Summarize the following text to main points and sub-points and make detailed explain for them:

 
 
 
 
INTRODUCTION TO 
PEDIATRIC 
SURGERY FOR  
NURSES 
1 
 
 
Surgical Care for Infants and Children 
 
Introduction 
 Major differences from adults: 
 
o Body systems not fully developed 
o Their full physiological functions and reserve are small 
o They are very fragile 
o Temperature regulation 
o Body fluids and electrolyte:  
 80% in full term is water, which decreases to 60% in adults 
o Special way of feeding 
o Different ways for pain relief 
o Immature systems: 
 
 Small blood volume 
 In neonate about 80 ml/kg body water  
 In 3.5 kg neonate: 280 ml total blood volume 
 
 Immature respiratory system 
  
 only about ½ alveoli are present at birth 
2 
 
 
 Immature hepatic function 
 The common example is physiologic jaundice 
 
Preoperative care 
 Routine: 
 vital signs: pulse, temp., BP, RR 
 Urine: Amount and colour 
 Empty stomach  
 Food:  midnight before operation 
 Breast milk: 4 hrs before 
 Clear fluids: 2 hrs before 
 Assessment for operation: 
 General: 
 Anemia, hypoprotienemia, dehydration, and chest condition 
 Local: 
 Assessment of the site of operation i.e no infection 
 Special Considerations: 
 varies according to the operation e.g: 
 Bowel preparation: for colonic and rectal operations 
3 
 
 Mark site of operation 
 Social 
 knowledge to parents as regards the operation 
 Help to relieve anxiety about problems (complications) 
 
Postoperative Care 
 Immediate postoperative day: 
 General: 
 Vital signs 
 Level of consciousness 
 
 Local: 
 Incision 
 Bleeding 
 Pain medication: oral (if tolerating), I.M, suppository 
 Subsequent postoperative days: 
 General: 
 vital signs 
 Urine: Amount and colour 
 Signs of Infection: Fever and ++HR (chest, cannula) 
 Local: 
 Incision 
 Pain medication 
 Care of wound 
4 
 
 
 Special postoperative care 
 according to the operation: care for chest tube and watch for 
respiratory distress in CDH 
 
Postoperative Feeding: 
 
Peritoneum opened 
 Paralytic ileus lasts for 1-3 days: 
 NPO 
 NG TUBE: patency, amount, colour 
 I.V fluids and electrolytes: rate and deficit 
 Urinary catheter: patency, amount, colour 
 Feeding  start when: 
 Bowel sounds return: pass flatus 
 NG tube becomes clear 
Peritoneum not opened 
 No fear of ileus and start feeding 2 hrs postoperatively 
 If breast fed: clear fluid then breast 
 In older infants and children: 
Clear fluids->soft diet->normal feeding 
 
 
5 
 
Wound Care 
 Objective: 
 Keep wound clean and dry 
 Observe for signs of infection: swelling, redness, purulent drainage 
 Method (how to care): 
 Dressing + drain:  
 Types of drains:  
 Corrugated rubber 
 Tube 
 Portovac 
 What to do? dress daily until drain removed 
 When removed? When it stops draining 
 Drains used to drain: blood, bile, urine, serum 
 No drain: 
 Don’t disturb unless signs of infection: 
 General: fever 
 Local: 
 Dressing: Soak, bad odor 
 Wound: redness, swelling ,purulent 
drainage 
 If infected dress daily with antiseptic solution until 
it dries 
 No dressing: shower as usual 
 Special: varies with operation and depend on immediate 
postoperative care 
6 
 
 Congenital Diaphragmatic Hernia 
 Definition: Opening in the diaphragm through which 
the abdominal contents herniate into the thoracic 
cavity during prenatal development. 
 Mortality 50-80% 
 Degree of pulmonary hypoplasia determines outcome 
 Types: 
 Anterior (Morgagni) CDH 
 Posterior (Bochdalch) CDH 
 Clinical Picture: 
 Depends on severity of defect 
 Fetal U/S: abdominal organs in chest 
 Respiratory distress soon after birth 
 Scaphoid abdomen 
 ↓ breath sounds 
 Bowel sounds over chest 
 Cardiac sounds on right side 
7 
 
 Investigations: 
 Plain chest and abdomen: 
 loops of intestine in chest in continuity 
with bowel in abdomen 
 Management: 
 Neonatal emergency 
 Preoperative: 
 NG tube 
 IV fluids 
 Ventilation 
 ECMO? 
 Manage pulmonary hypertension 
 Operation 
 Surgical reduction of hernia after being physiologically 
stable 
 Postoperative: 
 Respiratory support till lungs function probably 
 Nursing care: 
 Preoperative : 
 Routine 
 Semi Fowler’s position on affected side with head of bed 
elevated 
 Care of respiratory distress: 
 Oxygen mask 
 Mechanical ventilation 
8 
 
 Postoperative: 
 Routine 
 Care of chest tube 
 Care for respiratory distress: 
 Oxygen mask 
 Mechanical ventilation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
9 
 
Congenital Hypertrophic Pyloric Stenosis 
 Definition and incidence: 
o One of the most common surgical disorders of 
early infancy. Circular muscles of the pylorus 
hypertrophy and block gastric emptying 
 Pathology: 
Hypertrophic pylorus 
↓ 
 
 
Pyloric tumor 
↓ 
Pyloric canal elongated and narrow 
↓ 
Gastric outlet obstruction 
 
↓ 
Vomiting 
 
↓ 
Losing H + Cl 
 
↓ 
Hypochloremic alkalosis 
 Clinical manifestations: 
o Vomiting: 
 Progressive 
 Projectile 
 Non bilious 
o Mass: 
 Mobile 
 Firm 
 Olive shaped 
 Rt. Upper quadrant 
o Visible peristalsis from Lt. to Rt. 
o Dehydration 
o Metabolic alkalosis 
o Constipation 
10 
 
 Diagnostic evaluation: 
o Plain X-ray abd. 
 Narrow pylorus 
 Dilated stomach 
 
o Ba meal 
 Long narrow pyloric canal 
 Delayed gastric emptying 
o Abdominal U/S 
 Pyloric mass 
 
 Therapeutic management: 
o Pyloromyotomy is the definitive ttt. 
o Not an emergency but performed without delay on 
well hydrated infants. 
 
 
 
Nursing care: 
o Preoperative: 
 NG tube, gastric wash with warm saline. 
 Correct dehydration and electrolyte 
 Child kept warm and quiet 
 Prevent aspiration 
 Respiratory distress assessed 
o Postoperative: 
 Remove NG tube immediately and begin feeding 4-6 hrs after 
surgery if bowel sounds normal. 
 May delay feeding for 24 hrs and leave NG tube in place and give 
I.V fluids.  
 Feeding: (routine) 
11 
 
Esophageal Atresia with 
Tracheoesophageal Fistula 
 Definition: 
o Congenital malformation in which the esophagus terminates before 
it reaches the stomach and a fistula is present with the trachea 
 Types: 
o In type C: (most common type 85%)  
 Proximal atresia, distal fistula(TOF)  
o In type A: (10%): pure atresia 
 Proximal and distal atresia(EA)  
 Pathology: 
o Aspiration (excessive salivation) 
o Air passing down the fistula (type C)  
 Severe abdominal distension  
 Reflux of gastric Hcl 
o Pneumonia 
 
12 
 
 Clinical manifestation: 
o Coughing, chocking with feeding and cyanosis. 
o Excessive salivation 
o Failure to pass NG tube 10 cm beyond gum line  
o Abdominal distension  
 Diagnostic evaluation: 
o Prenatal U/S: Polyhydraminos 
o Plain X-ray: 
 Proximal esophagus dilated with air (atresia) 
 Coiled Ryle in proximal esophagus 
 Abdominal distension (Fistula)(type C)/ Gasless abdomen 
 (type A) 
o X-ray with contrast: 
 Blind upper pouch 
 
 
 
 
 
 
 
 
13 
 
 Therapeutic management: 
 
o EA with TOF is a critical neonatal emergency 
o Aim: prevention of aspiration 
 Keep infant supine with head of bed elevated 
 Continuous or frequent suction every 5-10 min. 
 I.V fluids/ TPN. 
o Surgical repair is the main line of treatment 
o Small gap: ligation of fistula and end-end anastmosis 
o Long gap: 
 Ligation of fistula 
 Gastrostomy 
 Cervical esophagostomy 
 Later: esophageal replacement(colon, stomach interposition) 
 Nursing care of infant with EA and TOF: 
o Preoperative: 
 Immediately after birth: 
 Warmer + humidified oxygen 
 Prepare for surgery 
o Immediate Postoperative: 
 Care of chest tube: patency/ amount (output)/ colour 
 Care of esophagostomy: 
 Clean with gauze to absorb saliva 
 Change frequently to prevent constant wetness 
 Provide skin care 
 Clean with ½ strength H2O2, once daily 
 Oral stimulation with pacifier : to allow practice in swallowing 
 Care of gastrostomy tube: 
 Clean site with ½ strength H2O2, once daily 
 Rinse with H2O ointment 
 Rotate once daily 
 Keep tube elevated to allow gastric contents to pass to 
small intestine 
14 
 
Intussusception 
 Definition: 
o Invagination of a segment of intestine into the distal bowel which results 
in bowel obstruction 
 Pathology: 
o If neglected: 
Obstruction  →   Gangrene  →   Perforation    →    Peritonitis 
 
 
Clinical Manifestation: 
o Well nourished 
o Recurrent attacks of pain 
o Vomiting 
o Bloody mucus stool (red current jelly) 
o Abdominal mass 
o Sepsis, shock (if neglected) 
 Diagnostic evaluation: 
o Abdominal X-ray:  
 Bowel obstruction 
 
15 
 
o Abdominal u/s: 
 Mass 
o Barium enema: 
 Claw sign, coiled spring sign 
 Therapeutic Management: 
o Initially:  
 Hydrostatic reduction with air, saline or barium enema until free 
flow of contrast into terminal ileum 
o If reduction fails: 
 Immediate surgery 
 Simple reduction 
 Resection and anastomosis (if gangrenous) 
 
16 
 
 Nursing care of child with I.O: 
o Before reduction of intussusception: 
 Pain  →  analgesics 
 Vomiting (fear of aspi

Summary :