Notes on some common childhood gastrointestinal defects and its nursing management

1. Medical & Surgical Conditions of
Childhood
Gastrointestinal Systemdefects
CleftLip & Palate, Exomphalosand Oesophageal Atresia
StephanopoulosK. J. Osei
Student nurse(BSN)

2. Introduction
• Congenal anomalies may be caused by genetic or
environmental factors
• Congenital anomalies account for large percentage of
health problems seen in neonates and children

3. Objectives
• Explain some common gastrointestinal system defects
that occur in child including causes, treatment and
pathophysiology
• Discuss with our mates the nursing management of
these conditions focusing on physiological, physical
and psychological nursing interventions

4. • Wait a minute lets check
this out
• Baby Kunle a 3-day old
neonate on delivery
presented with an
indentation formed on
his upper lip.

5. What is Baby Kunle
suffering from?
How many kids like Baby
Kunle suffer such condition?
How do I manage baby Kunle
as a Nurse?

6. Cleft lip and cleft Palate
• Cleft lip is a small gap or an indentation formed
on top of the lip.
• Cleft lip can occur with cleft palate or alone.
• Most common facial malformations that occurs in
newborns

7. Incidence
• Most common facial malformations that occurs in newborns
• Cleft lip; 1 in 1000 births. More in males
• Cleft Palate: 1 in 2500 births. More in females

8. • CAUSES
Not really clear
• Risk factors
Heriditary or genetic disorders
Environmental factors (exposure to
alcohol,anticonvulsants & other teratogens)

9. Pathophysiology
1.Lips closes earlier
than palate
2. cleft lip and palate
occurs due to failure of
maxilliary & premaxilliary
processes to form together
in 5th- 8th weeks
3. Palate form within the 8th-10th
weeks. later bone forms within
the roof tissue to form hard
palate

10. Clinical Picture
• Distended abdominal due to
swallowing air
• Abnormal formation of the lip
• Abnormal formation of the palate
Assesment:
• 1. Use tongue depressor to open
baby's mouth and inspect palate
• 2. wear gloves
• 3. Insert a finger in baby's mouth
• 4. Palpate for Intact palate and
note any indentation
Diagnostic Investigation
• Prenatal ultrasonography
Types
• Partial: small notch on vermiform
border
• Complete: notch continues to
nose
• Unilateral
• Bilateral

12. Treatment
• Surgery
 Cheiloplasty: to surgically repair the cleft lip within the first 3 months
after birth to provide adequate sucking.
 Palatoplasty: to surgically repair the cleft palate between 12 months
and 18 months of age before the child begins speaking
• Management team: pediatricians, nurses,
orthodontists,prosthodontists, otolaryngologists, speech therapists, and
occasionally psychiatrists

13. Nursing management
• Nursing diagnosis Prior to surgery
1. Imbalanced Nutrition: Less than Body Requirements related to
inability to suck secondary to cleft lip
2. Compromised Family Coping related to visible physical defect
3. Anxiety of family caregivers related to the child’s condition and
surgical outcome
4. Deficient Knowledge of family caregivers related to care of child
before surgery and the surgical procedure

14. • Nursing diagnosis post surgery
• Risk for Aspiration related to a reduced level of consciousness after
surgery
• • Breathing Pattern related to Ineffective anatomical changes
• Risk for Deficient Fluid Volume related to NPO status after surgery
• • Imbalanced Nutrition: Less than Body Requirements related to difficulty
in feeding after surgery
• • Acute Pain related to surgical procedure

15. • Nursing diagnosis post surgery
• Risk of Injury to the operative site related to newborn’s desire
to suck thumb or fingers and anatomical changes
• • Risk for Infection related to surgical incision
• • Risk for Delayed Growth and Development related to
hospitalizations and surgery
• • Deficient Knowledge of family caregivers related to long-term
aspects of cleft palate

16. Nutrition
1. Breastfeeding more sucessful as breast can mold and cover
indent
2. Bottle feeding: A soft nipple with crosscut tip or large nipple with
holes to aid free flow of milk
3. child with cleft palate only or early repair learns how how to suck
early
4. lamb nipple and aspeto tube
5. child should be kept upright. if unilateral feed at unaffected side.
child must be upright during feeding
6. monitor coughing,sputter, choking and aspiration (careful feeding)

17. • Psychosocial support for family
1. encourage family to verbalize feeling and reassure them pointing
out that their feelings are valid
2. provide explanation on disease condition and perioperative care
3. show behaviour of acceptance towards child

18. • Post operative care
• Immediate Op
• lateral position to drain mucus and prevent aspiration
• Position child to aid nasal breathing (mouth-nasal breathing change)
• continous observation for aspiration
• finger and elbow restraints to prevent child undoing the repair. Monitor
restraints
• Monitor IV site, fluid flow rate every 2hrs,I&O
• Administer prescribed analgesic ot only for comfort but to prevent child from
crying which may cause repair suture damage due to tension

19. Post-op
• Gently clean baby's mouth with clear or tepid water after feed
• clean sutures with sterile cotton and N/S. May apply bactriban. Open dressing
• Teach family how to care for sutures
• Provide sensoy stimulation: talk,cuddle and respond to child when crying aids in
stimulating suckle reflex
• Post- nutrition
• start clear fluid if child is no longer nauseated
• breastfeeding
• if palate repair avoid nipples,spoons or straws
• surgeon determines progression of diet from liquid to solid foods

20. • Esophageal Atresia

21. Intro
• Atresia is the abscence of a normal body opening or
abnormal closure of a body passage
• Fistula is an abnormal connection between hollow organs
or connection between an organ and the skin.
• Eesophageal atresia with or without fistula into the tracheal
is a serious and common anomaly that causes respiratory
distress.(An Emergency)
• Most occurs 5 weeks of gestation when the forgut normally

22. Types
• phot

23. Clinical presentation
• Frothy saliva
• Excessive drooling (overfilled pouch)
• Coughing due to excessive secretions
• Gagging when feeding
• Feedings exiting the mouth and nose
• Aspiration
• Difficulty breathing (choking & cynosis)
• Distended stomach
This child's life depends on your careful
observation
Diagnostic invesitgation
Barium oesophagogra

24. Why this could lead to severe complications
• Any mucus or fluid ends in blind pouch which become filled and
overflows resulting in aspiration into the trachea
• The newborn may have frothing and excessive drooling and periods of
respiratory distress with choking and cynosis
• If there is a fistula at the distal portion of the esophagus, gastric content
may reflux into the lungs and cause chemical pneumonia
• DO NOT FEED this child. Feeds could be aspirated and lead to
aspiration pneumonia

25. Treatment
• Suction the contents of the blind pouch.
• Insert NG tube to decompress the stomach.
Surgery: Repair the fistula and/or blind pouch.
First stage: Gastrotomy and drainage of proximal pouch
2nd stage: resection and end to end anastamosis
Surgical repair is complex and is done in stages
Chest tube may be inserted to drain chest fluid
Broad spectrum antiobiotics for risk of pneumonia

26. Nursing management
• Pre-op
• Nil per Os. Insert NGT as orderd
• Semi fowlers supine positioning to facilitate gastric
drainage
• Suction the contents of the blind pouch as ordered.
• No pacifier because this increases saliva production.

27. Postoperative care:
• Monitor vital signs and repiratory status closely.
• Monitor IV fluids, mediations (antibiotics) & parenteral nutrition closely
• Nutrition:
• monitor I&O, and daily weight,
• Proper gastromy feeding till anastamosis heal (usually postoperative
day 5 to 7); removal of chest tube is done first and esophagogram is
performed to check anastamosis integrity.
• before oral feeding take precautions,
• oral feeding start with sterile water first then small feeding of formula or
breastmilk.

28. Post Op
• Nutrition:
• Inspect cervical esophagostomy site and apply protective
ointement, barier dressing.Monitor anastomotic leak
evidenced by purent chest tube drainage
• Use pacifier during NPO to stimulate suckling
• Parent teaching: identifying behavious that indicated need
for suctioning like respiratory distress signs during feeding
or when mucus is excess

29. Exomphalus
(A.K.A OMPHALOCELE)

30. Intro
• Omphalocele is the herniation of abdominial content through the
umbilical ring usually with an intact peritoneal sac
• The transculent sac contains bowel and other abd. contents
• Rupturing of the sac results in eversceration (gushing out) of
abd. content
• In gastroschisis however the hernia is lateral to the umblical ring
and theres no membrane covering the exposed abd. content

31. Incidence
• Relatvely rare
Exomphalos
Gastoroschisis

32. Diagnostic investigation & Treatment
• Investigations
 Prenatal Ultrasonography
• Treatment
 Surgery
 Replacement of the organs into the abdomen could
be difficult since theres limited space. this mostly
happens with large exomphalos
 suture skin over defect and as child grows the
abdomen would be enlarge enough for
replacement

34. Nursing mgt
• Cover defect immidaitely after bith with
gauze mostened with sterile saline to
prevent heat loss and drying
• Monitor vital signs frequently very (2-
4 hrs) especially temperature for heat
loss or fever

35. Pre op
• NPO status
• IV fluids administration for fluid and electrolyte balance
• Monitor signs of infection
• Handle infant carefully to prevent rapture of sac

36. post-op
• pain mgt
• infection prevention
• fluid and elctrolyte balance
• adequate nutrition
• In gastroschicis the exposed bowel is covered loosely
with saline soaked pads

37. Gastroschisis
• In gastroschicis the exposed bowel is covered loosely
with saline soaked pads and the abdomen is losely
wraped with plastic (rubber) bag or drape or silo bag
• Tight wrapping causes pressure on the expanding organs
and could result in necrosis]

38. Care in gastroschisis
• Surgery is done within several hours after birth
• Pre o and post op mgt similar to that of exomphalos
• Instruct childs parent to avoid tub bath until incision heals
• strenous activity should be avoided...WHY?

39. Conslusion
• Gastrointestinal defects poses challenges to child's
nutrtion and elimination
• Care nursing observation promotes early detection
• Proper nursing interventions are live saving also
contributes quality of life
• Y da mo nyinaa ase

40. References
• Hatfield, N.T. 2008. Broadribb's Introductory Pediatric Nursing (7th
ed.). Retrieved www.pdfdrive.net of February 14, 2019
• Johnson J.Y. & Keog J. 2010 Pediatric Nursing Demystified.
Retrieved www.pdfdrive.net of February 14, 2019
• Sylvestri L. A. 2017 . Saunders Comprehensive Review for the
NCLEX-RN (7th ed.) Retrieved www.pdfdrive.net of February 14,
2019
• Google images

41. • Y da mo nyinaa
ase