Imperforate anus Known as the stricture of the anus Problems occur in 1:5000 live births More common in males Occur as an additional complication of Spinal cord defects.
Assessment May reveal no anal formation Abdominal distention is evident No stool will pass Absent of wink reflex
Diagnostic X- ray Sonogram Urinalysis
Therapeutic management Surgical repair Post-op care - No rectal temp taking - Stool softener is given - Place a diaper under but do not put on - Side-lying position - May need rectal dilatation once or twice a day
- Instruct parents in care ofcolostomy
Nursing priority: - Record the first passage of meconium stool. If infant does not pass stool within 24 hours, further assessment is required.
Cleft Lip - A fissure of the upper lip to the side of the midline, which may vary from a slight notch to a complete separation extending into the nostril; may be unilateral or bilateral
- Caused by failure of the maxillary process to close in early fetal life; usually occurs during the 6 th week of gestation
- Increased incidence in males; occurs in about 1:800 live births
Assessment: - Visible at birth an incompletely formed lip
Treatment: - Surgical repair is done early (2-6 months)
Nursing intervention Goal: To provide preoperative care A. Maintain Nutrition - Use a large-holed nipple or a modified nipple - Feed slowly - Burp frequently - Rinse cleft with water every after feeding - Elevate head of bed, put pillow under the mattress B. Prepare parents for newborns surgery - Encourage parents to position infant flat on back or side - Encourage parents to place infant in arm restraints periodically - Encourage parents to feed infant with the same method Goal: To provide postoperative care A. Prevent trauma to suture line and maintain patent airway - Observe for respiratory distress - Provide suction equipment at bedside - Position on side or back and elevate head of bed - Used soft elbow restraints - Cleanse suture line after each feeding: use cotton-tipped applicator and roll along the suture line - Prevent any crust or scab formation on lip and suture line
B. Provide for adequate nutrition - Feed in an upright position - Feed slowly ( burp at frequent intervals) C. Provide discharge teaching to parents - Encourage to cuddle and play infant to decrease crying - Provide referrals to speech therapist
Cleft Palate - Failure of fusion of the secondary palate; may involve the soft and hard palates along with the alveolar (dental) ridge.
- Generally associated with low birth weight infant, increased incidence of other malformations especially GI tract defects
assessment Opening in roof of mouth; usually associated with cleft lip Sucking difficulties Breathing problems Later problems: - Speech and hearing difficulties - Increased incidence of URTI and otitis media Treatment Surgical: may be done in stages - Usually repaired around 18 months to allow for bone growth; some are delayed until 4 years.
Nursing intervention Goal: To provide preoperative care A. Maintain nutrition - Use a modified nipple for feeding( lambs nipple, brecht feeder, cup) - Feed child in semi-upright position - Cleanse mouth after feeding with water B. Prevent infections C. Provide support and teaching to parents
Goal: To provide postoperative care A. Maintain patent airway - Observe for respiratory distress - Position on side or abdomen to provide drainage of mucus B. Prevent injury and trauma to suture line - Restraints: Elbow infant, jacket older child - Avoid use of straw, suction catheter, tongue depressor, pacifiers or spoons - Decrease crying C. Maintain nutrition - Give fluids initially, then advance to diet based on age - Older child: not allowed to eat hard items such as: crackers, potato chips - Cleanse mouth after each feeding with water D. Provide guidance to parents - Provide emotional support - Provide referrals to speech and orthodontist as needed
Spina bifida - Congenital anomaly of the spinal cord characterized by nonunion between the laminae of the vertebrae. - A neural tube defects results in midline defects and closure of the spinal cord - Most common site is lumbosacral area TYPES 1. Spina bifida occulta a. Noncystic spina bifida - Results on failure of the spinous processes to join posteriorly in the lumbosacral area, usually around L5 and S1 b. Neuromuscular disturbances may be apparent with foot weakness, bowel and bladder sphincter disturbance, and numbness and tingling of the extremities. c. Infant may have no apparent clinical manifestations. - Dimpling on the site 2. Spina bifida cystica a. Meningocele: a sac-like cyst of meninges filled with spinal fluid that protrudes through a defect in the bony part of the spine. b. Myelomeningocele: a sac-like cyst containing meninges, spinal fluid, and a portion of the spinal cord with its nerves that protrudes through a defect in the vertebral column; other defect most frequently associated with hydrocephalus. - Paralysis of lower extremities - Musculoskeletal deformities - Neurogenic bladder and bowel
Risk factors - Maternal Folic-acid def. - Previous pregnancy affected by neural tube defect Etiology - Combination of unknown genetic/environmental factors - Advanced maternal age - High levels of AFP (alpha-feto protein)
Treatment A. Occulta: no treatment B. Meningocele/meningomyocele: - Surgical - Closure of defect with 24-48 hours to decrease risk of infection, relieve pressure, repair sac, and possibly insert a shunt.
Nursing intervention Observe for irritation, CSF leakage and signs of infection Maintain asepsis; cover lesion with moist sterile dressings Position patient on the abdomen or semiprone with sandbags Provide optimum skin care, especially to perineal area
Detect early development of hydrocephalus - Measure head and check circumference frequently - Check fontanels for bulging and separation of suture line Check for abnormal movement of extremities, absent or abnormal flexes, incontinence, fecal impaction, flaccid paralysis or lower extremities Observe for increased ICP Observe for signs of meningeal irritation
Provide parental bonding and education regarding proper positioning, feeding, skin care and exercises. Teach the parents credes maneuver to prevent urinary retention
Hydrocephalus A congenital or acquired condition characterized by anincrease in the accumulation of CSF within the ventricular system. Causes: - Neoplasm - Aqueductal stenosis - Spina bifida - Congenital cyst/ vascular malformations Types A. Communicating - Due to increased production of CSF or impaired absorption of CSF B. Non-communicating - Due to obstruction/blockage of CSF circulation between ventricles and subarachnoid space
assessment Fronto-occipital circumference increases at abnormally fast rate Split sutures and widened distended, tense fontanelles Prominent forehead, dilated scalp Sunset eyes, nystagmus Irritability, vomiting Unusual somnolence
Convulsion High-pitched cry
Implementation Operative management a. Ventriculoperitoneal shunt - Connection between ventricles and peritoneal cavity b. Ventricular atrial shunt - Connection between ventricles and right atrium c. Ventricular drainage - Provides external drainage of fluid
Observation of shunt functioning (not fnng well: dilated cerebral veins) Shunt needs to be modified as child grows Continual testing for developmental abnormalities/mental retardation Discharge planning - Measure the head circumference: tape measure Monitor for increased ICP - LOC earliest sign - Restlessness - Pupillary changes - V/S changes: Inc BP dec Pulse
Intussusception Telescoping of one portion of the bowel into another portion The condition results in an obstruction to the passage of intestinal contents INCIDENCE: Males affected two times more than females Usually occurs between 3-12 months of age
Assessment Colicky abdominal pain Vomiting Bile-stained fecal emesis One or two normal stool then currant jelly-like stools containing blood and mucus Hypoactive or hyperactive bowel sounds Tender distended abdomen Palpable sausage-shaped mass in the upper quadrant Therapeutic interventions Medical reduction by hydrostatic pressure ( barium enema)
Surgical procedure; sometimes with intestinal resection Nursing interventions Monitor for signs of perforation Insertion of NGT Administer antibiotics Start and IV line Monitor passage of normal brown stool
Colic Paroxysmal abdominal pain or cramping Baby cries for longer than 3 hours everyday for more than 3 days a week Extreme end of normal crying behavior The condition is harmless though is can be distressing to the parents or carers. Is uncontrollable, extended crying in baby Incidence About 20% of babies get colic Boys and girls equally affected Often occurs in 1 st born child and those born later Appears around 2-4 weeks of age and can last for 3 months or longer in some cases.
Cause: - Unknown ASSESSMENT - Characteristics of the cry - Diet of breastfeeding mother - When the attack occur in relation to feeding - Activity of caregiver around time of attack - Mothers habit such as smoking
Treatment No single medicine or proven cure for colic Different babies are comforted by different measures Parents who bottle-feed their babies may try a new formula Continue breatsfeeding Carry the baby in front sling or back pack Warp snugly in a blanket (swaddling) Take the baby for a car ride or a walk outside Give a tummy or back rubs Take a shower together warm water may be comforting
Hirschsprungs disease Characterized by a congenital absence of ganglion cells in the myenteric plexus of the colon Congenital aganglionic megacolon Most common site is the rectosigmoid colon
Risk factors/ Etiology - Congenital, may be associated with Down syndrome ASSESSMENT - Inadequate or absent peristalsis (Newborn) - Failure to pass meconium within 24-48 hours after birth - Vomiting - Abdominal distention - Reluctance to take fluids Older infant - Passage of watery stools or diarrhea (ribbon- like stools) - Failure to thrive - Lack of appetite - Persistent constipation, impactions DIAGNOSTICS - Rectal biopsy - Barium enema
Treatment Surgical correction involves creation of a temporary colostomy, then a pull-through of the colon to a point near the rectum. After the reanastomosis has healed, the temporary colostomy is closed.
Nursing intervention Allow parents to ventilate feeling regarding congenital defect of infant Foster parent-infant attachment Maintain a low residue diet: low fiber, high calorie, high protein diet Measure abdominal girth Administer stool softener as ordered Careful explanation of colostomy to parents
Care of colostomy Colostomy: opening of the colon through the abdominal wall, stool is generally semisoft and bowel control may be achieved. - Maintain regular irrigations - Irrigate colostomy same time each day to assist in establishing a normal pattern of elimination
Failure to thrive Failure to thrive is a delay in physical growth and weight gain that can lead to delays in development and maturation. Failure to thrive is a diagnosis given to children who are consistently underweight or who do not gain weight for unclear reasons. The diagnosis is based on a growth chart comparison, thorough examination, and parents' answers to specific questions about the child's health and environment. Normal growth: - Normal child usually 2x their weight by 4mos and 3x by 12mos CAUSE: 1. Environmental and social factors - Parental neglect or abuse - Chaotic family 2. Medical disorder - Cleft lip and palate - infections - HIV - intolerance to milk - GERD
Diagnoses are made in infants and toddlers in the first few years of life. Use standard growth chart to plot weight, length and head circumference Failure to gain weight for 3 consecutive months during the first year of life.
Treatment High calorie diet to catch up growth Treat the specific cause Sometimes child may be hospitalized
Trisomy 21 Down syndrome Characterized by chromosomal abnormality related to an extra chromosome 21. CAUSE: - Unknown - Associated with maternal age greater than 35 y. o
assessment Mental retardation Marked hypotonia Altered physical development Large tongue Simian crease Slanting eyes Low set ears Usually associated with CHD
Diagnostic test - AFP usually decreased TREATMENT - Establish adequate nutrition - Provide parental education - Refer parents for genetic counselling
Meningitis Viral or bacterial infection affecting the meninges CAUSE: - Virus - Bacteria - Fungal
Assessment Headache Fever Photophobia Signs of meningeal irritation - Nuchal rigidity - Kernigs sign - Brudzinskis sign - Opisthotonic position Changes of LOC Seizures Special symptoms in infants - Refuse feedings, vomiting, diarrhea - Bulging fontanelles - Vacant stare - High-pitched cry
Implementation Medications - Antibiotic penicillin (DOC) - Antifungal amphotericin - Mycobacterium INH, streptomycin NURSING INTERVENTION - Implement strict isolation until first 24 hours of antibiotic treatment - Refer to audiologist
Wilms Tumor Nephroblastoma Most common intraabdominal tumor in children associated with congenital anomalies especially in the genito-urinary tract Associated with genitourinary anomalies Majority of children (80%) are younger than 5 years, peak incidence at 3 years
Assessment Swelling or mass on the abdomen Painless abdominal tumor (first sign) Abdominal pain as tumor enlarges Fever Nausea and vomiting Blood in the urine Hypertension
Diagnostics Biopsy Ct scan MRI X-ray
Treatment A. Surgery - Is frequently scheduled within 24-48 hours after the diagnosis. - Nephrectomy: Kidney is removed but the adrenal gland may be spared, depending on the invasiveness of the tumor. If both kidneys are involved the less affected kidney is retained, bilateral nephrectomy is the last resort.
Nursing intervention Nsg. Priority: POST A SIGN ABOVE THE BED THAT READS: DO NOT PALPATE ABDOMEN Handle the child carefully to prevent trauma to the tumor site. Prepare the child for the surgery, including anticipation of a large incision and dressing. Assess V/S especially BP Refer parents to a geneticist
Poisoning Aspirin Poisoning Lead poisoning Tylenol poisoning
Assessment: 1. ABC rule - Treat the patient first then the poison 2. Identify poison - Amount and time of ingestion
3. Diagnostics - Urine and serum analysis - Long-bone x-rays if lead deposits is suspected - CT scan and EEG
Implementation 1. Prevention a. Child proofing - Store all potentially poisonous substances in locked-out-of-reach area b. Increased awareness of precipitating factors - Growth and development characteristics under/overstimating the childs capabilities - Changes in household routine - Condtions that increase family tension of family members 2. Instructions for caretakers in case of suspected poison ingestion a. Recognize signs and symptoms of accidental poisoning - Change in childs appearance/behavior; presence of unusual substances in childs mouth, hands, play area, burns, blisters or suspicious odor. b. Initiate step to stop exposure c. Save any substance, vomitus, stool and urine
d. Induce vomiting if indicated 3. Ipecac direct stimulation of vomiting center and gastric irritant; a. dose: 9-12months -10ml do not repeat 1-2 years old 15ml 12 years and older 30 ml b. Follow each dose with a clear fluids (4-8oz) c. Position childs head lower than the chest to prevent aspiration
d. Repeat once every 30 minutes for child over than 12 months e. If no vomiting after 2 doses, transfer to ER f. Contraindications to inducing vomiting - When child is danger or aspiration - When substance is petroleum distillate or strong corrosive substance g. General considerations - Water may be used to dilute the toxin: avoid giving large amounts of fluid when medication has been ingested
- Milk may delay vomiting 4. Emergency care a. Basic life support - Respiratory - Circulation b. Gastric lavage c. Activated charcoal : 5-10gms for each g of toxin - Give within 1 hour of ingestion and after emetic - Mix with water to make a syrup