Peds exam 2 (unit 3.2)

What should be promoted in G tube post-op care?

Involvement of parents

What should parents be educated on if the G tube comes out?

Wash with soap and water and put it back in

Why is encouraging sucking important in G tube post-op care?

It provides oral stimulation, preventing oral eversion and supporting speech development

What should be done with the G tube post-op prior to feeds?

Leave the tube open to gravity

Why should the G tube be left open to gravity post-op?

To allow air and secretions to come out of the stomach and give the body time to settle down

Cleft lip with or without cleft palate

most common craniofacial malformation

1 in 700 births

more common in males

What is cleft lip?

Incomplete fusion of embryonic structures surrounding the oral cavity.

Can cleft lip be unilateral or bilateral?

Yes, cleft lip can be unilateral or bilateral.

Is cleft lip associated with palate involvement?

Yes, cleft lip can occur with or without palate involvement.

What are some associated abnormalities with cleft lip?

Abnormal development of the external nose, nasal cartilages, and/or nasal septum.

Cleft Palate

When the primary and secondary palatine palates fail to fuse during embryonic development

may involve the soft palate, but can extend into the hard palate

Diagnostic evaluation of cleft palate/lip

cleft lip with or without cleft palate is apparent at birth

can be diagnosed by sonogram as early as 14 weeks

Examine the hard and soft palates with a finger

treatment of cleft lip

usually involves no long-term intervention after surgery, other than possible scar revision

treatment of cleft palate

management after surgery usually involves cooperative efforts of multidisciplinary team

- plastics, orthodontics, otolaryngology, speech/language therapy, audiology, nursing, social work

Cleft feeding troubles

unable to suck properly

troubles with bottles, breastfeeding can still work, depending on the severity of the cleft

Use the side-lying position because milk pools into the cheek, making it easier for the baby

Haberman feeders

special nipple/bottle; squeeze bottle while baby sucks

Dr. Brown valve/disk

regulates the flow of milk

Esophageal Atresia

failure of esophagus to develop as a continuous passage

doesn't connect correctly to stomach

no food can reach stomach (cause breathing issues or choking)

surgical intervention needed

Tracheoesophageal fistula

Failure of the esophagus and trachea to separate into distinct structures

Clinical manifestations (EA & TEF)

frothy saliva in the mouth -> choking and coughing with lots of secretions

sudden coughing and choking with feeding

The formula comes out of the nose and mouth -> eat until blockage is hit, and then it comes back up

Dx evaluation (EA and TEF)

Attempt to pass an NG tube (inability warrants further investigation)

radiopaque catheter and X-rays

Bronchoscopy to visualize the fistula

Therapeutic management (EA and TEF)

maintence of airway (bulb suction)

prevention of aspiration pneumonia

surgical repair of abnormal structure

Pre-operative care (EA and TEF)

NPO

IV fluids/parenteral nutriton

suctioning of mouth/nose

supportive care to parents

upright position

Surgical Repair (EA and TEF)

one stage

done after adequetly hydrated, proactive treatment of pneumonia and patient is well enough

thoracotomy with division of TEF and end-to-end anastomosis of the esophagus

First feeding post-op (EA and TEF)

sterile water only

Pyloric stenosis

1 in 1,500 births

affects boys 5 more times than girls

familial (20% chance if mother had)

develops in the first few weeks of life

Pathophysiology: pyloric stenosis

circular muscle of the pylorus thickens because of hypertrophy

produces severe narrowing of the pyloric canal between the stomach and duodenum

Lumen may be partially or completely obstructed

(can take whole bottle but will have a large amount of spit up -> the more they eat, the more they throw up)

Clinical manifestations: pyloric stenosis

non-bilious vomiting in early stages -> projectile vomit

usually around 3 weeks -> more symptoms when they take in more food

infant is irritable because they're hungry

prolonged vomiting -> leads to dehydration

can palpate the mass

weight loss or no gain

Dx evaluation: pyloric stenosis

mass is best felt on empty stomach

dx made by H&P

If H&P is inconclusive, -> sonogram is performed, which shows a mass and thickening

Therapeutic management: pyloric stenosis

Surgical relief of pyloric obstruction by pyloromyotomy is standard therapy

good prognosis and low mortality

Nursing considerations: pyloric stenosis

know S&S of pyloric stenosis

assess signs of infection -> depressed fontanels & skin turgor

Post-op: pyloric stenosis

regulation of fluid therapy

Re-establish normal feedings 4-6 hours post op (sterile water first)

Hernias

an abnormal opening which allows protrustion of an organ/organs through muscle wall

concern: impaired circulation or compromise of other organs or structures

types of hernias

umbillical

inguinal

diaphramatic

Umbilical hernia

fusion of the umbilical ring incomplete

more apparent during crying

more common with premies

usually resolve by 3-5 years or may have surgery to correct (5%)

should be soft, reducible, and have the same skin color

Inguinal Hernia

a congenital defect of failure of the peritoneal lining to close

allows intestines to descend into the inguinal cnal

severe cases (girls): into labia

severe cases (boys): into the scrotum

Incidence (umbilical and inguinal hernia)

80% of all child hernias

more frequent in boys (7:1)

10-20 per 1000 births

Clinical manifestations: umbilical and inguinal hernias

painless swelling, varies in size

dissapear during rest

appear when cries, strains, coughs, or stands

Sometimes, a herniated loop of intestine becomes partially obstructed, causing pain

Therapeutic management: umbilical and inguinal hernia

elective surgical repair after dx

usually done outpatient

Nursing consideration: inguinal and umbilical

prompt recognition

wound care

pain management

Congenital diaphragmatic hernia (CDH)

when the diaphragm does not form completely leaving enlarged opening

abdominal organs enter thoracic cavity, compress lungs, and shift heart

1 in 5,000 births

diagnostics (CDH)

possible as early as 25 weeks (anatomy scan)

3 diagnostic features of CDH

Polyhydramnios - excess amount of amniotic fluid

mediastinal shift - organs are squished to one side of body

presence of loops of bowel in the chest cavity

Clinical manifestations of CDH

acute respiratory distress on delivery

absent breath sounds of affected side

cyanosis

mediastinal shift

scaphoid (concave) abdomen

Therapeutic management of CDH

immediate respiratory assistance

GI decompression to prevent respiratory compromise (NG to empty stomach to decrease pressure)

IV fluids

umbilical catheterization

paralyzing agents

emergency surgical repair after stabilization

Hirshsprung disease

Causes a blockage of the intestine because of a lack of nerves in the bottom segment of colon

starts at distal end of colon and rectum

results in obstruction -> chronic constipation

1 in 5,000 births (4x more common in males)

Clinical manifestations: Hirshsprung

vary according to length of bowel affected

Newborn:

- abdominal distention, vomiting, constipation, failure to pass meconium within 48 hours

older:

- chronic constipation with ribbonlike foul-smelling stools, a thin child with a protruberant abdomen

Diagnosis: Hirschsprung disease

usually made after failure to pass meconium and signs of obstruction (bilious vomiting refusal to feed, abdominal distention)

barium enema - look for affected part of bowel

rectal biopsy - surgeon takes several samples moving up the colon until ganglion is found (bowel is later removed up to that point)

Hirschprungs: considerations

observe passage of meconium

Pre-op

- IV fluids

- NPO, NG for gastric decompression

- Rectal dilation/irrigation to promote stooling

Post-op

- routine abdominal post-op care - NG to suction

- no rectal meds or temps

complications: short bowel syndrome (malabsorption from lack of surface area after bowel removal)

Imperforate anus

malformation of the anus without an obvious opening

may occur with or without a fistula

- between rectum and GU system

- between rectum and perineum

dx - imperforate anus

no meconium or meconium in urine/vagina if fistula present

inability to insert a thermometer into the rectum as anus is covered/blocked

abdominal distention

vomiting

3 stages of management for imperforate anus

colostomy at birth

Reconstructive anoplasty at 3-4 mo

Take down colostomy 6 weeks later and attach to the created anus

post-op care: imperforate anus

suture line care

NPO

IV fluids

colostomy care and teaching to parents

Extrophy of the bladder

severe defect of the GU system with externalization of the bladder and other structures and separation of pelvic bone

"inside out bladder"

1 in 35,000 - 50,000 births

more common in males

Nursing care: extrophy of the bladder

Hygiene of bladder area (sterile non-adherent moist dressings)

fluid management - large areas of exposed tissues increase the risk for dehydration because urine is just spilling out

Treatment objectives: extrophy of the bladder

reconstructive repair for:

- preservation of sexual function

- attainment of urinary control

- prevention of UTIs

Post op: extrophy of the bladder

observation of renal function - maintenance of catheter patency

traction and immobilization of pelvis till fully healed movement can impact healing

home care for children facing multiple surgeries

Hypospadius

where the urethra opens on ventral surface of penis

foreskin will look shortened or abnormal

severity can range from openeing being just below the meatus to being on perineum

1 in 300 births

treatment of hypospadias

Surgical correction done for 3 reasons

1. psychosocial

2. promote straight stream (lowers risk for infection)

3. future sexual function

**delays circumcision

**infertile if not fixed

post-op considerations: hypospadius

no soaking in tub

antibiotic ointment

cleaning the surgical site

Testicular torsion

painful scrotal swelling

abrupt severe constant pain in scrotum, lower abdomen, and groin 90% with nausea and vomiting

- peak incidence in boys 12-18

Present with scrotal edema, the affected testis is tender, swollen, and slightly elevated; the testis may lie horizontally

surgical emergency

The long-term viability of the testis relies on the time to deterioration, -> will lose the testicle if the blood flow is gone for too long