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Republic of the Philippines

Isabela State University


City Of Ilagan, Isabela

Hypertrophic Pyloric Stenosis (HPS)


Infantile hypertrophic stenosis or pyloric stenosis

 Pyloric stenosis is an abnormal thickening and/or narrowing of the pylorus muscle.

 Normally, food and other stomach contents pass into the small intestine through the pylorus,
which is the exit of the stomach. The thickened pyloric muscle causes a narrowing of the
pyloric channel. As a result, liquid and/or food cannot pass out of the stomach into the small
intestine.

 The pylorus is the muscular sphincter located where the stomach joins the first part of the small
intestine (duodenum).

 Normally, the pylorus contracts to keep food in the stomach for digestion and relaxes to let
the food out into the intestine. For reasons that doctors do not fully understand, the pylorus
becomes thickened and sometimes closes off (called stenosis), blocking material from
leaving the stomach. This blockage usually occurs in the first month or two of life.

 Pyloric stenosis affects 3 out of every 1,000 babies born. It is more likely to affect full-term,
first-born male infants, and less likely to affect female infants.
 More common in Caucasian infants, especially those of European descent.
 About 15% of infants born with pyloric stenosis have a family history of the condition. An infant
is three times more likely to develop pyloric stenosis if the mother had the disease as an infant, as
compared to the father
 The symptoms usually occur starting around the third week of life, but it could be up to age 5
months.

Causes
 Unknown, but genetic and environmental factors might play a role. Pyloric stenosis usually isn't
present at birth and probably develops afterward.

Risk factors
 Sex.  Smoking during pregnancy.
 Race.  Early antibiotic use.
 Premature birth.  Bottle-feeding.
 Family history.

Complications
 Failure to grow and develop.
 Dehydration. Frequent vomiting can cause dehydration and a mineral (electrolyte) imbalance.
Electrolytes help regulate many vital functions.
 Stomach irritation. Repeated vomiting can irritate your baby's stomach and may cause mild
bleeding.
 Jaundice. Rarely, a substance secreted by the liver (bilirubin) can build up, causing a yellowish
discoloration of the skin and eyes.

Signs and symptoms


 Vomiting after feeding. The baby may vomit forcefully, ejecting breast milk or formula up to
several feet away (projectile vomiting). Vomiting might be mild at first and gradually become
more severe as the pylorus opening narrows. The vomit may sometimes contain blood.
Non-bilous
 Persistent hunger. Babies who have pyloric stenosis often want to eat soon after vomiting.
 Stomach contractions. You may notice wave-like contractions (peristalsis) that ripple across
your baby's upper abdomen soon after feeding, but before vomiting. This is caused by stomach
muscles trying to force food through the narrowed pylorus.
 Dehydration. Your baby might cry without tears or become lethargic. You might find yourself
changing fewer wet diapers or diapers that aren't as wet as you expect.
 Changes in bowel movements. Since pyloric stenosis prevents food from reaching the intestines,
babies with this condition might be constipated.
 Weight problems. Pyloric stenosis can keep a baby from gaining weight, and sometimes can
cause weight loss.

Etiology
It has been found that HPS specimens, the muscle layer is deficient in:
 The quantity of nerve terminals
 Markers for nerve supporting cells
 Peptide containing nerve fibers
 It is postulated that this abnormal innervation of the muscular layer leads to failure of
relaxation of the pyloric muscles, increased synthesis of growth factors, and subsequent
hypertrophy, hyperplasia and obstruction.
 There is an increased evidence of HPS in infants receiving Erythromycin. The reason is
unclear, although a prokinetic effect on gastric muscle contraction is postulated.

Diagnosis
Physical Examination
 Palpation, the mass is firm (olive), mobile, approximately 2cm, best palpated from the left,
located in the midepigastrium beneath the liver edge.
 Palpation requires a calm infant with relaxed abdominal musculature.
 Best felt with an empty stomach in the right upper quadrant; palpate from the left side and
wait for several minutes
Diagnostic Procedure
 Blood tests. Electrolytes, pH, BUN, and creatinine levels should be obtained at the same time as
intravenous access in patients with pyloric stenosis.
 Abdominal X-rays. A diagnostic test that uses invisible electromagnetic energy beams to
produce images of internal tissues, bones, and organs onto film.
 Abdominal ultrasound. A diagnostic imaging technique that uses high-frequency sound waves
and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to
view internal organs as they function, and to assess blood flow through various vessels.
 Barium swallow/upper GI series. A diagnostic test that examines the organs of the upper part of
the digestive system: the esophagus, stomach, and duodenum (the first section of the small
intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of
organs so that they will show up on an X-ray) is swallowed. X-rays are then taken to evaluate the
digestive organs.

Pathophysiology
Treatment
 Prehospital care. As with all pediatric resuscitations, prehospital care in patients with pyloric
stenosis should be consistent with pediatric advanced life support (PALS) recommendations for
infants who are dehydrated or in shock.
 Correction of dehydration. If significant dehydration has occurred, immediate treatment
requires correction of fluid loss, electrolytes, and acid-base imbalance, starting with an initial
fluid bolus (20ml/kg) of isotonic crystalloid.
 Diet. Feeding can be initiated 4-8 hours after recovery from anesthesia, although earlier feeding
has been studied; infants who are fed earlier than 4 hours do not have a worse total clinical
outcome; however, they do vomit more frequently and more severely, leading to significant
discomfort for the patient and anxiety for the parents.
Surgical Management
 Pyloromyotomy. A surgical procedure called a pyloromyotomy, also known as a
Fredet-Ramstedt operation, is the treatment of choice. May be performed laparoscopically.
 Complications are uncommon (≤5%) but include incomplete myotomy, duodenal perforation,
haemorrhage and wound infection.
Pharmacologic Management
Medications used to treat pyloric stenosis symptomatically are:
IV atropine. The intravenous dose of atropine for treatment of pyloric stenosis ranges in studies from
0.04 to 0.225mg/kg/day and is given for 1 – 10 days.
Oral atropine. Oral atropine (0.08 – 0.45mg/kg/day) is continued, after IV therapy has been deemed
successful, for 3 weeks to 4 months.

Pre-operative Fluid Management


 Stop oral feeds
 Avoid the use of a gastric tube, if possible, as this may exacerbate electrolyte losses. however,
where there is ongoing vomiting, a gastric tube allows accurate measurement of losses in order to
calculate replacement of ongoing losses
 Resuscitation fluid: infants with signs of shock, or moderate or severe dehydration should be
given a normal saline bolus of 20ml/kg
 3 separate iv fluid solutions are used. they can be co-infused through the same iv and
independently increased or decreased according to the results of ongoing clinical and biochemical
assessments
Post-operative Management
 Cardiac and respiratory monitoring should be performed for 24 hours because of the risk of
apnoea
 Feeding can be restarted within 6 hours of surgery (at surgeon's direction)
 Modest regurgitation is common after pyloromyotomy due to pyloric and antral spasm, and
gastric irritation. However, this should not delay the introduction of feeds
 Demand feeding is preferable to a restricted feeding regimen as it appears to reduce the time to
achieve full feeds and shortens hospital stay, although vomiting may be greater initially.Vomiting
generally settles within several days of surgery, although some infants will have underlying
gastro-oesophageal reflux
 Intravenous maintenance fluid should be continued at 100 mL/kg/d until two adequate feeds have
been tolerated (≥ 60 mL)
 Paracetamol usually provides sufficient analgesia
 Infants are usually discharged within 2-3 days

Nursing assessment
Assessment in a child with pyloric stenosis include:
 Assess the child’s history of vomiting. Ask when the vomiting started and determine the
character of the vomiting.
 Assess for the child’s elimination. Ask the caregiver about constipation and scanty urine.
 Physical exam. Physical exam reveals an infant who may show signs of dehydration; obtain the
infant’s weight and observe skin turgor and skin condition, anterior fontanelle, temperature,
apical pulse rate, irritability, lethargy, urine, lips and mucous membranes of the mouth, and eyes;
observe for visible gastric peristalsis when the infant is eating.
Nursing responsibility
 Consider thermoregulation at all times
 Before transport to theatre, transfer infant to incubator set at neutral thermal environment
(NTE) temperature
 Ensure incubator will be plugged in and pre-warmed for the infant to be transferred into in
Recovery
 After return to the ward, ensure infant's temperature is stable prior to transferring to open cot
 Monitor infant's temperature hourly until stable
 Routine post anaesthetic observations
 Monitor wound and report abnormalities to surgeon
 Observe for bleeding, redness, swelling, ooze from incision site
 Refer Wound Care guideline
 Maintain adequate fluid balance chart
 Monitor IV site
 Maintain adequate nutrition and fluid intake. If the infant is severely dehydrated and
malnourished, rehydration with intravenous fluid and electrolytes is necessary; feedings of
formula thickened with infant cereal and fed through a large-holed nipple may be given to
improve nutrition; feed the infant slowly while he or she is sitting in an infant seat or being held
upright.
 Provide mouth care. The infant needs good mouth care as the mucous membranes of the mouth
may be dry because of dehydration and omission of oral fluids before surgery; a pacifier can
satisfy the baby’s need for sucking because of the interruption in normal feeding and sucking
habits.
 Promote skin integrity. The infant is repositioned, the diaper is changed, and lanolin or A and D
ointment is applied to dry skin areas.
 Promote family coping. Include the caregivers in the preparation for surgery and explain the
importance of added IV fluids, the reason for ultrasonographic or barium swallow examination,
and the function of the NG tube and saline lavage; describe the surgical procedure to be
performed; and explain what to expect and how long the operation will last.

Prepared by:
Abigail Basco
Jonalyn Abregado
Francois Diether Adolfo
BSN - III
Republic of the Philippines
Isabela State University
City Of Ilagan, Isabela

PNEUMONIA

I. PNEUMONIA - inflammation of the lung parenchyma leading to pulmonary consolidation because


alveoli is filled with exudates

A.ETIOLOGIC AGENTS
1.Streptococcus pneumoniae ( pneumococcal pneumonia )
2.Hemophilus influenzae ( bronchopneumonia )
3.Klebsiella pneumoniae
4.Diplococcus pneumoniae
5.Escherichia coli
6.Pseudomonas aeruginosa

B.HIGH RISK GROUPS


Children less than 5 y/o
Elderly

C.PREDISPOSING FACTORS
1.Smoking
2.Air pollution
3.Prolonged immobility ( hypostatic pneumonia )
4.Aspiration of food ( aspiration pneumonia )
5.Over fatigue

Pathophysiology
the infecting organism trigger inflammation of the airways, inflammatory exudate fills alveolar air
spaces, producing lung consolidation. impairedgas exchange in the alveoli leads to various degrees of
hypoxia, depending on the amout of lung tissue affected.

D.SIGNS AND SYMPTOMS

1.Productive cough, greenish to rusty


2.Dyspnea with prolong expiratory grunt
3.Fever, chills, anorexia, general body malaise
4.Cyanosis
5.Pleuritic friction rub
6.Rales/ crackles on ausculatation
7.Abdominal distentionparalytic ileus

E.DIAGNOSTICS

1.Sputum GS/CSconfirmatory; type and sensitivity;


(+) to cultured microorganis
2. CXR- (+) pulmonary consolidation
3. CBC
▪ Elevated ESR ( rate of erythropoeisis )N = 0.5-
1.5 ( compensatory mech to decrease O2 )
▪ Elevated WBC
4. ABG- PO2 decreased ( hypoxemia )
F.NURSING MANAGEMENT

1.Enforce CBR ( consistent to all respiratory disorders )


2.Strict respiratory isolation
3.Administer medications as ordered
▪Broad spectrum antibiotics
°Penicillin- pneumococcal infections
°Tetracycline
°Macrolides
Azithromycin ( OD x 3/days )
1.Too costly
2.Only se: ototoxicity- transient hearing loss
▪ Anti-pyretics
▪ Mucolytics/ expectorants
4.Administer O2 inhalation as ordered
5.Force fluids to liquefy secretions
6.Institute pulmonary toilet- measures to promote expectorate of secretions
▪DBE, Coughing exercises, CPT (clapping/vibration ),Turning and repositioning
7.Nebulize and suction PRN
8.Place client of semi-fowlers to high fowlers
9.Provide a comfortable and humid environment
10.Provide a dietary intake high in CHO, CHON, Calories and Vit C
11.Assist in postural drainage
▪Patient is placed in various position to drain secretions via force of gravity
▪Usually, it is the upper lung areas which are drained
▪Nursing management:
° Monitor VS and BS
° Best performed before meals/breakfast or 2-3 hours p.c. to prevent gastroesophageal reflux
or vomiting ( pagkagising maraming secretions diba?
Nakukuha? )
°Encourage DBE
°Administer bronchodilators 15-30 minutes before procedure
°Stop if pt. can’t tolerate the procedure
°Provide oral care after procedure as it may affect taste sensitivity
°Contraindications:
-Unstable VS
-Hemoptysis
-Increased ICP
-Increased IOP ( glaucoma )
°Encourage DBE
°Administer bronchodilators 15-30 minutes before procedure
°Stop if pt. can’t tolerate the procedure
°Provide oral care after procedure as it may affect taste sensitivity
°Contraindications:
-Unstable VS
-Hemoptysis
-Increased ICP
-Increased IOP ( glaucoma )
12. Provide pt health teaching and d/c planning
▪Avoidance of precipitating factors
▪Prevention of complications
°Atelectasis
°Meningitis
▪Regular compliance to medications