I need to know how write a nurses note on the child with pyloric stenosis?

NURSING NOTE

Patient: [Patient Name]

Age: [Age]

Sex: [Sex]

Date: [Date]

Diagnosis: Pyloric Stenosis

Chief Complaint: Vomiting

History of Present Illness: The patient is a [age] [sex] who presents with a history of projectile vomiting for the past 2 weeks. The vomiting occurs after every feeding and is forceful and non-bloody. The patient has also had difficulty gaining weight and has been irritable.

Physical Examination:

- General: The patient is in no apparent distress.

- Vital Signs: Temperature 37.5°C, heart rate 120 bpm, respiratory rate 30 bpm, blood pressure 90/60 mmHg

- Head and Neck: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.

- Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

- Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs.

- Gastrointestinal: Mild abdominal distension. Bowel sounds are present in all 4 quadrants.

- Musculoskeletal: No tenderness, pain, or deformity.

- Neurological: Alert and oriented x3. Cranial nerves grossly intact. Normal strength and sensation.

Laboratory Studies:

- CBC: WBC 12,000/μL, hemoglobin 11.0 g/dL, platelets 300,000/μL.

- Electrolytes: Sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 24 mEq/L.

- Blood urea nitrogen 18 mg/dL, creatinine 0.8 mg/dL.

- Liver function tests are normal.

Imaging Studies:

- Abdominal ultrasound revealed hypertrophy of the pyloric muscle and a narrowed pyloric channel.

Diagnosis: Pyloric Stenosis

Treatment Plan:

- The patient will be NPO and will receive IV fluids.

- The patient will be started on antibiotics to prevent infection.

- The patient will undergo a pyloromyotomy to correct the pyloric stenosis.

Prognosis:

The prognosis for pyloric stenosis is excellent with early diagnosis and treatment.