Infant with Pyloric Stenosis care plan - help

[ExodusPaige66]

I am writing a care plan for a 3 week old child diagnosed with pyloric stenosis. We need two diagnoses, 1 short term goal and 1 long term goal, and 3 independent interventions for each goal.

I have already chosen dehydration as the top priority, I have that care plan finished.

I am now working on the second care plan, on which I chose nutrition; less than body requirements r/t forceful vomiting AEB pyloric sphincter obstruction.

My short term goal is: patient will consume adequate nourishment within 6 hours postop, have 2 interventions for it and need one more. The two I have - "watch for s/s of infection, institute feedings shortly after surgery"

My long term goal: patient will be free of signs of malnutrition by discharge. I also have 2 interventions for this, and need 1 more. The two I have - "weight and emasure length of child and utilize a growth chart, recognize severe protein calorie malnutrition can result in septicemia and organ failure"

Our nursing diagnosis book is NOT tailored towards infants - so these care plans have been very difficult. Under the "Nutrition, lessthan body requirements, imbalanced" section, everything is about people who dont WANT to eat, not someone who physically cant because of vomiting.

Does anyone have suggestions of what my last 2 interventions should be?

[MendedHeart]

When you say "adequate nourishment" in your first short term goal, it needs to be measurable and specific...such as amount/type...what is considered adequate nutrition?

[KelRN215, BSN, RN]

"Adequate nourishment within 6 hours post-op"... I am not even sure what you mean by this. What is "adequate nourishment" for an infant? Is it realistic to expect an infant to be taking a full diet 6 hours after GI surgery?

[ExodusPaige66]

"Feedings are usually instituted soon after surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. The are offered slowly, in small amounts, and at frequent intervals as ordered"

That is NOT what I need help with. I will fix those things later, at this point I need help figuring out my interventions.

[MendedHeart]

Well you must have a clearly defined goal in order to plan interventions. ..for example...if you had an order to start promote at 20ml/hr and advance by 20ml every 8 hours to reach goal of 80ml/hr..then you would plan your interventions...monitor bowel souns.flush tube every 8 hours and before and after meds..etc etc..

[MendedHeart]

Also..for your first one..infection is not really a priority intervention for your ND and goal..also you want to monitor for nausea and vomiting..what about for the second one..weigh patient daily and monitor labs such as total protein and albumin/prealbumin as ordered

[ExodusPaige66]

Thank you so much. I do need a more clear goal - getting the information fixated on an infant is very difficult - I think I need to purchase an infant care plan book. Or just not use nutrition as the second nsg dx, but my text states fluid balance and nutrition are top priorities for pyloric stenosis.

I thought infection really wasn't good, I just didn't know what else to put.

Your comments help me try to really focus the goals and interventions more clearly.

[MendedHeart]

No problem..I think nutrition is an excellent one especially because its an infant

[Esme12, ASN, BSN, RN]

You are problem solving here so follow the 5 steps of the nursing process.

1. assessment
   
2. nursing diagnosis
   
3. planning
   
4. implementation
   
5. evaluation
   

Pyloric stenosis and pylorotomy (pyloromyotomy) should be researched as part of assessment. Pyloric stenosis is one of the causes of pediatric vomiting. These infants often suffer from failure to thrive and dehydration.

Pylorotomy is a surgical treatment for the pyloric stenosis. What do you want to know about medical treatments?

• expected patient behavior during the healing phase
  
• anticipated physician orders
  
• potential complications
  

After assessment you can move on to nursing diagnosis (problem identification). You should be concerned with actual problems that exist now or that may come about in the future (complications).

So your main concerns are....dehydration (fluid) and failure to thrive (nutrition).

How do you assess fluid balance in the infant? How many wet diapers should they have to indicate hydration? Infants are very susceptible to weight loss/gain at this age....so how would you measure this? What would your goal be that would indicate wt loss or gain is acceptable or not? How would a growth chart be applied to this?

[KelRN215, BSN, RN]

Thank you so much. I do need a more clear goal - getting the information fixated on an infant is very difficult - I think I need to purchase an infant care plan book. Or just not use nutrition as the second nsg dx, but my text states fluid balance and nutrition are top priorities for pyloric stenosis.

I thought infection really wasn't good, I just didn't know what else to put.

Your comments help me try to really focus the goals and interventions more clearly.

Nutrition is the right problem to focus on but "infant will take adequate nutrition within 6 hours" is not measurable the way you have worded it and is likely not attainable. An infant returning from the OR will return with a running IV. You should expect for the baby to be on strict I&O- how will you assess this? An infant also will likely begin eating post-op before an adult would since infants eat around the clock. As a pediatric nurse, I have never started an infant on clears- infants should not drink water because it can mess up their sodium levels and pedialyte is fairly useless. My hospital considered breast milk to be a "clear liquid" but orders for post-op infants were always "advance diet as tolerated". If it is a formula fed infant and they want to feed, I would let them feed. They may be slow to feed at first (the baby will be a little tired from the anesthesia and maybe nauseous) and the parents will need encouragement to continue trying.

[nurseprnRN, BSN, RN]

Yep, when it says "These are the priorities," that's something to pay attention to. It seems clear that nursing assessments and interventions would address fluid intake and output (you have some hints how to do that-- what are others? consult your peds text for information on that) and nutrition ( this doesn't have to be in the first few hours postop-- nutrition and weight gain won't happen today, so think of a long(er) term goal. Also, even little farts have pain postop-- what's an appropriate way to assess that and manage it? (peds textbook again :) )

What about patient teaching? What should the parents know about the surgery, expected outcomes, early and later postop course, followup?