Transcript Esophogeal Atresia Type A

Highlights of the developing
gastrointestinal system
• Saliva
– newborns produce little saliva until 3-4 months of age
– Sucking and extrusion reflex until 3-4 months
• Stomach
– increases to 200-300 by 12 months
– Immature muscle tone of lower esophageal sphincter
and low capacity of the stomach
– Deficient digest enzymes lead to gas, diarrhea
sensitization for food allergies and microscopic
hemorrhages
Highlights of the developing
gastrointestinal system
• Intestinal
– Infants vulnerable to GI infections due to
lower intestinal flora and reduced stomach
acidity
– Breast milk increases flora and provides some
protection
– Myelination of nerves to anal sphincter
matures at about age two
Highlights of the developing
gastrointestinal system
• Liver
– Immature at birth resulting in inefficient detoxifying
of substance and medications
– Slow development of glycogen storage capacity
during early infancy
• Other
– Infants are more prone to dehydration and fluid and
electrolyte imbalances due to greater body surface
area, high rate of metabolism and immature kidney
function
Credits
• The previous slides on the highlight of the
developing GI system and the next slide on
abdomen assessment tips are credited to:
Pediatric Nursing Made Incredibly Easy
BY: Lippincott Williams and Wilkins
Abdomen assessment tips
• Warm hands
• Note guarding when child is moving
around
• Flex knees to relax muscles
• Deep breathing or distraction
• Use child’s hands to “help” with the exam
• Auscultate before palpation
Esophageal Atresia
Tracheoesophageal Fistula
• Basic terminology
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Esophagus: tube that connects the mouth to the stomach
Trachea: "windpipe"
Atresia: absence of a normal opening
Congenital: found at birth
Fistula: abnormal passage from a body organ to the body
surface or between two internal body organs.
Taken from Texas Pediatric Surgery Associates @
http://www.pedisurg.com/PtEduc/TEFEsophageal_Atresia.htm
Esophageal Atresia
Type A
• Both segments of
the esophagus
end in blind
pouches. Neither
segment of
esophagus is
attached to the
trachea.
Tracheal Esophageal Fistula
Type B
• The upper segment
of the esophagus
forms a fistula to
the trachea (TEF).
The lower segment
of the esophagus
ends in a blind
pouch (EA). This is a
very rare form of
EA/TEF.
TEF Type C
• The upper segment
of the esophagus
ends in a blind
pouch (EA). The
lower segment of
the esophagus is
attached to the
trachea (TEF). This
is the most common
type of EA/TEF.
TEF Type D
• Both segments of
the esophagus
are attached to
the trachea. This
is the rarest form
of EA/TEF.
TEF Type E
• There is no
esophageal atresia
as the esophagus is
continuous to the
stomach. However,
fistula is present
between the
esophagus and the
trachea.
Credits
• The last five slides were taken from the
EA/TEF Child and Family Support
connection at:
– http://www.eatef.org/description.html
Manifestations of EA/TEF
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Prenatal polyhydraminos
Vomiting or choking on first feeding
Appearance of drooling in infancy
Frothy saliva in mouth
Abdominal distension
Aspiration pneumonia
Nursing Care for EA/TEF
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Assessment of newborn first feeding
Place any infant with symptoms on NPO
Suction to clear the airway
Gastrostomy tube to decompress stomach
Head elevated
IV
Antibiotics
Oxygen
Note that bag/mask ventilation may cause gastric
distention if a distal fistula is present
An important emotional need
• Make sure these infants are provided with
sucking to satisfy this most important need
and to avoid “oral aversion”
Associated Congenital Defects
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Cardiac
Gastrointestinal
Genitourinary
Musculoskeletal
Additional Credits to:
• DWAYNE C. CLARK, MD, LCDR, MC,
USNR; Esophageal Atresia and
Tracheoesophageal Fistula. American
Family Physician. Feb 15, 1999.
Imperforate Anus
The tissues between the
GI tract and anus are
separated
Ranges from stenosis to
complete separation
to failure of the anus
to form
GI tract may form a
fistula to GU tract
Imperforate Anus
Imperforate Anus
Manifestations
• Patency of anus checked at birth by taking
a rectal temperature. All temperatures
afterwards are axillary.
• Failure to pass meconium in the first 24
hours
Imperforate Anus
Nursing Measures
• NPO and prepared for surgery
• High type defects require a colostomy and anal
repair at a later date.
• Anal repair requires post operative dilatation of
the new anus (to improve muscle tone and
prevent narrowing) will begin in the hospital
and continue for some months. Stool
softeners and a high-residue diet will need to
continue throughout childhood.
Credits
• Hebe Molmenti, M.D., Ph.D
• Medline Plus
• http://www.nlm.nih.gov/medlineplus/en
cy/presentations/100030_4.htm
Pyloric Stenosis
• Pyloric Stenosis (narrowing) is an
obstruction at the lower end of the stomach
(pylorus) caused by an overgrowth
(hypertrophy) of the circular muscles of the
pylorus or by spasms of the sphincter
Pyloric Stenosis
Diagram of normal
stomach and
pylorus. Note the
cross-section
showing normal
pyloric opening
Pyloric Stenosis
• Diagram of stomach
with pyloric
stenosis. Note the
cross-section
showing how the
pyloric opening is
very narrowed.
Pyloric Stenosis
Post Surgery
• Diagram of stomach
after repair of pyloric
stenosis. Note (in the
cross-section) how an
incision has been made
in the muscle,
enlarging the pylorus
and relieving the
obstruction
Credits
• The last three slides on pyloric Stenosis are
from the website of Texas Pediatric
Surgical Associates
• http://www.pedisurg.com/PtEduc/Pyloric_
Stenosis.htm
Manifestations of
Pyloric Stenosis
• Symptoms begin at 2 to 3 weeks
• Projectile vomiting
• Constantly hungry and will eat
immediately after vomiting
• Symptoms of dehydration and malnutrition
• Olive shaped mass in Right Upper
Quadrant
Nursing Care
• Care for dehydration and electrolyte
imbalances
• NPO; prepare for surgery
Post operative Care
Pyloric Stenosis
• Progress feeding from oral electrolyte solution to
formula or breast milk
• I/O; daily weights
• Provide for suck need
• Incision clean and dry
• Frequent burping
• Elevated and on right side after feeding
• Pain management
Celiac Disease
• Known as gluten enteropathy or celiac
sprue; results in mal-absorption
• Autoimmune response to gluten, a type of
protein found in wheat, barley, rye and to a
lesser extent oats
• Immune system attacks and damages the
villi that normally absorb nutrients
Small intestine villi
Small intestine villi
Normal and celiac
Clinical Manifestations of Celiac
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Bulky, frothy, foul smelling stool
Fatty stools (steatorrhea)
Diarrhea or constipation
Weight loss/failure to thrive
Anemia
Anorexia
Coagulation difficulties and vitamin deficiencies
Pot belly and muscle wasting
Diagnosis of Celiac
• Immunoglobulin A (IgA)
• anti-tissue transglutaminase (tTGA)
• IgA anti-endomysium antibodies (AEA)
Treatment of Celiac
Gluten Free Diet
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Wheat, Barley, Rye, Oats
Durum
Couscous
Semolina
Spelt
Kamut
Bulgur
Triticale
• Malt
• Hydrolyzed Vegetable
protein (HVP)
• Hydrolyzed Plant Protein
(HPP)
• MCG products
• Some vegetable cooking
sprays
• Some medications
• Some cosmetics
Credits on Celiac Disease
• http://digestive.niddk.nih.gov/ddiseases/pu
bs/celiac/
• Elliot, David MD
@http://www.uihealthcare.com/news/curre
nts/vol4issue2/celiacdiseae.html
• National Foundation for Celiac Awareness
Hirschsprung’s Disease
• Absence of ganglionic innervation to the
muscle of a segment of the bowel, usually
in the lower portion of the sigmoid colon.
This results in a lack of normal peristalsis
Hirschsprung’s Disease
Normal and Abnormal
Hirschsprung’s Disease
Clinical Manifestations
• Failure to pass meconium in the first 24 to
48 hours
• Abdominal distention and palpable stool
masses
• Ribbon like stools
• Anorexia, vomiting, failure to thrive
• Bile stained or fecal vomiting
Hirschsprung’s Disease
Surgical Treatment
Hirschsprung’s Disease
Nursing Care
• Pre-surgery may need enemas; remember normal
saline enemas to prevent water intoxication!
• Post op care:
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IV fluids, I/O, wound care
Possible ostomy care
No rectal thermometer or suppositories
Oral feedings once bowel sounds begin
Continence of stool may be delayed in these kids,
advise parents accordingly
Intussusception
• The slipping of one part of the intestine
into another part just below it, usually seen
at the ileocecal valve. The slipping is often
referred to as telescoping.
Intussusception
Intussusception
clinical manifestations
• Pain: loud cries, straining efforts, kicking and
drawing of the legs towards abdomen
• Bilious vomits
• Currant jelly stools from blood and mucous
• Fever
• Possible signs of shock
• A very rigid abdomen
• Sausage shaped mass in the RUQ
Intussusception
Post operative Nursing Care
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IV
Antibiotics
I/O
Incision Care; possible colostomy care
Monitor Bowel Sounds
Pain management
Meckel’s diverticulum
• Small duct that fails to disappear during
fetal life usually near the ileocecal valve; a
small pouch is formed.
• Manifested by painless bleeding from the
rectum and sometimes abdominal pain
• May progress to hemorrhage,
inflammation, obstruction.
• Treated by surgery
Meckel’s Diverticulum
Inguinal Hernia
• Protrusion of part of the abdominal
contents through the inguinal canal in the
groin
• May be:
– Reducible
– Incarcerated
– Strangulated
Inguinal Hernia
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Gastroenteritis
Vomiting and Diarrhea
• Inflammation of the GI system
• Often manifested by vomiting and/or
diarrhea
Gastroenteritis; vomiting
• Persistent vomiting can lead to
dehydration, electrolyte imbalance and
alkalosis
• I/O and lab values must be monitored
• Oral rehydrating solutions are the main line
of therapy; in severe vomiting IV may be
necessary
A word on Phenergan and Tigan
in pediatric population
• Isolated usage with extreme caution
• Phenergan contraindicated in children under two
due to side effect of respiratory depression.
• Both drugs may contribute to development of
Reye’s syndrome or unfavorably influence its
outcome.
• Both drugs extra pyramidal effects may confuse
the diagnosis of Reyes Syndrome
Gastroenteritis; diarrhea
Evaluate hydration status
Assist in appropriate hydration measures
Assist in determining the cause of diarrhea
Regular diet (if no vomiting) avoiding fatty
and high sugar foods
Some patients can not tolerate milk during
and after gastroenteritis, but 80% can
Dehydration; Pediatric Points of
Vulnerability
• Newborn 77% water compared to adults 60%
• Greater body surface of infants compared to
children compared to adults
• Younger the patient, higher the metabolic rate
and more unstable the heat regulating mechanism
• Immature kidneys limit ability to conserver H2O
Three types of dehydration
• Isotonic
– Loss of equal amounts of fluid and electrolytes
– Shock is of concern with isotonic dehydration
• Hypotonic
– Loss of more electrolytes than fluid
– At risk for water intoxication
• Hypertonic
– Loss of more fluids than electrolytes
Nursing implications to types of
dehydration
• Careful assessment of lab values
• Document at least one void before giving
IV potassium
• Prudent selection of fluids offered
– Hypertonic: sodium free or low sodium drinks
– Hypotonic: electrolyte replacement drinks
Symptoms of Dehydration
• Quality of pulse
decreased
• Heart rate increased
• Skin turgor decreased
• Fontanelle sunken
• Mucous membranes
dry
• Weight evaluation
• Sunken eye orbits
• Delayed capillary
refill
• Decrease in mental
status
• Urine output <1
ml/kg/hr
• Increased thirst
Appropriate Rehydration
Formulas
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Naturalyte
Pediatric electrolyte (NutraMax
Pedialyte
Infalyte (Rice based, Mead Johnson)
Rehydralyte (Ross)
WHO/UNICEF oral rehydration salts
Rehydration Therapy
• Mild (3-5%) 50mL/kg ORT plus
replacement of continuing loss in a four
hour period (stools: 10 mL/Kg)
• Moderate (6-9%) 100 mL/kg ORT plus
replacement of continuing losses during a 4
hour period
• Severe 20 mL/kg per IV over one hour
Appendicitis
• The appendix is a small, tube-like structure
attached to the first part of the colon.
• Appendicitis is an inflammation of the
appendix.
• Appendicitis is considered a medical
emergency.
• Acute appendicitis is treated by surgery to
remove the appendix.
• The most serious complication of appendicitis
is rupture, which can lead to peritonitis and
abscess.
Appendicitis
Clinical Manifestations
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Initial periumbilical pain which increases
Pain localizes to RLQ
Vomiting
Diarrhea
Guarding or rigidity of abdomen
Rebound tenderness
Pain in thigh when lifting in supine
Gastroesophageal reflux
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Lower esophageal sphincter is relaxed
Vomiting, weight loss, failure to thrive
Aspiration pneumonia a risk
DX with barium swallow and pH
monitoring of the esophagus
GER CARE
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Burping
Avoid overfeeding
Thickened cereal
Upright at 30-40 degrees
– Prone
– Sidelying
– Not supine
Medical Management of GER
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Reglan; metoclopramide
Tagamet; cimetadine
Zantac; ranitidine
Surgery may be indicated
G-tube or J-tube in severe cases
Failure to Thrive
• Infants who fail to gain appropriate weight
or loose weight
• Organic
• Inorganic
Nonorganic Failure to Thrive
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Infant/child appears wary of caregivers
Unresponsive to cuddling
Apathetic and ragdoll in appearance
Dysfunctional factors in family
Alcohol and drug abuse
Signs of physical abuse/neglect
FTT Care
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Rule out organic causes of failure to thrive
Usual hospitalization
Support the parents
Assist in establishing attachment with
parents
• Assist in teaching parenting skills
• Assist in getting parents into support
systems
Pinworms
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Enterobiasis
White thread like worms
Comes out at night to lay eggs on anus
Child has itchy anus
Spread and reinfected by oral fecal route
Pinworm Care
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Handwashing
Clip fingernails
Ointment to bottom
Clean linens
Treat whole family
RX: anithelmintics
– Mebendazole or Vermox
– Pyrantel pamoate or Antiminth
– Pyrvinium pamoate or Povan
Roundworms
• Ascariasis
• Southern states
• Child ingests the egg from contaminated
soil
• Read cycle of round worms page 653
Pediatric Poisoning Principles
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Volume of a swallow about 3 mls
Education towards prevention
Poision control center
Ipecac syrup no longer advised in home
Activated charcoal is often utilzed
– Ipecac and activated charcoal neutralize one
another
Acetaminophen poisoning
• Most commonly ingested drug
• Overdose results in hepatic destruction
• Remember that tylenol drops are very
concentrated and make sure you know
which parents have on hand
Acetaminophen poisoning
• Empty the stomach with lavage or emesis
• N-acetylcystein (Mucomyst)
• Every four hours for 72 hours
• Monitor liver enzymes
Salicylate Poisoning
• Aspirin and Oil of wintergreen
• Vitamin K to control bleeding
• Peritoneal dialysis if acute renal failure
Lead Poisoning (Plumbism)
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Primary source: Paint from old building
Most common 18 mos-3 years
Azarcon is another source
Lead poisoning has lasting effect on central
nervous system
Lead Poisoning Manifestations
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Weakness
Weight loss
Irritability
Anorexia
Vomiting
Abdominal pain
Anemia, pallor
• CNS involvement
– Muscular
incoordination
– Convulsions
– Encephalitis
Chelation Therapy
• Calcium Disodium Versenate (CaEDTA)
– Deep IM or IV
• Mild may be treated with DMSA
• British antilewisite or BAL