first year of life. The common presentation of this condition is between the age of one and five months. Forceful, projectile vomiting is a hallmark symptom that occurs after eating and a palpable, firm, mobile mass can be felt in the upper right quadrant. Diagnostic testing such as an abdominal ultrasound is the test of choice and a laparoscopic Ramstedt pyloromyotomy is the cure. What a scary situation the family will face. Spitting up is one thing, but projectile vomiting can catch anyone off guard, one may think the child has gastroesophageal reflux when in fact the need surgery. Assessing for
dehydration as you both mentioned is imperative because their acid-base and electrolytes can become imbalanced quickly. Assessing their sleeping patterns, irritability, the elasticity of their skin, as well as their sunken fontanels are other ways for assessing for dehydration. According to the 5-minute clinical consult, an IV using D5 ½ NS with 20 meq of Kcl works best (2018). Thank you both for a great post. Joy Reference Domino, F. J. (2018). The 5-minute clinical consult standard, 2015. [electronic resource]. Philadelphia. Pa. : Wolters Kluwer Health, 2018. Retrieved from https://chamberlainuniversity.idm.oclc.org/login? url=https://search.ebscohost.com/login.aspx? direct=true&db=cat04724a&AN=nur.B000007993&site=e ds-live&scope=site
Sasha Morales Sasha Morales Oct 6, 2018Oct 6, 2018 at 3:14pm Manage Discussion Entry Hi Heather, While the reoccurrence of pyloric stenosis in a baby is rare, it has been seen that often, the siblings of a person with pyloric stenosis is at higher risk for getting pyloric stenosis. With that in mind, patient education is especially important, so the parents can identify the symptoms sooner. “Pyloric stenosis may also cause the baby to be hungry, weight loss, signs of dehydration, dry mouth, crying with no tears, fatigue, fewer bowel movements, and projectile vomiting” (Smith, 2017). Parents will always blame themselves for what happens to their child, even if it is something that could not be controlled, like pyloric stenosis. However, empowering them with
also helps the doctor. And again, like I mentioned in my post, emotional support for the parents is huge. Always remind them there is nothing they could have done to prevent this. Taylor Davis
Collapse SubdiscussionTheresa Schwindenhammer Theresa Schwindenhammer Oct 5, 2018Oct 5, 2018 at 3:28pm Manage Discussion Entry Taylor Great post! I think we should educate all new parents to keep a log or journal of their babies daily intake and output. This is very important in the overall health of the infant and can also help us to help them if something is wrong with the baby. Dr. Schwindenhammer
Taylor Davis Taylor Davis Oct 7, 2018Oct 7, 2018 at 1:30pm Manage Discussion Entry Dr. Schwindenhammer, I know when the time comes and I have my own children, I will be keeping a diary or my child's intake and output. Thank you for your comment. Taylor Davis
Susan Rushing Susan Rushing Oct 7, 2018Oct 7, 2018 at 8:56pm Manage Discussion Entry Tiffani & Taylor, I enjoyed reading your responses this week. Keeping track of hydration in infants is very important. I worked with a pediatrician for a while and she would always make us completely strip the baby down to weigh them. We often had to weigh diapers too if there was any hydration issues going on. I can remember some of the poor new parents being so mad that we had to take all of those layers off those babies they had probably just struggled to dress. New parents need so much support and encouragement. I really like the idea about the diary. That is very organized and helpful especially if someone else must step in and keep the child. I, of course, was never that organized with my own children but I can see how that would be very helpful to have access to. Suggesting this to new parents would be a great idea. -Susan Rushing
Collapse SubdiscussionMolly Dauberger Molly Dauberger Oct 1, 2018Oct 1, 2018 at 3:36pm Manage Discussion Entry Pyloric stenosis is a condition caused by the enlargement of the pylorus. The cause of the enlargement is idiopathic, however, some factors are considered as possible triggers (McCance, Huether, Brashers & Rote, 2014). Increased maternal gastric secretions in the last trimester, possibly due to maternal stress, can cause increased gastric secretions in the infant (McCance, Huether, Brashers & Rote, 2014). With the true cause being unknown, there are several possibilities. There is a thought that the antibiotic, erythromycin, given to a pregnant mother close to birth or while she is
educated about notifying the infant’s PCP or EMS of the above mentioned signs and symptoms. References McCance, K., Huether, S., Brashers, V. & Rote, N. (2014). Pathophysiology: The biologic basis for disease in adults and children , 7th ed. St. Louis, MO: Elsevier Mosby. Ndongo, R., et al. (2018). Infantile hypertrophic pyloric stenosis: A 4-year experience from two tertiary care centres in Cameroon. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5771033/
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Collapse SubdiscussionSara Rodriguez Sara Rodriguez Oct 1, 2018Oct 1, 2018 at 11:53pm Manage Discussion Entry Molly, Pyloric stenosis can be a scary thing for new parents, and it is more common in Caucasians and more in males to females. It is less common in mixed race parents as well. (Subramaniam, S., & Bechtel K. 2017). Helping the parents on what to do next after their baby is diagnosed with pyloric stenosis, such as finding a surgeon and answering all their questions. After the surgery, the child may need some IVF for 12 hours or less and then feeding the child can begin. Surgery is good, with complete recovery for the child. Educating the parents about after the surgery, that 80% of after kids will continue to regurgitate after surgery. If the child continues to vomit 5 days after surgery that they may want to do another test to see what needs to happen again. Following up is just as important before and after the surgery is done. Reference
Subramaniam, S., & Bechtel K. (2017). Pediatric pyloric stenosis. MedScape. Retrieved from https://emedicine.medscape.com/article/803489-overview
Molly Dauberger Molly Dauberger Oct 2, 2018Oct 2, 2018 at 4:59pm Manage Discussion Entry Sara, I completely agree...education is going to be the best intervention for the parents of this child. I think the parents need to be well prepared through education that recovery is most likely and that surgery is generally the best option. These parents definitely need to be aware that they did nothing wrong and that there is no reason to feel guilty. As Dr. Schwindenhammer mentioned, these parents need to be reassured of that. It is also rare I think in our adult mindset that surgery is the first and immediate option. However, in this case it certainly is. That may be something that the parents need to be educated about as well.
Gregory Higgins Gregory Higgins Oct 6, 2018Oct 6, 2018 at 8:45pm Manage Discussion Entry Sara, I didn't find anything about the sex or race aspect of the incidence, so thanks for sharing that! Following up with any procedure or treatment is always super important
themselves and feel frustrated. These feelings can interconnect with the sadness and anxiety mothers can experience with postpartum depression. It would be very important to recognize this stress as the health care provider. I would try to encourage parents to discuss their feelings and promote a supportive network such as getting them connected with other family support groups. Much education should be provided on pyloric stenosis. I would have the parents watch a video or provide education before leaving the office so they clearly understand, but being careful not to overwhelm them. References American Psychological Association. (2018). When your child is diagnosed with chronic illness. Retrieved from: https://www.apa.org/helpcenter/chronic-illness- child.aspx (Links to an external site.)
Sara Rodriguez Sara Rodriguez Oct 3, 2018Oct 3, 2018 at 4:52am Manage Discussion Entry Dr. Schwindenhammer, You are right about parents needing education about their child and pyloric stenosis. It can be scary for the new parents to find out that their baby at 3-5 weeks is going to get surgery. It is more common in girls than boys. If the new baby has a sibling that had pyloric stenosis, the chances of the new baby getting pyloric stenosis increases. It can be hard for new parents already tired and stressed from a new baby and then to find out the new baby has pyloric stenosis. Parents should also have emotional support and tell them that this was not their fault. A support group is also recommend for new parents, because other parents have been though the same situation according to Subramaniam. (2017). Pyloric stenosis can be fixed with surgery and the baby should be good after 12-24 hours, then the parents can resume eating. Telling the parents that the baby may
become fuzzy for a couple of days and may need more breast milk or formula to compensate for the surgery. Reference Subramaniam, S. & Bechtel, K (2017). Pediatric pyloric stenosis. MedScape. Retrieved from https://emedicine.medscape.com/article/803489-overview Reply Reply to Comment
Collapse SubdiscussionHeather Meucci Heather Meucci Oct 3, 2018Oct 3, 2018 at 10:09am Manage Discussion Entry Dr. Schwindenhammer, I think you hit the nail on the head. It is terrifying bringing a child into this world. All the what ifs or could bes? We worry is my child going to be healthy? This this case the family got just that, their baby was healthy at birth at first glance. Then quickly turned for the worse requiring surgery. These parents just like any parent would question, if they could have done anything differently. As a mom, I would think I should have known something was wrong, it's my child. The reality of it is, this child would have developed this no matter what the parents would have done. They need to know they caught it early and helped save their child's life. Some parents don't catch this for various reasons and if it goes untreated, it can lead to severe fluid and electrolyte imbalances, chronic malnutrition and could be fatal within 4 to 6 weeks ((McCance, Huether, Brashers, & Rote, 2013). These parents attentiveness to their child, allowed for medical treatment and yes it save his life. Support for these parents is key to successful treatment of this little boy and it starts with making sure the parents take "blame" out of the situation. Heather
listen to her cry as they took her away and that made all the difference in the world. I carry that feeling with me now as I care for patients and their families in the surgery center. I want the parents to feel like somebody cares as much as that nurse did for me. Most of our younger patients are there for dental procedures, but are still scared and their parents are usually very anxious. Most of the children cry when it is time to head to the operating room and you can see the heartbreak in the parent’s eyes. Some of the CRNAs use their iPads to pull up the patient’s favorite show to keep the preoccupied to at least make the trip back to the operating room easier and a little less stressful. Sometimes it is the smallest things that make the biggest impacts. As you indicated, making the parents of these children aware of the fact that it is nothing they have done to cause the pyloric stenosis or resulting treatment is so important. As parents we have a tendency to beat ourselves up and take any hurt or heartache that our children are feeling and place the blame on ourselves. Support for the parents is an important aspect of the management and treatment of these patients and should not be overlooked. Tiffani
Theresa Schwindenhammer Theresa Schwindenhammer Oct 5, 2018Oct 5, 2018 at 3:34pm Manage Discussion Entry Tiffani, Great post! That was very nice of that nurse to allow you to be with your child until they went to sleep. The crying my son did when they took him away made me feel like I was letting him down but they would not let me go back with him to surgery. Of course when I tell him the story he says he doesn't remember so not to worry but its still awful to feel that helpless. I really like the idea of using the Ipads. Perhaps someone in the OR could videoconference with the parents so they can be updated. Dr. Schwindenhammer
(2 likes)
Jordan Miller Jordan Miller Oct 7, 2018Oct 7, 2018 at 9:11pm Manage Discussion Entry Tiffani, Great examples of distraction, which can ease the transition for the patient and help the parents. I was charge one day and we had a pediatric admission. My friend was the peds nurse and I told him I would help him go start the IV. I know this is one of the hardest things for me to do as a nurse, especially when they are big enough to talk to you and know whats happening. The 4 year old was terrified and kept screaming, “I don’t like you, you can leave now!” I then realized that I had to stop and remind myself to get down on the patient’s level. I got down beside the bed and talked with her and told her about my kids and how my son had been hospitalized last year. The distraction did not help very much, but I finally decided to pull out my phone and put it on Youtube! I ask her what did she want to watch, and proceeded to turn it to a small video so we could get the IV started. My friend held her arm and I stuck her. Thankfully, we got the IV the first time, but she was more upset after the stick. I kept reinforcing that the worst part was over. I feel like sometimes we are not honest enough with the patient. Some people do not want to hear the honest truth, but we deserve that no matter who we are. I then tried to comfort the little girl with crayons and I printed off coloring sheets of her favorite character. She was still not very happy, she was quite scared of any nursing personnel. I hope I reached her level to comfort her. The day went on, and her mother brought me a little picture that she had made me, she wrote I love you and signed it. This made my day! I had never had a personal piece of artwork from a pediatric patient, so it warmed my heart. I feel like I connected with her because I was so honest. Pediatrics is hard, its always scared me a little and I know I have a wealth to learn. I’m sure telemedicine could be incorporated into the perioperative world to help ease anxiety.Telemedicine
References Gage-Bouchard, E. A., LaValley, S., Panagakis, C., & Shelton, R. C. (2015). The architecture of support: the activation of preexisting ties and formation of new ties for tailored support. Social Science & Medicine, 134 , 59–65. https://doi- org.chamberlainuniversity.idm.oclc.org/10.1016/j.socscim ed.2015.04.
Stephanie Welch Stephanie Welch Oct 4, 2018Oct 4, 2018 at 7:39pm Manage Discussion Entry Dr. Schwindenhammer, I agree about surgery being a very frightening thing as you must let go of all sense of control over as you place the life of your loved one in the hands of others. I think it is even harder if you are from the healthcare setting, because you tend to focus on all the horror stories from your own working experiences. You better understand the risks and the amount of medical errors that are all potentials, so when it is your own child in that position it is the worst. My son is four years old and he has been put to sleep already three times for PE tubes, once for nasal sutures after a wagon fall at school, and then once for an MRI. I remember each wait feeling as if it took an eternity with a sickening pit in my stomach until I was reunited with our baby. The parents will need to be provided support this time and definitely reassured that they will be in good hands.
Collapse SubdiscussionReneth Inthasack Reneth Inthasack
Oct 4, 2018Oct 4, 2018 at 10:15pm Manage Discussion Entry Dr. Schwindenhammer, As a soon-to-be mother to my twin boys, I can imagine how frightened you must had felt. So far, I have gone for emergency check-up twice during this pregnancy just to make sure my babies are okay in my womb. The first time I went in because I had more intense abdominal pain, and it turned out to be it was the round ligament that I was experiencing. The second time which just happened this past Sunday (at 25 weeks). I thought my cervix was prolapsing out of my genital area. I called my perinatal hotline and they advised me to go in labor and delivery for check-up and observation. It turned out that it was not my cervix, but it was the lining that was swollen and looked a lot like cervix. I still remember how I felt as I was making my way to the labor and delivery. I felt like I had no soul. I do not remember my surroundings at all. When the doctors confirmed that it was not my cervix, and that the babies weer okay, I felt so relieved. So I think that, in addition to teaching parents of pyloric stenosis patient it is not their fault, it is also important to be supportive and attentive to the parents' emotions during this difficult time. Thank you, Reneth
Theresa Schwindenhammer Theresa Schwindenhammer Oct 5, 2018Oct 5, 2018 at 3:36pm Manage Discussion Entry Reneth, How frightening for you. I am so glad everything is ok. Dr. Schwindenhammer
