N-Trivia

Hirschsprung’s Disease (Aganglionic Megacolon)
Placenta Accreta, Increta, Pancreta
Abdominoplasty
Otoplasty

Hirschsprung’s Disease (Aganglionic Megacolon)

Posted: 07 Oct 2010 05:55 PM PDT

Definition: It involves an enlargement of the colon, caused by the bowel obstruction resulting from an aganglionic section of bowel or absence of ganglion cells – nerve do not function correctly and normal relaxation of bowel cannot occur. The length of the bowel that is affected varies but seldom stretches for more than about 30 cm.

Clinical Manifestations:

1. Newborn period:

a. abdominal distention

b. failure of passage of meconium within the first 48 hours of life

c. develops disinterest in feeding

d. repeated vomiting

2. Older infants and children

a. suffers from chronic constipation

b. tympanic abdominal distention

c. poor feeding

d. failure to thrive

e. irritable and fretful

f. Diarrheal enterocolitis – common complication below 3 months

g. fever

i. passage of ribbon like stools

Diagnostic examinations:

Barium enema may reveal megacolon
Rectal biopsy
Anorectal Manometry – it shows that the external sphincter contracts normally but does not relax

Etiology:

Heredity – The incidence is sporadic, however there is an increasing incidence in the family
Associated conditions
-strongly associated with Down syndrome ( 5-15% of patients with Hirschsprung disease also have trisomy21)
Waardenburg syndrome, congenital deafness, malrotation, gastric diverticulum and intestinal atresia

Medical Management:

Initial intravenous hydration, NPO (nothing per orem) status, intestinal and gastric decompression
Decompression – Nasogastric tube insertion or either digital rectal examination or normal saline rectal irrigations 3 to 4 times daily.
Surgical options: Colostomy at the level of normal bowel

*Surgery done in a 3 stage approach:

1. Temporary colostomy

2. Definitive Repair / Diversion Procedure

a. Abdomino-Perineal Procedure

b. Duhamel

c. Scaves Approach- Endorectal – Pulithru

c.1. done 8 months to 1 year

c.2. Infants has weight of 20 pounds

3. Closure of colostomy

Nursing Management:

Asses immediately for enterocolitis.
Avoid taking body temperature rectally because it may damage the mucosal lining

Prevention of constipation – small frequent feeding with low residue diet
Administration of oral and systemic antibiotics
Use of stool softeners
Provide a comfortable position- Semi-fowler’s to relieve dyspnea of abdominal distention
Encourage the family members to have a diet which includes corn and rice
Encourage parents to verbalize their anxieties as well as teach them the proper care of colostomy.

Nursing Care Plan – Hirschsprung’s Disease

More information about Hirschsprung's Disease

Placenta Accreta, Increta, Pancreta

Posted: 07 Oct 2010 05:31 PM PDT

Placenta Accreta, Increta, Pancreta

Definition

Placenta Accreta is an intrapartum complication characterized by the abnormal implantation of the placenta. Normally, chorionic villi attaches to the uterine endometrium. With this complication, the point of attachment extends to the layers of myometrium.

Review of Related Anatomy and Physiology

Uterus, the pear-shaped hollow muscular organ, houses the fetus until delivery. This structure has three layers namely: the perimetrium, myometrium and endometrium.

Perimetrium – the outermost layer that covers the uterus. ("Peri" means outside)
Myometrium – located at the middle part of uterus. "Myo" denotes muscle, thus, this layer contains thick muscular layers.
Endometrium – the innermost layer that responds to hormonal variations (estrogen and progesterone) during the menstrual cycle. The chorionic villi (finger-like projections that attaches to the uterine wall) penetrates into this portion of the uterus during implantation. ("Endo" means inside)

In a female reproductive cycle, the uterine endometrium normally sloughs off the thickened vascular surface that precedes the actual secretion of blood flow. With fertilization, it continues to be crammed with blood to accommodate and nourish the embryo. Following this condition, uterine endometrium is now called decidua, which has three separate areas:

Decidua Basalis – point of attachment between the maternal vessels and trophoblast (structure that forms the placenta and membrane). Lies under the embryo. (To remember easily Basalis comes the word "base" meaning "under/below")
Decidua Capsularis – part of endometrium that expands and encapsulates the implanted trophoblast. .(To remember easily Capsularis comes the word "capsule" meaning "to enclose/above")
Decidua Vera (Parietalis) – remaining portion of the uterine endometrium. (To remember easily Parietalis comes the word "parietal" meaning "wall of a hollow organ")

Types of Placenta Accreta

This obstetric complication is categorized depending on the depth of its attachment:

Placenta Accreta – chorionic villi attaches deeply into the uterine wall but does not penetrate the myometrium. This is the most common form of the condition. (Accreta starts with letter A, so it Attaches)
Placenta Increta – chorionic villi invades or infiltrates the muscular layer. (Increta starts with letter I, so it Invades/Infiltrates)
Palcenta Pancreta/Percreta – chorionic villi penetrates beyond the myometrium into the entire uterine wall and possibly to other adjacent organs such as the bladder. This is the least common of the three conditions. (Pancreta starts with letter P, so it Penetrates)

Pathophysiology

Predisposing Factors

Scarring of tissues from previous infection
Previous uterine surgery (Dilation and Curettage, Cesarean Section, Myomectomy)
Thin decidua or absent deciduas basalis
Presence of tumor

Signs and Symptoms

Usually signs and symptoms are not detected until labor and delivery. However, for some third trimester bleeding would be noted.

During labor and delivery massive bleeding is observed. In cases when deciduas basalis is absent, the placenta will not loosen and fails to be delivered.

Complications

Uterine rupture
Massive bleeding
Disseminated intravascular coagulation (DIC)

Diagnostic test

Ultrasound
MRI

Medical Management

Conservative treatment is done if the woman wants to maintain her fertility under the condition that no active bleeding is present. This treatment saves the uterus but poses higher risk of complications and low successful rate. Techniques for this treatment are as follows:

The placenta is left in the uterus and the cord is ligated.
Closure of the uterus is performed.
Methotrexate (an antineoplastic agent) is usually given to the woman to destroy the still attached placenta.

Women taking Methotrexate should be monitored for:

WBC and platelet count (thrombocytopenia and leucopenia may occur 7-14 days after the initiation of treatment)
Blood Urea Nitrogen (BUN), Creatinine, and urine pH (should be above 7.0)
Presence of dry and nonproductive cough may be an early sign of pulmonary toxicity
Symptoms of gout must be assessed frequently (increased uric acid, joint pain, edema). Methotrexate causes increase serum uric acid. Allopurinol may be given to decrease uric acid levels.

After the techniques are implemented, prophylactic antibiotic is started to prevent infection. Follow-up includes frequent or daily ultrasound sessions to monitor uterine involution and placental condition.

Surgical Management

Early detection of placenta accreta will prevent serious complication. The safest modality is a planned cesarean section and hysterectomy (surgical removal of the uterus).

Nursing Management

Obtain a detailed obstetric history.
Assist with modalities implemented.
For clients taking Methotrexate, instruct the woman to increase fluid intake to at least 2 L each day as uric acid formation is increased with the drug use.
Provide emotional support to the woman and family.

Possible Nursing Diagnosis

Diagnosis of Placenta accrete with a massive blood loss is an emergency; objective should consider the brief time frame of the emergency condition.

Impaired tissue integrity R/T deep attachment of the placenta
Fear R/T pregnancy outcome secondary to placenta accrete
Grieving, dysfunctional R/T loss of a body part after hysterectomy

image from embryology.med.unsw.edu.au, picsdigger.com

Abdominoplasty

Posted: 07 Oct 2010 04:04 PM PDT

Definition

Removal of loose, redundant abdominal skin and underlying subcutaneous fat, and repair of the rectus muscle as necessary.

Discussion

The procedure is performed for cosmetic purposes, to reduce a disproportionately large collection of fat in the abdomen.
It should not be performed for weight reduction.
A variety of techniques can be used according to the fat distribution and the surgeon's preference.

Positioning

Supine, with arms extended on armboards.

Packs/ Drapes

Basic pack with transverse Lap sheet.

Instrumentation

Basic plastic tray
Extra Criles or Kochers may be needed.

Supplies/ Equipment

Basin set
Suction
Scales for weighing specimens
Blades
Needle counter
Drainage unit

Procedure

An incision is made just above the inguinal fold, "aW" which is extended on the umbilicus, creating a diamond shape.
The umbilicus is preserved for later replacement under the flap.
Dissection is usually begun at the lower portion of the W incision and progress upward, leaving a fine layer of areolar tissue over the fascia.
Each lateral branch of tissue is excised.
The amount predetermined before removal so that the defect can be closed with moderate tension.
If there is a separation of the rectus muscle, it is repaired by taking "tucks" to shorten the muscle.
If a large ventral hernia is present, it may be repaired with synthetic mesh.
The wound is closed with heavy absorbable suture (deep fat) and a running subcutaneous suture.
The vertical branches are closed first, and the umbilicus is repositioned in the vertical scar.
The use of drains is according to the surgeon's preference.

Perioperative Nursing Considerations

Strict aseptic technique must be maintained.
Weigh and record the weight of the specimen.
Encourage the patient not to make strenuous activities.

Otoplasty

Posted: 07 Oct 2010 03:56 PM PDT

Definition

Correction of a congenital defect that causes the ears to protrude prominently from the side of the head (lop ears).

Discussion

The procedure is usually performed bilaterally, but it can involve only on ear. The procedure may also refer to the correction of microtia and other congenital deformities of the ear. The ideal time for the corrective procedure to be performed is usually around 4 years of age or before the child enters school, in order to prevent ridicule by the child's peers.

Positioning

Supine; arms may be tucked in at the side. If unilateral, the affected ear is up, and the other is supported on a soft headrest to avoid damage. For a bilateral otoplasty, the head is placed in a accommodating position by the surgeon.

Packs/ Drapes

Head drape with ears exposed
Split sheet with basic pack

Instrumentation

Plastic procedure tray
Small rasps

Supplies/ Equipment

Headrest e.g. doughnut or shea
Basin set
Suction
Blades
Needle counter
Local anesthetic
Syringes
Solutions
Sutures

Procedure

A variety of techniques are used to correct this defect. A common approach involves incising the skin on the posterior side of the concha.
The underlying cartilage is then incised or scored.
Interrupted sutures (absorbable or non absorbable) are placed through the cartilage to tighten it.
The resulting effect "pins" the ears closer to the head.
The incision is closed with fine interrupted sutures and a bulky dressing is applied.

Perioperative Nursing Considerations

For a unilateral procedure, keep the lowermost ear well padded to avoid pressure injury.
The table may be turned for easier access.
Do not allow preparation solution to pool in or around the ear.
A sterile cotton pledget may be placed in the ear to avoid solution dripping into the ear.