Pyloric Stenosis Nursing Care Planning and Management

Pyloric stenosis is the muscle at the stomach outlet thickening until food cannot pass into the small intestine. The infant vomits, dehydrates, and fails to thrive. Your work is vigilant monitoring of fluids and electrolytes, family teaching, and coordinating with the team around the corrective surgery.

What is Pyloric Stenosis?

Pyloric stenosis, also called infantile hypertrophic pyloric stenosis (IHPS), is the most common cause of intestinal obstruction in infancy. The circular muscle fibers of the pylorus hypertrophy and the lumen narrows severely. The pylorus thickens to as much as twice its size, elongates, and takes on a cartilage-like consistency; with the stomach's outlet obstructed, the stomach dilates.

Pathophysiology

Blair first reported autopsy findings of pyloric stenosis in 1717. Marked hypertrophy and hyperplasia of the 2 muscular layers of the pylorus (circular and longitudinal) narrow the gastric antrum. The pyloric canal lengthens and the whole pylorus thickens. The mucosa is usually edematous and thickened, and in advanced cases the stomach becomes markedly dilated against the near-complete obstruction.

Statistics and Incidences

Incidence is 2-4 per 1000 live births. Death is rare and unexpected; the reported mortality rate is very low and usually follows delayed diagnosis with eventual dehydration and shock. IHPS is more common in whites than Hispanics, blacks, or Asians, at 2.4 per 1000 live births in whites, 1.8 in Hispanics, 0.7 in blacks, and 0.6 in Asians. It carries a male-to-female predominance of 4-5:1, and 30% of patients are first-born males. The usual age of presentation is approximately 2 to 6 weeks of life, and about 95% of cases are diagnosed in infants aged 3-12 weeks.

Causes

The causes are multifactorial. A cohort study found that treating young infants with macrolide antibiotics was strongly associated with IHPS. A nationwide study of nearly 2 million Danish children born between 1977 and 2008 gives strong evidence for familial aggregation and heritability. Impaired neuronal nitric oxide synthase (nNOS) synthesis has been implicated, as it has in achalasia, diabetic gastroparesis, and Hirschsprung disease.

Clinical Manifestations

Pyloric stenosis is rarely symptomatic in the first days of life. It has occasionally been recognized shortly after birth, but the average infant shows nothing until about the third week of life. Classically the infant has nonbilious vomiting or regurgitation that may turn projectile (in as many as 70% of cases), and the infant is still hungry afterward. Jaundice may develop and resolves once the disease is corrected. As obstruction worsens, dehydration and malnutrition appear: poor weight gain, weight loss, marasmus, decreased urine output, lethargy, and shock. In as many as 60-80% of infants, a firm, nontender, mobile, hard pylorus 1-2 cm in diameter, the "olive," is palpable in the right upper quadrant at the lateral edge of the rectus abdominis. Gastric peristalsis may be visible just before emesis as the waves try to push past the obstruction.

Assessment and Diagnostic Findings

Diagnosis is usually clinical. Obtain electrolytes, pH, BUN, and creatinine at the same time as IV access. If the presentation is typical and an olive is felt, the diagnosis is almost certain, but formal ultrasonography is still recommended to evaluate the pylorus and confirm. Barium swallow shows abnormal retention of barium in the stomach and increased peristalsis.

Medical Management

Prehospital care follows pediatric advanced life support (PALS) recommendations for infants who are dehydrated or in shock. Correct fluid loss, electrolytes, and acid-base imbalance first, starting with an initial fluid bolus (20 ml/kg) of isotonic crystalloid. Feeding can begin 4-8 hours after recovery from anesthesia; infants fed earlier than 4 hours do not have a worse total clinical outcome, but they vomit more frequently and severely, which means more discomfort for the infant and anxiety for the parents. The treatment of choice is pyloromyotomy, also known as the Fredet-Ramstedt operation.

Pharmacologic Management

IV atropine for pyloric stenosis ranges across studies from 0.04 to 0.225 mg/kg/day, given for 1 to 10 days. Once IV therapy is deemed successful, oral atropine (0.08 to 0.45 mg/kg/day) is continued for 3 weeks to 4 months.

Nursing Management

Nursing Assessment

Assess the history of vomiting: when it started and its character. Ask the caregiver about constipation and scanty urine. On physical exam the infant may show dehydration, so obtain weight and check skin turgor and condition, the anterior fontanelle, temperature, apical pulse rate, irritability, lethargy, urine, the lips and oral mucous membranes, and the eyes. Watch for visible gastric peristalsis while the infant eats.

Nursing Diagnoses

Common diagnoses include imbalanced nutrition (less than body requirements) related to inability to retain food; deficient fluid volume related to frequent vomiting; impaired oral mucous membrane related to NPO status; risk for impaired skin integrity related to fluid and nutritional deficit; and compromised family coping related to the seriousness of the illness and impending surgery.

Nursing Care Planning and Goals

The plan aims to improve nutrition and hydration, maintain mouth and skin integrity, and relieve family anxiety.

Nursing Interventions

If the infant is severely dehydrated and malnourished, rehydrate with IV fluid and electrolytes; formula thickened with infant cereal and fed through a large-holed nipple can improve nutrition, given slowly with the infant upright in a seat or held. Provide good mouth care, since the oral membranes may be dry from dehydration and withheld oral fluids before surgery, and offer a pacifier to satisfy the need to suck during the interruption in feeding. Promote skin integrity by repositioning, changing the diaper, and applying lanolin or A and D ointment to dry areas. Promote family coping: involve caregivers in surgical preparation, explain the added IV fluids, the reason for ultrasonography or barium swallow, and the function of the NG tube and saline lavage, describe the procedure, and tell them what to expect and how long it will last.

Evaluation

The plan is met when nutrition and hydration improve, mouth and skin integrity hold, and family anxiety eases.

Documentation Guidelines

Document individual findings (contributing factors, interactions, the nature of social exchanges, specifics of behavior), intake and output, characteristics of vomitus, cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and attainment of or progress toward the desired outcomes.