Cleft Lip/Palate  Some infants may have a nasal mold

apparatus applied before surgery to

 the fusion fails to occur in varying
shape a better nostrils.
degrees, causing this disorder to range
from a small notch in the upper lip to
total separation of the lip and facial
structures up into the floor of the nose,
with even the upper teeth and gingiva
absent.

Cleft lip (Cheiloschisis) Assessment

 is more prevalent among boys than girls  Sonogram

and occurs at a rate of approximately 1  Inspection of the mouth at birth.
in every 700 live births  Assess the child for other congenital
 It appears to be caused by the anomalies
transmission of multiple genes aided by
Therapeutic Management
teratogenic factors present during weeks
5 to 8 of intrauterine life, such as a viral  Cleft lip is repaired surgically shortly
infection, certain seizure medicines such after birth, sometimes at the time of the
as phenytoin, maternal smoking or binge initial hospital stay or between 2 and 10
drinking, hyperthermia, stress, and weeks of age
maternal obesity.  A revision of the original repair may be
 Folic acid deficiency may also be necessary when the child reaches 4 to 6
associated with incomplete anterior years of age
midline closures  The repair of cleft palate is usually
postponed until a child is 6 to 18 months
old.
Cleft palate (Palatoschisis)  Repairs made before this change may be
ineffective and may have to be repeated
 an opening of the palate, is usually on  Early repair also helps infants experience
the midline and may involve the anterior the pleasure of sucking
hard palate, the posterior soft palate, or
both o It may be a separate anomaly, but Preoperative Period
as a rule it occurs in conjunction with
 It may be possible for an infant with a
cleft lip o It tends to occur more
cleft lip to breastfeed because the bulk
frequently in girls than boys.
of the mother's breast tends to form a
 May need caring support to bond with
seal against the incomplete upper lip
an infant whose face is deformed in this
 The best feeding method for the child
way
with cleft lip may be to support the baby
 Facial contours change as a child grows,
in an upright position and feed the infant
a revision of the original repair or a nasal
gently using a commercial cleft lip nipple
rhinoplasty to straighten a deviated
 If the surgical repair will be done
nasal septum may be necessary when
immediately, the mother will be able to
the child reaches 4 to 6 years of age.
breastfeed as early as 7 to 10 days after
surgery
 Be certain an infant with a cleft lip is less suture line tension than bottle or
bubbled well after feeding because of a breastfeeding After Palate Surgery
tendency to swallow air caused by the  Liquids are generally continued for the
inability to grasp a nipple or syringe edge first 3 to 4 days and then a soft diet is
securely with the mouth folled until healing is complete
 If a cleft extends to the nares, an infant  When the child begin eating soft food he
will breathe through the mouth, causing should not use a spoon because a child
the oral mucous membranes and lips to will invariably put it against the roof of
become dry the mouth and possibly disrupts sutures
 Offering small sips of fluid between  Be certain milk is not included in the first
feedings can help keep the mucous fluids offered because milk curd tend to
membranes moist and prevent cracks adhere to the suture line
and fissures that could lead to infection  After feeding offer the child clear water
 Infants with cleft palate cannot suck to rinse the suture line and keep is as
effectively either, because pressing their clean as possible
tongue or a nipple against the roof of
Imperforate Anus
their mouth could force milk up into
their pharynx, leading to aspiration  is a stricture or the absence of the anus,
 The most successful method for feeding  In week 7 of intrauterine life, the upper
this infant, like the child with cleft lip, is bowel elongates to pouch and combine
to use a commercial cleft palate nipple with a pouch invaginating from the
that has an extra flange of rubber to perineum.
close the roof of the mouth  These two sections of bowel meet, the
membranes between them are
Preoperative Period
absorbed, and the bowel is then patent
 A Breck feeder, am apparatus similar to a to the outside.
bulb syringe, or a Haberman feeder may  If this motion toward each other does
be used not occur or if the membrane between
 The nipple can be used with a plastic the two surfaces does not dissolve, an
bottle that can be squeezed gently to imperforate anus occurs.
increase the flow of the feeding to
Assessment
compensate for poor sucking
 The condition may be detected by a
Postoperative Period
prenatal sonogram.
 After surgery for cleft lip or palate, an  It is discovered at birth when inspection
infant is kept NO for approximately 4 of a newborn's anal region
hours  A "wink" reflex (touching the skin near
 The infant is then introduced to small the rectum should make the anus
amount of liquids (plain water) to contract) cannot be elicited if sensory
prevent vomiting nerve endings in the rectum are not
 No tension is placed on a lip suture line intact.
to keep the sutures from falling apart  Even with all these methods, some
and leaving a large scar instances of the stricture will not be
 The infant is usually feed using a detected at birth because the anus
specialized feeder because this causes
 appears as usual and the stricture exists Infants:
so far inside that it can't be seen.
• Failure to pass meconium
 By 24 hours, no stool will be passed, and
abdominal distention will become • Ribbonlike stools (stools passing through
evident. such a small, narrow segment look like
 An Xray or sonogram will reveal the ribbons)
disorder if the infant is held in a slightly
head down position to allow swallowed • Abdominal distension
air to rise to the end of the blind pouch • Bile- stained vomiting
of the bowel.
 This method is also helpful to estimate • Shock
the distance the intestine is separated • Episodes of diarrhea & constipation
from the perineum or the extent of the
correction that will be necessary. In older children:

Therapeutic Management • Constipation with abdominal distension

 The degree of difficulty in repairing an • When stool passed foul smelling, and liquid
imperforate anus depends on the extent in consistency
of the problem.
• Malnourished and anemic
 If the rectum ends close to the perineum
(at or below the level of the levator ant DIAGNOSTIC EVALUATION:
muscle) and the anal sphincter is
• Hirschsprung's disease is suspected in a
formed, repair involves simple
baby who has not passed meconium within
laparoscopy with anastomosis of the
48 hours of birth.
separated bowel segments.
 A repair becomes complicated if the end •Rectal examination
of the rectum is at a distance from the
•Palpation
perineum (above the levator ani muscle),
the anal sphincter exists only in an •Anorectal manometry
underdeveloped form, or a fistula to the
bladder or vagina is present. •Barium enema & Rectal biopsy
 If the repair is estimated to be extensive, Therapeutic Management
the child may be given a temporary
colostomy and the final repair  Repair of aganglionic megacolon involves
performed when the infant is somewhat dissection and removal of the affected
older (6 to 12 months) section, with anastomosis of the
intestine (termed a pull through
HIRSHSPRUNG'S DISEASE operation).
 is a disorder of the gut caused due to  Because this is a technically difficult
congenital absence of ganglion cells in operation to perform in a small
the submucosal and myentric plexus of abdomen, the condition is generally
intestine. It is also known as Megacolon treated in infants by two stage surgery o
or Congenital Aganglionic Megacolon. first, a temporary colostomy is
established, followed by bowel repair at
12 to 18 months of age. o After the final
 surgery, children should have a Post-operative care:
functioning, normal bowel.
I. Monitor vital signs, observe
 In the few instances in which the anus is
abdominal bleeding.
deprived of nerve endings, a permanent
II. Place the child in comfortable
colostomy will need to be established
position according to the physician
Repair of aganglionic megacolon involves
order.
dissection and removal of the affected
III. Child is NPO, so administer IV fluids
section, with anastomosis of the
as ordered
intestine (termed a pull through
IV. Monitor bowel sound.
operation).
V. Colostomy care is to be done which
 Surgeons frequently perform a single
includes following:
operation to fix intestinal obstruction
 Observe stoma for its colour (reddish-
when Hirschsprungs disease is initially
pink colour)
diagnosed. The goal of the surgery is to
 Observe for bleeding, purulent drainage,
remove the diseased section of the
edema.
intestine and to pull the healthy portion
 Provide bland diet
of the intestine down to the anus. This is
 apply zinc oxide ointment on skin
called a pull-through procedure. In most
around stoma.
cases, this surgery can be done with
minimally invasive techniques. It can Frequently empty the collecting bag
sometimes be performed entirely
through the anus, leaving no scars at all. 1. Keep the colostomy clean and dry.
2. Educate parents about colostomy
NURSING MANAGEMENT: care.
3. Encouraging and supporting the
Pre- operative care:
family during this stressful time is the
I. Assessment, complete history of key nursing intervention.
new born
II. After diagnosis, nurse must help
parents.
III. Nurse taught about giving isotonic
enema, suppositories and stool
softeners.
IV. Low residue diet must be given to
the child.
V. Monitor vital signs & abdominal
girth of child
VI. Keep the child in semi-fowlers
position.
VII. Withhold oral feeds & Nasogastric
aspiration done on the night before
surgery.
The history of medical research on human subject against even the remote
subject is as old as the history of medicine possibilities of injury, disability or
Itself. Ancient physicians believed that death.
dissection of human cadaver to study human 8. It should be conducted only by
anatomy was insufficient to gain knowledge scientifically qualified persons with
about the malfunctions of the body. highest degree of skill throughout
the experiment.
 Vivisection - a form of ancient
9. During experiment the human
experimentation performed on living
subject is free to discontinue the
animals including man, using operation
process should he feel physically and
(cutting or dissecting) designed to
mentally incapable to continue.
promote some knowledge of
10. Like-wise the scientist in charge of
physiological and pathological processes.
the experiment must be prepared to
terminate it if there is probable cause
 The Nuremberg Code, (the birth of
that the experiment might result in
Informed consent) a 10 point principles
injury or death to experimental
lo be fallowed in human
subject.
experimentation and foremost of these
is voluntary and Informed consent of
subject Justification for human experimentation:

Nuremberg 10point principles: 1. Animal studies are Inadequate

because human physiology and
1. The voluntary consent of subject is
psychology are different and unique.
absolutely essential.
2. The biochemical constitution and
2. The experiment should yield a fruitful
metabolism of humans are very
result for the good of society. cannot
much different from those of
be achieved by other methods, not
animals.
random and unnecessary
3. Contemporary medicines have
3. Should be designed based on result
become effective because il has
of animal experimentation and the
become scientific.
justified results will justly the
4. Experimentation on human subjects
performance of the experiment.
is necessary if we have to develop
4. It should be so conducted as to avoid
new drugs, new therapies, and new
all unnecessary physical. mental
methods of prevention for serious
suffering and injury
diseases that beset mankind.
5. No experiment should be conducted
5. It is necessary to develop certain
if death or disabling injury might
vaccines and drugs that can stop the
occur except it the physician will
spread of contagious diseases.
serve as subject.
6. The degree of risk should never
The moral issue of human
exceed by the humanitarian
experimentation is not to help o
importance of the problem to be
experimental subject but to advance
solved.
future knowledge for future patients.
7. Proper preparation and adequate
facilities be provided to protect
Two kinds of experiments: 5. Answer any questions asked about
the procedure
a) Therapeutic
6. Make It clear that he is free to
b) Non-therapeutic
withdraw consent w/out penalty

Informed consent is also

Medical therapy (therapeutic experiment) -
Is designed and conducted for the benefits of 1. Recognition of individual's
the experimental subject either to diagnose autonomy
or treat an illness. 2. The right to sell-determination
3. To form his own opinion
Purposes

1. to relieve suffering and to restore to

health
2. To cure diseases
3. correct disorders
4. bring about normal bodily
functioning

Medical research (non-therapeutic

experiments) not designed to benefit the
experimental subject directly but only to
derive knowledge that can be utilized in the
treatment of other persons with similar
aliments.

Purposes:

a) To acquire better understanding of

the chemical and physiological
processes that are involved in
human functioning
b) Is Interested in the effectiveness of
therapies in ending disease
processes and restoring functioning
c) Interested in the formulation of
theories that can serve as a basis for
treating other individuals

Information element of informed consent:

1. explain procedure and purposes

2. Underscore risk and discomfort
expected
3. Describe possible benefits of the
experiment
4. Point out appropriate alternatives