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?

1. A

   Measure abdominal girth before administering a saline enema

2. B

   Leave the measuring tape beneath the child

3. C

   Measure abdominal girth after administering a saline enema

4. D

   perform a digital rectal examination

Appeared in: NORCET 10 Mains

Explanation

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• The primary goal is to obtain necessary data (abdominal girth) while minimizing patient distress.
• Leaving a measuring tape in place under the child is a practical comfort measure that reduces the need for repeated rolling or repositioning.
• This technique minimizes physical stimulation and disturbance, directly addressing the cause of the child's restlessness and irritability.
• It also ensures that the measurement is taken at the same location each time, improving the accuracy and consistency of monitoring for changes in distension.

Why Other Options Were Wrong

• Option A: This action relates to the timing of the measurement to establish a baseline before an intervention (enema), not to the method of reducing the child's distress during the procedure itself.
• Option C: This action is performed to evaluate the effectiveness of the enema in reducing distension. It does not address the problem of how to perform the measurement without causing irritability.
• Option D: A digital rectal examination is an invasive diagnostic procedure used to assess rectal tone or relieve impaction. It would cause significant distress and is not a comfort measure or related to measuring abdominal girth.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing management of a pediatric patient with Hirschsprung disease, focusing on comfort measures during assessment to guide bedside assessment, documentation, and the next nursing action.
• Monitoring for abdominal distension is a critical nursing responsibility in patients with Hirschsprung disease, as a sudden increase in girth can signal the onset of Hirschsprung-Associated Enterocolitis (HAEC), a medical emergency.
• Implementing simple comfort measures, like leaving a measuring tape in place, can improve patient cooperation, reduce stress for both the child and caregivers, and lead to more accurate assessments.
• What if? If the abdominal girth measurement shows a rapid increase, and the child also develops a fever, lethargy, and explosive, foul-smelling diarrhea, the nurse must recognize these as signs of enterocolitis. The immediate action is to make the child NPO, notify the healthcare provider urgently, and prepare for emergency interventions such as IV fluid resuscitation, nasogastric decompression, and broad-spectrum antibiotics.

How to Approach the Question

• First, identify the core clinical problem: The child is distressed by a necessary and frequent nursing assessment (abdominal girth measurement).
• Next, analyze the diagnosis: Hirschsprung disease involves a risk of abdominal distension, making the measurement crucial.
• Evaluate each option based on whether it directly solves the problem of the child's distress from the procedure itself.
• Eliminate options that address a different goal (e.g., timing of the measurement for baseline or evaluation) or are irrelevant and potentially harmful (e.g., an invasive diagnostic test).
• Select the option that represents a practical, patient-centered comfort measure that allows the assessment to be completed with minimal disturbance.

Concept Tested & Keywords

• Concept Tested: Nursing management of a pediatric patient with Hirschsprung disease, focusing on comfort measures during assessment.
• Stem keywords: Hirschsprung disease, child, abdominal girth, restless, irritable
• Lead-in keywords: most appropriate nursing action
• Clinical cues: A child with a known diagnosis of Hirschsprung disease requires frequent monitoring.
• Clinical cues: The child's irritability is directly linked to the frequent measurements, indicating a need for a less disruptive technique.

Question ID

QT6gH6gc-3lth9TC_QTm2B

Copy ID

Reference Book

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

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