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An interdisciplinary project that changed practice in Feeding methods after pyloromyotomy. (Continuing Education Series).

Hypertrophic pyloric stenosis (HPS) is an acquired condition of unknown etiology in which the pylorus muscle, the circumferencial muscle of the pyloric sphincter, becomes thickened causing elongation and obliteration of the pyloric channel (Raffensperger, 1990). It occurs in 1.5 to 4 out of 1,000 live births, usually within the first 3-5 weeks of life (Wong et al., 1999). There is some evidence of a genetic predisposition, with increased incidence in first-born males. Initially vomiting may be intermittent, but as the pylorus becomes more hypertrophied, projectile, nonbilious vomiting occurs with each feeding (Schwartz, 1998).

At the onset of symptoms infants may be thought to have feeding intolerance, milk allergy, overfeeding, or gastroesophogeal reflux (Morganelli, 2000). As the hypertrophy progresses, the diagnosis of HPS is confirmed by physical examination, upper gastrointestinal (UGI) study, or abdominal ultrasound. On abdominal examination, the pylorus muscle may be palpated as an olive-shaped mass in the epigastric region. An UGI will show a narrowing of the pyloric channel (see Figure 1). There is a potential risk of vomiting and aspiration of barium after a UGI, therefore barium is aspirated after the procedure using a nasogastric tube (Schwartz, 1998). The most common imaging study is abdominal ultrasound (Garcia & Randolph, 1990). With imaging, the diameter and length of the pyloric muscle is measured. Criteria may vary among institutions. A positive ultrasound for HPS reveals a pyloric muscle thickness of 4 mm or more and a pyloric channel length of 16 mm or more.

[FIGURE 1 OMITTED]

Surgical repair of HPS is not an emergency. Surgery is delayed until electrolyte balance is restored and the infant receives necessary fluid resuscitation. The level of dehydration and electrolyte imbalance depends on the length and severity of vomiting. Gastric losses cause hypochloremia and metabolic alkalosis that may take up to 24-48 hours to correct (Morganelli, 2000). To prepare the patient for anesthesia and surgical repair, sufficient time must be taken to correct electrolytes to within the normal range and stabilize fluid status. Pre and postoperative nursing care of the child with HPS takes into account the status of the patient and the surgical intervention (see Table 1).

The standard operation is a pyloromyotomy, which is performed through a small, transverse, upper abdominal incision or through a periumbilical incision. The pylorus is identified, and the hypertrophied muscle is split to the submucosa, which allows the pyloric channel to open (Schwartz, 1998) (see Figures 2 & 3). Some surgeons prefer laparoscopic pyloromyotomy. Complications from surgery are rare, but include gastric or duodenal perforation (Raffensperger, 1990) and wound infection. Overall, the surgery is well tolerated by the infants.

[FIGURES 2-3 OMITTED]

Planning for Change

After pyloromyotomy, infants usually achieve full feedings within 2-3 days and are discharged from the hospital. It has been a traditional belief that the slow reintroduction of feedings is necessary to prevent emesis. Infants at Children's Hospital Boston were being fed by the conventional feeding regimen, which was developed over 30 years ago. This regimen consisted of a 6-hour NPO period after surgery followed by small, frequent feedings increasing in strength and volume. Parents were not allowed to feed their infants immediately; a registered nurse (RN) or clinical assistant (CA) would feed them for the first part of the regimen. During this time, parents would be educated about feeding progression, frequent burping, and positioning after feeding. If the infant had emesis, the same volume and strength of the previous feeding would be offered at the next feeding. Intravenous (IV) fluids continued until the infant was tolerating feedings of 60 cc. Once the entire feeding regimen was tolerated without emesis, the IV was discontinued and the infant was discharged home, usually within 4872 hours.

Recently, some pediatric surgeons have changed their practice with the advancement of feeds (Gollin et al., 2000). Intuitively, nurses at Children's Hospital Boston believed some infants could tolerate a more rapid progression of feedings and began to question the conventional feeding regimen. At the same time, a few pediatric general surgeons were beginning to order a more liberal postoperative feeding advancement. Other surgeons and nurses still believed slow advancement was necessary to decrease emesis in these patients. Postoperative feeding orders were written according to attending surgeon preference. Parents often asked about the type of feeding method and when they would be able to feed their infant postoperatively. The variations in feeding practices among surgeons made preoperative parent education difficult.

As patients were fed by both conventional regimen and ad lib methods, nursing staff continued to question which method was better for patients. Were infants fed ad lib more likely to have more emesis? Which group of patients was able to attain full feedings sooner? Was there a difference in length of stay? Nurses needed evidence to recommend a change in the feeding practice and initiated a study to discover the answers. An interdisciplinary project could answer their questions and provide sufficient evidence to make recommendations.

Literature Review

Although the nursing literature contained no information on feeding methods for patients with HPS postoperatively, the medical literature revealed differing opinions on the topic. Some studies comparing slow, incremental increases in feeds with more rapid advancement demonstrated an increase in emesis with the more rapid advancement, but with no adverse effects. For example, Georgeson, Corbin, Griffen, and Breaux (1993) compared four feeding variations postoperatively, dependent on surgeon preference. When feedings were advanced quickly there was an increase in amount and incidence of vomiting. Despite the vomiting, these patients had a shorter length of stay, and no patients were readmitted for vomiting or dehydration. In contrast, another study recommended waiting 18 hours before re-introducing feeds postoperatively, with slow advancement of feedings after this period (Turnock & Rangecroft, 1991).

Wheeler and colleagues (1990) conducted a randomized study with three different feeding methods. The first group of infants were kept NPO for 4 hours postoperatively, then feeds were slowly increased over 48 hours. The second group of infants was kept NPO for 4 hours postoperatively, then fed more rapidly over 16 hours. The third group of infants was kept NPO for 24 hours, then progressed to normal, full feedings. Results showed no significant difference in the episodes of vomiting or the mean duration of hospital stay. The researchers concluded that vomiting is self-limiting and independent of the type of feeding regimen. In another study that compared postoperative feedings after pyloromyotomy, ad lib feeders had slightly more emesis, but reached full feeds sooner (Carpenter et al., 1999). No patients were re-admitted once discharged after tolerating two consecutive full feeds, suggesting that this would be a suitable criterion for discharge.

Gollin et al. (2000) retrospectively studied three feeding protocols comparing advancement to full feeds within 13 hours postoperatively to two more conservative protocols with slow advancement of strength and volume of feeds postoperatively. This study showed that the majority of infants were advanced to full strength feeds without emesis. Overall, there was no higher frequency or number of episodes of emesis with the rapid advancement of strength and volume of feeds. Therefore, once full feeds are tolerated, these infants could safely be discharged home earlier.

The Project Study

A 6-month retrospective study was designed to compare conventional regimen feeds to ad lib feeds in postoperative pyloromyotomy patients. Only patients who underwent uncomplicated, conventional pyloromyotomy were studied. Those who underwent laparoscopic pyloromyotomy were excluded. Several factors were studied including gestational age, age at diagnosis, feeding method, time to full feeding from surgery, and re admissions. The physician-nurse collaboration was established at the outset and facilitated cooperation in carrying out the feeding methods as well as collecting data.

Data were collected on patients fed by one of two methods determined by specific surgeon preference. Conventional regimen patients were kept NPO for 6 hours after surgery and incrementally advanced to full feeds slowly (see Table 2). These infants were held to previous feeding amounts if emesis occurred, and if emesis occurred several times, the patient was kept NPO again for 4-6 hours. These patients were discharged once the entire feeding regimen was tolerated without emesis.

Ad lib regimen patients were kept NPO until fully recovered from anesthesia and then given one feeding of sugar water. They then advanced to full formula or breast milk. They received 30-60 cc for the first feeding, then an increased volume as tolerated every 2-3 hours (see Table 3). If these infants had emesis, re-feeding could begin immediately. Discharge was considered for these patients once two 60-cc feedings were tolerated without emesis.

Outcome of the Study

The project resulted in publication of statistically significant findings and ultimately a change in nursing care for the infants particularly related to feedings (see Study Abstract). The interval from the operating room to toleration of full feeds averaged 25.4 hours for children fed on the conventional regimen and 20.3 hours for the ad lib group. The length of stay for the conventional regimen group averaged 35.8 hours and 28.5 hours for the ad lib group. There were no readmissions to the hospital for either group. It was clear from the data and from the nurses' experiences that ad lib feedings could be instituted in practice without complications. The interdisciplinary approach helped to answer a nursing care question and change practice based on the evidence obtained through a careful research plan.

The interval from the operating room to toleration of full feeds was significantly less with the ad lib feeding group than with the conventional regimen group. There was no significant difference in number of emesis with either group. The length of stay for the ad lib group was significantly decreased. The conclusion of the study was that the ad lib method of feeding decreases time to full diet with no significant difference in postoperative emesis. A significant decrease in time to discharge was demonstrated without an increase in readmission rates. An additional benefit was the cost saving with decreased length of stay (Garza, Morash, Dzakovic, Mondschein, & Jaksic 2002).

Nursing Implications and Practice Changes

The study results were presented to the Surgical Clinical Practice Committee, which meets weekly. This is a forum for sharing clinical information with a primary focus on improving systems related to patient care within the surgical service using an interdisciplinary team approach. It includes a team of physicians, nurses, pediatric nurse practitioners (PNPs), clinical nurse specialists (CNSs), pharmacists, patient case managers, and administrative staff. The mission of the Surgical Clinical Practice Committee is to improve patient care outcomes by alignment and integration of services.

Once the committee discussed the study results, it was agreed that post pyloromyotomy patients were to be fed by the ad lib method. The study results were then presented to the Chief of Surgery as well as to the entire attending general surgical staff. There was consensus that the ad lib method of feeding would replace the conventional regimen feeding method due to the positive study results.

Once the change in practice was approved, all staff nurses, PNPs, and general surgical residents were educated about the change. The new feeding recommendations were posted on the inpatient surgical unit and included in the House Officer's Manual at the annual revision. Staff nurses were educated about the practice change at a staff meeting, via e-mail, and with a poster.

Postoperative Care Changes

Postoperative care for pyloromyotomy patients has changed in several ways. Parents are encouraged to participate in all aspects of the infant's care immediately after surgery. After recovery from anesthesia, infants are fed by their parents. Parents are reassured that emesis commonly occurs postoperatively, but that this does not mean the surgery was unsuccessful. The infant is re-fed as soon as he or she is interested in feeding again after emesis. There is no waiting period or reversal to a previous volume of feeding as in the past. Infants may breast feed once they have tolerated at least one 30 cc bottle of expressed breast milk. As in the past, parents are instructed about feeding techniques including burping the infant before and frequently during the feeding. Changing diapers and bathing prior to feeding and quiet holding after a feeding is still recommended. Once an infant tolerates two feedings of 60 cc each without emesis, he or she is ready for discharge home. Infants post-pyloromyotomy are discharged home earlier than in the past as a result of the change to ad lib feeding method.

Printed instruction sheets for HPS patients are reviewed with the parents (see Figure 4). These include instructions about feeding, bathing, pain medication, wound care, as well as when to call the surgeon or pediatrician. Parents are reassured at discharge that some emesis is expected at home and need not be reported to the surgeon unless it becomes persistent or bilious. Any fever, redness, or drainage from the wound should also be reported to the surgeon, as well as pain that is unrelieved by acetaminophen. The pediatric general surgeon usually examines the infant during one postoperative visit within 2 weeks, then the pediatrician or primary care provider resumes care.
Figure 4. Discharge Information Sheet

Information

Family Education and Resource Program
Children's Hospital
300 Longwood Avenue
Boston, MA 02115

Home Care Instructions for Patients after Pyloromyotomy

This sheet gives you information on how to care for your infant after
he or she has had a pyloromyotomy.

Nutrition

* At home, give your baby formula or breast milk. Spitting up once in a
while is normal.

* If your baby vomits most or all of a feeding, wait 15 minutes, and
try giving the feeding again.

* If you bottle feed, burp your baby before the feeding and after every
1 to 2 ounces.

* If you breast feed, burp your baby before nursing and after 10 to 15
minutes on each breast.

* After each feeding, lay your baby on the right side, use an infant
seat, or hold your baby quietly for a half hour.

Activity

* Have your baby rest for a half hour after each feeding. Then your
baby can return to usual activities, such as rocking or playing with
toys.

Pain

* Your baby may feel some mild discomfort at home. Give your child
acetaminophen (Tylenol[R] or Feverall[R]), as directed by the
doctor or nurse practitioner.

Wound and Skin Care

* Your baby may have a clear plastic or gauze bandage over the
pyloromyotomy wound. There may also be small, thin pieces of a
special tape called Steri-strips. The bandage and strips may
begin to peel off in the next few days. If they fall off, you
may leave it off. Otherwise, they will be removed by the doctor
or nurse practitioner at a follow-up visit.

* Keep the area clean and dry. Give your infant a sponge bath until
tub baths are allowed by the doctor or nurse practitioner.

Emotional Recovery

* After surgery, your child may be tired or irritable. It takes time to
heal. Use this time for rest and quiet activities.

When to Call Your Child's Doctor or Nurse

Call if:

* you notice redness or swelling at the wound site;

* you notice any bleeding or drainage from the wound site;

* your infant has pain that doesn't get better after acetaminophen
is given;

* your infant has a fever of 100.5 [degrees] F or higher;

* your infant vomits most or all of 2 feedings in a row; or

* you have questions or concerns.


The development and outcome of this postoperative feeding study illustrates the importance of collaboration within an interdisciplinary team in making a change in practice. Nurses questioned, researched, and studied HPS feeding methods with the support of the surgical staff and nursing administration. A key component of the successful implementation of the feeding change was the education of all staff involved.

Study Abstract

Purpose: The optimal feeding regimen for neonates after pyloromyotomy for hypertrophic pyloric stenosis (HPS) remains controversial. This study sought to compare ad lib feedings to a conventional feeding regimen with regard to time to full diet, length of hospital stay, and re-admission rates.

Methods: A 6-month review of 36 consecutive patients who underwent pyloromyotomy for HPS was undertaken. Patients were fed in one of two ways according to specific surgeon preference. Conventional regimen patients (n = 19) were kept NPO for 6 hours after surgery and incrementally advanced to full feeds. Ad lib (n = 17) patients were kept NPO until fully reversed from anesthesia and then given full strength for formula or breast milk. Discharge was considered when two feed of 60 cc were tolerated.

Results: Twenty-eight males and eight females with a mean age of 5.0 +/- 1.7 [SD] weeks, gestational age of 39 +/- 2.1 weeks, weight of 4.0 +/- 0.9 kg, and operating time of 56 +/- 12 minutes were studied. The interval from OR to full diet was significantly less with ad lib feeding on the conventional regimen [20.3 +/- 5.0 vs. 25.4 +/- 8.3 hours, p < .05]. The ad lib group also had a significantly decreased length of hospital stay [28.5 +/- 8.9 vs. 35.8 +/- 11 hours, p < .05]. There were no re-admissions in either group.

Conclusion: Ad lib feeds decrease time to full diet and discharge without an increase in re- admission rates. The estimated potential savings per patient using ad lib feeds were $392.00. Thus, the use of ad lib feeds after pyloromyotomy for HPS appears indicated.

Note: From: Garza, J.J., Morash, D., Dzakovic, A., Mondschein, J.K., Jaksic, T. (2002). Ad lib feeds decrease hospital stay in neonates post-pyloromyotomy. Journal of Pediatric Surgery, 37(3), 493-495.
Table 1. Pre and Postoperative Nursing Care of the Child with HPS at
Children's Hospital Boston

On admission to the hospital, infants with HPS require stabilization of
fluid and electrolyte balance prior to departing for the operating room
for pyloromyotomy. In cases where electrolytes are normal on admission,
the surgery is performed without delay. Generally it will take 24-48
hours to correct severe dehydration and metabolic alkalosis (Wong et
al., 1999).

1. Nursing database assessment and physical including but not
limited to:

* history of vomiting

* assessment of hydration and nutritional status

* vital signs

* weight

2. Blood chemistries:

* sodium

* potassium

* chloride

* blood urea nitrogen

* creatinine

* glucose

* carbon dioxide

3. Insertion of intravenous (IV) line for access:

* fluid bolus as ordered by pediatric general surgeon

* maintenance IV fluids until surgery

4. Maintenance of NPO status

5. Accurate intake and output recorded

6. Documentation of emesis

7. Insertion of nasogastric tube for gastric depression if
emesis is excessive

8. Consents for anesthesia and pyloromyotomy discussed with parents
and then signed

9. Ongoing education and support of parents by nursing staff related to
the diagnosis, treatments, surgery, and postoperative care.

10. Abdominal ultrasound if not done prior to admission to inpatient
surgical unit

Parents

Parents are encouraged to room in with their infant throughout the
hospitalization when possible. Many parents are often exhausted and
emotionally distressed as their infant may have been vomiting for days
or even weeks prior to the hospitalization. Admission to the hospital
is an unexpected event. Providing a place for parents to rest is
critical for well being and coping ability. Reassurance and education
about the diagnosis and treatment of pyloric stenosis is ongoing. A
breast pump is provided for expression of breast milk for lactating
mothers while the infant is NPO.

Surgical Planning

Surgical repair of the pyloric stenosis is scheduled once the
patient has normal electrolytes. Parents stay with their infant
in the preoperative area, then are reunited in the post anesthesia
care unit (PACU). Once evaluated and passed by an anesthesiologist
using a post anesthesia recovery score, the patient will return to
the inpatient surgical unit. Premature infants and neonates under
4 weeks of age require cardiorespiratory monitoring for 24 hours
to observe for apnea.

Pain Management

Postoperative pain is managed with acetaminophen in the immediate
postoperative period, then every 4-6 hours as needed. Some surgeons
administer a local anesthetic subcutaneously before closing the
incision. For most patients this provides pain relief for 8-10 hours.
Table 2. Post-Pyloromyotomy Conventional Regimen Feeding Method

NPO x 6 hours after surgery

D5W 30 cc q2 hours x 2

1/2 strength formula/breast milk 30 cc q2 hours x 3

Full strength formula/breast milk 45 cc q2 hours x 2

Full strength formula/breast milk 60 cc q3 hours x 2

Full strength formula ad lib q4 hours or may breast feed

If emesis, hold feeding for 2 hours, then resume feeds at previous step

RN or CA feeds infant until 60 cc tolerated, then parents may feed
infant

Frequent burping recommended

Discharge home once regimen tolerated without emesis

Note. From Adzick, N.S., Wilson, J.M., Caty, M., Fishman, S., Saenz,
N., Jennings, R., Buchmiller, T., DiFiore, J., Fischer, A., & Hamilton,
T. (Eds.). (1999). Department of surgery's house officer's manual (12th
ed.). Boston: Children's Hospital Boston.
Table 3. Post-Pyloromyotomy Ad lib Feeding Method

NPO until fully awake

D5W x 1

Full strength formula/breast milk in bottle, 30-60 cc

May breast feed once fed breast milk 60 cc by bottle x 1

If emesis, may re-feed as soon as infant appears hungry

Parents may feed infant

Frequent burping recommended

Consider discharge once two consecutive feedings of 60 cc tolerated
without emesis

Note. From Adzick, N.S., Wilson, J.M., Caty, M., Fishman, S., Saenz, N.,
Jennings, R., Buchmiller, T., DiFiore, J., Fischer, A., Hamilton, T., &
Puder, M. (Eds.). (2000). Department of surgery's house officer's manual
(13th ed.). Boston: Children's Hospital Boston.


Acknowledgement: The author would like to thank Jane Murphy, RN, CS, MS, PNP; Judith Mahoney, RN, BSN; and Tom Jaksic, MD, PhD, for their assistance in development of this manuscript.

References

Adzick, N.S., Wilson, J.M., Caty, M., Fishman, S., Saenz, N., Jennings, R., Buchmiller, T., DiFiore, J., Fischer, A., & Hamilton, T. (Eds.). (1999). Department of surgery's house officer's manual (12th ed.). Boston: Children's Hospital Boston.

Adzick, N.S., Wilson, J.M., Caty, M., Fishman, S., Saenz, N., Jennings, R., Buchmiller, T., DiFiore, J., Fischer, A., Hamilton, T., & Puder, M. (Eds.). (2000). Department of surgery's house officer's manual (13th ed.). Boston: Children's Hospital Boston.

Carpenter, R.O., Schafer, R.L., Maeso, C.E., Sasan, F., Nuchtern, J.G., Jaksic, T., Harberg, F.J., Wesson, D.E., & Brandt, M.L. (1999). Postoperative ad lib feedings for hypertrophic pyloric stenosis. Journal of Pediatric Surgery, 34, 959-961.

Garcia, V.F., & Randolph, J.G. (1990). Pyloric stenosis: Diagnosis and management. Pediatrics in Review, 11, 292-295.

Garza, J.J., Morash, D., Dzakovic, A., Mondschein, J.K., & Jaksic, T. (2002). Ad lib feeds decrease hospital stay in neonatespost-pyloromyotomy. Journal of Pediatric Surgery, 37(3), 493-495.

Georgeson, K.E., Corbin, T.J., Griffen, J.W.W., Breaux, C.W., Jr. (1993). An analysis of feeding regimens after pyloromyotomy for hypertrophic pyloric stenosis. Journal of Pediatric Surgery 28, 1478-1480.

Gollin, G., Doslouglu, H., Flummerfeldt, P., Caty, M., Glick, P., Allen, J.E., & Azizkhan, R.G. (2000). Rapid advancement of feedings after pyloromyotomy for pyloric stenosis. Clinical Pediatrics, 39, 187-190.

Morganelli, J.J. (2000). Hypertrophic pyloric stenosis. In B.V. Wise, C. McKenna, G. Garvin, & B.J. Harmons (Eds.), Nursing care of the general pediatric surgical patient (pp. 316-321). Gaithersburg, MD: Aspen.

Raffensperger, J.G. (1990). Hypertrophic pyloric stenosis. In Swenson's pediatric surgery (pp. 211-219). Norwalk, CT: Appleton & Lange.

Schwartz, M.Z., (1998). Hypertrophic pyloric stenosis. In J.A. O'Neill, Jr., M.A. Rowe, J.L. Grosfeld, E.W. Fonkalsrud, & A.G. Corans (Eds.), Pediatric surgery (Volume Two) (pp. 1111-1116). St. Louis, MO: Mosby.

Turnock, R.R., & Rangecroft, L. (1991). Comparison of postpyloromyotomy feeding regimens in infantile hypertrophic pyloric stenosis. Journal of the Royal College of Surgeons of Edinburgh 33, 164-165.

Wheeler, R.A., Najmaldin, A.S., Stoodley, N., Griffiths, D.M., Burge, D.M., & Atwell, J.D. (1990). Feeding regimens after pyloromyotomy. British Journal of Surgery, 77, 1018-1019.

Wong, D.L., Ahmann, E., DiVito-Thomas, P.A., Hockenberry-Eaton, M., Winkelstein, M.L, & Wilson, D. (Eds.). (1999). The child with gastrointestinal dysfunction. In Whaley and Wong's nursing care of infants and children (pp. 1563-1565). St. Louis, MO: Mosby.

CE POSTTEST

Approaches to a Selection Nursing Procedures

The purpose of this continuing education series is to promote the pediatric nurse's understanding of approaches to selected nursing procedures.

Effective pediatric nursing practice in clinical settings consists in great measure of the nurse's ability to successfully perform a variety of nursing procedures. Changes in approaches to both simple and complex procedures come forth as a result of research findings or sometimes simply a nurse discovering a new or more effective method of doing things. At other times, tried and true methods are revisited and either meet the test of time or are discarded and replaced by more satisfactory ones. Pediatric nurses who keep abreast of approaches to procedures will be better prepared to perform them as a part of routine nursing care in pediatric settings.

This continuing education series features three articles that focus on procedures. The first article describes catheter-related thrombosis in pediatrics. The second articie discusses effective airway clearance for children with cystic fibrosis. The third article reports findings of a study of feeding methods after pyloromyotomy.

ASSIGNMENT

McCloskey, D. (2002). Catheter-related thrombosis in pediatrics. Pediatric Nursing, 28(2), 97-106.

Donahue, M. (2002). "Spare the cough, spoil the airway:" Back to the basics in airway clearance. Pediatric Nursing, 28(2), 107111.

Morash, D. (2002). Interdisciplinary approach: Practice changes in feeding methods after pyloromyotomy. Pediatric Nursing, 28(2), 113-118, 137.

Objectives:

1. Discuss current approaches to a selection of procedures.

2. Describe the signs, symptoms, and treatment options for the three most common catheter-related thromboses.

3. List three methods of airway clearance.

4. Discuss the implications of findings of a study comparing postoperative feeding methods for infants with hypertrophic pyloric stenosis (HPS).

5. Discuss the pediatric nurse's role regarding staying current on procedures commonly used in his or her practice setting.

This activity for 3.0 contact hours is provided by Anthony J. Jannetti, Inc., which is accreditted as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA). Anthony J. Jannetti, Inc. is an approved provider of continuing education by the California Board of Registered Nursing, CEP No. 5387.

Articles accepted for publication in the continuing education series are refereed manuscripts that are reviewed in the standard Pediatric Nursing review process with other articles appearing in the journal.

This test was reviewed and edited by Judy A. Rollins, MS, RN, Pediatric Nursing associate editor; Veronica D. Feeg, PhD, RN, FAAN, Pediatric Nursing editor; and Marion E. Broome, PhD, RN, a Pediatric Nursing Editorial Board member.
Earn 3.0 Contact Hours

Questions

1.  Secondary hemostasis is

    a. the process of vascular contraction
       and the accumulation of a platelet
       plug at the site of vascular injury.
    b. measured by the bleeding time.
    c. the transformation of liquid blood into a
       solid gel via the formation of fibrin.
    d. both a and b.

2.  The factors that are used to decide
whether a venous access device is used
is
    a. patient need.
    b. access to veins.
    c. ability to care for the device.
    d. length of therapy.
    e. all of the above.

3.  Thrombotic and infectious complications
comprise the largest percentage of complication
in venous access in infants and
children.

    a. True.
    b. False.

4.  Fibrinolysis is the process by which

    a. tissue plasminogen activator converts
       plasmin to plasminogen to form fibrin,
       which is broken down further into fibrin
       degredation products.
    b. plasmin converts tissue plasminogen
       activator to plasmin to form fibrin,
       which is broken down further into fibrin
       degradation products.
    c. tissue plasminogen activator activates
       plasminogen to plasmin to form fibrin,
       which is broken down further into fibrin
       degradation products.
    d. none of the above.

5.  A fibrin sheath obstruction is best
    defined as

    a. a clot within the internal lumen of a
       catheter that causes a complete occlusion.
    b. a clot that obstructs venous blood
       flow around the catheter, usually at
       the venous entry point.
    c. a layer of platelets that protects the
       catheter from infection.
    d. a sheath that is made up of fibrin clot
       that encases a catheter tip causing a
       partial or complete occlusion.

6.  Cough is

    a. the defense mechanism used to clear
       excessive secretions and foreign
       materials from the airways.
    b. a reflex stimulated by receptors located
       in the respiratory tract.
    c. a response to mechanical irritation.
    d. a response to mucus in the airways.
    e. all of the above.

7.  During normal breathing there is no
    equal pressure point.

    a. True.
    b. False.

8.  Which airway clearance technique is
    considered the standard by which all
    others are measured?

    a. Chest physical therapy.
    b. Positive expiratory pressure.
    c. High frequency chest wall oscillation.
    d. Active cycle of breathing.

9.  Which of the following products is a
    mechanical device that uses high frequency
    chest wall oscillation to provide
    airway clearance?

    a. Flutter[R] Device.
    b. ThAIRapy Vest[R].
    c. Both a and b.
    d. None of the above.

10. Which method of airway clearance is
    preferred for infants and toddlers?

    a. Chest physical therapy.
    b. Flutter device.
    c. ABI vest.
    d. AD/ACB.

11. In hypertrophic pyloric stenosis (HPS),
    the pyloric muscle becomes hypertrophied
    causing partial gastric outlet
    obstruction. Which presentation would
    be most indicative of the diagnosis of
    HPS?

    a. Occasional emesis of small amounts of
       formula 30 minutes after feeds.
    b. Nonprojectile, bilious emesis immediately
       after feeds.
    c. Small amounts of nonbilious, nonprojectile
       emesis immediately after feeds.
    d. Intermittent, projectile, nonbilious
       emesis after feeds that increase in
       severity.
    e. Projectile, bilious emesis not related to
       feeds.

12. Prior to diagnosis of HPS, the initial
    cause of an infant's vomiting is often
    thought to be

    a. adrenogenital syndrome.
    b. milk intolerance or allergy, overfeeding,
       or GER.
    c. gastroenteritis.
    d. metabolic or neurological problem.
    e. pylorospasm.

13. Upon arrival at the hospital, most infants
    with HPS have some degree of electrolyte
    imbalance and dehydration. What
    do the blood chemistries most commonly
    show?

    a. Hypoatremia and metabolic acidosis.
    b. Hypochloremia and metabolic alkalosis.
    c. Hyperatremia and respiratory acidosis.
    d. Hypochloremia and metabolic acidosis.
    e. Hyperkalemia and metabolic acidosis.

14. The slow, incremental feeding regime for
    infants after pyloromyotomy has been
    replaced with the following ad lib
    method:

    a. NPO until awake, feed D5W once, then
       formula or breast milk 30-60 cc.
    b. NPO for 4 hours, feed formula immediately
       as tolerated.
    c. NPO in PACU, feed D5W twice, then
       formula slowly.
    d. NPO for 1 hour, feed formula or breast
       milk 90 cc twice.
    e. NPO until awake, breast feed or formula
       for three feedings.

15. What are the discharge criteria for HPS
    patients?

    a. Toleration of full feeds for 24 hours
       without emesis.
    b. Parents able to feed infant without
       emesis.
    c. Toleration of two consecutive full feeds
       without emesis.
    d. Weight gain for 2 days.
    e. Toleration of one feeding of formula
       without emesis.


[ILLUSTRATION OMITTED]

Donna Morash, RN, is a Staff Nurse Ill, Infant/Toddler Unit, Surgical Programs, Children's Hospital Boston, Boston, MA.
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Author:Morash, Donna
Publication:Pediatric Nursing
Geographic Code:1USA
Date:Mar 1, 2002
Words:5144
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