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• Choking


  Signs of gagging, evidence of binding in vomitus, signs that the object may be lodged in the throat or chest, increased salivation, drooling, gapping or difficulty swallowing, signs that the object may be lodged in the pharynx, discomfort in the throat or chest, more likely with a fish or chicken bone or large piece of meat
• Seek medical advice even if the object is smooth and small, usually less than the size of a nickel
• If no treatment is advised, check the stool for passage of the object, do not give laxatives
• Hirschsprung disease (HD)


  A congenital anomaly that results in mechanical obstruction from inadequate motility of part of the intestine
• Hirschsprung disease accounts for about one-fourth of all cases of neonatal intestinal obstruction
• The incidence of Hirschsprung disease is 1 in 5000 live births
• Hirschsprung disease is four times more common in males than in females and follows a familial pattern in a small number of cases
• Mutations in the RET protooncogene have been found in children with Hirschsprung disease
• Pathology of Hirschsprung disease


  • Absence of ganglion cells in the affected areas of the intestine, resulting in a loss of the rectosphincteric reflex and an abnormal microenvironment of the cells of the affected intestine
• Congenital aganglionic megacolon


  The primary defect in Hirschsprung disease, which is the absence of ganglion cells in the myenteric plexus of Auerbach and the submucosal plexus of Meissner
• Effects of the absence of ganglion cells in Hirschsprung disease

  Lack of enteric nervous system stimulation, decreased ability of the internal sphincter to relax, unopposed sympathetic stimulation of the intestine resulting in increased intestinal tone, loss of the rectosphincteric reflex
• In about 80% of cases, the aganglionic segment includes only the rectum and some portion of the distal colon (short-segment disease)
• In 15% of cases, the entire colon or part of the small intestine may be involved (long-segment HD)
• In 5% of cases, there may be total intestinal aganglionosis
• Clinical manifestations of Hirschsprung disease


  • Newborn period: Failure to pass meconium within 24 to 48 hours after birth, refusal to feed, bilious vomiting, abdominal distention
  • Infancy: Failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive, watery diarrhea, fever, appears significantly ill
  • Childhood: Constipation, ribbonlike, foul-smelling stools, abdominal distention, visible peristalsis, easily palpable fecal mass, undernourished, anemic appearance
• Most children with Hirschsprung disease are diagnosed in the first few months of life
• Typically, 99% of term infants pass meconium in the first 24 hours of life, whereas few infants with Hirschsprung disease do so
• Therapeutic management of Hirschsprung disease

  • Operative procedures: Pull-through, Swenson procedure, Duhamel procedure
  • Preoperative management: Fluid and electrolyte replacement, colonic cleansing
  • Postoperative management: Removal of the aganglionic bowel to relieve obstruction, restore motility, and preserve function of the external anal sphincter
• The pull-through procedure consists of pulling the normal bowel through the muscular sleeve of the rectum after the mucosa has been removed
• Simpler operations, such as an anorectal myectomy, may be used in very short-segment disease
• After the pull-through procedure, some children may experience recurrent enterocolitis, prolapse, or constipation, requiring further treatment or retraining therapy
• Nursing care management of Hirschsprung disease


  • Helping the family cope with the child's condition, fostering infant-parent bonding, providing pre- and postoperative care, managing the child's nutritional and elimination needs
• SECTION X Childhood Nutrition and Elimination Problems
• of repair include an anastomotic leak, strictures caused by sein or ischemia, esophageal motility doorders using driphagia, respiratory compromise, scoliosis, chest wall deformity, and GER
• Anastomotic esophageal strictures may cause dysphagia, choking, and respiratory distress
• The strictures are often treated with tine emphageddon
• Feeding difficulties are often ponent for months or years after surgery and the infant must be monitored closely to ensure adequate wright pan, growth, and development
• In some cases laparoscopic fondoplication may be required
• At times the infant must be fed via gastrostomy jejunostomy to provide adequate caloric intake
• Nursing respeity for detection of this serious malformation begins immediately after birth

  1. For the infant with the clasic signs and symplums of EA (see Nursing Alert) the major concern is the establish ment of a patent airway and prevention of further respiratory com promise

  2. Cyanosis is usually a result of laryngeal spot caused by of saliva into the larynx from the proximal esophageal pouch or aspira on it normally moles after removal of the secretions from the oropharynx by suctioning

  3. The passage of a small-gauge orogastric (OG) feeding tube via the mouch into the stomach during the initial nursing physical assessment is helpful to determine the presence of EA or other obstructive defects
• Preoperative Care

  1. The nurse carefully suctions the mouth and nasopharynx and places the infant in an optimum position to facilitate drainage and avoid aspiration

  2. The most desirable position for a newbor who is suspected of having the typical EA with a TEF (eg, type C) is supine (or sometimes prone) with the head elevated on an inclined plane of at least 30 degrees

  3. This positioning minimizes the reflux of gastric secretions at the distal esophagus into the trachea and bronchi, especially when intraabdominal pressure is elevated

  4. It is imperative to immediately remove any secretions that can be aspirated

  5. Until surgery the blind pouch is kept empty by intermittent or continuous suction through an indwelling double-lumen catheter passed orally or nasally to the end of the pouch

  6. In some cases a per- cutaneous gastrostomy tube is inserted and left open so that any air entering the stomach through the fistula can escape, thus minimizing the danger of gastric contents being regurgitated into the trachea

  7. The gastrostomy tube is emptied by gravity drainage

  8. Feedings through the gastrostomy tube and irrigations with fluid are contraindicated before surgery in the infant with a distal TEF
• Nursing interventions


  1. Respiratory assessment

  2. Airway management

  3. Thermoregulation

  4. Fluid and electrolyte management

  5. Parenteral nutritional support
• Often the infant must be transferred to a hospital with a specialized care unit and pediatric surgical team
• The nurse advises the parents of the infant's condition and provides them with necessary support and information
• Postoperative Care


  1. Adequate thermoregulation is provided

  2. The double-lumen NG catheter is attached to low-suction or gravity drainage

  3. Parenteral nutrition is provided

  4. The gastrostomy tube (if applicable) is returned to gravity drainage unt feeding

  5. If a thoracotomy is performed and a chest tube is inserted, w to the appropriate function of the dosed drainage item is ingen

  6. Pain management in the postoperative period is importantes should provide pain management for the neonate staf a theracecopic approach is used

  7. In the first 24 to 36 hun h underping a similar procedere

  8. Tracheal suction should only be done using a prem and with extreme caution to avoid mjury to the suture love

  9. If tolerated, gastrostomy lerdings may be initiated and until the esophageal anastomosis is healed

  10. Before ord fantas or oplagram will verify the integrity of the esophages arsike initiated and the chest tube (if applicable) is removed, a contes make certain the infant is able to swallow without choking

  11. The nurse must carefully observe the initial attempt at aral k are begun with sterile water, followed by frequent small amp w milk or formula

  12. Until the infant is able to take a sufficiem a mouth, oral intake may need to be supplemented by boka on o gastrostomy feedings

  13. Ordinarily infants are not i can take oral fluids well

  14. The gastrostomy tube may be reman discharge or maintained for supplemental feedings at hone
• Upper respiratory tract complications are a constant danger to life in both the preoperative and postoperative penols
• In addition to pneumonia, the infants are in constant danger of requery o resulting from atelectasis, pneumothorax, and laryngol elets
• Any significant respiratory difficulty after removal at secretions w reported to the surgeon mediately
• The infant should be o for anastomotic leaks and signs of infection such as purulent Can drainage, an increased white blood cell count, and temperat discharge
• For the infant who requires esophageal replacement, sucking should be provided with a pacifier