BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
MALAYBALAY CITY,
BUKIDNON

IN PARTIAL FULFILLMENT OF THE REQUIREMENT OF THE COURSE

NCM 109 RLE

CASE STUDY:
PYLORIC STENOSIS

SUBMITTED TO:
GIOVANNI JAN N. SANCHEZ RN, MAN

SUMBITTED BY:
CABATIC, MARIA ANGELICA G.

APRIL 2020
 Table of Contents

Table of Contents i

I. Introduction 1

II. Purpose of the Study 3

III. Data Base and History 4

IV. Family History 6

V. Psychosocial Profile and Gordon’s Functional Health Pattern 7

VI. Nursing Assessment 10

VII. Review of Systems 19

VIII. Anatomy and Physiology of The Digestive System 20

IX. Pathophysiology 39

X. Medical/Surgical Management 40

XI. Laboratory
41

XII. Diagnostic Procedure 42

XIII. Nursing Care Plan 43

XVIII. Discharge Plan 49

i
I. INTRODUCTION

Pediatric nursing is a specialization of the nursing profession that focuses on

pediatrics and the medical care of children specifically from infancy to teenage years.

This is an important field for the health of the children is distinct from adults due to

the growth and development that occurs throughout childhood. By taking a

preventative and proactive approach in providing care, pediatric nurses aim to

mitigate health problems before they occur. Pediatric nurses not only work directly

with children and their families but they also serve as policy advocates for major

change within the field of pediatric health care.

According to the Centers for Disease Control and Prevention (CDC), every 4.5

minutes, a baby is born with a birth defect in the United States. That means nearly

120,000 babies are affected by birth defects each year. Birth defects may affect how

the body looks, works, or both and it can vary from mild to severe. Depending on the

severity of the defect and what body part is affected, the expected lifespan of a person

with a birth defect may or may not be affected. One of this type of birth defect is most

commonly called as Pyloric Stenosis.

Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS),

is the most common cause of intestinal obstruction in infancy. IHPS occurs secondary

to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a

functional gastric outlet obstruction. It is a condition where the passage (pylorus)

between the stomach and small bowel (duodenum) becomes narrower. Basically, for

babies with pyloric stenosis, the valve is too large and does not allow food to pass

through and therefore it becomes trapped in the stomach. It tends to occur most

frequently in first-born White male infants. The cause is unknown, but multifactorial

inheritance is the likely cause.

1
 According to Epidemiological Features of Infantile Hypertrophic Pyloric

Stenosis in Taiwanese Children: A Nation-Wide Analysis of Cases during 1997–

2007(2011), The incidence rate of IHPS varies from 0.17 to 4.4 per 1000 live births

among different populations around the world. In the study Prevalence of infantile

hypertrophic pyloric stenosis in Texas, 1999-2002(2008), it was found a generally

lower incidence in Asian populations of differing backgrounds such as Chinese (0.18

per 1000 live births), Vietnamese (0.44 per 1000 live births), Asian Indians (0.59 per

1000 live births) and Filipinos (0.43 per 1000 live births) when compared to white

populations.

The higher risk of pyloric stenosis in boys than girls is the earliest noted and

most consistent epidemiologic feature of the disease. In a combination of data from 13

series published before 1951, among 2506 cases, 82.8% were male—a male to female

(M:F) ratio of 4.8:1. In the 5 largest series published since 1995, there were 8160

cases of which 81.5% were male. Four of these series were from the United States,

but very similar findings have been reported from Canada, Australia, Denmark,

Sweden, and England. It appears that a 4- to 5-fold higher risk of this disease in boys

has been characteristic of the disease for many years and in all countries in which it is

common.

2
II. Purpose of the Study

General Objectives:

At the end of the study, the learners will be able to obtain knowledge about the
Pyloric stenosis which is also known as Infantile Hypertrophic Pyloric Stenosis
(IHPS) as well as right approach and develop positive attitude in rendering care
towards patient having the condition.

Specific Objectives:
At the end of effective reading and comprehension of the study, the learners will
be able to:

Identify normal growth, development and behavior as well as approaches to

abnormalities in digestive system.
Describe preventive, promotive, curative and rehabilitative care of children.
Review pediatric anatomy and physiology of the digestive system.
Formulate Nursing Care Plans appropriate for patients with Pyloric stenosis.
Apply principles of nursing and pharmacology applicable for pediatric patients.

3
III. Data Base and History

I. BIOGRAPHIC DATA
Name of patient: X
Date of Birth: 02-25-2020 Sex: M Age: 4 weeks old
Address: 8090 Sherman St. Lenoir, NC 28645
Religion: Catholic Civil Status: Single
Nationality: Caucasian Occupation: N/A Income: N/A
Type of Health Insurance: Informant: Relationship to client:
National Health Insurance Mrs. B Mother

Address of Informant: 8090 Sherman St. Lenoir, NC 28645

Reliability of Informant: ☒ Reliable ☐ Not Reliable Reason: The mother is
fully conscious and is in
the right state of mind to
answer the questions
asked.
Attending Physician: Dr. Nathan Woods
Impression/Admitting Diagnosis: Pyloric Stenosis

II. CHIEF COMPLAINTS

Dehydration due to excessive vomiting.

III. HISTORY OF PRESENT ILLNESS

Prior to admission, patient x has been experiencing frequent episodes of
projectile vomiting within 30 to 60 minutes after feeding since march 24, 2020. “He
was already vomiting the past few days but it only happens occasionally so we
thought it was just normal not until yesterday when he was vomiting every time after
he was fed” as the mother of the patient stated.

IV. PAST HEALTH HISTORY

Patient x was born February 25, 2020 via NSVD and was said that the mother
of the patient was smoking on the first two months of gestation due to unknown
pregnancy but then stopped when she knew she was pregnant. The mother was able to
receive full immunizations during first, second and third trimester of pregnancy and
the patient was able to receive HepB vaccine at birth.

4
AL LERGIES ☐ Yes ☒ No
MEDICATIONS TAKEN: NONE
BLOOD TRANSFUSION ☐ Yes ☒ No

IV. FAMILY HISTORY

5
 Patient X is the first child and therefore has no siblings. The mother of the
patient was said to have the same condition during infancy but has already recovered
and is now completely healthy while the father has hypertension and diabetes. The
Patient’s mother has two siblings and she is the youngest, her eldest brother is
diseased due to cancer while the other sibling is completely healthy. The grandfather
on the mother side is diseased due to stroke and the grandmother has goiter. On the
other hand, the father of the patient has only one sibling and is suffering from
diabetes. Both the grandparents on the father’s side is alive but the mother has
diabetes while the grandfather is completely healthy.

VI. GENOGRAM

Maternal Side Paternal Side

Legend:
- Female
- Male
- Diseased
- Stroke
- Goiter
- Cancer
- Hypertension
- Diabetes
- Pyloric Stenosis
- Recovered from
pyloric stenosis

V. Psychosocial Profile and Gordon’s Functional Health Pattern

6
HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
The patient’s guardian verbalized that to keep her child (the patient) healthy she
ensures that her child gets the right immunization and vaccinations on time and
follow the doctor’s order for her child for no further complications. Washes her
hands before handling her baby, ensures correct handling of her infant to avoid any
accidents, learned how to properly swaddle the baby and making sure that the baby
in his diaper is comfortable, clean and safe to prevent any skin rashes or infection
and to prevent any development of urinary tract infection. Also the mother bathes
the baby on schedule to prevent any drying of skin, proper umbilical cord care,
feeding the baby on time and burping afterwards and ensures that the infant gets
enough rest throughout the day and night.
NUTRITION/METABOLIC PATTERN
The mother says that she switched to bottle feeding three days after birth due to
anxiety about her baby not liking her breastmilk. Her formula-fed newborn takes 2-
3 ounces (60-90 mL) of formula per feeding and eats every three to four hours per
day. So far, the patient isn’t allergic to his milk but the mother is starting to have
second thoughts due to the patient’s frequent vomiting.
ELIMINATION PATTERN
The patient defecates once every two days, usually brown in color and small in
amount. Usually cries whenever defecating and patient usually voids that could fill
up one or two wet diapers a day since his third week.
ACTIVITY/EXERCISE PATTERN
Sleeps a lot during the day and parents lets the baby cry making sure that his cry
is not due to medical reasons to help stretch the baby’s muscles.
COGNITIVE/PERPETUAL
Actively uses their perceptual systems to acquire information from their
surroundings. Can discriminate mother from other women by the smell and by the
sound of their voice. Responds to tactile stimulation. Olfaction and taste are well
developed and affected by maternal diet.
SLEEP-REST PATTERN
In the first few days, the average newborn sleeps between 16-18 hours a day
(Iglowstein et al 2002). By four weeks, newborn sleep averages about 14 hours but
the range is considerable. Some four-week-old babies sleep as little as 9 out of 24
hours while others sleep for 19 hours a day (Iglowstein et al 2002).
ROLE/RELATIONSHIP PATTERN, SELF CONCEPT
Since the patient is an infant, he is in the first stage of Erickson’s Psychosocial
Stage which is Trust vs mistrust. Infants are dependent on their caregivers, so
caregivers who are responsive and sensitive to their infant’s needs help their baby
7
develop a sense of trust. Enjoys watching face of primary caregiver, needs play and
time in prone position.
SELF-PERCEPTION/SELF-CONCEPT PATTERN
In Jean Piaget’s cognitive development, the patient is still in the sensorimotor
stage where infants acquire knowledge through sensory experiences and
manipulating objects. A child’s entire experience at the earliest period of this stage
occurs through basic reflexes, senses and motor responses.
STRESS AND COPING PATTERNS
The patient is still a month old, he only uses his cries as a relief of stress or sign
of any discomfort.
VALUE AND BELIEF PATTERN
The patient’s mother verbalized that their religion is Roman Catholic. She said
they believe in one God only and do not believe in other things but only on what is
in the Bible. They go to church every Sunday and is a firm believer of Jesus Christ.
SEXUALITY-REPRODUCTIVE STAGE
In Sigmund Freud’s psychosexual stage of development, the patient is still i oral
stage wherein the libido is centered in the baby’s mouth. He gets much satisfaction
form putting all sorts of things in his mouth to satisfy libido and thus it demands.
Which at this stage in life are oral or mouth oriented such as, sucking, biting and
breastfeeding.
RECREATION, HOBBIES, AND PETS
The patient’s parents spare time to play with the child in order for the patient to
feel love and affection. Also, the patient’s family does not own any pets.
PERSONAL HABITS
Sleeping in about fourteen hours a day is the only habit that is developed by the
infant patient.
OCCUPATIONAL HEALTH PATTERNS
Their family is not exposed to any hazards at work because they all work at the
office.
SOCIO-ECONOMIC STATUS
His mother works at a private company as an engineer and has a monthly salary
of 7 thousand dollars per month and his husband also works at a private company
as an dentist which he earns 14 thousand dollars per month. The mother verbalized
that their earnings is enough to provide for their everyday needs.
ENVIRONMENTAL HEALTH PATTERN
They live in a Subdivision and are not exposed to any hazards at home. Their
house far from the road and is not dusty. Their house is well ventilated and with
proper lighting and is full of trees and plants but is organized.
SOCIAL PATTERN
Since the patient is still a four-week-old infant, he expresses his feelings with

8
alert, widened eyes and a rounded mouth. The bond grows between parents and
their baby during this stage.

VI. Nursing Assessment

A. DIGESTIVE/METABOLIC/NUTRITION

Objective Subjective
General Appearance: Usual Diet: Diet as Tolerated
☐ Alert/responsive ☒ Apathetic No. of meals per day: 5x a day
☐ Cachexia ☐ Abd’l Distention No. of fluid drink each day: 12 to 24
☐ Mass ☐ Tenderness/pain ounces a day
Alcohol and Beverages: milk
Skin: ☒ Dry ☐ Warm ☐ Cold Use of Tabaco: none
Loss of Appetite:
☐ Moist
☐ Anorexia ☐ Bulimia
Edema: None
Body weight:
☐ Pitting ☐ Non-pitting Grade:
N/A ☐ Previous 3.8kg ☐ Current 3.5kg

Eyeball: ☒ Sunken ☐ Moist ☐

Dry Undesired Weight loss: ☐ Yes ☐
No
☐ Others(specify)
Undesired Weight gain: ☐ Yes ☐
No
Mouth: ☐ Dentures ☐ Braces

9
☐ Cleft Palate ☐ Cleft Lip ☐ Ulcers Abdominal Pain: none
☐ Lesions: none ☐ LUQ ☐ RUQ ☐ LLQ ☐ RLQ

No. of teeth: Describe (PQRST): N/A

☐ Upper 0 ☐ Lower 0
Food restrictions R/T intolerance and
health problems or religious
Tongue: ☒ Dry ☐ Moist
practices?
☐ Furrows > NONE
Type of Feeding: Replacement feeding Difficulty in eating and swallowing:
Intravenous Fluid: D5IMB > None but vomits every after 30-60
Date of insertion: 03-24-2020 mins after feeding
☐ Loss of appetite ☒ Nausea
Wounds: none -
☒ Vomiting
Type: N/A
Location: N/A
Previous/Recent Illness:
Tube/Drainage: none ☐ Pneumonia ☐ Diabetic ☐ Heartburn
Color & Amount: none ☐ Gastric Ulcer ☐ Colon Cancer
☐ Thyroid Problem ☐ Abdominal
Vital Signs: T38.5°C P170bpm R60cpm Distention ☐ Abdominal
BP 50/40mmHg Pain/tenderness

Body Types: Elimination pattern:

☐ Ectomorph ☐ Mesomorph ☐ Diarrhea ☒ Constipation
☒ Endomorph ☐ Obese ☐ Thin Frequency of BM: Once every two
days

Character, Frequency, Amount,

Color, Odor:
> defecates once every two days and
usually small in amount. Brown in color
and has a little mucus in it. Also, it has
foul odor.
Drugs that affected the GI system:
> None.
Remarks: Nursing Diagnosis:
Has problems regarding insufficient Imbalanced nutrition: less than body
absorption of nutrients for the patient’s requirements
age. Also, frequent vomiting was noted.

B. RESPIRATORY SYSTEM
Objective Subjective
Breath Sounds: Previous/Recent Illnesses:

10
☐ Diminished/Absent ☐ Stridor ☐ Bronchitis ☐ Emphysema ☐
☐ Rales/Crackles ☐ Rhonchi/Wheezing Asthma
☐ None (atelectasis) ☒ ☐ Bronchiectasis ☐ Pneumonia
Bronchovesicular ☐ Hydrothorax ☐ Pneumothorax
Others: ☐ Hemothorax ☐ CHF ☐ Chest
Trauma ☐ Lung Cancer
Resonance:
☒ Resonant (specify) Nose and Sinuses:
☐ Hypo (specify) ☐ Epistaxis
☐ Obstruction_______(specify)
Retractions: N/A

Respiration/Oxygenation: Pleuritic Pain (chest pain on deep

☒ Normal (Relax, Effortless and Quiet) inspiration)
☐ Tachypnea ☐ Bradypnea ☐ Biot’s ☐ Yes ☒ No
☐ Pallor ☐ Cyanosis ☐ Pursed lip
☐ Nasal Flaring ☐ Cheyne-stoke Dyspnea (Use Visual Analog Scale):
☐ Restlessness ☐ Hyperventilation ☐ Mild ☐ Moderate ☐ Severe
☐ Hypoventilation ☐ At rest ☐ On exertion ☒ No
☐ Labored/Use accessory Muscle Dyspnea
(specify)
☐ O2 Inhalation - N/A liters/min Breathing Treatments/Medication:
RR: 60cpm O2sat 98% None

Smoking:
LOC: ☐ Alert ☒ Lethargic
☐ Yes For how long: __________
☐ Obtunded ☐ Stupor ☐ Comatose
☒ No
Tube/Drainage: none
☐ CTT ☐ Oral Airway Nutrition:
☐ Endotracheal Tube ☐ Ventilator ☐ Anorexia ☐ fatigue ☐ cachexia
☒ weight loss
Cough: ☐ Productive ☐ Non-
productive ☐ Weak ☐ Forceful Comments:

Sputum: none
☐ Mucoid ☐ Bloody ☐ Rusty ☐
Frothy
☐ Thick Tenacious Color:
____________

Chest: ☐ Tenderness ☐ Mass

☐ Crepitus ☐ Barrel Chest
☐ Asymmetrical ☐ Pigeon’s chest

Tactile Fremitus: ☐ Increase

☐ Decrease Location/Area: _____

11
 Excursion: ☐ Normal ☐ Decrease

Lung Consolidation: ☒ Absent

☐ Present
Location/Area: N/A

Remarks: Nursing Diagnosis:

No other unusualities found

C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Objective Subjective
Temperature: 38.5°C Previous/Recent Illness: Pneumonia
☐ CVA ☐ CHF ☐ MI ☐
Blood Pressure: 50/40mmhg Thrombophlebitis
Pulses Rate: 170bpm ☐ Family History of HPN ☐ Renal
Failure
Heart Rhythm: ☐ Bleeding Disorder
☐ Tachycardia
☐ Bradycardia Do you experience any of the
☐ Arrhythmia/ Dysrhythmia following?
☐ Chest pain ☐ Arm pain
Jugular Veins Distention: ☐ Leg pain ☐ Joint and Back
☐ Positive ☐ Negative ☐ Dyspnea ☐ Orthopnea
☐ Cough ☐ Numbness and
Nail bed Color: ☒ Pink ☐ Blue Tingling
☐ Pale ☐ Light headedness ☐ Fatigue and
weakness
Capillary Refill: Normal - less than 2 ☐ Palpitations
sec
Exercises: none
Edema: none
Frequency: N/A
☐ Pitting ☐ Non-Pitting Duration: N/A
Location: N/A
Problem experience with usual
Varicosities: activity and exercise: none
☐ Yes ☒ No
Location: none Factors Affecting Activity
Intolerance:

12
Calf Tenderness (Homan’s Sign): none
Right ☐ Positive ☒ Negative
Left ☐ Positive ☒
Negative

Remarks: Nursing Diagnosis:

Patient has above normal temperature Hyperthermia
and no other unusualities found.

D. INTEGUMENTARY SYSTEM
Objective Subjective
Skin: Skin history and Disorders: None
☒ Dry ☐ Intact ☒ Warm ☐ Cold
☐ moist
Turgor: decreased

☐ Pallor ☐ Cyanosis ☐ Jaundice

☐ Rashes ☐ Albinism ☐ Erythema
☐ Itching ☐ Petechia ☐ Acanthosis
☐ Drainage ☐ Swelling ☐ Surgical
Wound ☐ Discoloration
☐ Ecchymosis/hematoma
☐ Decubitus Ulcer Stage _________

Edema: none
☐ Pitting ☐Non-pitting Grade: -_
Region: N/A

Primary Skin Lesions: none

☐ Macule ☐ Papule ☐ Pustule
☐ Plaque ☐ Nodule/Tremor
☐ Vesicle/Bulla ☐ Cyst ☐ Wheal
Others: N/A

Secondary Skin Lesions: none

☐ Scale ☐ Crust ☐ Erosions
Others: N/A
Temperature: 38.5°C

Hair: ☐ Alopecia ☐ Hirsutism

13
☐ Patchy hair loss
Distribution: Even

Nails:
☐ Dirty ☐ Pallor ☐ Cyanosis
☐ Clubbing ☐ Paronychia
☐ Onycholysis

Capillary refill: Normal (Normal less

than 2 sec)
Color: Pink

Remarks: Nursing Diagnosis:

No unusualities were found

E. ELIMINATION
Objective Subjective
Mobility and Dexterity: Previous/Recent Surgery/Illness:
☒ Ambulatory ☐ Non-ambulatory Pneumonia
☐ Bedridden ☐ with assistive device
History of pain and discomfort: None
Tubes/Drainage/Stoma: none Diet: Hypoallergenic
☐ Colostomy ☐ Ileostomy ☐
Elimination Habits: 2-3x a
NGT
day___________
☐ Catheter (specify): N/A
Number Flatulence Passed:
Abdomen: _________
☐ Soft ☒ Firm (normal is 13-21x/day)
☐ Distended ☐ Non-distended
Bowel:
Bowel Sounds: (5 – 20 sounds/min) ☐ Loose bowel movement ___x/day
☐ Normoactive ☐ Hypoactive ☒ Constipation ☐ Impaction
☒ Hyperactive ☐ Absent ☐ Fecal Incontinence
☐ Retention/distention ☐ Black/tarry
Measurement:
Intake: 12 – 24 ounces a day stool ☐ Fresh blood ☒ Mucus
Urine Output:
Edema: none Urine:
☐ Pitting ☐ Non-pitting Grade: - ☐ Dysuria ☐ Urgency ☐ Polyuria
_____ ☐ Oliguria ☐ Nocturia ☐ Dribbling
☐ Incontinence ☐ Hematuria
Occult blood: ☐ Positive ☒ ☐ Retention ☐ Voiding freely
Negative ☐ Neurologic Impairment ☒ Residual

14
 ☐ Not tested urine (> 100ml)
Anus:
☐ Mass ☐ Hemorrhoids ☐ Polyps Describe CFACO. Describe comfort
and/or gene-bleeding, and/or
☐ Abscesses ☐ Inflammations ☐
discharge.
Fissures
>Voids less than normal due to
☐ Smooth Rectal walks ☐ Strong dehydration
Sphincter
☐ Rectal Prolapse ☐ Excoriations Medication taken that interferes with
☐ Lesions (specify) _____ normal elimination
☐ Ulcers (specify) _____ ☐ Laxatives ☐ Cathartics
☒ Not Assessed _____ ☐ others

Ostomy: Fluid intake per day: 12 – 24 ounces a

☒ None ☐ Temporary ☐ Permanent day
☐ Gastrostomy ☐ Jejunostomy ☐
Ileostomy Physical Activity: none
☐ Colostomy
Excessive Perspiration and Odor
Describe CFACO of ostomy drainage: Problem:
N/A ☐ Yes ☒ No

Remarks: Nursing Diagnosis:

Some unusualities were found such as
lesser than normal for a 4-week-old
infant stool. Lesser than normal output
due to patient’s underlying condition.

F. MUSCULOSKELETAL SYSTEM
Objective Subjective
Mobility: Do you experience any of the
☒ Ambulatory ☐ Non-Ambulatory following?
☐ Bedridden ☐ Cast/mold ☐ Lumbar pain ☐ Thoracic Pain
☐ Traction (specify) – N/A ☐ Cervical Pain ☐ Joint pain
☐ Assistive devices (specify) - N/A

Gait:
☐ Propulsive Gait ☐ Scissors Gait
☐ Spastic Gait (Hemiplegic)
☐ Waddling Gait
☐ Steppage Gait ☐ Foot drop
☐ Amputated Limb ☒ Normal
☐ Others ______________________

Posture: Normal

15
☐ Lordosis ☐ Kyphosis
☐ Scoliosis ☐Corrective Device
(specify) __________

Club foot (Talipes): None

☐ Varus ☐ Valgus ☐ Equinovarus
☐ Calcaneus

Muscle Strength:
RATE: 5/5 Classification: Normal
Strength
Explanation: muscle is functioning
normally and is able to maintain its
position even when maximum resistance
is applied.
☐ Atrophy ☐ Spasm ☐
Impaired ROM
☐ Joint swelling
☐Contractures/Deformities
☐ Tingling/Numbness ☐ Pressure
Ulcers
☐ Hyper-atrophy

Calf Tenderness (Homan’s Sign):

Right ☐ Positive ☒ Negative
Left ☐ Positive ☒ Negative

Activities of Daily Living:

Score: low
Explanation: Since patient is still an
infant, he is still completely dependent
to its mother.

☐ Bathing - ☐ Toileting -
☐ Bed Mobility - ☐ Dressing -
☐ Grooming - ☐ Feeding -

Remarks: Nursing Diagnosis:

There are no unusualities assessed

16
 G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC
Objective Subjective
LOC: Check the Following Risk Factors:
☐ Alert ☒ Lethargic ☐ Comatose normal
☐ Unresponsive ☐ Obtunded ☐ ☐ Older Adulthood ☒ Male
Stupor ☐ Hx Stroke or TIA ☐ Hypertension
☐ Decorticate ☐ Decerebrate ☐ Smoking ☐ Hx CVD
☐ Sleep apnea ☐ High level of
Responsive to: Cholesterol
☒ Verbal Stimuli ☒ Painful Stimuli ☐ Drug Abuse ☐ DM
☐ Oral Contraceptives
Glasco Coma Scale:
☐Menopausal ☐ Overweight
Eye Opening
Verbal Response
Motor Response
Do you experience any of the following:
GCS Score
none?
☐ Blurring ☐ Diplopia ☐ Photophobia
Cushing Triad: ☐ Positive ☒ Negative
(Respiratory changes, Increase BP, ☐ Pain ☐ Inflammation ☐ Cataract
Decreasing LOC) ☐ Glaucoma ☐ Headache
☐ Unusual Discharges
Pupillary Size: ☒ PERRLA ☐
Anisocoric ☐ Moves All Extremities
(MAE)

Orientation: ☐ Person ☐ Place

☐ Time/Date ☐ Pain (Pain Scale:
_______)

Vital Signs: BP:50/40mmhg T: 38.5°C

P: 170bpm R: 60cpm

Signs
Brudzinski’s sign: ☐ Positive ☒
Negative

Kernig’s sign: ☐ Positive ☒

Negative
Reflexes:
Patellar ☒ Positive ☐ Negative
Biceps ☒ Positive ☐ Negative
Triceps ☒ Positive ☐ Negative
Achilles ☒ Positive ☐ Negative
Remarks: Nursing Diagnosis:

17
Unusualities regarding patient’s level of Deficient fluid volume
consciousness was noted due to
dehydration.

VII. REVIEW OF SYSTEMS

HEAD:
 Normocephalic
 Hair: evenly
FACE: distributed
 Symmetric  Cognitive:
 No unusual Lethargic
movements 18
EYES: CIRCULATORY:
 Symmetric
 20/20 vision  BP = 50/40
VIII. ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE SYSTEM
The function of the digestive system is to break down the foods you eat,

release their nutrients, and absorb those nutrients into the body. Although the small

intestine is the workhorse of the system, where the majority of digestion occurs,

and where most of the released nutrients are absorbed into the blood or lymph, each of

the digestive system organs makes a vital contribution to this process (Figure 1).

Figure 1 Components of the Digestive System All digestive organs play

integral roles in the life-sustaining process of digestion.

As is the case with all body

systems, the digestive system does not work in isolation; it functions cooperatively

with the other systems of the body. Consider for example, the interrelationship

between the digestive and cardiovascular systems. Arteries supply the digestive

organs with oxygen and processed nutrients, and veins drain the digestive tract.

These intestinal veins, constituting the hepatic portal system, are unique; they do not

19
return blood directly to the heart. Rather, this blood is diverted to the liver where its

nutrients are off-loaded for processing before blood completes its circuit back to the

heart. At the same time, the digestive system provides nutrients to the heart muscle

and vascular tissue to support their functioning. The interrelationship of the digestive

and endocrine systems is also critical. Hormones secreted by several endocrine

glands, as well as endocrine cells of the pancreas, the stomach, and the small intestine,

contribute to the control of digestion and nutrient metabolism. In turn, the digestive

system provides the nutrients to fuel endocrine function. Table 23.1 gives a quick

glimpse at how these other systems contribute to the functioning of the digestive

system.

Accessory Structures

Each accessory digestive organ aids in the breakdown of food (Figure 23.3).

Within the mouth, the teeth and tongue begin mechanical digestion, whereas the

salivary glands begin chemical digestion. Once food products enter the small

intestine, the gallbladder, liver, and pancreas release secretions—such as bile and

enzymes—essential for digestion to continue. Together, these are called accessory

20
organs because they sprout from the lining cells of the developing gut (mucosa)

and augment its function; indeed, you could not live without their vital contributions,

and many significant diseases result from their malfunction. Even after development

is complete, they maintain a connection to the gut by way of ducts.

Histology of the Alimentary Canal

Throughout its length, the alimentary tract is composed of the same four tissue

layers; the details of their structural arrangements vary to fit their specific functions.

Starting from the lumen and moving outwards, these layers are the

mucosa, submucosa, muscularis, and serosa, which is continuous with the mesentery

(see Figure 23.3).

The mucosa is referred to as a

mucous membrane, because mucus

production is a characteristic feature

of gut epithelium. The membrane

consists of epithelium, which is in

direct contact with ingested food,

.
Figure23.3 Layers of the Alimentary Canal The wall of the alimentary
canal has four basic tissue layers: the  mucosa, submucosa, muscularis, and
serosa. and the lamina propria, a layer of

connective tissue analogous to the

dermis. In addition, the mucosa has a thin, smooth muscle layer, called the muscularis

mucosa (not to be confused with the muscularis layer, described below).

Epithelium—In the mouth, pharynx, esophagus, and anal canal, the epithelium

is primarily a non-keratinized, stratified squamous epithelium. In the stomach and

intestines, it is a simple columnar epithelium. Notice that the epithelium is in direct

contact with the lumen, the space inside the alimentary canal. Interspersed among its

epithelial cells are goblet cells, which secrete mucus and fluid into the lumen, and

21
enteroendocrine cells, which secrete hormones into the interstitial spaces between

cells. Epithelial cells have a very brief lifespan, averaging from only a couple of days

(in the mouth) to about a week (in the gut). This process of rapid renewal helps

preserve the health of the alimentary canal, despite the wear and tear resulting from

continued contact with foodstuffs.

Lamina propria—In addition to loose connective tissue, the lamina propria

contains numerous blood and lymphatic vessels that transport nutrients absorbed

through the alimentary canal to other parts of the body. The lamina propria also serves

an immune function by housing clusters of lymphocytes, making up the mucosa-

associated lymphoid tissue (MALT). These lymphocyte clusters are particularly

substantial in the distal ileum where they are known as Peyer’s patches. When you

consider that the alimentary canal is exposed to foodborne bacteria and other foreign

matter, it is not hard to appreciate why the immune system has evolved a means of

defending against the pathogens encountered within it.

Muscularis mucosa—This thin layer of smooth muscle is in a constant state of

tension, pulling the mucosa of the stomach and small intestine into undulating folds. These

folds dramatically increase the surface area available for digestion and absorption.

As its name implies, the submucosa lies immediately beneath the mucosa. A broad

layer of dense connective tissue, it connects the overlying mucosa to the underlying

muscularis. It includes blood and lymphatic vessels (which transport absorbed

nutrients), and a scattering of submucosal glands that release digestive secretions.

Additionally, it serves as a conduit for a dense branching network of nerves, the

submucosal plexus, which functions as described below.

The third layer of the alimentary canal is the muscalaris (also called the

muscularis externa). The muscularis in the small intestine is made up of a double

layer of smooth muscle: an inner circular layer and an outer longitudinal layer.
22
The contractions of these layers promote mechanical digestion, expose more of the

food to digestive chemicals, and move the food along the canal. In the most proximal

and distal regions of the alimentary canal, including the mouth, pharynx, anterior part

of the esophagus, and external anal sphincter, the muscularis is made up of skeletal

muscle, which gives you voluntary control over swallowing and defecation. The basic

two-layer structure found in the small intestine is modified in the organs proximal and

distal to it. The stomach is equipped for its churning function by the addition of a

third layer, the oblique muscle. While the colon has two layers like the small intestine,

its longitudinal layer is segregated into three narrow parallel bands, the tenia coli,

which make it look like a series of pouches rather than a simple tube.

The serosa is the portion of the alimentary canal superficial to the muscularis.

Present only in the region of the alimentary canal within the abdominal cavity, it

consists of a layer of visceral peritoneum overlying a layer of loose connective

tissue. Instead of serosa, the mouth, pharynx, and esophagus have a dense sheath of

collagen fibers called the adventitia. These tissues serve to hold the alimentary canal

in place near the ventral surface of the vertebral column.

Digestive System Processes and Regulation

The digestive system uses mechanical and chemical activities to break food

down into absorbable substances during its journey through the digestive system.

Table 23.3 provides an overview of the basic functions of the digestive organs.

ease as nutrients to the body.

23
 Table 23.3

Table 23.3 cont’d

24
Digestive Processes

The processes of digestion include six activities: ingestion, propulsion, mechanical or

physical digestion, chemical digestion, absorption, and defecation.

 The first of these processes, ingestion, refers to the entry of food into the alimentary

canal through the mouth. There, the food is chewed and mixed with saliva, which

contains enzymes that begin breaking down the carbohydrates in the food plus some

lipid digestion via lingual lipase. Chewing increases the surface area of the food and

allows an appropriately sized bolus to be produced.

Food leaves the mouth when the tongue and pharyngeal muscles propel it into the

esophagus. This act of swallowing, the last voluntary act until defecation, is an

example of propulsion, which refers to the movement of food through the

25
 digestive tract. It includes both the

voluntary process of swallowing and the

involuntary process of peristalsis.

Peristalsis consists of sequential,

alternating waves of contraction and

relaxation of alimentary wall smooth

muscles, which act to propel food along (Figure 23.5). These waves also play a role

in mixing food with digestive juices. Peristalsis is so powerful that foods and liquids

you swallow enter your stomach even if you are standing on your head.

Digestion includes both mechanical and chemical processes. Mechanical

digestion is a purely physical process that does not change the chemical nature of the

food. Instead, it makes the food smaller to increase both surface area and mobility.

It includes mastication, or chewing, as well as tongue movements that help break

food into smaller bits and mix food with saliva. Although there may be a tendency to

think that mechanical digestion is limited to the first steps of the digestive process, it

occurs after the food leaves the mouth, as well. The mechanical churning of food in

the stomach serves to further break it apart and expose more of its surface area to

digestive juices, creating an acidic “soup” called chyme. Segmentation, which occurs

mainly in the small intestine, consists of localized contractions of circular muscle of

the muscularis layer of the alimentary canal. These contractions isolate small sections

of the intestine, moving their contents back and forth while continuously subdividing,

breaking up, and mixing the contents. By moving food back and forth in the intestinal

lumen, segmentation mixes food with digestive juices and facilitates absorption.

In chemical digestion, starting in the mouth, digestive secretions break down

complex food molecules into their chemical building blocks (for example, proteins

26
into separate amino acids). These secretions vary in composition, but typically contain

water, various enzymes, acids, and salts. The process is completed in the small

intestine.

Food that has been broken down is of no value to the body unless it enters the

bloodstream and its nutrients are put to work. This occurs through the process of

absorption, which takes place primarily within the small intestine. There, most

nutrients are absorbed from the lumen of the alimentary canal into the bloodstream

through the epithelial cells that make up the mucosa. Lipids are absorbed into lacteals

and are transported via the lymphatic vessels to the bloodstream (the subclavian veins

near the heart). The details of these processes will be discussed later.

In defecation, the final step in digestion, undigested materials are removed

from the body as feces.

Digestive System: From Appetite Suppression to Constipation

Age-related changes in the digestive system begin in the mouth and can affect

virtually every aspect of the digestive system. Taste buds become less sensitive, so

food isn’t as appetizing as it once was. A slice of pizza is a challenge, not a treat,

when you have lost teeth, your gums are diseased, and your salivary glands aren’t

producing enough saliva. Swallowing can be difficult, and ingested food moves

slowly through the alimentary canal because of reduced strength and tone of muscular

tissue. Neurosensory feedback is also dampened, slowing the transmission of

messages that stimulate the release of enzymes and hormones.

Pathologies that affect the digestive organs—such as hiatal hernia, gastritis,

and peptic ulcer disease—can occur at greater frequencies as you age. Problems in the

small intestine may include duodenal ulcers, maldigestion, and malabsorption.

Problems in the large intestine include hemorrhoids, diverticular disease, and

27
constipation. Conditions that affect the function of accessory organs—and their

abilities to deliver pancreatic enzymes and bile to the small intestine—include

jaundice, acute pancreatitis, cirrhosis, and gallstones.

In some cases, a single organ is in charge of a digestive process. For example,

ingestion occurs only in the mouth and defecation only in the anus. However, most

digestive processes involve the interaction of several organs and occur gradually as

food moves through the alimentary canal (Figure 23.6).

Some chemical digestion occurs in the mouth. Some absorption can occur in the

mouth and stomach, for example, alcohol and aspirin.

Figure 23.6 Digestive Processes The digestive processes are ingestion, propulsion, mechanical digestion,
chemical  digestion, absorption, and defecation.

28
The Stomach

Although a minimal amount of carbohydrate digestion occurs in the mouth,

chemical digestion really gets underway in the stomach. An expansion of the

alimentary canal that lies immediately inferior to the esophagus, the stomach links the

esophagus to the first part of the small intestine (the duodenum) and is relatively fixed

in place at its esophageal and duodenal ends. In between, however, it can be a highly

active structure, contracting and continually changing position and size. These

contractions provide mechanical assistance to digestion. The empty stomach is only

about the size of your fist, but can stretch to hold as much as 4 liters of food and fluid,

or more than 75 times its empty volume, and then return to its resting size when

empty. Although you might think that the size of a person’s stomach is related to how

much food that individual consumes, body weight does not correlate with stomach

size. Rather, when you eat greater quantities of food—such as at holiday dinner—you

stretch the stomach more than when you eat less.

Popular culture tends to refer to the stomach as the location where all

digestion takes place. Of course, this is not true. An important function of the stomach

is to serve as a temporary holding chamber. You can ingest a meal far more quickly

than it can be digested and absorbed by the small intestine. Thus, the stomach holds

food and parses only small amounts into the small intestine at a time. Foods are not

processed in the order they are eaten; rather, they are mixed together with digestive

juices in the stomach until they are converted into chyme, which is released into the

small intestine.

As you will see in the sections that follow, the stomach plays several important roles

in chemical digestion, including the continued digestion of carbohydrates and the

29
initial digestion of proteins and triglycerides. Little if any nutrient absorption occurs

in the stomach, with the exception of the negligible amount of nutrients in alcohol.

Structure

There are four main regions in the stomach: the cardia, fundus, body, and pylorus

(Figure 23.15). The cardia (or cardiac region) is the point where the esophagus

connects to the stomach and through which food passes into the stomach.

Located inferior to the diaphragm, above and to the left of the cardia, is the dome-

shaped fundus. Below the fundus is the body, the main part of the stomach. The

funnel-shaped pylorus connects the stomach to the duodenum. The wider end of the

funnel, the pyloric antrum, connects to the body of the stomach. The narrower end is

called the pyloric canal, which connects to the duodenum. The smooth muscle pyloric

sphincter is located at this latter point of connection and controls stomach emptying.

In the absence of food, the stomach deflates inward, and its mucosa and submucosa

fall into a large fold called a ruga.

Figure 23.15 Stomach The stomach has four major regions: the cardia, fundus, body, and pylorus. The addition of  an inner oblique
smooth muscle layer gives the muscularis the ability to vigorously churn and mix food.

30
The convex lateral surface of the stomach is called the greater curvature; the concave

medial border is the lesser curvature. The stomach is held in place by the lesser

omentum, which extends from the liver to the lesser curvature, and the

greater omentum, which runs from the greater curvature to the posterior abdominal

wall.

Histology

The wall of the stomach is made of the same four layers as most of the rest of

the alimentary canal, but with adaptations to the mucosa and muscularis for the

unique functions of this organ. In addition to the typical circular and longitudinal

smooth muscle layers, the muscularis has an inner oblique smooth muscle layer

(Figure 23.16). As a result, in addition to moving food through the canal, the stomach

can vigorously churn food, mechanically breaking it down into smaller particles.

Figure 23.16 Histology of the Stomach The stomach wall is adapted for the functions of the stomach. In the  epithelium, gastric pits lead to
gastric glands that secrete gastric juice. The gastric glands (one gland is shown enlarged  on the right) contain different types of cells that
secrete a variety of enzymes, including hydrochloride acid, which  activates the protein-digesting enzyme pepsin.

The stomach mucosa’s epithelial lining consists only of surface mucus cells,

which secrete a protective coat of alkaline mucus. A vast number of gastric pits dot

the surface of the epithelium, giving it the appearance of a well-used pincushion, and

31
mark the entry to each gastric gland, which secretes a complex digestive fluid

referred to as gastric juice.

Although the walls of the gastric pits are made up primarily of mucus cells,

the gastric glands are made up of different types of cells. The glands of the cardia and

pylorus are composed primarily of mucus-secreting cells. Cells that make up

the pyloric antrum secrete mucus and a number of hormones, including the majority

of the stimulatory hormone, gastrin. The much larger glands of the fundus and body

of the stomach, the site of most chemical digestion, produce most of the

gastric secretions. These glands are made up of a variety of secretory cells. These

include parietal cells, chief cells, mucous neck cells, and enteroendocrine cells.

Parietal cells—Located primarily in the middle region of the gastric glands

are parietal cells, which are among the most highly differentiated of the body’s

epithelial cells. These relatively large cells produce both hydrochloric acid (HCl)

and intrinsic factor. HCl is responsible for the high acidity (pH 1.5 to 3.5) of the

stomach contents and is needed to activate the protein-digesting enzyme, pepsin. The

acidity also kills much of the bacteria you ingest with food and helps to

denature proteins, making them more available for enzymatic digestion. Intrinsic

factor is a glycoprotein necessary for the absorption of vitamin B12 in the small

intestine.

Chief cells—Located primarily in the basal regions of gastric glands are chief

cells, which secrete pepsinogen, the inactive proenzyme form of pepsin. HCl is

necessary for the conversion of pepsinogen to pepsin.

Mucous neck cells—Gastric glands in the upper part of the stomach contain

mucous neck cells that secrete thin, acidic mucus that is much different from the

32
mucus secreted by the goblet cells of the surface epithelium. The role of this mucus is

not currently known.

Figure 23.16 Histology of the Stomach The stomach wall is adapted for the

functions of the stomach. In the epithelium, gastric pits lead to gastric glands that

secrete gastric juice. The gastric glands (one gland is shown enlarged on the right)

Table 23.6

contain different types of cells that secrete a variety of enzymes, including

hydrochloride acid, which activates the protein-digesting enzyme pepsin.

Gastric Secretion

The secretion of gastric juice is controlled by both nerves and hormones.

Stimuli in the brain, stomach, and small intestine activate or inhibit gastric juice

33
production. This is why the three phases of gastric secretion are called the cephalic,

gastric, and intestinal phases (Figure 23.17). However, once gastric secretion begins,

all three phases can occur simultaneously.

pha

ses :

Figure 23.17 The Three Phases of Gastric Secretion Gastric secretion occurs in three

cephalic, gastric, and intestinal. During each phase, the secretion of gastric juice can

be stimulated or inhibited.

34
 The cephalic phase (reflex phase) of gastric secretion, which is relatively

brief, takes place before food enters the stomach. The smell, taste, sight, or thought of

food triggers this phase. For example, when you bring a piece of sushi to your

lips, impulses from receptors in your taste buds or the nose are relayed to your brain,

which returns signals that increase gastric secretion to prepare your stomach for

digestion. This enhanced secretion is a conditioned reflex, meaning it occurs only

if you like or want a particular food. Depression and loss of appetite can suppress the

cephalic reflex.

The gastric phase of secretion lasts 3 to 4 hours, and is set in motion by local

neural and hormonal mechanisms triggered by the entry of food into the stomach. For

example, when your sushi reaches the stomach, it creates distention that activates

the stretch receptors. This stimulates parasympathetic neurons to release

acetylcholine, which then provokes increased secretion of gastric juice. Partially

digested proteins, caffeine, and rising pH stimulate the release of gastrin from

enteroendocrine G cells, which in turn induces parietal cells to increase their

production of HCl, which is needed to create an acidic environment for the conversion

of pepsinogen to pepsin, and protein digestion. Additionally, the release of gastrin

activates vigorous smooth muscle contractions. However, it should be noted that the

stomach does have a natural means of avoiding excessive acid secretion and potential

heartburn. Whenever pH levels drop too low, cells in the stomach react by

suspending HCl secretion and increasing mucous secretions.

The intestinal phase of gastric secretion has both excitatory and inhibitory

elements. The duodenum has a major role in regulating the stomach and its emptying.

When partially digested food fills the duodenum, intestinal mucosal cells release a

hormone called intestinal (enteric) gastrin, which further excites gastric juice

35
secretion. This stimulatory activity is brief, however, because when the intestine

distends with chyme, the enterogastric reflex inhibits secretion. One of the effects

of this reflex is to close the pyloric sphincter, which blocks additional chyme from

entering the duodenum.

The Mucosal Barrier

The mucosa of the stomach is exposed to the highly corrosive acidity of gastric juice.

Gastric enzymes that can digest protein can also digest the stomach itself. The

stomach is protected from self-digestion by the has several components. First, the

stomach wall is covered by a thick coating of bicarbonate-rich mucus. This mucus

forms a physical barrier, and its bicarbonate ions neutralize acid. Second, the

epithelial cells of the stomach's mucosa meet at tight junctions, which block gastric

juice from penetrating the underlying tissue layers. Finally, stem cells located where

gastric glands join the gastric pits quickly replace damaged epithelial mucosal cells,

when the epithelial cells are shed. In fact, the surface epithelium of the stomach is

completely replaced every 3 to 6 days.

Digestive Functions of the Stomach

The stomach participates in virtually all the digestive activities with the exception of

ingestion and defecation. Although almost all absorption takes place in the small

intestine, the stomach does absorb some nonpolar substances, such as alcohol and

aspirin.

Mechanical Digestion

Within a few moments after food after enters your stomach, mixing waves begin to

occur at intervals of approximately 20 seconds. A mixing wave is a unique type of

peristalsis that mixes and softens the food with gastric juices to create chyme. The

initial mixing waves are relatively gentle, but these are followed by more intense

36
waves, starting at the body of the stomach and increasing in force as they reach the

pylorus. It is fair to say that long before your sushi exits through the pyloric sphincter,

it bears little resemblance to the sushi you ate.

The pylorus, which holds around 30 mL (1 fluid ounce) of chyme, acts as a filter,

permitting only liquids and small food particles to pass through the mostly, but not

fully, closed pyloric sphincter. In a process called gastric emptying, rhythmic mixing

waves force about 3 mL of chyme at a time through the pyloric sphincter and into the

duodenum. Release of a greater amount of chyme at one time would overwhelm the

capacity of the small intestine to handle it. The rest of the chyme is pushed back into

the body of the stomach, where it continues mixing. This process is repeated when the

next mixing waves force more chyme into the duodenum.

Gastric emptying is regulated by both the stomach and the duodenum. The presence

of chyme in the duodenum activates receptors that inhibit gastric secretion. This

prevents additional chyme from being released by the stomach before the duodenum

is ready to process it.

Chemical Digestion

The fundus plays an important role, because it stores both undigested food and gases

that are released during the process of chemical digestion. Food may sit in the fundus

of the stomach for a while before being mixed with the chyme. While the food is in

the fundus, the digestive activities of salivary amylase continue until the food begins

mixing with the acidic chyme. Ultimately, mixing waves incorporate this food with

the chyme, the acidity of which inactivates salivary amylase and activates lingual

lipase. Lingual lipase then begins breaking down triglycerides into free fatty acids,

and mono- and diglycerides.

37
The breakdown of protein begins in the stomach through the actions of HCl and the

enzyme pepsin. During infancy, gastric glands also produce rennin, an enzyme that

helps digest milk protein.

Its numerous digestive functions notwithstanding, there is only one stomach function

necessary to life: the production of intrinsic factor. The intestinal absorption of

vitamin B12, which is necessary for both the production of mature red blood cells and

normal neurological functioning, cannot occur without intrinsic factor. People who

undergo total gastrectomy (stomach removal)—for life-threatening stomach cancer,

for example—can survive with minimal digestive dysfunction if they receive vitamin

B12 injections.

The contents of the stomach are completely emptied into the duodenum within 2 to 4

hours after you eat a meal. Different types of food take different amounts of time to

process. Foods heavy in carbohydrates empty fastest, followed by highprotein foods.

Meals with a high triglyceride content remain in the stomach the longest. Since

enzymes in the small intestine digest fats slowly, food can stay in the stomach for 6

hours or longer when the duodenum is processing fatty chyme. However, note that

this is still a fraction of the 24 to 72 hours that full digestion typically takes from start

to finish.

38
39
IX. PATHOPHYSIOLOGY

PREDISPOSING FACTORS PRECIPITATING FACTORS

 First-born white males of
northern European ancestry
 Male
 Bottle-feeding
 Low serum lipids
 Persisting duodenal hyperacidity,
due to a high parietal cell mass
(pcm) and loss of gastrin control
 Genetic factors
 Lack of exposure to vasoactive
 Mother smoking during
Pregnancy
 Deficiency of nitric oxide
synthase containing neurons
 abnormal myenteric plexus
innervation
 Infantile hypergastrinemia
 Exposure to macrolide
antibiotics
intestinal peptide in breast milk
 Hypersensitivity to motilin

ETIOLOGY
Hypertrophy and hyperplasia of the 2 (circular and longitudinal) muscular layers of
the pylorus occurs, leading to narrowing of the gastric antrum. The pyloric canal
becomes lengthened, and the whole pylorus becomes thickened. The mucosa is
usually edematous and thickened. In advanced cases, the stomach becomes markedly
dilated in response to near-complete obstruction.

Surgery: Pyloromyotomy

S/sx: Projectile vomiting,

sour smelling vomitus,
drooling, gagging, spit-ups,
regurgitation, constant
Delayed gastric emptying hiccups

 Control hydration

Decreased nutrient absorption  IV rehydration

S/sx: increased hunger,

persistent abdominal pain
and vomiting, foul- smelling
stools, weight loss,
increased susceptibility to
infection, slowing of growth
and weight gain, has dry
and scaly skin rashes.

40
X. MEDICAL/SURGICAL MANAGEMENT

Treatment: Pyloromyotomy

Surgery is needed to treat pyloric stenosis. The procedure (pyloromyotomy) is

often scheduled on the same day as the diagnosis. If your baby is dehydrated or has

an electrolyte imbalance, he or she will have fluid replacement before surgery.

In pyloromyotomy, the surgeon cuts only through the outside layer of the

thickened pylorus muscle, allowing the inner lining to bulge out. This opens a

channel for food to pass through to the small intestine.

Enlargement of the pylorus causes a Pyloromyotomy is often

narrowing (stenosis) of the opening from the
stomach to the intestines, which blocks done using minimally invasive
stomach contents from moving into the
intestine surgery. A slender viewing

instrument (laparoscope) is

inserted through a small incision

Backflow of stomach contents
near the baby's navel. Recovery

from a laparoscopic procedure is usually quicker than recovery from traditional

surgery, and the procedure leaves a smaller scar.

After surgery, the patient might be given intravenous fluids for a few hours.

You can start feeding your baby again within 12 to 24 hours. The patient might want

to feed more often since some vomiting may continue for a few days.

41
 Potential complications from pyloric stenosis surgery include bleeding and

infection. However, complications aren't common, and the results of surgery are

generally excellent. Also, there are no known medications for this condition.

XI. LABORATORY RESULTS

Blood tests will reveal low blood levels of potassium and chloride in

association with an increased blood pH and high blood bicarbonate level due to loss

of stomach acid (which contains hydrochloric acid) from persistent vomiting. There

will be exchange of extracellular potassium with intracellular hydrogen ions in an

attempt to correct the pH imbalance.

Hypochloremic hypokalemic metabolic alkalosis is the characteristic

biochemical disturbance observed in pyloric stenosis.

42
XII. DIAGNOSTIC PROCEDURES

Ultrasonography

 The criterion 89j

Barium upper GI study

 Effective when ultrasonography is not diagnostic

 Should demonstrate an elongated pylorus with antral indentation from the

hypertrophied muscle

 May show the "double track" sign when thin tracks of barium are compressed

between thickened pyloric mucosa or the "shoulder" sign when barium

collects in the dilated prepyloric antrum

 After upper GI barium study, irrigating and removing any residual barium

from the stomach is advisable to avoid aspiration

Endoscopy

 Reserved for patients with atypical clinical signs when ultrasonography and

UGI studies are nondiagnostic

43
44
XIII. NURSING CARE PLANS

Problem 1 (PE format): Deficient fluid volume r/t hypotonic dehydration

Cause analysis: The negative fluid balance causing dehydration results from increased output.

Level of Prioritization: High

Goal: The patient will be able to maintain fluid volume at functional level

CUES DESIRED OUTCOMES INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent: Short Term Goal:

-mother states that At the end of 2 hours -Establish rapport to - To gain trust and Goal successfully met.
the patient exhibits of continuous nursing care the client and significant confidence After 2hrs of nursing care
excessive thirst. and proper health others and proper health
teachings the patient will teachings the patient
Objective: - Monitored and - To obtain baseline data
manifest: manifested:
recorded v/s
-Dry mucous membrane
- Decreased risk for * Decreased risk for
- Provide proper - To avoid other fluid
- Increased body complications of fluid complications of fluid
ventilation and cool loses through excessive
temperature volume deficit volume deficit
environment. sweating.
-Increased pulse rate -Significant others will * Significant others
Collaborative:
know the proper understand the

43
 -Dry skin intervention of the - IVF administered as - To deliver fluids intervention of the
problem. ordered. Maintained at accurately at desired rates. problem
- Sunken eyeballs
proper regulation.
- Establish normal Long Term Goal:
- Slightly sunken
body temperature of 37°C
fontanels Goal met as evidenced by
Long Term: no further abnormal
-vaguely weak in
changes in vital signs.
appearance After 2 days of
continuous nursing care
and proper health
teachings the client will
maintain fluid volume at
functional level as
evidenced by:

- Maintain normal vital

signs of temperature
37°C, pulse rate of 80-
160bpm and respiratory
rate of 30-60cpm.

44
Problem 2 (PE format): Hyperthermia r/t dehydration

Cause analysis: Body temperature elevated above normal range due to surface blood vessels constricting which effectively halted sweat

production.

Level of Prioritization: High

Goal: Maintain core temperature within normal range

CUES DESIRED OUTCOMES INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent: Short Term Goal:

-mother states that At the end of 1 hour - Provide tepid sponge - Enhances heat loss by After 1 hour of nursing

the patient is hot to touch of continuous nursing care bath evaporation and intervention, the client’s

Objective: and proper health - Assess fluid loss and conduction. temperature decreased

- Body temperature teachings the patient’s facilitate oral intake. - Increases metabolic rate from 38.5°C to 37°C as

above normal range temperature will return to - Provide proper and diaphoresis. evidenced by relief from

(38.5°C) normal as manifested by: ventilation and cool - Dissipates heat by discomfort of patient no

- Flushed skin: warm to - Temperature within environment. convection. further abnormal changes

touch normal range (36.5°C to - Monitor vital signs on patient.

45
 -Facial grimacing, 38°C) - Notes progress and

crying. - Relief signs of Collaborative: changes of condition. Long Term Goal:

- Weak in appearance discomfort such as - Maintain IV fluids as Goal met as the patient

grimacing and crying. ordered by the physician. - Prevents dehydration. was able to maintain

Long Term: - Administer anti- normal temperature of

After 2 days of pyretic as ordered by the - Reduces fever 36.5°C-38°C and no

continuous nursing care physician. further complications was

and proper health noted.

teachings the client will

maintain body

temperature in normal

range as 36.5°C-38°C

Problem 3 (PE format): Imbalanced nutrition: less than body requirements r/t inability to ingest/digest food

Cause analysis: Intake of nutrients insufficient to meet metabolic needs due to underlying condition of pyloric stenosis

Level of Prioritization: High

46
Goal: Display normalization of laboratory values

CUES DESIRED OUTCOMES INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent: Short Term Goal:

- Mother states that After 4hrs of nursing - Ascertain significant - To determine Goal successfully met.

the patient experiences intervention and proper others’ understanding of informational need of the After 4hrs of nursing care

excessive vomiting and health teaching, the individual nutritional client. and proper health

has not gain weight since client’s family will be able needs. teachings the patient’s

then. to verbalize understanding significant others

Objective: of causative factors when Collaborative: understood the causative

- Weak in appearance known and necessary - IVF administered as - To deliver fluids factors when known and

- Hyperactive bowel interventions ordered. Maintained at accurately at desired rates. necessary interventions.

sounds Long Term: proper regulation.

- Loss of weight After several - Assist in - To avoid any delays and

- Weakness of muscles independent and treating/managing prevent patient discomfort Long Term Goal:

collaborative underlying causative Still on further evaluation.

factors.
47
interventions, patient will - Consult

be able to show dietician/nutritional team - To implement

normalization of as indicated interdisciplinary team

laboratory results and will management.

no longer experience

excessive vomiting.

48
XIV. Discharge Plan

Medication  Encourage patient parent to follow medication

prescribe by the physician.

Exercise  Encourage patient’s parents to involve the child in

some newborn exercise time. This is something
that the child will learn to look forward to as an
opportunity to try out new moves and have the
parents’ attention. As the child grows, motivate
parents to continue the child’s workout while
incorporating new activities.

Treatment  Encourage patient’s parents to follow the doctor’s

order for any post-operative treatment given.
 Health teaching about proper incision care for
Health Teaching keeping the baby’s incision clean and dry should
be done.

 Other home care teachings should also be given to

the parents such as, feeding and pain treatment.

 Also health teaching about breastfeeding and its

benefit should be given to the patient’s mother.

Out Patient (check-up)  Encourage the patient’s parents to visit physician

as scheduled by the attending physician for further
evaluation of patients’ health status.
 Encourage patient’s mother to continue
Diet breastfeeding as the child is still an infant. If they
still use the formula, encourage parents to not give
the baby more than 3 ounces every three hours for
the first 3 days. After 3 days, the patient’s parents
can slowly increase the amount.
 Encourage the family to strengthen spiritual

49
Spiritual connection to God by prayers and attending mass.
Encourage the family to mediate to peaceful body and
soul.

50