Pediatric Post-Op Care: Key Considerations

Nursing Care of the Child Born with Physical or Developmental Challenges

• Common physical and developmental disorders occurring in newborns are discussed.
• Nurse's role is to help the nation achieve the 2020 National Health Goals related to infants born with physical or developmental challenges.
• Assessing infants born physically or developmentally challenged is part of nursing care.
• Formulating nursing diagnoses for infants born with physical or developmental challenges is necessary.
• Establishing expected outcomes to meet the needs of children with physical or developmental challenges is also essential.
• Nurses help parents manage seamless transitions across different healthcare settings.

Nursing Care Planning Using the Nursing Process and QSEN Competencies

• Plan nursing care using the nursing process, incorporating the six competencies of Quality & Safety Education for Nurses (QSEN).
• The six QSEN competencies are: patient-centered care, teamwork & collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics.
• Implement nursing interventions for infants born with physical or developmental challenges, such as preventing infections in children with neural tube disorders.
• Evaluate expected outcomes to determine the achievement and effectiveness of care.
• Integrate knowledge of congenital physical or developmental challenges with the nursing process, QSEN competencies, and Family Nursing to promote quality maternal and child health nursing care.

Cultural Diversity and Congenital Anomalies

• Causes of most congenital anomalies are unknown but likely involve a combination of environmental and genetic factors.
• Some people persist in the belief that infants with congenital anomalies are born to people less deserving than others.
• Common beliefs include myths that being looked on by an evil eye (mal de ojo in Spanish) can cause deformities, eating raisins causes brown marks, or eating strawberries causes red hemangiomas.
• New parents need explanation of their child's disorder and a chance to talk about why they believe their child's disorder happened, to relieve any guilt.

Essentials in caring for children with congenital anomalies:

• Skin-to-skin contact with parents at birth is vital, if possible.
• Provide effective long-term care and consideration so children can adjust to residual effects of their birth disorder.
• Nursing support is essential to transition the child to adult care health care providers.

2020 National Health Goals and Nursing Care

• Congenital anomalies like cleft lip, omphalocele, and neural tube disorders can be detected by sonogram during intrauterine life.
• Nurses can help achieve national health goals by urging women to enter pregnancy with adequate folic acid levels, ensuring prenatal care, and offering advice and support after a fetal or newborn disorder diagnosis.
• Increase the proportion of women delivering a live birth who took multivitamins/folic acid prior to pregnancy from a baseline of 30.1% to 33.1%.
• Reduce the occurrence of spina bifida from 34.2 per 100,000 live births to 10.8 per 100,000 live births per year.
• Reduce the occurrence of anencephaly from 24.6 per 100,000 live births to 22.1 per 100,000 live births per year.
• Increase the proportion of children with special health care needs who have access to a medical home from 47.1% to 51.8%.
• Increase the proportion of children aged 0-11 years with special health care needs who receive their care in family-centered, comprehensive and coordinated systems from a baseline of 20.4% to 22.4%.
• Increase the number of children aged 12 to 17 years with special health care needs from 13.7% to 15.1%.
• Target is improving the slow decline in maternal mortality ratio to 90 by 2020.
• Target for slow decline in infant mortality rate is 15 by 2022
• Target to slow decline in Tuberculosis incidence 427 by 2021
• Target to slow decline in Stunting among children 21.4 by 2021.

Care at Birth for Infants with Physical or Developmental Challenges

• Nurses must be familiar with the most frequently encountered physical or developmental anomalies present at birth.
• Primary health care providers typically deliver the initial news of congenital physical or developmental anomalies to parents.
• Nurses should be ready to answer parents' questions after the primary care provider informs them their child was born "less than perfect."
• Guide parents to reputable .edu or .gov sites for reliable information and encourage them to bring information with them when they ask questions.
• Explain the disorder and usual prognosis before showing the baby to the parents.

Physical and Developmental Disorders of the Skeletal System

• Absent or malformed extremities
• Finger and toe conditions
• Chest deviations
• Torticollis (Wry Neck)
• Craniosynostosis
• Achondroplasia
• Talipes disorder
• Developmental hip dysplasia

Absent or Malformed Extremities

• These can be caused by maternal drug ingestion, virus invasion, or amniotic band formation in utero.
• Prostheses can be fitted as early as 6 months, but can prevent a child from adjusting to extremity loss.
• Amputation of a malformed extremity part often improves function before a prosthesis is fitted.
• Learning to use a hand prosthesis takes weeks to months.
• Children with absent extremities may need help mastering a prosthesis and forming a positive body image.
• In the newborn period, introduce parents to the rehabilitation team.
• Visiting with a child who uses a prosthesis can convince parents that their child can lead a normal life.

Finger and Toe Conditions

• Polydactyly is the presence of one or more additional fingers or toes.
• Extra fingers are often just cartilge or skin tags (removal is sound and cosmetically).
• A supernumerary digit is usually amputated in infancy or early childhood.
• Syndactyly is where two fingers or toes are often fused.
• Fusing is usually caused by simple webbing.
• Separation of digits into two sound and cosmetically appealing ones is usually successful.
• In other instances, the bones of the fingers or toes are also fused (cosmetic appearance and function cannot be fully reconstructed).
• Encourage parents to air their feelings and concerns as they deliver news to family and friends, and assure them the child is perfect in other ways so they can accept the child.
• Children may need this same type of assurance as they grow older.

Chest Deviations

• Pectus Excavatum or "Funnel Chest" involves indentation of the lower sternum.
• It is the most common congenital deformity of the anterior chest.
• Occurs in about 1 in 500 live births and affects boys four times more often than girls.
• May not be present at birth, but becomes obvious as the child grows to school age or adolescence.
• Lung volume may be decreased due to heart displacement.
• The condition can be repaired for cosmetic or physiologic reasons.
• Pectus carinatum refers to the displacement of the sternum anteriorly, increasing the anteroposterior diameter of the chest.
• Pectus carinatum is usually surgically corrected.

Torticollis (Wry Neck)

• "Tortus" (twisted) and "collum" (neck).
• A congenital anomaly where the sternocleidomastoid muscle is injured and bleeds during birth.
• Tends to occur in newborns with wide shoulders when pressure is exerted on the head to deliver the shoulder (vaginal or cesarean birth).
• Infants hold their head tilted to the same side as the muscle that is involved.
• Injury may not be noticeable in the newborn, but may become evident only as the haemorrhage recedes and fibrous contraction occurs (at 1 to 2 months of age).
• Management includes passive stretching exercises (lying the infant on a flat surface and rotating the head through a full range of motion).
• Parents should look in the direction of the affected muscle, by holding the head to feed in a position so that the child must look in the desired direction
• With surgical correction and neck immobilizer may be needed if continues after one year of age.

Craniosynostosis

• The premature closure of the sutures of the skull.
• May occur in utero or early infancy, because of rickets or irregularities of calcium or phosphate metabolism.
• The dominantly inherited trait occurs more often in boys than in girls.
• Head tends to row anteriorly and posteriorly if closing sagittal closing.
• If coronal suture line fuses early, the orbits of the eyes become misshapen, and intracranial pressure may lead to eye disorders.
• Premature closure of the coronal suture line is associated with syndactyly, cardiac anomalies, choanal atresias, and elbow knee-joint disorder.
• Early detection is needed because premature closure will close the fontanelles, seal the skull, closed, and compromise brain growth.
• Diagnosed by Xray or UTZ.
• If sagittal line is involved, close observation only.
• If the coronal suture line is involved, surgery to the suture line to prevent brain compression and abnormally shaped head by 9 to 12 months

Achondroplasia (chondrodystrophia)

• Failure of bone growth inherited as a dominant trait, which cause a disorder in cartilage production in utero.
• Epiphyseal plate of the long bones cannot produce adequate cartilage for longitudinal bone growth, stunting both hands and legs.
• Bones of the cranium are of membranous origin, the head continues to grow normally, causing children's heads to appear unusually large.
• Individuals rarely reach a greater height than 4 ft 6 inch (140cm).
• Women with this condition have difficulty with childbearing because of a small pelvis, generally necessitating a cesarian birth.
• Foreheads are particularly prominent, and the bridge of the nose becomes flattened.
• Trunks are of near-normal size, but a thoracic kyphosis (outward curve) and lumbar lordosis (inward curve) of the spine may develop.
• Since this disease is related to cartillage not brain matter, gross motor development may be slowed, but intelligence is not affected.
• Diagnosed with Utz in utero and xray at birth.
• May be prescribed with a with growth hormone.
• Although still considered controversial, leg lengthening may be possible.
• Children should have parents to help them adjust well to their short stature and develop self-esteem to be happy in their body no matter what their final height.
• Inform children when older of they are more likely to pass this on to their children,.

Talipes Disorders

• From latin talus (“ankle”) and pes ("foot").
• Ankle- foot disorders popularly called clubfoot.
• Avoid using the term when discussing talipes disorders with parents, “clubfoot" implies permanent crippling to many people, but no longer occurs with effective surgery.
• Concerns with the surgery include variable children's shoe size and differences in length leg.
• One child is born with talipes disorder in every 1,000. the disorder occurs more often in boys than in girls.
• Some only have an unusual foot position (pseudotalipes) that came from a cramped intrauterine position.
• This can brought the foot into straight position by manual maipulation, by stretching the foot into line everyday to solve the problem in a short time.

Talipes Disorder Diagnosing and Treatment

• The earlier a true disorder is recognized, the better the correction will be.
• Straightening all feet to the midline should occur as part of the initial assessment to detect any disorders.
• A series of casts and braces are applied to mold the foot into good alignment in the newborn period.
• Diapers should be changed frequently.
• Checking the toes for coldness and blueness should be frequently.
• There should be careful evaluation of crying episodes,.
• Casts or braces must be re-adjusted.
• The final cast will be removed after approximately 6 weeks.
• The infant may have wear denis browne splints for the remainder of correction
• Parents may perform passive foot exercises.
• Children who do not recover from casting, will have a surgery option.

Developmental Hip Dysplasia

• Often referred to as congenital hip dysplasia.
• Improper formation and function of the hip socket.
• Affects approximately 1% to 2% of newborns and is the leading cause of orthopedic disability in childhood and adult life because it can lead to premature arthritis.
• Cause up to 28% of hip replacements in people under 60 years of age.
• An unusually flattened or shallow acetabulum prevents the head of the femur from remaining in the acetabulum and rotating adequately.

Developmental Hip Dysplasia Etiology:

• Cause: the condition is unknown, may be from a polygenic inheritance pattern.
• It may occur from a uterine position that causes less-than-usual pressure of the head on the acetabulum.
• Most often in children of Mediterranean ancestry.
• Six fold more likely in girls than in boys, possible because the hips are normally more flaring in females and because the maternal hormone relaxin causes the pelvic ligaments to be more relaxed during pregnancy
• An affected leg may appear shorter than the other when the child is on their back and a flexed hip.
• When the child lies supine and the thighs are flexed to a 90-degree angle toward the abdomen, one knee will be lower than the other.
• Hips abduct properly at a newborn.
• At follow up at 4-6 weeks it might be discovered through and secondary shortening of an adductor muscle at 4-6 weeks
• . Difficult to detect at birth in an infant who was born from a breech presentation because the knees tend to stiff and not flex readily.
• Xray, utz, MRI will definitively reveal the shallow acetabulum and lateral displacement of the femur head for dagnosis.
• Therapeutic Management: Positioning, splints/halters/casts, surgery and pin insertion.

Nursing Intervention Developmental Hip Dysplasia patients

• NURSING DIAGNOSIS: Deficit parental knowledge related to splint, halter or cast
• OUTCOME EVALUATION: parents verbalize correct technique for and correctly demonstrate
• Multiple diapers spread the child.
• Infants can be put on leg abducted frog or multiple diplers to hold it. harlet
• The pavlik harness help to reduce the time interval simplifies treatment.
• Lay the infants on their back grasp the baby's thigh’s to ensure alignment and apply it.
• It should be continually worn, but not during baths.
• The skin should assessed everyday to ensure proper usage. If parents don't utilize the harness, its effectivness will be reduced.
• spica cast can place the infant in front positions. Can use a cars seat. Assess the circulation by checking the pulse every 24 hours.
• Worstrated case will be the femral death and loss of future life will require more therapy. -
• Genreal Cares is that even though the child may require therapy, it still meeded surgerical correction.
• There child will be a long time till one year of age for child.
• Cares is that immunization is scheduled.

Physical and Developmental Disorder of the Gastrointestinal System

• Ankyloglossia (tongue-tie)
• Thyroglossal cysts
• Cleft lip and cleft palate
• Pierre Robin Sequence
• Esophagial atresia and tracheoesophageal fistulas
• Abdominal wall defects

Ankyloglossia

• Abnormal restriction of the tongue because of an tight abnmal frenulm.
• Most is an normal at birth, but just have an appearance.
• Surgically fix problems that prevent difficulties by speech.
• Do not encourage the patient if that is a concern that speech will be impared.

Thyroglossal Cysts

• The Arises are an embyotic to for the base of the tounge and cause abberrant.
• This disorder is from the dominantly inherited traits that causes abberrant.
• They are filled to be inflammed so the pressure can cause infection of the treacha.
• To remove it perform a surgey.
• It is important to check postive operative to enure that there isn’t and surgey.
• Iv anitbiotics.

Cleft lip

• This results when process don't fully close
• Boys are most likely to have it at a rate of 1-700. in the Asian culture.
• Genetic counseling ensure they understand why having an children that are high risks.
• Eitholog are from the teratogeic.

Hare lip & Cleft pallate

• This is an older term for the cleft pallate.
• The hard shell is caused due to lack of closure.
• The assessment is an good look check the palate and an good lightning in assessing the child with more congenital anomalies.
• You wil have all types of professionals, which are denist, udoligst, and surgey craneofacical an surgery is often at to help you.
• Revision is necessary around 4-6 years.
• Nasali z can be created to better help nostrils.
• Maleck protocol repair the platte it is caused in an great time.
• Sometime there is the an infant has an device that helps not increasing of speed.
• It can be the an result or excelleny.

Intervention/ Assessment Cleft lip

• It could be that pt intake is not meeting required and cause health.
• In take an diet of 50 lb
• aspiration can be an precaution and there has to be some surgeon that are taking the tissue which causs the infant injury or a commecerial cleft lip.
• If needed a breck or haberal.
• For surgery there are diffrent method that can allow an early operation.
• Offering small sips.
• For cleft its an commericial ruber to hold the roof.

Intervention/ Assessment Pt Care

• NPO till liquid is to be plain.
• No suture needs to be on the tension so that there will be less to happen
• The diet is to follow good diety till the wound can heal
• If need to be use an soft one so that the sututre dont come aprt

Risk after Pt Care

• AIR clearance when there is less surgery.
• Evaluate the respoistory the children till a baseline is set.
• Mouth sutcion to keep the infants at to cause an safe enviroment
• Do not place an the baby on an abdomen to have less presure and tension