A child diagnosed with Hirschsprung disease is admitted to the pediatric ward. The nurse plans to frequently measure the abdominal girth; however, the frequent measuring of abdominal girth makes the child restless and irritable. What is the most appropriate nursing action?

Appeared in: NORCET 10 Mains

Explanation

In Hirschsprung disease, frequent measurement of abdominal girth is a critical nursing assessment to monitor for bowel obstruction and the onset of enterocolitis, a life-threatening complication.
Leaving a measuring tape in place under the child at a marked level (e.g., the umbilicus) is a standard technique in pediatric nursing.
This method minimizes handling and disturbance, which directly addresses the problem of the child becoming restless and irritable.
It promotes atraumatic care by making a necessary, repetitive procedure less stressful for the child, while also ensuring consistency and accuracy of measurements.

Option A: This action is appropriate for evaluating the effectiveness of the enema but does not solve the problem of the child's distress caused by the frequency of the measurements throughout the day.
Option C: Similar to measuring before the enema, this action assesses the outcome of a specific treatment. It does not address the underlying issue of the child's irritability with the frequent act of measurement itself.
Option D: A digital rectal examination is an invasive diagnostic procedure, not a routine nursing assessment. It would cause more, not less, distress and is outside the scope of a nurse's independent actions to solve this particular problem.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing care for a child with Hirschsprung disease, specifically focusing on atraumatic care during assessments to guide bedside assessment, documentation, and the next nursing action.
A primary nursing responsibility in caring for a child with Hirschsprung disease is vigilant monitoring for signs of Hirschsprung-Associated Enterocolitis (HAEC), a life-threatening complication. Key signs include fever, explosive diarrhea, and increasing abdominal distension.
The principle of atraumatic care is fundamental in pediatrics. Nurses must find ways to perform necessary procedures while minimizing physical and psychological distress for the child and family.
What if? If the child develops a fever, lethargy, and explosive, foul-smelling diarrhea along with increased abdominal girth, the nurse's priority action would be to notify the healthcare provider immediately, as these are hallmark signs of enterocolitis, a medical emergency.

How to Approach the Question

First, identify the core clinical problem in the scenario: a child is distressed by a necessary, frequent nursing intervention (measuring abdominal girth).
Next, analyze the patient's diagnosis (Hirschsprung disease) and understand why this intervention is critical (monitoring for enterocolitis).
Evaluate each option based on whether it directly solves the stated problem (the child's distress) while still allowing the necessary assessment to be performed safely and effectively.
Eliminate options that are irrelevant to the problem (e.g., timing of enemas) or are inappropriate and potentially harmful (e.g., invasive diagnostic procedures).
Select the option that represents a practical, safe, and patient-centered nursing strategy that aligns with the principles of atraumatic care.

Concept Tested & Keywords

Concept Tested: Nursing care for a child with Hirschsprung disease, specifically focusing on atraumatic care during assessments.
Stem keywords: Hirschsprung disease, pediatric, abdominal girth, restless, irritable
Lead-in keywords: most appropriate nursing action
Clinical cues: The child's irritability during a necessary and frequent nursing assessment is the key problem to solve.

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E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 2 (pp 239-476 of 713) p. 161-163

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 78-80

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