NU225CL Unit 5 Pyloric Stenosis Case Study Example

Hungry Again Right After Every Vomit: A Case Study Analysis of Pyloric Stenosis in a Composite Five-Week-Old Boy, From the Cues at Home Through Electrolyte Correction Before Surgery to the Feeding Plan His Parents Take Home

[Student Name]

Purdue University Global

NU225CL: Pediatric Nursing Clinical

Unit 5 Case Study Analysis

[Instructor Name]

[Date]

The infant and family are composite; values are bracketed where illustrative, and diagnosis, fluids and surgery are directed by the medical and surgical teams.

Presentation

[Elijah], composite, 5 weeks, first-born, term birth, formula fed. For [four] days he has vomited after almost every feed, forcefully enough to land on the floor, with no green or yellow color. After each episode he cries and roots as if starving. Weight [4.1] kg, down from [4.4] kg at his two-week visit. [Three] wet diapers in 24 hours. Mildly sunken fontanelle, dry lips, capillary refill [3] seconds, heart rate [168]. Labs: sodium [134], chloride [88], potassium [3.1], bicarbonate [34] mmol/L. During a test feed, a firm, olive-sized mass is felt in the upper abdomen, and waves of stomach contraction can be seen crossing from left to right.

What the Cues Meant

No single cue makes the diagnosis; the pattern does. Forceful vomiting that is never green means the blockage is before the bile duct enters the bowel. A baby who is hungry right after vomiting is not sick in the usual sense; he is being fed and cannot keep it. His age, about three to six weeks, and being a first-born boy fit the condition's usual pattern, since boys are affected several times more often than girls (Ranells et al., 2011). Weight loss and fewer wet diapers show dehydration.

A baby who vomits and then wants to eat again at once is telling the nurse the problem is in the plumbing, not in his appetite.

Pathophysiology

In infantile hypertrophic pyloric stenosis, the muscle of the pylorus, the outlet of the stomach, thickens over the first weeks of life until milk cannot pass. The stomach contracts harder to push against the blockage, which is why the waves can be seen and why the vomiting is forceful. Repeated vomiting of stomach contents removes hydrochloric acid, so the body loses chloride and hydrogen ions and the blood becomes alkaline. The kidneys, trying to hold on to fluid during dehydration, retain sodium and lose potassium. The result is the typical lab picture: low chloride, low potassium and a high bicarbonate, a hypochloremic, hypokalemic metabolic alkalosis.

Treatment and Its Nursing Work

Ultrasound confirms a thickened, lengthened pyloric muscle. The operation, a pyloromyotomy, cuts the thickened muscle so milk can pass, and it is curative. But it is not an emergency. Anesthesia in an alkalotic, dehydrated infant is risky, because alkalosis can depress breathing after surgery, so fluids and electrolytes are corrected first. The nurse keeps him nothing by mouth, starts and monitors IV fluids with added potassium only after he is passing urine, weighs diapers, records every vomit, checks electrolytes as ordered and watches his breathing. A randomized trial found that laparoscopic pyloromyotomy led to full feeds and discharge somewhat sooner than the open operation, with similar complications (Hall et al., 2009).

Why the Scan Was Not the First Step

The diagnosis could be suspected at the bedside before any imaging. The nurse's history, forceful nonbilious vomiting, hunger afterward, his age and sex, and the test feed with a palpable olive, made the ultrasound a confirmation rather than a search. Recording those findings clearly in the admission note helped the team order the right study first and start fluids while waiting for it. A nurse who documents only "vomiting x 4 days" loses most of that information.

Priority Problems

1. Deficient fluid volume with electrolyte imbalance: diaper weights, heart rate, fontanelle, capillary refill, labs.

2. Risk for aspiration: vomiting infant kept on his side or upright after any vomiting, suction at the bedside.

3. Imbalanced nutrition: weight loss; feeding resumes after surgery on the surgeon's plan.

4. Parental anxiety and guilt: his mother asks whether she caused it by switching formulas.

Teaching His Parents

His parents are told plainly that pyloric stenosis is not caused by anything they did and that the formula change did not cause it. They learn why he cannot eat before surgery even though he is hungry, which is the hardest part for them to watch; a pacifier may comfort him. After surgery, feeds restart in small amounts and increase as tolerated. Some vomiting in the first day is common and does not mean the operation failed. At home, they watch the incision for redness or drainage, record wet diapers and call if vomiting returns forcefully after the first days, if he has fewer than [six] wet diapers a day or if he develops a fever (Perry et al., 2022).

Evaluation

After [24] hours of IV fluids, his chloride rose to [100] and bicarbonate fell to [27], and he had [six] wet diapers. He had a laparoscopic pyloromyotomy the next morning, took full feeds by the following evening and went home on day three, gaining weight at his follow-up visit.

References

Hall, N. J., Pacilli, M., Eaton, S., Reblock, K., Gaines, B. A., Pastor, A., Langer, J. C., Koivusalo, A. I., Pakarinen, M. P., Stroedter, L., Beyerlein, S., Haddad, M., Clarke, S., Ford, H., & Pierro, A. (2009). Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: A double-blind multicentre randomised controlled trial. The Lancet, 373(9661), 390-398. https://doi.org/10.1016/S0140-6736(09)60006-4

Perry, S. E., Hockenberry, M. J., Cashion, K., Alden, K. R., Olshansky, E., & Lowdermilk, D. L. (2022). Maternal child nursing care (7th ed.). Elsevier.

Ranells, J. D., Carver, J. D., & Kirby, R. S. (2011). Infantile hypertrophic pyloric stenosis: Epidemiology, genetics, and clinical update. Advances in Pediatrics, 58(1), 195-206. https://doi.org/10.1016/j.yapd.2011.03.005