Exemplars 4.1 & 4.5: Gastroesophageal Reflux Disease and Pyloric Stenosis

Transient relaxation of the lower esophageal sphincter.

An incompetent lower esophageal sphincter.

Increased pressure within the stomach.

Increased gastric contents.

Increased gastric volume, such as after meals.

Positioning that allows gastric content to remain close to the gastroesophageal junction, such as bending over and lying down.

Increased gastric pressure, such as obesity and wearing tight clothes.

Excessive alcohol consumption and smoking

Pregnancy

Obesity

Excessive alcohol consumption

Smoking

Hiatial hernia

Pregnancy

Wearing tight clothing

"Prolonged exposure to gastric contents can cause something cause esophagitis, which can cause red, easily torn tissue; ulcers; and eventually, permanent restriction of the esophagus."

"If you don't treat the gastrointestinal reflux, your child will have lifelong digestive issues."

"If you don't treat the gastrointestinal reflux, your child will be in constant pain when eating, which may lead to disordered eating patterns and nutritional issues in the future."

"If you don't treat the gastrointestinal reflux, your child has a high chance of getting esophageal cancer."

"We should give our child smaller and more frequent meals. This may require talking to his teacher about letting him have an additional snack during class."

"We will be sure to use the list of non-acidic foods that you gave us when we're feeding our child."

"It shouldn't be a problem that we give our child a healthy snack before bedtime. It's part of his bedtime routine."

"We should be careful to keep our child's weight down."

"I should probably stop drinking my daily cup of coffee, and avoid orange juice if at all possible."

"I usually go to bed between 11 and midnight. I should avoid eating right before that."

"I need to be careful what dresses I wear, but I can still wear my skinny jeans, although I'm not too pleased by my 'muffin top'."

"I should avoid smoking with my friends or stealing my parents' alcohol."

"I should probably loose a bit of weight since I'm currently obese."

A breakfast of apple juice, eggs, toast, and bacon.

A breakfast of tea and cereal with whole-fat milk.

A lunch of a peanut butter and jelly sandwich with whole-fat milk.

A dinner of spaghetti with garlic bread and a glass of water on the side.

Coughing

Difficulty swallowing

Asthma symptoms

Back arching

Periods of apnea

Frequent upper respiratory infections.

The lower esophageal sphincter is often immature.

Infants are often over-fed.

They aren't more likely to have issues with gastrointestinal reflux.

They have less stomach emptying.

"Try burping your baby after every 1-2 ounces of milk."

"Test your baby for allergies to cow's milk before giving it to him for the first time."

"If you're worried that your baby is choking on your breast milk too much, there are pre-thickened formulas available.

"Keep your baby upright for a maximum of 30 minutes after feeding."

"It should be okay to lay your baby back in his crib if you need to get up and feed him in the middle of the night."

"Something called the pyloric orifice has thickened from inflammation and swelling due to genetics."

"This disorder was probably caused by the antibiotic therapy I received in my last trimester of pregnancy."

"This disorder is almost exclusive to males."

"The obstruction between the stomach and first part of the small intestine is caused by inflammation and swelling in the pyloric orifice. The cause is unknown."

Immediately after birth

3-6 weeks after birth

3-6 months after birth

12 months or more after birth

Vomiting within 30 minutes of a normal feed

Projectile vomiting that sometimes contains blood

Persistent hunger

Visible peristalsis across the infant's abdomen

"A pyloromyotomy is a risky, but necessary, surgery needed to reverse your baby's pyloric stenosis. We will make a small incision and split the pyloric muscle so food and fluid can get through."

"A pyloromyotomy is a procedure in which we will make a small incision and split the pyloric muscle to allow passage of food and fluid. As with any surgery, it has its risks, which I am willing to discuss with you."

"A pyloromyotomy is a procedure in which we will make a small incision and split the pyloric muscle to allow passage of food and fluid. It is relatively free of risks."

"This surgery is needed to reverse your baby's pyloric stenosis."

Fluid and electrolyte balance must be restored prior to surgery.

If the parents will not consent to the surgery, CPS will need to be called.

An NG tube should be inserted prior to the procedure.

The child should be given a laxative prior to the surgery to "flush out" the GI tract.

Presence of visible peristaltic waves.

Hyperactive bowel sounds upon auscultation.

Olive-shaped mass in the right upper quadrant of the abdomen upon palpation.

Hypoactive bowel sounds upon auscultation.

Olive-shaped pass in the upper left quadrant of the abdomen upon palpation.

Skin recoils when pinched.

Anterior fontanelle is not depressed.

Nostrils are dry.

Infant has 3-6 wet diapers weighing between 20 and 30 g daily.

Urine specific gravity is 1.012

Chloride is 101 mEq/L

Sodium is 138 mEq/L

Potassium is 3.2 mEq/L

pH is 7.40

Keep infant NPO

Educate the parents about NPO status.

Assess running IV line hourly as part of purposeful rounding.

Aspirate and measure gastric contents prior to feeding via NG tube.

Ask the parents to call nursing personnel to change their child's diaper rather than changing it themselves.

Monitor weight daily.

Keep the infant swaddled.

Encourage the parents to hold and cuddle their baby.

Provide a pacifier.

Instruct the parents to slide the diaper gently under the buttocks rather than lifting the legs when diapering their baby.

Inform the parents that vomiting may still occur after surgery, and to feed the infant again when he/she is interested.

Instruct the breastfeeding mother to temporarily pump and use bottles so the infant can be burped after every 1-2 ounces.

Teach the parents to hold the infant upright for 30 minutes after feeding.

Advise the parents to wait a full hour after feedings to play with or rock their baby.

Inform the parents that it is normal for the bandages or strips to fall off on their own.

Tell the parents to only give their child sponge baths until the wound has healed.