A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A.
A
B.
B
C.
C
The Correct Answer and Explanation is:
In the case of a 2-month-old infant with Hirschsprung disease (HD), the nurse should primarily assess the abdomen, particularly focusing on signs of bowel obstruction or distention. Therefore, the correct hot spot to select would likely correspond to the area marked C on the artwork, which typically indicates the abdominal region.
Explanation:
Hirschsprung disease, also known as congenital aganglionic megacolon, is characterized by the absence of ganglion cells in the distal bowel, leading to a lack of peristalsis in that segment. This absence of nerve cells prevents the affected portion of the intestine from relaxing, causing severe constipation and potential bowel obstruction.
In infants with HD, several key manifestations may occur, primarily due to the inability to pass stool. As a result, the abdomen may appear distended due to trapped fecal material. The nurse should assess for:
- Abdominal Distension: A swollen or tense abdomen can indicate that stool is accumulating in the obstructed portion of the bowel.
- Palpation for Fecal Masses: The nurse should palpate the abdomen to check for any fecal masses, which may be felt as firm areas within the distended abdomen.
- Bowel Sounds: Auscultation of the abdomen may reveal diminished or absent bowel sounds in cases of significant obstruction, while hyperactive sounds may occur before an obstruction.
- Vomiting: Infants with HD may also exhibit bilious vomiting, which can indicate proximal bowel obstruction.
- Failure to Thrive: Chronic constipation can lead to feeding difficulties and poor weight gain, so assessing the infant’s growth and development is crucial.
By focusing on the abdomen (hot spot C), the nurse can effectively identify manifestations associated with Hirschsprung disease and monitor the infant’s condition for any changes that may necessitate further medical intervention, such as surgery to remove the affected bowel segment. Early detection and management are critical to prevent complications like enterocolitis or perforation.