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Neonal Illness of Git
Neonal Illness of Git
ARBAMINCH UNIVERSITY
COLLEGE OF MEDICINE AND HEALTH SCIENCE
SCHOOL OF NURSING
DEPARTMENT NEONATAL NURSING
INDIVIDUAL ASSIGNMENT ON NN TWO
BY:-AMBAYE BERHANU
ID.NO. PRHMS/011/2015
SUBMITTED TO: MR.AGEGNEHU B 1
SUBMISSION DATE: - DECEMBER 16, 2023
Out lines
Introduction
Definition
Epidemiology
01/09/24
Pathophysiology
Etiology
Clinical presentation
Diagnosis and differential diagnosis.
Management and nursing intervention 2
01/09/24
hirchispring diseases.
01/09/24
Discuss about clinical manifestation of
omphalocele,gastroschise and hirschisprung disease.
Provide appropriate nursing intervention for
gastroschis,omphalocele and hirshusprung disease.
Manage neonates with gastroschis,omphalocele and
4
hirchispring disease.
Introduction
01/09/24
intestines to protrude through an abnormal opening in
the abdomen.
Omphalocele and gastroschisis are the two main
types of abdominal wall defects and the result of
errors during embryologic development of the fetal
5
abdominal wall.
Cont….
01/09/24
Hirschsprung's disease (also called congenital a
ganglionic mega colon) occurs when some of your
baby’s intestinal nerve cells don’t develop properly,
delaying the progression of stool through the
intestines.
6
History of Gasroschisi and omphalocele
described Gastroschisis.
Gastroschise is derived from Greek word
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described Omphalocele.
Omphalocele derived from Latin word
7
Definition
Gastroschise is a herniation of abdominal contents
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through abdominal defect located to right of umbilicus.
Gastroschisis is a congenital abdominal wall defect
characterized by the complete lack of closure of the
abdominal musculature.
8
Cont…
01/09/24
abnormalities such as mal rotation, atresia or
stenosis.
Not commonly associated with other organ
anomalies.
Infants have a high proportion of intrauterine 9
growth restriction.
Epidemiology of gastroschise
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The incidence of gastroschisis between male infants
is similar to that of females infants.
The incidence of gastroschise is higher in singleton
than in twin gestations, and higher in offspring of
non-Hispanic White mothers than non-Hispanic Black
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mothers.
Studies of worldwide have consistently reported that
under 20 years age women have higher rate of
offspring with gastroschisis than the general obstetric
population.
01/09/24
This is likely related to lifestyle factors that are more
common in young people (e.g., cigarette smoking, use
of recreational drugs, alcohol consumption, low body
mass index, increased frequency of genitourinary
infection). 11
Cont….
01/09/24
Higher risk of preterm delivery in pregnancies with
gastroschisis (28%) compared with those without
gastroschisis (6%).
12
Cont.…
01/09/24
you would have another baby with the condition
Environmental exposure like tobacco use,cigerete
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folds of the embryo meet at the midline and fuse
together to form the anterior body wall.
However, in gastroschisis and other anterior body
wall defects, this fails to occur by either one or both
of the lateral body wall folds not moving properly to
meet with the other and fusing together. 14
This incomplete fusion results in a defect that allows
abdominal organs to protrude through the abdominal
wall, and the intestines typically herniate through the
01/09/24
rectus abdominis muscle, lying to the right of the
umbilicus.
Several hypotheses have been proposed to explain the
pathogenesis of gastroschisis; all involve defective
formation or disruption of the body wall in the
embryonic period, with subsequent herniation of 15
bowel .
Cont.…
Major hypotheses include:
01/09/24
Rupture of the amnion around the umbilical ring
and with subsequent herniation of bowel.
Abnormal involution of the right umbilical vein
leading to weakening of the body wall
Disruption of the right vitelline(yolk sac) artery
with subsequent body wall damage and gut 16
herniation.
Ethology of gastroschise
01/09/24
formation and development of the ventral body wall
during embryogenesis, resulting in herniation of the
bowel.
Rupture of Omphalocele.
01/09/24
vascular system)
Maternal age <20 years old
Alcohol consumption. 18
Socio-economic status.
Clinical Features of gastoschise
Defect to the right of intact umbilical cord allowing
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No covering sac
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herniated bowel.
Intestinal stenosis, short bowel, intestinal
atresia,perforation,necrosis or volvulus.
Necrotizing Enter colitis
Electrolyte imbalance
20
Clinical features of sepsis and anemia
Diagnosis of gastroschise
Gastroschisis can be diagnosed during pregnancy or
after the baby is born.
During pregnancy, there are screening test (prenatal
01/09/24
tests) to check for birth defects and other conditions.
Gastroschise can be detected by the end of the first
trimester (11 to 14 weeks) and certainly in the second
trimester.
Prenatal detection rates of gastro chis are over 90% 21
Ultrasound
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(MSAFP) assessment performed in Neural
tube defect, Abdominal wall defects,
duodenal or esophageal atresia.
Magnetic resonance imaging(MRI)
22
Differential diagnosis of gastroschise
Omphalocele.
Ectopic cords.
01/09/24
Limb-body wall complex.
Cloacal exstrophy.
Umbilical hernia.
Bladder exstrophy.
23
Pentalogy of Cantrell.
Management of gastroschise
Pregnancy Management
01/09/24
amniotic fluid volume are charted via ultrasound at
3 to 4-week intervals starting at 24 weeks
gestation.
Oligohydramnios may be related to fetal growth
atresia.
After delivery management
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infraction suspected immediate surgical
consultation is indicated.
01/09/24
Placement of peripheral intravenous access to provide
antibiotics and maintenance fluid is performed.
Intravenous fluids are administered and started in 80-
120ml/kg due to the exposed bowel fluid losses.
Heat management
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Radiant warmer
Fluid management
Nutrition
OG/NG TUBE
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Urinary catheter
Infection control.
ABC management.
28
Cont.…
01/09/24
return the exposed bowel and new organs to the
abdominal cavity while minimizing intestinal
injury or increased intra-abdominal pressure.
Two treatment options are present for
gastroschisis. The first is primary repair, and the
second is delayed closure 29
Cont.…
01/09/24
30
Cont.…
Staged closure,(repair)
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technique to treat gastroschisis
A synthetic material is used to create a sac to cover
31
Cont.…
01/09/24
32
Poste operative care of gastroschise
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Fluid and electrolyte balance.
Pain management.
Wound care
Monitoring bowel function.
Administer antibiotics.
33
Gastric decompression.
Nursing intervention of gastrioschise
Monitor gastroschisis defect and oxygen saturation
of new born.
01/09/24
Monitor neonate's central and peripheral perfusion
every 15 minutes prior to surgery.
Ensure Nasogastric Tube (NGT) is placed on free
drainage and aspirated hourly.
Document accurate fluid balance and undertake
34
01/09/24
35
Omphalocele
Definition
Omphalocele is herniation of umbilicus through
01/09/24
which abdominal contents protrude.
Omphalocele is an opening in the center of the
abdominal wall where the umbilical cord meets the
abdomen
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.
Omphalocele is a midline abdominal wall defect at
the level of the umbilical cord, from which abdominal
content herniates.
01/09/24
The defect is covered by a three-layer sac of
amion, Wharton's jelly and peritoneum.
Omphalocele is classified into three categories: small,
giant and ruptured . The term “giant omphalocele”
(GO) is defined as an abdominal wall defect that
37
measures ≥5 cm or that contains ≥75% of the liver.
Epidemiology of omphalocele
01/09/24
prevalence of approximately 2 and 4 per 10,000 live
births, respectively consistent with the worldwide
omphalocele prevalence of 2.6 per 10,000 births.
The prevalence of gastroschisis appears to be
increasing at a faster rate than that of omphalocele.
38
Cont.…
01/09/24
Modest associations between occurrence of
omphalocele in offspring and maternal obesity and in
utero selective serotonin reuptake inhibitor (SSRI)
exposure have also been reported in some studies,
while others have found no association.
39
Cont..
01/09/24
The occurrence of omphalocele appears to be more
common in offspring of mothers at the extremes of
reproductive age
Omphalocele associated with congenital anomalies
such as bowel atresia, Imperforated anus, Trisomy's
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13,18,21,Neural tube defect and cleft lip/palate.
Pathophysiology of omphalocele
01/09/24
41
Ethology of omphalocele
01/09/24
and chromosomal abnormalities.
It might also be influenced by other factors, such
as the mother’s habits during pregnancy, or it could
happen due to a combination of reasons
42
Riske factors of omphalocele
These factors can increase the risk of an omphalocele in
the fetus:
01/09/24
is linked to omphalocele.
developing omphalocele.
Consecutive birth
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likely to have a baby with omphalocele.
SSRIs are usually found in medications like
antidepressants.
Twins and
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Obesity.
Clinical Manifestation of Omphalocele
Central abdominal wall defect
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umbilicus
Herniated organs are usually small bowel and may
include large bowel and/or liver.
The cord inserts into the apex of the sac
01/09/24
46
Diagnosis of omphalocele
Prior to delivery
Perinatal ultrasound is diagnostic in 95% of cases
01/09/24
Prenatal ultra sound after 14weeks gestation is the
confirmatory test
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Umbilical cord hernia.
Ectopia cords.
Pentalogy of Cantrell. 48
Complication of omphalocele
Sepsis
Gastroesophagal reflux disease
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Necrotizing entercolitis
Intestinal atresia
Short gut syndrome
Renal vein thrombosis
Respiratory failure
Renal failure and Complication of total parenteral 49
nitration
Management of omphalocele
Pregnancy management
Fetal surveillance
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In fetal surveillance monitoring fetal growth and
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omphalocele.
Timing of birth
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Route of birth
52
Cont.…
After Delivery
with an Omphalocele is
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Follow same protocol &sequence of all newborns
53
Cont.…
After initial stabilization for the new born
should be inspected to confirm that it is intact &
then covered with anon adherent dressing to
01/09/24
protect the sac.
Covering the defect with a sterile dressing
soaked with warm saline to prevent fluid loss.
NGT decompression
54
Cont.…
Antibiotics
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Keep NPO until the surgical opinion obtained
Surgical management
55
Cont.…
Primary closure
In infants with small defects,.
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Small defects (2 to 3 cm) can be repaired in the first
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Figure ,Surgical management of Primary closure
of omphalocele
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Cont..
01/09/24
life and delayed closure.
Reducing a large defect or one that contains an
anatomically kinked liver can be done with Doppler
ultrasound guidance to ensure the vena cava and
hepatic outflow are not compromised during the silo
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reduction.
Cont.…
Omphaloceles (i.e., containing >75 percent of the
liver or defect greater than 5 cm) may be managed
by a combination of silo, a cellular dermal patch, and
01/09/24
skin graft or by promoting formation of an amniotic
sac escher by application of a sclerosing solution
(topical povidone-iodine), with delayed hernia
repair.
59
Poste operative care of omphalocele
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Fluid and electrolyte balance.
Pain management.
Wound care
Administer antibiotics. 60
Gastric decompression.
Differentiating characteristics between
Gastroschisis and Omphalocele
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61
Cont.…
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62
Hirsch sprung disease(congenital a ganglionic
mega colon)
Definition
Hirschsprung disease (HD) is a motor disorder of the
01/09/24
colon, which is caused by the failure of neural crest cells
(precursors of enteric ganglion cells) to migrate
completely during intestinal development during fetal
life.
It is the result of a ganglionic segment of the colon
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fails to relax, causing a functional obstruction.
Hirschsprung's disease (also called congenital a
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develop properly, delaying the progression of stool
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disease, ganglion cells don’t develop properly in the
rectum, delaying the progression of stool.
65
Epidemiology of HD
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The sex ratio decreases with more extensive
aganglionosis, approaching 1:1 for total colon
aganglionosis.
There is familial clustering for nonsyndromic HD,
with an overall recurrence risk of approximately 3
percent in siblings for short-segment disease or up to
17 percent if the proband has long-segment disease.
66
Pathophysiology of HD
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Ethology OF HD
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completely. However, genetic factors may be
involved, especially when longer lengths of
intestine are involved or when someone else in
the family also has the condition.
68
Cont.…
01/09/24
disease if one of the parents has the disease. (The
chances are higher if the mother is the one with
Hirschsprung's disease).
If a family has a child with Hirschsprung's
disease, there is a 3 to 12 percent chance that
another baby from the same parents will also
have the disease.
69
Cont.…
Hirschsprung's disease occurs five times more
frequently in boys than in girls.
01/09/24
Children with Down syndrome have a higher risk as
well.
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Clinical manifestation of HD
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Abdominal distention
Bile stained vomiting.
Episodes of diarrhea and constipation
Poor feeding.
Tight anal sphincter with an empty rectum
Shock and jaundice
71
Cont..
01/09/24
When stool passed foul smelling and liquid
in consistency.
Malnourished and anemic.
Poor feeding.
Fecal impaction and
Failure to thrive.
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Cont..
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73
Diagnosis of HD
Hirschsprung disease can be diagnosed by taking a
medical and family history, doing a physical exam,
and ordering tests. Although Hirschsprung disease
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develops before birth, doctors cannot diagnose the
disease until after an infant is born.
About half the people with Hirschsprung disease are
diagnosed in their first year of life.
About 80% of people with Hirschsprung disease are
diagnosed by age 7, and more than 90% are
diagnosed by age 13.
74
Cont.…
01/09/24
During a physical exam, a doctor typically
Reviews your child’s height and weight
Examines your child’s abdomen or belly for
swelling.
Performs a digital rectal exam having no stool
in the rectum or having explosive stool after a
rectal exam may be signs of Hirschsprung
75
disease
Cont.…
01/09/24
During a physical exam, a doctor typically
examines your child’s abdomen for swelling 76
Cont..
01/09/24
Imaging tests
Anorectal manometer and
Rectal biopsies.
Imaging tests
To check for signs of Hirschsprung disease,
doctors may use imaging tests such as x-ray
and ultrasound to view large intestine. 77
Cont.…
Anorectal manometer
Anorectal manometer is a test that checks how
01/09/24
well your child’s rectum is working.
During the procedure, the doctor inflates a
small balloon inside your child’s rectum.
Normally, the muscles in the rectum will relax.
If the muscles don’t relax, the doctor may
suspect your child has Hirschsprung disease.
78
Cont.…
Rectal biopsy
Doctors typically use rectal biopsies to confirm
01/09/24
or rule out a diagnosis of Hirschsprung disease.
During a rectal biopsy procedure, a doctor will
take small pieces of tissue from the rectum.
A pathologist will examine the tissue under a
microscope to look for signs of Hirschsprung
disease.
79
Differential diagnosis of HD
Meconium ileus.
Anorectal stenosis and
01/09/24
Pelvic tumors.
Anorectal malformation.
Neonatal sepsis.
Intestinal atresia,
Anorectal anomalies,
Duodenal atresia and pyloric stenosis.
80
Management of HD
Medical management
Intravenous hydration,
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Intestinal and gastric decompression.
Administration of isotonic enema.
Administration of stool softeners
Low residue diet
Antibiotics and
Rectal irrigation.
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Cont.…
01/09/24
After the diagnosis counseling the family
Nurse thought about giving isotonic enema,
suppositories and stool softeners.
Monitor vital sign and abdominal girth of child.
Keep the child in semi fowlers position.
Keep NPO and insert NG tube.
82
Cont.…
Surgical management .
Surgery to bypass or remove the affected part of
01/09/24
the colon is necessary for the patient to have proper
bowel movements. Several options exist for
surgical treatment of HD.
A pull-through surgery removes the diseased part
of the colon or bowel.
The section with nerve cells is then pulled through
the colon and replaces the lost area.
83
Cont.…
01/09/24
Pull-through surgery is the primary treatment for Hirschsprung disease
01/09/24
The ostomy method removes the abnormal portion of
the colon while the healthy colon is routed to a
surgical opening or “stoma” on the abdomen
Ostomy pouches are then attached to this abdominal
port from which the stool is passed, collected and
emptied. 85
Cont.…
01/09/24
completed.
If severe damage has occurred due to inflammation,
the ostomy pouch system may be a permanent
solution to prevent further damage.
86
Cont.…
An ostomy is performed to allow patients to pass
digestive waste as the bowel heals from Hirschsprung
disease
01/09/24
87
Cont.…
Poste operative management
Monitor vital signs, observe abdominal bleeding.
01/09/24
Keep NPO, so administer Iv fluids as ordered
Monitor bowel sound
Colostomy care is to be done which include to
Observe for bleeding, purulent drainage, edema and
apply zinc oxide ointment on skin around stoma.
88
` Cont..
01/09/24
Encouraging and supporting the family during this
stressful time is the key intervention of nurse.
89
Nursing Interventions of HD
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Relieving Pain
Providing Adequate Nutrition
Controlling Constipation in the Older Child
Preventing Complications Related to Colostomy
90
Summery
01/09/24
other organs to protrude through unusual
opening that forms on the abdomen.
Omphalocele and gastrischisis are the
commonest congenital abdominal wall defects.
The disease do have embryological origin is the
current most accepted theory for Omphalocele is
failure of the midgut to return back to the cavity
91
Cont.….
Primary closure or staged closure can be used by
using different criteria's for both condition
01/09/24
Hirschsprung’s disease is a congenital
malformation which is characterized by a lack of
ganglion cells in the intestine which prevents
peristaltic activity through the bowel.
Abdominal distension, bilious vomiting and/or
enterocolitis and an X-ray that suggests distal
bowel obstruction may suggest Hirschsprung’s
disease. 92
Cont.…
01/09/24
The most commonly used surgical procedure to
treat Hirschsprung’s Disease at the Children’s
Hospital at West mead is the Soave procedure
where normal intestine is “pulled through” to the
anus
Long segment or complex disease may be
initially managed with a stoma.
93
Cont.…
Once the colon has had time to heal in this position,
the stoma is closed and the pull-through procedure is
completed.
01/09/24
If severe damage has occurred due to inflammation,
the ostomy pouch system may be a permanent
solution to prevent further damage.
94
References
01/09/24
Up to date.
Medscape.
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01/09/24
96