Nursing Note Template: Pyloric Stenosis — Structured Clinical Documentation

Standardized nursing documentation for infantile hypertrophic pyloric stenosis (IHPS) ensures clear communication, continuity, and legal compliance.

NURSING PROGRESS NOTE — PYLORIC STENOSIS

Patient: [Name]        DOB: [Date]        Age: [Weeks]        Sex: [M/F]
MRN: [Number]        Date/Time: [Current]        Unit: [Peds/Surgery]

ADMISSION DIAGNOSIS: Hypertrophic Pyloric Stenosis
CHIEF COMPLAINT: Projectile vomiting × [duration], poor weight gain, dehydration

HISTORY OF PRESENT ILLNESS:
[Age]-week-old [sex] born at [GA] weeks via [delivery type]. Presents with [duration] of non-bilious, projectile vomiting after every feed. No blood/bile. Decreased wet diapers ([#]/day). Irritable, lethargic. No fever. Prenatal/neonatal history unremarkable. Feeding: [formula/breast] [oz] q[hrs].

VITAL SIGNS:
T: [°C]  HR: [bpm]  RR: [rpm]  BP: [mmHg]  SpO2: [%]  WT: [kg] (%ile)  HT: [cm] (%ile)

PHYSICAL EXAM:
General: [Alert/lethargic, hydration status: skin turgor, fontanelle, mucous membranes]
HEENT: [Normocephalic, no thyromegaly]
Cardiac: [RRR, no murmur, capillary refill <3 sec]
Respiratory: [Clear, no retractions]
Abdomen: [Soft, distended?], olive-shaped mass in RUQ/epigastrium? [Palpable/Not palpable], bowel sounds [hypo/normoactive], no tenderness.
Genitourinary: [Normal]
Skin: [Intact, turgor]

LABORATORY RESULTS:
CBC: WBC [K], Hgb [g/dL], Hct [%], Plt [K]
BMP: Na [mEq/L], K [mEq/L], Cl [mEq/L], CO2 [mEq/L], BUN [mg/dL], Cr [mg/dL], Glu [mg/dL]
Key: Hypochloremic, Hypokalemic, Metabolic Alkalosis (↓Cl, ↓K, ↑HCO3) — classic for pyloric stenosis.
Venous Blood Gas: pH [ ], pCO2 [ ], HCO3 [ ], BE [ ]

IMAGING:
Abdominal US: Pyloric muscle thickness >3 mm, length >15–17 mm, pyloric channel length >18 mm, "target sign" / "cervix sign." Diagnostic.

ASSESSMENT / NURSING DIAGNOSES (NANDA-I):
1. Deficient Fluid Volume r/t excessive vomiting AEB ↓UOP, ↑HR, ↓skin turgor, electrolyte imbalance.
2. Imbalanced Nutrition: Less Than Body Requirements r/t inability to retain feeds AEB weight loss [X%], ↓PO intake.
3. Risk for Aspiration r/t projectile vomiting.
4. Anxiety (Parental) r/t diagnosis, surgical intervention.

PLAN / INTERVENTIONS:
☐ NPO; IV access (2 large-bore) — D5 0.45% NS + 20 mEq KCl/L at maintenance + deficit replacement.
☐ Correct electrolytes: Replace K+ only after urine output confirmed; monitor q4–6h.
☐ NG tube to low intermittent suction (decompress stomach).
☐ Pre-op: Type & screen, consent, antibiotics (cefazolin) per protocol.
☐ Family education: Condition, surgery (pyloromyotomy), post-op feeding advancement, discharge criteria.
☐ Pain: FLACC scale; acetaminophen PRN; avoid NSAIDs.
☐ Skin care: Frequent repositioning, barrier cream.
☐ Monitor: I&O strict, VS q2–4h, abdominal girth, stool (currant jelly? — malrotation concern).

PRE-OP PRIORITY: Fluid/electrolyte resuscitation to normalize Cl, K, pH before anesthesia.

SIGNATURE: _________________________, RN        DATE/TIME: ____________

Key Documentation Pearls

• Document olive mass palpation (sensitivity ~70–80%).
• Electrolyte trend is critical — do not give K+ without urine output.
• Note parental understanding/teaching.
• Time-stamp all interventions.