Pilar C. Smith, RN, BSN
Lake Sumter Community College
Cleft Lip and Palate
 Cleft lip results when
the medial nasal and
maxillary processes fail
to join at 6 to 8 weeks of
gestation.
 Cleft palate results from
failure of the primary
patatal shelves, or
processes, to fuse at 7 to
12 weeks of gestation.
Manifestations/Diagnostic Assessment
Cleft lip:
 A notched vermilion border, cleft that involve the
alveolar ridge and dental anomalies.
Cleft palate:
 includes nasal distortion, midline or bilateral cleft with
variable extension from the uvula, soft and hard palates
and exposed nasal cavity. First sign may be formula
coming from the nose
Diagnostic is based on observation at birth and
complete examination in the neonatal period.
Assessment
Assess infant’s ability to suck, swallow and breathe
without distress and handle normal secretions.
Assess and record parents’ reactions as well as
interaction with the neonate.
Provide information about the causes of the defect
Encourage bonding through touching, holding
and examining their newborn.
Point out the newborn’s positive attributes.
Intervention
 Describe the degree of cleft and impairment of sucking.
 Modify feeding techniques as needed to allow adequate growth
 Provide alternative assistive feeding devices
 Hold infant in a more up-right position
 Burp infant more frequently
 Write down feeding program for parents to use at home
 Provide emotional support and positive reinforcement to parents
 Keep and accurate record of child’s growth by using a growth
chart.
 Orthopedic Latham device is use to expand and realign
 Explain preoperative and postoperative procedure
Surgical Intervention
 Cleft lip repair is usually performed by age 3 to 6
months. Cosmetic modification may be needed at
age 4 to 5 years.
 Cleft lip repair is usually performed by age 3 to 6
months. Cosmetic modification may be needed at
age 4 to 5 years.
Surgical Intervention
 Preoperative care:
 Oral feeding withheld for 6 hours
 IV line placement
 Postoperative care:
 Keep straws, pacifiers, spoons, or fingers away from the
child’s mouth for 7 to 10 days
 Do not take temperature orally
 Advance the child’s diet as tolerated from clear liquids to
soft diet within 48 hours.
Nursing Diagnoses
 Alteration in nutrition less then body requirement
related to the inability to suck
 The child will drink the recommended amount of
feeding within 30 minutes
 Knowledge deficit about feeding techniques and
surgery related to unfamiliarity with the information
 The parent will understand expected preoperative and
postoperative feeding techniques.
Esophageal Atresia with
Tracheoesophageal Fistula
 Esophageal atresia with TEF are congenital
malformations in which the esophagus terminates
before it reaches the stomach and/or a fistula is
present that forms an unnatural connection with the
trachea.
Manifestations
Failure to pass suction catheter or NGT at birth
Excessive oral secretions
Vomiting
Abnormal distention
Airless, scaphoid abdomen (atresia without
fistula)
3 “Cs” coughing and choking with feeding and
cyanosis
Diagnostic Assessment:
Hx. of maternal polyhydramnios (prenatal
clue)
IF NG tube cannot be passed 10 to 11 cm
beyond the gum line
Abdominal radiograph (X-ray) with watersoluble contrast medium < 1ml via NGT
Bronchoscopy and endoscopy
Management
 Keep infant warm and oxygenated
 Keep infant supine with the HOB elevated to keep
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gastric secretions from entering the lungs
NGT aspirate every 5 to 10 minutes to keep the keep
the proximal pouch clear
Intravenous IV fluids are essential
Surgical repair: Ligation of the fistula and end-to-side
anastomosis of the atresia
Nursing diagnosis and planning(read pp 520-522)
GER in children
 GER vs GERD.. Page 522
 Symptoms range from physiologic to pathologic
 Diagnostic exam includes barium swallow, upper GII
study, endoscopy
 Management: dietary alterations, positional changes,
medications and surgery
 Diet: predigested formulas.. Nutramigen or
progestimal, freq, small feedings, freq. burping, ?
Thickened feedings
 Positioning : supine
GER continued
 Medications: antacids for symptom relief, H2 receptor
antagonists.. Cimetidine, ranitidine to decrease acid
secretion, mucosal protectors, eg. Sucralfate for barrier
protection and PPI’s ompeprazole to suppress gastric
acid secretion and prokinetic agents metoclopramide
to accelerate gastric emptying
 Prevent complications
 Nursing care plan on page 527-529
Constipation and Encopresis
 Definition: page 529
 Etiology: change in diet, lack of exercise, emotional
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stress certain drugs pain from anal fissure or excessive
milk intake
Encopresis generally affects a child from 3 to 7 years
old more often in boys than girls.
Constipation affects children at any age.
s/s: constipation versus encopresis page 530
Abdominal x-ray DRE
Constipation and Encopresis cont..
 Therapeutic Management Page 530
 Nursing Care:
Assessment
 Nursing Diagnosis and Planning..page 531
 Interventions: Overcoming withholding, dietary
changes, changing the retention habit, emotional
support, home care
IBS
 Increased intestinal motility which can lead to spasm
and pain
 Etiology: stress and emotional factors, lactose
deficiency, tends to occur in families with a HX of
bowel disturbances can occur as constipation or
diarrhea
 S/S : abd pain unrelated to meals or activity Normal
growth mucous in stool
IBS cont
 Do definitive treatment Goal is aimed at identifying
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and reducing triggers and reducing bowel spasms
which decreases triggers
Diet is healthy well balanced moderate fiber lower fat
diet
Encourage child to eat slow and no carbonated
beverages, no juices
Med’s: EC peppermint oil capsules, antispasmodics
such as Levsin and Donnatal and antidepressants in
severs cases.
Psychosocial support
Gastroenteritis
 Cause: viruses, bacteria and parasites
 Etiology: ingestion of contaminated food or water and
person to person contamination. High risk groups are
children in daycare centers, preschools and long term
care facilities and those infected with HIV
 Giardia is the most common seen in children in day
care and rotovirus is the most common seen in infants
and young children
 Page 535 characteristics of infectious gastroenteritis
Gastro. Cont.
 S/S diarrhea, vomiting abdominal pain tenesmus and
fever dehydration is a consequence of gastro
 Stool culture O&P
 Management: replace water and electrolytes
 Prevention Rotovirus vaccine at age 2,4, 6 months
 What do we assess?
 Nursing Diagnosis- page 537
 Interventions- page 537
Ulcers
 Types
 Etiology
 Diagnostic tests
 S/S
 therapeutic management
Appendicitis
 Pain progressing in intensity and localizing to the RLQ
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at Mc Burney point page 538
Diagnostic evaluation?
Therapeutic management?
Nursing Diagnosis
Interventions
Volvulus
 Malrotation or twisting of the bowel that results in
obstruction.
 S/S pain, bilious vomiting
 Surgery is the cure
Hypertrophic Pyloric Stenosis
 Hypertrophic pyloric stenosis results when the circular
area of muscle surrounding the pylorus hypertrophies
and obstructs gastric emptying.
Manifestation
 Progressive projectile vomiting , especially after eating
 On palpation:
 Right upper quadrant movable firm olive-shaped mass can be
felt
 Visible peristaltic waves
 from left upper to right upper quadrant immediately before
vomiting.
 Dehydration:
 absence of tears, a weak cry, depressed fontanel, poor skin
turgor and dry mucous membrane.
 Metabolic Alkalosis
Diagnostic Assessment
 history of vomiting, visible peristalsic waves and a
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palpable pyloric mass
X-ray or US of the abdomen,
Barium swallow
Metabolic alkalosis
Decreased serum potassium and sodium levels
Increased Ph and sodiumbicarbonate, and decreased
chloride.
Indirect Bilirubin may be elevated.
Management
 IV fluids and electrolyte replacement
 NGT for stomach decompression
 Surgery:
 Pyloromyotomy, an incision of the pyloric
muscle to release the obstruction done by
Laparoscopy.
 Pre and postoperative care and home care.(read
Rowen pp.546-547)
 Assess family dynamics and support system
Nursing Diagnoses
 Fluid and electrolyte deficit related to vomiting
 Alteration in nutrition less then body requirement
related to vomiting
Intussusception
 Inussusception is an invagination of a section of the
intestine into the distal bowel that causes bowel
obstruction
Manifestation
 Classic sign
 Passage of bloody mucus (“currant jelly”) stool and diarrhea
 A sausage- shape abdominal mass
 Listlessness
 Paroxysm pain (pain that comes and go) than becomes
more constant
 Distention, hypo or hyperactive bowel sounds
 Sign and symptoms of dehydration
 Symptoms of shock and sepsis if obstruction has been
present for longer than 12 to 24 hours
 Fever, increased heart rate, changes in LOC
Management
 The goal is to restore the bowel to its normal
position and function.
 Hydrostatic reduction if child does not have
symptoms of shock or sepsis.
 Barium enema or air enema.
 Ultrasound-guided isotonic saline enemas
 Surgery:
 Laparoscopy is use if no bowel necrosis is present.
Nursing Diagnoses
 Ineffective tissue perfusion related to (GI) bowel
compression.
 Acute pain related to bowel obstruction and surgery
Hirschsprung disease
 Hirschsprung disease is
caused when
parasympathetic ganglion
cells in the wall of the large
intestine(colon) do not
develop before birth.
Without these nerves, the
affected segment of the
colon lacks the ability to
relax and move bowel
contents along.
Manifestation
 Delayed or absence of meconium stool in the neonatal
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period (cardinal sign)
Constipation since neonatal period
Frequent passage of foul-smelling ribbonlike or
pelletlike stools
Malnutrition
Abdominal pain and distention
Failure to thrive
Diagnostic Assessment
 Rectal examination:
 tight internal sphincter and absence of stool, follow by
an explosive release of gas and stool
 Barium enema
 Rectal biopsy (definitive)
 Absence of ganglia cells confirm the diagnosis
Management
 Treatment for mild to moderate
 Stool softener to relieve constipation and rectal
irritation
 Treatment for moderate to severe:
 Surgical intervention: the aganglionic portion of the
intestine is removed in two steps.
 In the neonatal period, performing a temporary colostomy.
 A complete surgical repair when the child weights 8 to 10 kg
(18 to 20 Lbs), the colostomy is closed during this time.
 Assess family member’s concerns and way of coping with
the problem
Nursing Diagnoses
 Constipation related to
aganglionic bowel and
inadequate peristalsis
 Impaired skin integrity
related to colostomy
and surgical repair.
Celiac disease
 Celiac disease, also known as gluten enteropathy
results from the inability to digest fully the protein
part of wheat, barley, rye, and oats.
 This results in the accumulation of glutamine in the
intestine, which has a toxic effect in the mucosal cell.
 This leads to atrophy of the villi and decrease
absorption of fat, carbohydrates and vitamins.
 It can cause severe diarrhea and dehydration.
Manifestation
 Profuse diarrhea especially foul-smelling fatty stools
 Growth failure: bellow the twenty-fifth percentile
 Abdominal distention and ascites
 Anemia
 irritability
 anorexia
 muscle wasting
 folate deficiency
 Edematous extremities
Diagnostic Assessment
 Serum antigliadin antibody (AGA) assay
 allows continued assessment and evaluation of dietary
changes
 Tissue transglutaminase (tTG)
 Breath hydrogen excretion test
 identify carbohydrate malabsorption.
Management
 All wheat, rye, barley, and oat should be eliminated
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from the diet
Replaced with corn and rice
Fat-soluble vitamins supplement and folate
Fluid replacement if child is dehydrated from severe
watery diarrhea
Correct acid-base imbalance
Albumin to treat shock
Corticosteroids to decrease severe mucosal
inflammation
Nursing Diagnoses
 Imbalance nutrition less then body requirement
related to malabsorption
 Delayed growth and development related to
malnutrition
Lactose Intolerance
 Inability to tolerate lactose
 Most case of lactose intolerance are the result of
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inadequate lactase
S/S diarrhea that is frothy, abdominal distention,
cramping pain and increase flatus
+1 or greater sugar values on stool clinitest can support
the diagnosis
Management: remove the milk
ND: page 553
reference
Health topics A-Z
http://adam.about.com/encyclopedia/Pyloric-stenosis.htm
University of Virginia Health System
http://www.healthsystem.virginia.edu/uvahealth/peds_digest/intussus.cfm
Healthline connect to better health
http://www.healthline.com/channel/hirschsprung-disease_images
Rowen,S. J., Weiler, J. A. (2007). The child with a gastrointestinal alteration. In
NursingCare of children principles and practice. (pp 507-5596). St. Louis,
Missouri: Saunders