University of San Agustin

General Luna St., 5000 Iloilo City, Philippines

www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING
Group 2

Demon, Karl
Deocampo, Trishia
Dinero, Myka Angelou
Ecogo, Ma. Raciela Aicha
Fuentes, Vea Shantellice
Gapuz, Andrew Louie
Gumabong, Ma. Noella
Lata, Winmarie Joyce
Magpusao, Zenna

CASE STUDY 1

SITUATION: Mr. and Mrs. B present to the emergency department with their 6 week old
infant, S.B. As the triage nurse, you ask the couple why they have brought S.B.
to the emergency department. Mrs. B states that, “My baby breast fed well for the first couple
of weeks but has recently been throwing up all the time, sometimes a lot and really forcefully.
He looks skinny and is hungry and fussy all the time. “You determine that this couple is
homeless and has been living out of their car for the past month. S. B has had no primary care
since discharge after delivery.

QUESTIONS:

1. What additional information will you need to obtain from Mr. and Mrs. B?

As a Triage nurse additional information that I need to obtain from Mr. and
Mrs. B are the following.

• Duration of breastfeeding
- When you breastfed, how long did it take?

It's important to know how long you've been breastfeeding because throwing up or vomiting
can happen if you feed your baby too quickly, swallow air, or overfeed them.

• Frequency of infant’s throwing up

- How frequently does your child throw up?

Having the information about the frequency of throwing up is helpful so we can assess if the
condition is severe or not. Since the doctor should be called if children have more than 6 to 8
episodes of vomiting, if the vomiting continues more than 24 to 48 hours,
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General Luna St., 5000 Iloilo City, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING
or if other symptoms (such as cough, fever, or rash) are present. However, persistent vomiting
can sometimes cause your child to become severely dehydrated

• Amount
- How much has your child throw up?

Seeking about this information will help triage nurse to assess if the child throws up that
much or not given that the child is skinny. Since too much vomiting can lead to dehydration
(not having enough water in the body). Children who are vomiting usually do not want to
latch, but this lack of appetite rarely causes a problem such as weight loss which is evident in
the scenario since the infant got skinny.

• Seeking information about the weight of the child at the time of delivery.
- What is the weight of your baby since he was born?

Obtaining information from the mother about the weight of the infant since
delivery serves as a baseline for a triage nurse to determine the infant's weight
loss.

• Color of the vomit

- What color or appearance does the vomit have?

It is important that triage nurse able to gather what is the color and appearance of the vomit
the child had. Since any neonate or infant with recurrent or bilious (yellow or green) emesis
or projectile vomiting most likely has a gastrointestinal obstruction and probably requires
surgical intervention. Blood in the vomit are the Swallowed blood (e.g. epistaxis, or in
neonate from maternal blood due to delivery or nipple trauma) Upper GI hemorrhage

• Check for Diarrhea

- Did your child vomit and then have diarrhea?

If diarrhea accompanies vomiting, the cause is probably gastroenteritis which is inflammation

of the digestive tract.

 Urine output
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General Luna St., 5000 Iloilo City, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING
Measuring urine output is also an information that the triage nurse should seek for. Triage
nurse will count the number of pads the infant used for a day. Also, the nurse will weigh the
diaper used to obtain urine output measure result.

 Family History
- - Does the family have history of this condition or any illness or
allergies present?

This information will aid the triage nurse in determining whether the baby's Pyloric
stenosis is due to genetic factors.

 Type of Infant’s Delivery

- What is your type of delivery during pregnancy?

Having information about the mother's delivery method will allow us to determine
whether she was delivered via CS or NSVD. Also because baby might be premature if
he or she was delivered via CS, her organs aren't fully developed and aren't
functioning properly. That could be the origin of the vomiting.

 Infection during Pregnancy

- - Have you acquired any infections during your pregnancy?

The triage nurse will benefit greatly from asking the mother if she had any infections during
her pregnancy. Since infection can have an impact on a baby's development, as well as the
use of antibiotics. Since antibiotics travel through the placenta, this will also affect the
development of baby's gastrointestinal system

2. What would you include in your physical assessment of S.B.?

• General appearance

Neurological:
 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING
Observe mental alertness, irritability, tetany, and lethargy because the baby with pyloric
stenosis is always hungry. Assess feeding of the baby as there may be failure to thrive.

Integumentary:
Examine the skin for color, skin turgor, and presence of lesions as poor skin turgor and
dryness may indicate dehydration and a mild yellow color indicates jaundice specifically
breastfeeding jaundice as baby with pyloric stenosis have difficulty in breastfeeding necause
of frequent vomiting.

Eyes:
Examine eyes if dry as it is also a sign of dehydration

Weight:
Measure weight to know whether patient S.B. has had major weight loss because of the
frequent vomiting and failure to thrive.

• Head and Mouth

Assess the anterior fontanelle as a sunken/depressed fontanelle may indicate dehydration.
Observe face if there is sign of weightloss and dehydration like sunken cheeks. Observe for
dry mucus or dry tongue as it indicates that the baby is dehydrated.

• Assess the child’s history of vomiting.

Ask when the vomiting started and determine the character of the vomiting whether she has a
forceful, projectile vomiting. Check if there is presence of mucus or blood and no bile.

• Cardiac
Assessing heart rate and rhythm. Presence of tachycardia may be a sign of dehydration, fever
or distress. The pulse rate of the baby may be increased as the heart tries to compensate for
the fluid deficit because of dehydration due to frequent vomiting of the patient.

• Abdominal
Assess bowel sounds. Using a stethoscope, the nurse listens for bowel sounds or evidence of
peristalsis in each section of the abdomen and records what is heard. Peristalsis are wavelike
contractions which are caused by stomach muscles trying to force food through the narrowed
pylorus. A firm non-tender olive mass may also be present in the right upper quadrant upon
palpation

• Gastrointestinal
Assess for the child’s stool and urine output particularly, the amount, characteristic, and odor.
More over, Check and weigh the pads used per day to determine if there is
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

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diarrhea and scanty urine that may be signs of dehydration. In pyloric stenosis, the muscles in
the stomach that connect to the small intestine enlarge this causes the opening of the pylorus
to become narrow .This stops food from moving from the stomach to the intestine. Thus, an
olive mass at the right upper quadrant may be visible due to enlargement and hyperistalsis or
visible peristaltic waves can be seen during feeding as the food tries to pass through the
narrow blockage. In auscultation, the bowel sounds are hyperactive as the baby passes loose
stools.

3. The emergency physician orders a complete blood count (CBC), complete metabolic profi

a.Na:128mEq/L,K:2.6mEq/L,Cl:90mEq/L,HCO3:28mEq/L- Metabolic Alkalosis

b.Na:130mEq/L,K:5.7mEq/L,Cl:94mEq/L,HCO3:22mEq/L-
c. Na:130mEq/L,K:3.9mEq/L,Cl:98mEq/L,HCO3:17mEq/L-
d. Na:148mEq/LK:4.1mEq/L,Cl:108mEq/L,HCO3:13mEq/

Explanation:

The normal range for HCO3 is between 22-26 mmol/L, and in Metabolic Alkalosis
there is an increase in serum bicarbonate or HCO3 thus among the answers the laboratory
results that indicate metabolic alkalosis is the one who has a bicarbonate level of 28 as it is
higher than normal as the body tries to compensate for the loss of acid. The normal value for
sodium in the body is between 135-145 mEq/L, the normal potassium level is between 3.5-
5.0 mEq/L, and chloride levels is between 95-105 mEq/L but in a state of metabolic alkalosis,
all these levels are decreased. In the patient’s case these levels decreased due to his severe
vomiting, when there is vomiting, the patient is losing hydrogen ions, sodium, potassium, and
chloride present in the hydrochloric acid or in the vomitus thus the body is losing acid and
becoming alkaline or becoming in a state of metabolic alkalosis. Thus the values,
Na:128mEq/L,K:2.6mEq/L,Cl:90mEq/L,HCO3:28mEq/L, indicate metabolic alkalosis
as there is decreased sodium, potassium, and chloride levels.

4. What is the underlying cause os S.B’s diagnosis of metabolic alkalosis?

The underlying cause of the patient’s diagnosis of metabolic alkalosis is his frequent
vomiting and loss of stomach acid. When the patient vomits, he loses the hydrogen ions and
key electrolytes present through the vomitus. His body loses acid as hydrochloric acid is
vomited away from the body thus making the body in an alkaline state or metabolic alkalosis.
These fluids that he vomited are rich in K+ and when you lose them you are losing hydrogen
ions and this causes the body to increase the bicarb
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING
level as it tries to compensate for the loss of acid, moreover, low potassium levels cause
reabsorption of HCO3- thus increase in bicarbonate. There is also decrease release of
pancreatic bicarbonate because of the obstruction thus there is retention of bicarbonate, and
the levels of HCO3 then increases in the lab results.

5. What additional assessment findings might reflect the consequences of

frequent prolonged vomiting in the infant?

a. Assessment of skin turgor – A patients normal skin turgor is less than 2 seconds
however if it is more than 2 seconds it could be a sign of fluid loss or dehydration,
which in S.B’s case , fluid loss is caused by frequent vomiting.

b. Assess for Vital Signs- Check patient’s temperature for hypothermia as it may
indicate dehydration. Check for patient’s heart rate as it will be increased as the heart
tries to compensate for the fluid deficit due to vomiting. Check for patient’s
respiration as the patient will have rapid shallow breaths

c. Assess for the eyes- The patient may be crying without tears as a result of
dehydration

d. Assessment of Head and Fontanels- A sunken fontanel could indicate that the
baby is dehydrated from frequent prolonged vomiting. The patient may also have
sunken cheeks due to dehydration

e. Assessment of mouth – A patient who is frequently vomiting may have a dry

tongue or mouth as a result of dehydration

f. Assess for risk for seizures , tetany and muscle spasms- The baby with
frequent prolonged vomiting has loss key electrolytes that is responsible for the
normal function of the body thus losing potassium and sodium may result to increased
risk for seizures and muscle spasms. Due to the electrolyte imbalance, the levels of
calcium will be affected also resulting in tetany .

g. Monitoring urinary output- A baby who has frequent prolonged vomiting could
have dehydration and lead to less urinary output or fewer wet diapers. Urine of baby
may also be dark colored due to dehydration.
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

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h. Assessment of weight and nutrition- The baby could lose weight due to
frequent prolonged vomiting as the gastric contents or food drank or eaten by the baby
were not absorbed by the body but is expelled out.

CASE 1 CONTINUATION:

S.B. is diagnosed with hypertrophic pyloric stenosis, admitted to the pediatric unit, and
scheduled for surgery.

QUESTIONS:

1. S.B.'s parents are concerned that their living situation contributed to S.B.'s
diagnosis. How would you respond to their concerns?

When dealing with parents of sick infants, one must be calm and patient. They
are typically seen to be worried and anxious about the situation. In this case, I would
tell the parents that the causes of pyloric stenosis are unknown but genetic and
environmental factors might play a role . Then I will educate the parents about the risk
factors for Pyloric Stenosis as follows:

a. Sex- Tell the parents that pyloric stenosis is observed more often in boys
and especially firstborn children than in girls.
b. Race- Pyloric stenosis is also more common in whites of European
ancestry, and less common in Black and rare in Asians
c. Premature birth- Tell parents that Pyloric stenosis is more common in
babies born prematurely than in full-term babies because it may be due to
underdeveloped organs.
d. Family history- Educate parents that pyloric stenosis may develop because
one in the family had history of it before. History of chronic illness ,
infection, and allergies may also play a role in causing the said condition.
e. Smoking during pregnancy- Tell parents that one of the environmental
factors that may cause pyloric stenosis is smoking either first hand or
secondhand during pregnancy.
f. Early antibiotic use- Educate parents that if their baby has taken any
antibiotics in the first weeks of life such as erythromicin, that it may
increase the risk for having pyloric stenosis as it interferes with the baby’s
peristalsis.
g. Bottle feeding- Teach parents that bottle feeding may increase risk of
pyloric stenosis in babies. This is because in breastfeeding aids in the
development of the intestinal mucosa barrier and provides immunologic
properties that prevents infection in baby that may result in pyloric
stenosis.
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General Luna St., 5000 Iloilo City, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

NURSING

Lastly, I will educate the parents the importance of having a safe environment for the
baby thus I will refer them then to a social worker that may help them in acquiring resources
for their needs and their baby’s needs. Then I will assure the parents that this condition is
treatable through surgery and clients often have fast recoveries after.

2. Mr. and Mrs. B. have questions about the necessity of surgery and question
what
is going to be done next. What are your responsibilities as you respond to
and Mrs. B.' s concerns?

As a nurse I will describe the surgical procedure to be performed and explain what to
expect and how long the operation will last. Also I will tell the client that the surgery is
necessary for the treatment of the baby’s condition. 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.The surgery is often done using minimally invasive surgery. A laparoscope is
inserted through a small incision near the baby's navel. Then I will assure them that recovery
from a laparoscopic procedure is usually quicker than recovery from traditional surgery, and
the procedure leaves a smaller scar. However the procedures to be done after the surgery will
be determined by the physician thus, i will tell them to ask the attending physician for more
queries about the next procedure.

I will educate the parents how to take care their baby after the surgery. Keep your
baby’s incision clean and dry. Don’t use lotion, powder, oil, or cream on the incision. You can
give your baby sponge baths for 2 days after the surgery. After that, you can give your baby
baths. Make sure to keep the incision out of the water. Don’t lift your baby under the arms.
This will stretch the stitches and may cause pain. Instead, lift your baby by supporting his or
her buttocks and head. If you breastfeed, you can breastfeed your baby as usual. If you use
formula, don’t give your baby more than 3 ounces every 3 hours for the first 3 days. After 3
days, you can slowly increase the amount.

S.B. returns to your unit following a pyloromyotomy. Mrs. B. is concerned when

she will be able to resume breastfeeding and what they need to do for their
baby.

3. What postoperative teaching would you provide to them?

 Explain to the parents of the infant that feeding can be initiated 4-8 hours as soon as
the baby wakes up from anesthesia and gradually increased the amount and
concentration of the feeding until full feeds are reached. Breast feeding may resume to
its normal feeding as before surgery. Small amounts of
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF

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vomiting are expected shortly after surgery until the baby's stomach has completely
healed from the procedure. They can be discharged from the hospital one or two days
after surgery.

 Ask for the cooperation of the parents for measuring the amount of liquid Intake and
urine output of the infant.

 Involved the parents in the wound care. Teach parents on incision or wound care and
also that they should not use lotion, oil, or powder on it.

 Warn parents that they should not lift baby under the arms as it will stretch stiches
instead they should lift the baby by supporting the buttocks and head.

 After the operation, no tub baths should be given for at least two days. Recommend
Sponge bathing for the infant the day following after two days from the operation.
Carefully pat dry the incision tapes after showering.

 Call the infants surgeon when there is active bleeding from the incision, difficulty
breathing, continuing vomiting and fever above 38 degrees.
 PYLORIC STENOSIS

PRECIPITATING FACTORS
PREDISPOSING
Sex
FACTORS 
 Race
 Smoking during pregnancy  Premature birth
 Early anti-biotic use DISEASE PROCESS  Family history of pyloric stenosis

Hypertrophy
Narrowing andand hyperplasia
obstruction of muscular
in the lumen oflayers of theantrum.
the gastric pylorus.

Stomach contents cannot flow easily through constricted

SIGNS AND SYMPTOMS

Impaired emptying of gastric contents

Peristaltic waves visible Dehydration symptoms Olive mass on RUQ

Projectile vomiting
from left to right across (sunken fontanels)
LAB0RATORY & DIAGNOSTICS PROCEDURE TEST
epigastrium during and after irritability, weight loss,
diarrhea, poor skin turgor,
Ultrasound X-rays of the baby's digestive system Endoscopy Blood tests
 TREATMENT

NURSING MANAGEMENT
MEDICAL MANAGEMENT

 Inform the parents to seek medical care if

vomiting develops or persists longer than 24
hours.
 Maintain adequate nutrition and fluid intake  Invasive Surgery of digestive system
as prescribed
IF TREATED AND MANAGE IF NOT TREATED(pyloromyotomy)
AND MANAGE
 Provide
 Infantmouth caresmall amounts during
vomit  Gastric
 Iv outlet obstruction
atropine
 Reposition client
the first dayto or
avoid
twoskin breakdown
after surgery  Electrolyte Imbalance
 Oral atropine
 Provide reassurance and comfort
but will gradually improve. measures.  Metabolic alkalosis
 provide
 Infantemotional
will besupport
able totodrink
the Family
breast  Paradoxical aciduria
 Explain toor
milk the parentswithout
formula the procedure
vomiting.and  Hypovolemic shock
what to expect postoperatively  Seizure
 Brain damage
GOOD PROGNOSIS
POOR PROGNOSIS
RECOVERY

DEATH
References:

❖ Belleza, M. (2021, February 11). Pyloric stenosis nursing care management and study guide. Nurseslabs. Retrieved May 24, 2022, from
https://nurseslabs.com/pyloric-stenosis/

❖ Default - Stanford Children's health. Stanford Children's Health - Lucile Packard Children's Hospital Stanford. (n.d.). Retrieved May 24, 2022, from
https://www.stanfordchildrens.org/en/topic/default?id=pyloric-stenosis-90P02404

❖ Vomiting in children and babies. NHS inform. (2021, April 2). Retrieved May 24, 2022, from https://www.nhsinform.scot/illnesses-and-
conditions/stomach-liver-andgastrointestinal-tract/vomiting-in-children-and-babies

❖ Consolini, D. M. (2022, May 23). Vomiting in Infants and Children. MSD Manual Consumer Version. https://www.msdmanuals.com/home/children-s-
healthissues/symptoms-in-infants-and-children/vomiting-in-infants-and-children

❖ Digestive Health Team. (2021, March 8). Do You Know When to Visit the Hospital for Vomiting? Cleveland Clinic. https://health.clevelandclinic.org/what-
causes-vomitingand-what-should-you-do-about-it/

❖ Physicians Immediate Care. (2021, June 14). Nausea, Vomiting, and Diarrhea.
https://physiciansimmediatecare.com/services/illnesses/nausea-vomiting-anddiarrhea

❖ Pyloromyotomy (inpatient care) - what you need to know. Drugs.com. (n.d.).

https://www.drugs.com/cg/pyloromyotomy-inpatient-care.html

❖ Sathyaseelan Subramaniam, M. D. (2021, June 22). Pediatric pyloric stenosis.

Practice Essentials, Pathophysiology, Epidemiology.
https://emedicine.medscape.com/article/803489-overview

❖ Sarah. (2021, September 24). Fluid and electrolytes nursing review: Comprehensive.
Registered Nurse RN. Retrieved May 24, 2022, from
https://www.registerednursern.com/fluid-and-electrolytes-nursing-reviewcomprehensive/

❖ Mayo Clinic. (2022, November 03). Pyloric stenosis. Mayo Clinic. (2022, November 03). Pyloric stenosis. https://www.mayoclinic.org/diseases-
conditions/pyloricstenosis/symptoms-causes/syc-20351416