Cleft Lip and Cleft Palate • Etiology- Failure of maxillary and median nasal processes to fuse during embryonic development Remember the psycho-social implications for these children and families
Assessment • Unilateral, bilateral, midline
Treatment • Surgical repair between 3 and 6 months • Multidisciplinary team - involving many specialists including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists. • Reconstruction begins in infancy and can continue through adulthood. • Homecare by the family prior to surgery
Pre-op Nursing Care Two Main Goals: 1. Prevention of Aspiration 2. Maintain Nutrition
Pre-op Nursing Care May breast feed if has small cleft lip If bottle fed, use compressible bottle, longer nipple, larger hole in nipple, any other special device for feeding this infant. Feed slowly in upright position and bubble frequently Keep bulb syringe and suction equipment at bedside Position on side after feeding
Pre-Op Nursing Care • What are problems that the nurse needs to be alert for during feedings? • Lack of proper seal around nipple to create necessary suction • Excessive air intake • Use of special feeding techniques • Feeder with compressible sides • Syringes with tubing
Pre-op Nursing Care • Remind parents that defect is operable- show photographs of corrected clefts Before After
Therapeutic Management Surgical Correction A number of professionals are involved including surgeons, nurses, ear, nose, and throat specialists, audiologists, speech therapist, orthodontists, and plastic surgeons.
Post-Op Care • Prevent trauma to suture line • Logan’s bow to protect site • Do not allow to suck • Maintain upper arm restraints • Position supine • No hard objects in mouth- straws, pacifiers, spoons • Do not take temperature orally • Reduce Pain • Mild analgesics and sedatives • Parents to provide, holding, rocking, and parental voices
Post-op Care • Prevent Infection • Cleanse suture lines as ordered • rinse with water after each feeding • Use cotton swab, use rolling motion vertically down suture line • Apply anti-infective ointment as ordered • Call Doctor for any swelling or redness, bleeding, drainage, fever • Make early Referrals to appropriate team members • Assess for Complications • Otitis media, hearing loss, speech difficulties, growth, altered dentition.
Malformation from failure of esophagus to develop as a continuous tube Upper Esophagus Trachea Lower Esophagus An atresia is the absence or closure of a normal body tubular passage, such as the esophagus and it ends in a blind pouch. A tracheoesophageal fistula is when the esophagus connects with the trachea.
Signs and Symptoms Excessive amounts of salivation / mucus, frothy bubbles in the mouth and sometimes nose Three “C’s” - Coughing, choking, and cyanosis when fed, overflow may be aspirated Food may be expelled through the nose immediately following the feeding Rattling respirations and frequent respiratory problems such as aspiration pneumonia Gastric distention, if fistula History of polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction
Diagnosis and Management • Early diagnosis • Ultra sound • Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray • Surgical repair • Thoracotomy and anastomosis
Post-Op Nursing Care • Maintain airway • Maintain thermoregulation • Maintain nutrition • Gastrostomy Tube feedings • Prevent trauma • Monitor for potential complications • Constipation or diarrhea • Blockage of esophagus • Infection • Monitor weight , growth and developmental achievements
Imperforate Anus Incomplete development or absence of anus in its normal position in perineum.
Assessment • Most commonly diagnosed upon Newborn Assessment • Symptoms • Absence of anorectal canal • Failure to pass meconium • Presence of anal membrane
Treatment Anal stenosis is treated with repeated anal dilation Surgery
Abdominal Wall Defects Omphalocele Gastroschisis
Omphalocele Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac.
Gastroschisis herniation of abdominal viscera outside the abdominal cavity through a defect in the abdominal wall to the side of the umbilicus. Not covered.
Diagnosis Permit a early diagnosis Alpha-fetaoprotein Ultrasound
Pre-op Treatment and Nursing Care • Focus is on protection of the contents / sac. Cover with warm, sterile, saline-soaked dressings over the defect. • Maintain temperature – esp. with gastroschisis because it is not covered and lose of fluids • May choose to replace the gut to the abdomen gradually over several weeks. May place silo or silastic material over gut until it returns to the abdomen. • Maintain hydration – start IV (NPO) • NG tube to decompress stomach
Oomphalocele Repair While the baby is deep asleep and pain-free (under general anesthesia) an incision is made to remove the sac membrane. The bowel is examined closely for signs of damage or additional birth defects. Damaged or defective portions are removed and the healthy edges stitched together. A tube is inserted into the stomach (gastrostomy tube) and out through the skin.
Gastroschisis Repair Surgical repair of abdominal wall defects involves replacing the abdomen through the abdominal wall defect, repairing the defect if possible, or creating abdominal organs back into the a sterile pouch to protect the intestines while they are gradually pushed back into the abdomen.
Post-op Nursing Care • Maintaining fluid and electrolyte balance • TPN via central venous catheter to provide nutrition while bowel rests and heals • Progress to oral feedings once bowel motility occurs • Prevent Infection • IV antibiotics • Assess for Complications • Ileus • Educate parents
Gastroesophageal Reflux Disease(GERD) The cardiac sphincter and lower portion of the esophagus are weak, allowing regurgitation of gastric contents back into the esophagus.
Assessment: Infant • Regurgitation almost immediately after each feeding when the infant is laid down • Excessive crying, irritability • Failure to Thrive • Life Threatening Risk / Complications: • aspiration pneumonia • apnea
Assessment: Child • Heartburn • Abdominal pain • Cough, recurrent pneumonia • Dysphagia
Major Complication is Acute Gastric Bleeding
Diagnosis • Assess Ph of secretions in esophagus if <7.0 indicates presence of acid • Also diagnosed using Barium Swallow and visualization of esophageal abnormalities
Management & Nursing Care • Small frequent feedings of predigested formula or thicken the formula • Frequent burping • Positioning –keep upright for 30 minutes after feedings. Use reflux board to keep head elevated. • Avoid excessive handling after feedings. Reflux board
Medications • H2 Histamine receptor antagonists – reduce gastric acidity • Zantac and Pepcid • Proton-pump inhibitors • Prevacid • Prilosec • Gastric emptying • Reglan • Antacids • Gaviscon **be sure to study nursing implications and side effects
Management and Nursing Care In a fundoplication, the upper part of the stomach is wrapped around the lower end of the esophagus and stitched in place, reinforcing the closing function of the cardiac sphincter. If history of apnea, bradycardia, r/t GER—needs continuous cardiac and apnea monitoring. Arrange for CPR teaching for caregivers If infant does not responds to non-invasive therapy, then a Nissen fundoplication may be done to increase the competence of the cardiac sphincter.
Post-op Nursing Care Assess for pain, abdominal distention, and return of bowel sounds. Teach parents about gastrostomy tube feedings
Diarrhea Infectious Gastroenteritis
Diarrhea/GastroenteritisSevere • A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. • Most infectious diarrheas in this country are caused by: • Giardia – most commonly seen in daycare centers • Rotovirus – seen in infants in young children
Clinical Manifestations • Increase in peristalsis • Large volume stools • Increase in frequency of stools • Nausea, vomiting, cramps • Increased heart & resp. rate, decreased tearing and fever • Complications: • Dehydration • Metabolic acidosis
Complications Dehydration Metabolic Acidosis
The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size which limits ability to rehydrate quickly.
Dehydration Infant Child Decreased tear production Skin non-elastic Decreased urinary output Thirsty Restless • Depressed fontanels • Sunken eye orbits • Fussy, Irritable • Thirsty • Fewer wet diapers
Treatment & Nursing Care • Treat cause • Fluid and electrolyte balance • Weigh daily • Monitor I&O • Assess for dehydration • Isolate • Skin care
Oral Rehydration Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea