College of Nursing

East Coast Institute of Medical Sciences

Child Health Nursing (Key Notes) – Unit V

ESOPHAGEAL ATRESIA WITH TRACHOESOPHAGEAL FISTULA – TOPIC – I

Definition Causes
TEF - Abnormal connection between trachea and  Maternal alcohol and smoking
esophagus  Exposure to methimazole
EA - Failure of esophagus to form  Prolonged mechaincal ventilation
 Maternal polydramnious
 Maternal DM
Classification Management
 Esophageal Atresia without TEF  Propped up position
 EA with proximal TEF  Nil per oral
 EA with distal TEF  Airway clearance
 EA with both proximal and distal TEF  Oxygen therapy
 H type TEF  IV fluid therapy
Clinical Features  Naso gastric tube aspiration
 Coughing  Gastrostomy
 Chocking  Ligation of fistula and end to end anastamosis
 Cyanosis  Cervical esophagotomy:
 Drooling of saliva  Esophago-coloplasty
 Respiratory distress  Esophago-gastroplasty
 Abdominal distension
 Regurgitation
 Aspiration pneumonia
 Laryngospasm
Diagnostic Evaluation Nurses Responsibility
 Antenatal diagnosis of condition by USG  Airway clearance
 Ultrasonography  Maintaining nutrition and prevention of
 Plain X ray abdomen aspiration
 Chest X ray  Preventing infection
 Passing of radiopaque catheter through  Minimizing pain
esophagus  Reducing anxiety
 Bronchoscopy
 ECG
CONGENITAL MEGA COLON – TOPIC – II

Definition Causes
Absence of ganglionic nerve cells in sigmoid  Unknown etiology
colon and rectum cause extreme dilation  Hereditary
 Genetic mutation
Red Flags Of Hirschsprung's Disease Management
 Delayed (> 24hrs) meconium  IV fluid therapy
 Neonatal constipation  NG tube aspiration
 Family history  Antibiotic therapy
 Poor growth  Colonic irrigation with saline
 Abdominal distension  Enemas
 Down's syndrome and other chromosomal  Stool softners
abnormalities  Colostomy or ileostomy
 Ligation of aganglionic part followed by end
Clinical Features
to end anastomosis
 Delayed passage or no passage of meconium  Duhamel’s operation or retrorectal transanal
 Bilious vomiting pull through surgery
 Fecal vomiting  Soave’s operation or endorectal pull through
 Abdominal distension surgery
 Constipation  Swenson’s operation or abdominoperineal
 Diarrhoea pull through surgery
 Dehydration
 Obstipation Nursing Management
 Visible peristalsis  Detail history
 Ribbon like, fluid like or pellet stools  Bowel habit
 Anemia  Feeding habit
 Malnutrition  Neonatal assessment regarding passage of
 Failure to thrive meconium, presence of constipation,
Diagnostic Evaluation characteristics of stools, enemas or
 Rectal examination: tight anal sphincter and suppositories needed or not
empty rectum.
 Plain X ray abdomen
 Ingestion of radioopaque markers measure
intestinal transit time
 Barium enema
 Anorectal manometry
 Colonic biopsy
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS – TOPIC – III
Definition Causes
Hypertrophy of the two muscle layers of the  Unknown
pylorus causing obstruction of the gastric outlet  Maternal stress
 Increased prostaglandin level
 Deficient production of neuronal nitric oxide
synthase
 Immature pyloric ganglion cells with abnormal
muscle innervation
 Use of macrolide antibiotics
 Transpyloric feeding
Clinical Features Management
 Nonbilious vomiting and projectile vomiting  IVF - 5% glucose or 0.45% saline can be given
 Constant hunger  Nasogastric decompression
 Decreased quantity of stools and urine output  Atropine Methyl Nitrate
 Starvation diarrhoea or Constipation  Methyl Scopolamine Nitrate
 Greenish stools Ramstedt’s pyloromyotomy
 Gastric hemorrhage Laproscopic pyloromyotomy
 Dehydration Endoscopic baloon dilation of pylorus
 Shallow breathing
 Epigastric fullness with visible peristalsis Nurses Responsibility
 Palpable olive shape mass
 Jaundice  Maintenance of fluid and electrolyte balance
 Hypochloremic alkalosis  NG aspiration to reduce vomiting
 Hypernatremia  Place the baby in upright position during
 Hypoklemia feeding
 Malnutrition  Small frequent feeding to be given
  Gentle handling of babies
 NPO 8 - 12 hours after surgery
Diagnostic Evaluation  feeding can be started with 1-2 teaspoon clear
 Physical examination 5% NS given for every 2 hours for about 8
 Plain X ray abdomen hours.
 USG abdomen  After feeding baby should be in elevated
 Upper GI barium study position for 45 - 60 mins
 Upper GI endoscopy
 Blood examination
INTESTINAL OBSTRUCTION – TOPIC – IV
Definition Diagnostic Evaluation
Interruption in the normal flow of intestinal  History collection
contents through the intestine  Physical examination
 X ray abdomen
Classification  Barium enema
Congenital intestinal obstruction  Proctoscopy
 Intestinal atresia  Sigmoidoscopy
 Malrotation of gut  USG
 Meconium plug syndrome  Blood examination
 Meconium ileus  Elevated serum amylase level
 Annular pancreas
Management
 Mickle’s diverticulum
 Hirschsprung’s disease or congenital  IV fluid therapy
megacolon  Nasogastric decompression
 Analgesics
Classification  Antibiotics
Acquired intestinal obstruction:  Resection of bowel and end to end anastomosis
 Intussusception  Ladd's Procedure
 Volvulus or twisted loop of intestine  Enterotomy to remove foreign bodies
 Tumor or hematoma  Conservative hydrostatic reduction
 Hernia or strangulation  Hypertonic enema - to remove worms
 Stricture or stenosis
Inflammatory diseases
Clinical Features Nurses Responsibility
 Abdominal colic  Provide rest and comfort
 Abdominal distension  Relieve pain by analgesics
 Bilious vomiting  Maintain fluid and electrolyte balance by IV
 Absence of passing flatus fluid therapy and recording of intake and
 No passage of stools output
 Fever  Provide adequate respiration by relieving
 Drowsiness abdominal distension through nasogastric tube
 Dehydration aspiration
 Toxicity
 Red currant jelly stools
 Sausage shaped lump palpable in upper
abdomen
 Cervix like mass
 Blood in rectal examination
CLEFT LIP AND CLEFT PALATE – TOPIC –V

Definition Diagnostic Evaluation

Cleft Lip - Gap or indentation in the lip or split  History collection
Cleft Palate – Incomplete fusion of lateral palatine  Newborn examination at birth
process, nasal septum and medial palatine process  Palpate palate with gloved finger or visual
examination with flash light
 In utero ultrasonography
Causes Management
 Genetic factors  Extra time and patency for feeding
 Exposure to teratogens  Haberman feeder
 Alcohol  NUK nipples
 Anticonvulsants  Katori spoon feeding
 Use of phenytoin during pregnancy  ESSR technique
 Smoking during pregnancy  Dental obturator
 Advance parental age  Cleft lip repair or Cheiloplasty
 Maternal intrauterine condition  Millard repair(Unilateral cleft lip)
 Randall- Graham or Rose-Thomson
Classification
procedure
 Microform cleft lipor Forme frusta  Cleft palate repair or palatoplasty
 Unilateral Incomplete cleft lip  Tympanostomy tube insertion
 Unilateral complete cleft lip  Genetic counselling
 Bilateral incomplete cleft lip
 Bilateral complete cleft lip
 Mixed bilateral incomplete and complete cleft lip
 Incomplete cleft palate
 Complete cleft palate
 Submucous cleft palate
Clinical Features
 Notched vermilion border Nurses Responsibility
 Nasal distortion  Protecting the operative site.
 Exposed nasal cavities  Place metal appliance on cheeks for
 Misaligned teeth relaxation and prevent tension on suture
 Passage of milk through nasal passages during  Elbow restraints to prevent the child from
feeding rubbing /jacket restraint in older child
 Recurrent ear infection  Periodically remove the restraint for
 Speech difficulties irritation
 Poor weight gain and failure to thrive  Adequate analgesia, antibiotics are given
for pain
DIAPHRAGMATIC HERNIA – TOPIC - VI

Definition Causes
Posterolateral defect of the diaphragm that causes  Idiopathic cause
passage of the abdomen viscera into the thorax  Chromosomal and genetic abnormalities
 Environmental exposure during pregnancy
 Nutritional problems during pregnancy
Classification Management
 Bochdalek hernia  Endotracheal intubation
 Morgagni hernia  Avoid bag and mask ventilation
 Diaphragm eventration  Infant placed on affected side and semi-
 Hiatus hernia fowler’s position
 Nasogastric aspiration
Clinical Features
 IV fluid therapy
 Respiratory distress  Continous monitoring of ABG
 Tachypnea  Ionotropic drugs may be needed for cardiac
 Chest retraction function.
 Cyanosis  Bicarbonates for metabolic acidosis
 Gasping  Extra-corporeal membrane
 Diminished or absent breath sound on affected oxygenation(ECMO)
side  Inhaled nitric oxide for pulmonary
 Excavated abdomen with sternal protrusion hypertension
 Displacement of heart sounds to the  Replacing the abdominal viscera in the
contralateral side abdominal cavity and repairing the
 Bowel sound heard over the chest diaphragmatic defect. It done after 6-18 hours
 Scaphoid abdomen of birth.
 Hypoxia  Malrotation of intestine also corrected during
Diagnostic Evaluation surgery

 History collection Nurses Responsibility

 Physical examination  Assess respiratory pattern and effort after birth.
 Antenatal ultrasound 16 - 24 WOG  Provide semi fowler’s position placing on
 Plain X ray of the thorax and abdomen affected side.
 Blood gas and PH  Provide mechanical ventilation, oxygenation
 Aminocentesis advised.
 Barium study  Avoid bag and mask ventilation.
 Handle the infant gently and minimally.
 Watch the signs of infection, respiratory
distress and feeding difficulty postoperatively.
ANORECTAL MALFORMATION – TOPIC - VII
Definition Causes
Birth defect in which anus and rectum does not  Unknown cause
develop properly  Due to arrest in embryonic development of the
anus, lower rectum and genitourinary tract at
the 8th week of gestation
Classification Management
 Anal Stenosis  Anal dilation is done for anal stenosis
 Anal Atresia  Rectal cutback anoplasty or Y-V plasty
 Rectal Atresia  Perineal anoplasty
 Rectoperineal Fistula  Colostomy
 Rectovaginal Fistual  Posterior saggital anorectoplasty
 Cloaca
 Recto-Bladder Neck Fistulas
 Rectovestibular Fistula
 Rectourethral Fistula
 Anal Agenesis
Clinical Features
 No obvious anal opening
 Absence of meconium
 Abdominal distension
 Gloved fingers or thermometer cannot be
inserted
 Passage of urine through anus
 Constipation
 Passage of stools through fistula
Diagnostic Evaluation
 Physical examination Nurses Responsibility
 Abdominal X ray  Examine the anal opening, site of fistula
 Abdominal ultrasound  Check for signs of intestinal obstruction
 CT scan  Monitor hydration and nutritional status
 MRI  Observe any signs of infection
 Barium enema  Observe the pattern of elimination
 X-ray with inverted infant (ie) invertogram
 Urine examination
 Micturing cysto urethrogram(MCU)
 Intravenous pyleogram
BLADDER EXSTROPHY – TOPIC - VIII
Definition Causes
Congenital malformation of the bladder and  Unknown
urethra in which the bladder is turned inside out.  Inherited factor
 Failure of abdominal wall to close during fetal
development.
Clinical Features Management
 Absent anterior bladder wall and exposed  Complete Primary Repair of Exstrophy
bright red posterior bladder (CPRE)
 Constant urinary dribbling through defect  Modern Staged Repair of Exstrophy (MSRE)
 Ulceration of bladder mucosa
 Skin excoriation
 Infection
 Separation of symphysis pubis
 Flattened puborectal sling
 Shortening of a pubic rami
 Narrowed vaginal oriface, labia widely
separated
Diagnostic Evaluation
 History collection Nurses Responsibility
 Physical examination  Demonstrated how to keep the bladder area
 Ultrasonography clean
 Cystoscopic examination  Apply ointment to skin
 Intravenous pyelogram  Diaper should changed frequently.
 Urogrammes  Stool is removed immediately
 Avoid immersing the infant during the bath
 Avoid pressure on the exposed bladder wall.
 Provide loose clothing
 Teach parents to identify signs of infection
 Involve the parents in child care
HYPOSPADIAS – TOPIC - IX
Definition Causes
Urethral opening on the ventral aspect (under  Unknown cause
surface) of the penis  Invitro fertilization
In females into the vagina  Advanced maternal age
 Several teratogenic drugs
 Genetic factors
 Associated congenital anomalies
Classification Management
 Glandular hypospadias  Meatotomy done after 3 months old
 Coronal hypospadias  Chordee correction
 Penile or penoscrotal hypospadias  Advancement of prepuce at 2-3 years of age
 Perineal hypospadias  Urethroplasty is done 3-4 months after chordee
correction
Clinical Features
 Opening of urethra at a location other than the
tip of the penis
 Downward curve of the penis
 Hooded appearence of the penis
 Abnormal spraying during urination
 Voiding in sitting position in boys
Diagnostic Evaluation
 IVP, MCU are performed to detect Nurses Responsibility
abnormalities of upper urinary tract,  Maintain a position of comfort; Properly set
vesicoureteric reflux(VUR) and bladder the catheter to avoid tension and kinking
capacity.  Encourage use of relaxation technique
 MRI and Ct scan
 Pelvic X ray
 USG urogenital system

EPISPADIAS – TOPIC - X
 Definition Diagnostic Evaluation
Urethral opening in the dorsal aspect of the penis  IVP, MCU are performed to detect
abnormalities of upper urinary tract,
vesicoureteric reflux(VUR) and bladder
capacity.
 MRI and Ct scan
 Pelvic X ray
 USG urogenital system
Classification Management
 Glandular epispadias  Penile lengthening and chordee correction at
 Penile epispadias 1.5-2 years of age.
 Penopubic epispadias  Urethral reconstruction done 6 months after
 Subsymphyseal epispadias first stage.
 Bladder neck reconstruction and correction of
VUR at 3-4 years of age
 Cystoplasty done 2-3 years after third stage
Clinical Features operation.
 Abnorml opening from the joint between the Nurses Responsibility
pubic bone to the area above the tip of the  Relief from pain.
bone.  Encourage use of relaxation techniques;
 Reflux nephropathy  Apply ice compress as indicated
 Short, widened penis with abnormal curvature  Educate parents that medications will prevent
 UTI pain and restlessness and allow for healing.
 Widened pubic bone  Improve urinary elimination
 Urinary incontinence
 Urine permanently dripping through meatus
 Involuntary urine loss with stress
 Abnormal Clitoris and labia

SPINA BIFIDA – TOPIC - XI

 Definition Causes
Malformation of the spine in which the posterior  Maternal radiation
portion of lamina of one or more vertebra fails to  Drugs and chemicals
fuse, with or without defective development of  Malnutrition
the spinal cord  Genetic determinants
 Inadequate intake of folic acid and zinc
Risk Factors Diagnostic Evaluation
 Folate deficiency  History collection
 Family history of neural tube defects  Physical examination
 Some medications( Valporic acid)  X ray chest and spine
 Diabetes  Myelography and CT scan
 Obesity  Ultrasonographic scanning of the uterus
 Increased body temperature  Amniotic fluid analysis(16-18 weeks):
elevated AFP
Classification
 Chorionic villus sampling
 Spina bifida occulta
 Spina bifida cystic Management
• Meningocele
• Meningomyocele  Skin grafts or Z closure.
 VP shunt procedure
Clinical Features
 Flaccid, partial paralysis of lower extremities Nurses Responsibility
 Varying degree of sensory defect  Neonate usually placed under the warmer
 Urinary incontinence  Sac will be cleansed with sterile normal saline
 Lack of bowel control or hydrogen peroxide
 Rectal prolapsed  Application of antibiotic dressing
 Skin depression or dimple  Changed every 2-4 hours
 Abnormal tuft of hair  Diaper is not applied
 Soft, subcutaneous lipomas  Crede’s method every 2-3 hours
 Progressive distrubance of gait  Cast or passive stretching exercise or both
 Bowel and bladder sphincter distrubances  Diet modification
 Suppositories
 Administration of folic acid 400mcg\day