GIT for nursing school

1. Samir gouda
prof of pediatric surgery
Moukhtar Mahdy
Pediatric Surgeon

4. Children are not young Adults

5.  They are very fragile
 Difficult to regulate the body temperature of
newborns & infants
 80% of young child’s weight is fluids in comparison
with 60% in adults.
 They more liable for electrolytes imbalances
 They need special ways for feeding
 Pain killers and using of narcotics are more risky for
children

6. They have small blood volume (in neonates about
80-85 ml/ kg)
Their full physiological functions and reserves are
little:
◦ Immature respiratory system
◦ Immature hepatic function
◦ Immature renal function
We do everything weight
based
We do everything warm

7. Why the OR is so hot?!!
Babies really can’t do that…
Have no fat in them
No hair on them
Don’t shiver , not built in them yet

9. General assessment for operation (Heart chest
condition, anemia, hydration status,…..etc)
Local assessment of the site of operation (no
infection)
Assessment of parent knowledge and give then
simple preoperative information about operation.
(Family Consent )
Ensure that the child is physically and
psychologically prepared for surgery
Blood grouping , LAB Results ...

10.  Measuring Vital signs
 Assess urine for amount, color,…etc
 Ensure Empty stomach !!
◦ Stop all food from the midnight before
surgery
◦ Stop breast feeding 4 hours before surgery
◦ Stop clear fluids 2 hours before surgery
◦ !! ....

11.  Immediate post-operative day
 General
◦ Positioning !!!
◦ Vital signs
◦ Level of consciousness
◦ Hydration
◦ Intake & output
 Local
◦ Surgical incision
◦ wound care
◦ Assess for bleeding
◦ Pain medication

12. - General
◦ Vital signs
◦ Signs of infection
◦ Hydration
◦ Intake & output
Local
◦ Surgical incision
◦ Care of wound
Pain medication

13. Congenital Diaphragmatic
Hernia
)CDH(
Congenital Diaphragmatic
Hernia
)CDH(

15.  CDH: Opening in the diaphragm through
which the abdominal contents herniates into
the thoracic cavity during prenatal
development.

16. on the left side in 85% of cases.
Loops of bowel, even most of the abdominal contents,
may protrude into the hemithorax on the involved side.
If the hernia is large, the lung on the affected left side
will be hypoplastic
Mortality rate 50-85%

18.  Antenatal ultrasound (abdominal organs
in chest)
 Respiratory distress soon after birth
(RDS).
 Respiratory difficulty develops a few
hours or days later
 Scaphoid abdomen
 Diminished air entery
 Bowel sounds over chest
 Auscultation of heart sounds on right
side of the chest
 Persistent pulmonary hypertension

20.  Clinical manifestations
 Plain chest and abdomen X-ray

21. oNeonatal surgical
emergency
oThe infant should be
immediately intubated and
ventilated
oContinuous suction with a
double-lumen Nasogastric
tube

22. • NG tube (decompression)
◦Intravenous fluids
◦Ensure ventilation
◦Extracorporeal Membrane
Oxygenation (EMO)
◦Manage pulmonary
hypertension

23. Operation: surgical reduction of hernia after
being physiologically stable.
Postoperative: respiratory support till lungs
function probably

25. Preoperative care
oRoutine preoperative care
oSemi-Fowler’s position on affected
side with head of bed elevated.
oCare for respiratory distress
(positioning,oxygenation, mechanical
ventilation)

26. Postoperative care
Routine postoperative care
Care for chest tube????
Care for respiratory distress????

30. TEF. It is a congenital malformation in
which the esophagus terminates before it
reaches the stomach and a fistula is
present with the trachea

34. Coughing, chocking
with feeding and
cyanosis
Excessive salivation
Failure to pass NG
tube NO.10

35.  Past history of mother’s polyhydraminos
during pregnancy.
 Plain X-ray
◦ Dilated proximal esophagus with air (Atresia)
◦ Abdominal distention (indicates presence of
fistula)
X-ray with contrast (Blind upper esophageal
pouch)

36. EA with TEF is a critical neonatal surgical
emergency.
The aim of preoperative management is to get the
infant into optimal condition for surgery.
Oral feedings are withheld.
Continuous suction

38. NICU for prevention of aspiration
Aspirate from NG tube /5-10 minutes.
I.V. fluids
Surgical repair is the main line of treatment

39.  The infant should be positioned
as the head elevated in the
reverse Trendelenberg
position

40.  When the infant's condition is
stable, extrapleural surgical
repair of the esophageal
atresia and closure of the
tracheoesophageal fistula can
be performed end to end
anastomosis.
 If the patient presented late
osophagostomy and
gastrostomy will be done

41. Immediately after birth:
Warm the baby
Give humidified oxygen
Prepare for surgery (general preoperative care)
X ray , after the NG tube
Ask for Echocardiogram

42. Immediate postoperative:
 Care for chest tube (patency & output)
 Care of esophagostomy:
◦ Clean with gauze to absorb saliva
◦ Change the gauze frequently to prevent constant wetness
 Provide skin care
 Oral stimulation with pacifier to allow practice in
swallowing
 Care of Gastrostomy tube

44. CHPS: Narrowing of the pyloric sphincter at
the outlet of the stomach.
Obstruction of the pyloric lumen due to pyloric
muscular hypertrophy

47. No abnormal signs in the first week or
two after birth.
 Forceful projectile vomiting of
feedings without bile usually begins
late in the first month of life.
 Gastric peristaltic waves may be
visible, crossing the epigastrium from
left to right.
 Weight loss, dehydration

48. Distended upper abdomen
Decreased frequency and quantity of
stool
Visible gastric peristalsis
Delayed diagnosis may lead to repeated
vomiting, dehydration, failure to gain
weight

49. Palpation of a discrete, 2- to 3-cm, firm,
movable pyloric olive-like mass deep in the
right side of the epigastrium.
Abdominal Ultrasonography.
If the diagnosis is uncertain, a barium swallow
will show delayed gastric emptying and the
typical "string sign" of a markedly narrowed,
elongated pyloric lumen.

50. Restore hydration status by I.V.
fluids
Assess the amount,
characteristics, and frequency of
vomiting.
Monitoring intake and output
Careful observation and
recording of vomiting and bowel
elimination.

51. NG tube insertion
General hygienic care
Support family
Monitor G&D parameters

53. The treatment of choice is a
longitudinal pyloromyotomy

54. Ensure adequate hydration
Care for operative side
NG tube should be maintained, oral hygiene
should offered
Give clear oral fluids from 4-6 hours
postoperatively as ordered.
Feed the baby slowly; burp frequently, and
in high Fowler's position on the right side
after feeding.
Family teaching and follow-up

55. Biliary Atresia
)extrahepatic(
Biliary Atresia
)extrahepatic(

56.  Absence of the bile ducts outside of the
liver, More common in females.

57. 




60. Jaundice
Dark urine, stained diapers.
Stool color becomes white or tan.
Hepatosplenomegaly
Poor fat metabolism, failure to thrive.
Pruritus, irritability.
If uncorrected the child may develops liver cirrhosis

61.  History, physical examination
 Growth parameters and nutritional assessment
 Blood tests (CBC, liver enzymes)
 TORCH titers
 Exploratory laparotomy
 Abdominal Ultrasonography.

62. Many children develop progressive cirrhosis and
need liver transplantation
High-caloric formula containing fats that can be
digested without bile.

63. The child should provide water soluble
vitamins
Phenobarbital may be given to promote
bile flow.
Low-salt diet and diuretics Supportive
care for parents
Comfort measures for child.

65.  Absence of the anus in its
normal position in the perineum

66.  Low IA: Blind pouch below the Levator ani
muscles
 High IA: Blind pouch above Levator ani muscles

69. o Failure to pass meconium
o Absence or stenosis of anal canal
o Presence of anal membrane
o External fistula to perineum
o Passage of meconium from the vagina or in
urine

70. Nursing Care of the child with IA:
Role in diagnosis:
Ensure that meconium is not passed in the first 24
hours after birth
 Look at anus
 Pass a rectal thermometer to determine its patency.
 If there is stool in urine or vagina: report immediately
 nursing assessment, to identify other GI or urogenital
problems
 Immediate plans are made for surgical intervention

72. Perineal examination
during routine neonatal
assessment
Plain X-ray,
inventogram to
differentiate between
high and low IA.

73.  Low IA: Perineal anoplasty, followed by anal
dilatation
 High IA: Sigmoid colostomy , Pull- through
technique (pulling the colon from the abdomen
through the perineum), anal dilatation and closure
of colostomy.

74.  In low lesions (Perineal Surgical Incision)
 Skin care at anoplasty site
 Parent teaching about anal dilatation
 In addition to general post-operative care
 In high lesions (Colostomy /pull-through)
◦ Colostomy care
◦ Skin care
◦ Home care & parent teaching

75. Hirschsprung
Disease
)Congenital
Megacolon(

76.  Absence of ganglion cells in the rectum and
to varying degrees upwards in the colon,
causing functional obstruction

79. ◦ Affects males 4 times as frequently as females.
◦ In approximately 12.5% of patients
Hirschsprung disease may be familial

80. Neonatal period
Delayed passage of meconium within the 1st 24
hours after birth.
Reluctance to ingest milk
Bile-stained vomitus

81. Infancy period
Failure to thrive
Abdominal distention.
Chronic constipation, fever
Attacks of vomiting and
Explosive watery diarrhea
(Ominous sign)

82. Childhood period
Chronic constipation
Abdominal pain and distention
Ribbon like, foul-smelling stools
Visible peristalsis
palpable fecal mass
Failure to thrive
Narrow spastic rectum, no stool during per rectum
examination
Bowel obstruction, attacks of enterocolitis
The longer the disease goes untreated, the greater
the chance of developing toxic enterocolitis (toxic
Megacolon).

83.  Clinical manifestations
 Plain abdominal X-ray (intestinal obstruction)
 Barium enema: Proximally: very distended colon
 Distally: contracted colon
 In between: Tapered bowel
(Transitional zone)
 Rectal biopsy (No ganglion cells)

85. Surgical removal of all Aganglionic bowel
segment.
Colo-anal anastomosis (Abdominal-Perineal
pull-through operation).
Relive chronic constipation by stool softeners
and rectal irrigation
Temporary colostomy

87. Improve nutritional status by
providing smaller and more frequent
feedings
Assess hydration status by
monitoring intake and out put and
daily weight

88. Note and record the frequency and
characteristics of stools
Administer enema to relive constipation
(Isotonic solution)
No rectal temperature

89. Periodically measure abdominal girth
Assess for any R.D. due to abdominal distention
Giving medication (Antibiotic and stool softeners)
Support the parent and child
Care for colostomy

90. IntussusceptionIntussusception

91.  Invagination or telescoping of one portion of
the intestine into another, causing
obstruction

92. The cause of intussusceptions is unknown. It may
be linked to viral infections, intestinal polyps,
lymphoma, and foreign body obstruction.
Incidence is about three times higher in males
than in females

93.  Sever paroxysmal abdominal
pain, causing the child to scream and
draw his or her knees to the abdomen
 Vomiting of gastric contents (Bile-
stained or fecal emesis)
 Currant Jelly stool containing
blood and mucus

94. Tender, distended abdomen, possibly
with a palpable mass
Shock like syndrome
Palpable sausage-shaped mass in
upper right quadrant
Empty lower right quadrant
Fever and signs of peritonitis.

96.  Abdominal X-ray (bowel obstruction)
 Abdominal ultrasound( mass )
 Barium enema

97.  Initially: hydrostatic reduction with barium
enema
 If reduction fails: immediate surgery

98.  Assess hydration status Encourage intake of
clear fluids after surgery
 Monitor bowel elimination status
 Postoperatively: monitor for signs of infections,
assess surgical wound, V.S
 Support the child and family
 Routine postoperative care

100.  Clefts of lip and palate are facial malformations that
occurred during embryonic development appear
separately or, more often, together.

101. Deformed dental structures are
associated with CL.
CL with or without CP is more
common in males.
CP alone is more common in
females.

104. collaborative efforts of a number of specialists:
pediatrician, nurses, plastic surgeon, orthodontist,
and speech therapist.
Medical management is directed toward closure of
the cleft (s),
prevention of complications, and
facilitation of normal G&D.

105. Surgical correction of CL (Z- plasty) usually done at
1-3 months of age
Surgical correction of CP (Platoplasty) is done 12-
18 months of age, before the child develops faulty
speech habits.

106. Routine preoperative care
Feed in an upright
position to prevent aspiration,
a soft, large-holed nipple
or rubber-tipped syringe
or cleft lip or palate bottle
may be used.

107. Burp frequently because of swallowed air.
Prevent infection from irritation of the lip, restrain infant's arms
if needed.
Teach parents the need for dental hygiene and regular
dental supervision.
Emotional support to the parent (emphasize the positive
appearance of the child after surgical correction).
Help the mother to give breast milk using alternative methods.

108. Maintain a patent airway because of edema
and infant's habit of mouth breathing.
Protection the operative site from trauma
and infection.

109. Elbow restraints are needed to prevent the
child from rubbing the suture line of surgery.
CL correction the child should be scurried in
supine or upright position.
Prevent crying, because of pressure on suture
line; encourage a parent to stay.

110. CP correction the child should be scurried in prone
position.
Gentle aspiration of mouth and nasopharyngeal
section may be needed to prevent aspiration.

111. Feed same as before surgery
Clear fluids are offered when the infant has fully
recovered from anesthesia.
When the baby returned to his feeding, mouth
care after each feeding is must.
Skin care on the suture line should be
maintained.
Family teaching and discharge plan.

115. Write down what should be done as a routine pre-operative work up
Choose the best single answer
After 2 hours of delivering a newborn baby ,the
nurse noticed the oxygen saturation goes down
(cyanosis ) , she reported to the doctor who
noticed a scaphoid abdomen , Bowel sounds
over chest and ordered an X-ray that shows
some abdominal content in the chest , what is the
most likely
diagnosis

116. Choose the best single answer
In the NICU , the nurse noticed that her newborn
assigned baby , have too much saliva , while she
tried to pass the Nasogastric tube , she failed , so
she called on the Doctor, who found the tube
recoils and comes back up , what is the most
probable diagnosis of this case

117. Choose the best single answer
A mother walks in the clinic , with her 45 days old
child, she have a smell , also her shoulder is
stained with milk ,she says that her child always
vomit shortly after feeding , the child looks
underweight and dehydrated,
What is the most probable diagnosis
What is the operation done to correct this
condition

118. Choose the best single answer
A 3 weeks old baby with Jaundice ,Dark urine,
stained diapers, Stool color is white or tan and
Hepatosplenomegaly
What is the operation done to correct this
condition
What is the most probable diagnosis

119. Choose the best single answer
Newborn baby , with imperforate anus , the
invertogram shows Blind pouch above Levator ani
muscles
What is the type of this anomaly
What is the operation done to correct this
condition

120. Choose the best single answer
Delayed passage of meconium within the 1st 48
hours after birth increases the suspicion of which
disease

121. Choose the best single answer
A 9 month old boy , come to the emergency
department , with sever abdominal colicky pain ,
with red current jelly stool in the diaper , what is
the most possible diagnosis
What is the first line of treatment

122. Conginetal diaphragmatic
Hernia
Congenital
Megacolon
Narrowing of the pyloric
sphincter at the outlet
of the stomach
Type C is the most common type