Case study on Esophageal Atresia with Tracheo esophageal Fistula

ESOPHAGEAL ATRESIA WITH TRACHEO-

ESOPHAGEAL FISTULA

(EA with TEF)

Pabitra Sharma

MN 2nd year

CMC

1

Objective

General objective

To conduct the in depth case study by using nursingprocess.

Specific objectives

• To collect information regarding the bio-demographyand present/past history of the case.

• To obtain detail knowledge about disease conditionEA/TEF including signs and symptoms causes, medicalsurgical and nursing management, pharmacological andcomplications.

• To obtain knowledge upon various diagnosticprocedures performed regarding the disease.

2

Objective Contd…

• To identify child progress and management of

case.

• To perform a physical examination of case.

• To provide holistic nursing care using

appropriate nursing theory.

• To provide health education to parents.

3

Background of the study:

This case study is prepared on child with

esophageal atresia with Tracheo esophageal

fistula by taking the case of Kanti Children

Hospital in Surgical intensive care unit for the

partial requirement of Advanced Child Health

Nursing Practicum II.

4

Methodology for this case study

The methodology adopted to produce this report

was based on the interview, observation,

examination, and discussion with on duty

doctors, staffs, teachers and friends, and also by

referring various text books and references.

5

Rationale for selecting the case

Esophageal atresia with Tracheo esophageal fistula is a serious and less common birth defect

TEF occurs in around every 3500 birth

As time advances, the exact cause for this problem still unknown.

EA with TEF always associated with other o-congenital anomalies

In the context of Nepal, outcome of this condition is not much as satisfactory and mortality rate was near about 100%.

So, I choose the case of EA with TEF/

6

Patient profile

Informants: mother and grandmother of neonate

Bio-demographical Information:

Name: B/O Sarmila Rana

Age/Sex: 4 days /Female

Date of admission: 2073/09/24

Diagnosis: Esophageal Atresia with TreacheoEsophageal Fistula

Ward: Surgical Intensive Care Unit (SICU)

7

Profile Contd….

IP No:

Bed no: 260

Address: Surkhet

Mother’s name: Sarmila Rana

Education: Primary

Occupation: Housewife

Father’s name: Education: Primary

Occupation: Farmer

Religion: Hindu

Name of Informants - Sarmila rana, devkala rana

8

Chief Complaints

• Excessive Salivation since birth

• Bluish after each feed attempt since birth

• Difficult in breathing since birth

• Coughing after immediate (1st ) feeding

• Abdominal distension after 24 hour of birth

9

History of Present Illness

According to mother, baby was born at PHCC afterterm gestation. Baby seems normal immediatelyafter birth and cry immediately. But after 30 minuteof birth when mother tries for feeding she observedexcessive salivation from baby’s mouths and babyturn to bluish when she feed baby. After feedingbaby immediately vomits and baby had difficultiesin breathing. After that they bought baby atNepalgunj hospital, where she diagnosed as EA withTEF. Later they bought baby here (KCH) for furthersurgical management.

10

Contd..

History of Past Illness

No any other problems except atresia and fistula

11

Obstetric and birth history

Antenatal:

• Maternal illness during pregnancy: not significant

• Medication used during pregnancy: Iron and Albendazole

• Antenatal checkup: 4 times

• Period of gestation: Completed 40 weeks gestation.

• The mother had taken two dose of TD vaccine.

12

Contd..

Natal:

• Place of delivery: PHC delivery

• Type of delivery: Normal delivery with tear

• Condition of baby at birth: Immediately cried soon after birth.

• Birth weight : 2300gm

Postnatal:

• Mother had not any visible problems

• Baby is admitted in KCH

13

Contd..

Immunizations

She is 5 days aged newborn and till the date she had not immunized for BCG Vaccine due to her congenital anomaly.

Nutritional History

• Baby used to vomits immediately after each feeds

• Baby was kept in NPO

14

Contd…

Family History• Type of family: Nuclear family

• Number of family member: 2

• Any hereditary disorders in the family: No

• Any history of TB, HTN, DM or other chronic illness in the family: History of TB in the maternal family (to the grandfather) and grandfather of patient was died due to respiratory problem

15

Growth and Development

Physical development:

• Failure to gain weight as per age

• Current weight: 1830 gram

• Current height: 46cm

• Head circumference: 34 cm

• Chest circumference: 31 cm

• Abdominal girth: 33cm

16

Physical Examination

General inspection:

• General appearance: ill looking

• Nutritional status: dehydrated, reduced birth weight

Birth weight 2300gram

Present actual weight=1800gram

Expected weight 2070gram(approximately)

Nutritional Status=1.83 /2.07 * 100%

=8/11*100%

=88%

• Hygiene: poor

• Poster : well flexed

17

Contd…

Vital signs:

• Temperature: 96.9°F

• Respiration: 48/minute

• Pulse: 136/minute

Other measurements:

• Length: 46cm

• Weight: 1.83Kg

• Head circumference: 34 cm

• Chest circumference: 31 cm

18

Summary of physical examination

A referred case of Baby of Sarmila Rana

admitted at Kanti Child Hospital on 2073-9-24

with diagnosis of EA with TEF. History taking

and physical examination was done on the date

of 2073-9-25. There was Excessive Salivation

dry skin and decreased skin turgor, short ness of

breathing and abdominal distension.

19

Disease Profile

Embryology

The esophagus and trachea both develop from theprimitive foregut. In a 4- to 6-week-old embryo, thecaudal part of the foregut forms a ventraldiverticulum that evolves into the trachea. Thelongitudinal tracheo-esophageal fold fuses to form aseptum that divides the foregut into a ventrallaryngo tracheal tube and a dorsal esophagus. Theposterior deviation of the tracheo esophagealseptum causes incomplete separation of theesophagus from the laryngo tracheal tube and resultsin a TEF.

20

Disease

Esophageal atresia is a serious birth defect in whichthe esophagus, the long tube that connects the mouth tothe stomach, is segmented and closed off at any point.

A tracheo-esophageal fistula is an abnormal connection(fistula) between the esophagus and the trachea.

TE fistula is a birth defect, which is an abnormality thatoccurs as a fetus is forming in its mother's uterus. When ababy with a TE fistula swallows, the liquid can passthrough the abnormal connection betweenthe esophagus and the trachea. When this happens, liquidgets into the baby's lungs.

22

Incidence

• TOF occurs in around every 3500 birth

• In KCH total 5 cases of EA with TEF with in 3 monthof period with 100% mortality.

• Male dominance

• Common in prematurity

• 34% of cases common in low birth weight (<2500gm)

• Approximately 50% of neonates with EA or TOF haveanother anomalies (cardiac 14.7-28%)

• 2% risk of recurrence is present when a sibling isaffected

• Increase in advanced maternal age

23

Etiology

Exact causes still unknown

Some believed theories

• Esophageal occlusion and failure of recanalization

• Spontaneous deviation of tracheo-esophageLseptum

• Abnormal migration of putative tracheo-esophageal septum

• Mechanical obstruction

• Teratogens – Doxorubicin, Methimazole24

Some believed theories

• HOX D group of genes

• Maternal alcohol and smoking

• Exogenous sex hormones

• Prolonged mechanical ventilation or

tracheotomy

• Maternal polyhydraminous

• 1st trimester exposure to DM

25

Classifications

In 1929 E.C Vogt, a radiologist classified theanomaly anatomically

Type 1 Absent esophagus

Type 2 EA with out TEF

Type 3 EA with Fistula

• EA with proximal TEF

• EA with distal TEF

• EA with proximal and distal TEF

Type 4 isolated TEF with intact esophagus

26

Types

Types A in this type, there is Esophageal Atresia

and proximal and distal segment are blind. There is

no communication between trachea and esophagus.

This type is present in 3-7% of total cases

Types B in this type, Esophageal Atresia is present

and the blind proximal segment of esophagus

connects trachea by a fistula. The distal end of

esophagus is blind. This type is present in 0.8% of

cases

28

Types

Type C in this type, Esophagus Atresia I present.The proximal end of esophagus is a blind pouch anddistal segment of esophagus is connected by fistulato trachea. This is the commonest type, and presentin about 87% of cases.(case study patient alsodiagnosed with type C EA with TEF after surgicalprocedure)

Type D it is the rarest type that occurs in 0.7%cases. In this type, both upper and lower segment ofesophagus communicate with trachea

29

Contd..

Type E in this type, esophagus and trachea are

normal and completely formed but are connected

by a fistula. This type is also known as” H’ type

and is present in 4.2% cases

30

Contd..

32

Contd..

33

Clinical Manifestation

IN Book

1. Violent response occurson feeding (3 C)

• Infant coughs and chokes

• Fluid returns through noseand mouth

• Cyanosis occur

• The infants struggles

2. Excessive secretionscoming out of nose andconstant drooling of saliva

In Patient

3 ‘C’

• Cough and chokesfrequently

• Cyanosis after feeding

• Difficulty in breathing

• Continuous secretioncoming out from mouthand nose

34

Clinical Manifestation

In book

3. Frothy saliva

4. Abdominal distension occurs inpresence of type III, IV and Vfistula

5. Intermittent unexplainedcyanosis and laryngospasmscaused by aspiration ofaccumulated saliva in blindesophagus pouch

6. Pneumonia may occur due tooverflow of

7. Milk and saliva fromesophagus through fistula into thelungs

In patient

• Frothy saliva was present

• Abdominal distension

• Intermittent cyanosis

• Not seen before surgery (signsof pneumonia seen after 3 daysof surgery)

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Association of co –complication

• Cardiovascular 35%

• Genitourinary 24%

• Gastrointestinal 24%

• Neurologic 12%

• Musculoskeletal 20%

36

Association of co –complication

Structural Association

• VACTRAL association (20%

• Vertebral 17%

• Anal 12%

• Cardiac 20% (in patient- Echo report (10/11 shows tiny ASD )

• Renal 16%

• Limb 5%

37

Contd..

CHARGE association

• Coloboma

• Heart defect

• Atresia choanae

• Developmental Retardation

• Genital hypoplasia ear deformity

Schisis association (Omphalocele, NTD, cleft lip and palate and genital hypoplasia)

38

Contd..

Syndrome Association• DiGeorge Sequence• Polysplenia sequence• Holt-Oram Syndrome• Peirre Robin Sequence• Feingold Syndrome• Fanconi Syndrome• Townes-Brock Syndrome• Bartsocas- papas Syndrome• McKusic -Kaufman Syndrome

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Diagnosis

In book

History taking

• History of continuousdrooling

• Cyanosis

• Vomiting after each feeding

• Repeated cough


• Nasal flaring and grunting

• (Coughing, choking andcyanosis= ‘C’)

In patient

History taking

• History of continuous

drooling

• Cyanosis


• Repeated cough


• Abdominal distension (after

24 hour of birth)

40

Diagnosis Contd….

In book Clinical examination

• NG tube insertion

Inability to pass a NG tube intostomach because it meetsresistance

Laboratory Studies

• CBC count

• Serum electrolyte levels

• Venous gas concentrations

• BUN and serum creatinine levels

• Blood glucose level

• Serum calcium level• ABG concentrations as necessary

In patient

• NG tube inserted only for 8

cm

• (Recorded below)

ABG not performed

41

Diagnosis Contd….

In book Radiologic examination

The EA/TEF can be suspectedprenatally if

• USG examinations- revealspolyhydraminous, absence of afluid-filled stomach, a smallabdomen, lower than expectedfetal weight, and a distendedesophageal pouch

• Fetal MRI- may be used toconfirm the presence of EA/TEF

In patient

• USG done, but there was noany evidence ofpolyhydraminous (As perhistory by mother)

• Not performed

42

Diagnosis Contd….

In book • Chest x-ray taken with radiopaque

catheter placed in esophagus to check for obstruction: standard chest x-ray shows a dilated air –filled upper esophageal pouch and can demonstrate pneumonia

• Bronchoscopy visualizes fistula between trachea and esophagus

• Abdominal ultrasound and echocardiogram to check for cardiac abnormalities

Genetic testing

• Chromosome analysis

• Microarray genomic hybridization (array GH)

In patient

• Chest x-ray – x ray shows

that partial placement of NG

tube, due to closed end

esophagus

• Bronchoscopy not

performed

• Echo done ( Tiny ASD)

Genetic testing

Not performed

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Management

In patient Medical Management

• Management to prevent furtheraspiration and pneumonitis

• Start broad spectrum antibiotic andchest physiotherapy

• A sump catheter/double lumen reploglecatheter for continuous low pressurenegative suction

• Positioning of infants to prevent reflux:upright sitting/head up or prone position

• Vit K analog should be given

• Routine ET intubation should beavoided

• Maintain / provide thermal care

• Supplemental oxygen

In book • NPO and IVF 10% dextrose

• Start broad-spectrum antibiotic

• Chest physiotherapy done while morning care of baby

• low-pressure suction

• Positioning of infants to prevent reflux: upright sitting/head up or prone position

• Vit K analog given for three day

• Maintained / provided thermal care

• Supplemental oxygen via head box at 7 lit per minute

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Surgical Management

Immediate primary repair: indications are

• No pulmonary complications

• Weight of the child >2 or 2.5kg

• No major associated congenital anomalies

• Healthy baby

• Gap between distal and proximal esophagus <2cm

Delayed surgical intervention: indications are

• Pneumonia

• Sepsis

• Congenital malformations

• Severe prematurity

• Gap > 2.5cm

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Contd..

In book • Infant born with esophageal

atresia without fistula early gastrostomy

• Kimura, Livaditis, Scharli or Foker procedures (Where esophagus is rejoined and ends of esophagus are sutured back together)

• Infants born with esophageal atresia with fistula (early gastrostomy) Then portion of esophagus containing fistula is removed

In patient

• After correction of

hydration level and

obtaining normal value of

sodium and potassium level,

Surgery is planed and

performed on 2073-09-27

Right Thoracotomy with

Fistula repair with End to

end anastomosis

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Operative procedure

• Anesthesia- GA and Caudal (Propofol 5mg + 0.5% Bupivacaine and haloperidol as maintenance)

• Right poster lateral thoracotomy through 4th intercostal space

• Proximal oesophageal pouch is mobilised after ligating vena azygous

• Fistula with trachea is identified and tracheal end of fistula is closed.

• End to end anastomosis of distal and proximal oesophagus is done by single layer of 4/0 synthetic sutures

• Sterile feeding tube of size 8 fr is left in stomach, passed through nose.

• Chest is closed with chest tube drain

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Pharmacological management

• Inj. 1/5 NS+5% dextrose 800ml over 24 hours

• Inj Meropenim 130mg

• Inj. Eldervit 1 amp in I pint &

• KCL 5cc in next pint

• Inj Vik K

• Inj. Metron 75 mg TDS

• Inj, Aciloc 10mg IV BD

• Inj. Pethidine 8 mg TDS

• Syrup Azithro 100mg

• Ing Albumin

• Ing Astamine

48

Nursing Management

• Respiratory assessment

• Airway management

• Thermoregulations

• Fluid and electrolyte management

• Potential nutritional support

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Complications

• Tracheomalacia

• Anastomotic leak

• Strictures

• Dysphagia

• Respiratory distress

• Gastro-esophageal reflux

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Prognosis

Waterston’s prognostic classification

Group birth weight pulmonary congenital survival

Status anomalies

A >2500g No pneumonia no anomalies 100%

B 1800-2500g moderate Moderate 85%

C <1800gm severe severe 65%

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Prognosis

Spitz Classification

Group Features Survival

I Birth wt>1500g,no major cardiac disease 97%

II Birth wt <1500g, or major cardiac disease 59%

III Birth wt <1500g, and major cardiac disease 22%

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FLORENCE NIGHTINGALE’S ENVIRONMENTAL MODEL

Nightingale’s grand theory focused on the

environment. Environment is the surrounding

matters that influence or modify a course of

development; the system must interact and adjust

to its environment.

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Contd..

The environment is viewed as all the external conditions andinfluences that affect the life and death and development oforganisms. Environment is capable of preventing, suppressingor contributing to disease, accidents or death. She identifiedventilation and warmth, light, noise, variety, bed and bedding,cleanliness of rooms and walls, and nutrition as major areas ofthe environment the nurse can control. When one or moreaspects of the environment are out of balance, the clients mustuse increased energy to canter the environmental stress. Thesestress drawn the client of energy needed for healing. Theseaspects of the physical environment is also influenced by thesocial and psychological environment of the individual.

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Contd..

Selected patient B/o Sarmila Rana 19 days old

and is the case of EA with TEF. Baby was

operated and had many invasive procedure like

I/V canulation ,Catheterization, etc. If the

environment is not suitable infection and other

complication will develop and it affects on

baby’s progress, so the environmental theory of

Florence Nightingale seems more applicable for

caring the patient.

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Contd..

Physical environment:

• Cleanliness – From the day I started to care of

selected patient, I kept her clean and visitors

are encouraged to maintain the hygiene

themselves and allow minimal handling to

patient. When baby was admitted in SICU,

strict aseptic technique was followed in care of

wound.

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Contd…

Bed and bedding – Bedding is an important part

of the environment. Dirty and soiled linen

contains large quantities of organic matter and

provided ready source of infection. This organic

matter enters the sheets and stays there unless the

bedding is changed and aired frequently. I kept

the bedding neat and clean and dry by managing

the soiled linen properly.

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Contd…

Ventilation and warming – A steady supply offresh air was the most important principles sonursing. The temperature of the room should bealso maintained. The patient should not be toowarm and too cold. Baby was kept warm underwarmer and changed Napkin when it was soiledin order to prevent from heat loss. Temperaturewas monitored every 2 hourly. Mother wascounseled to keep baby under sunlight aftershifting to surgical ward.

58

Contd…

Noise – Noise is another environmental element. Itry to keep the noise at minimal level by limiting thenumber of visitors in the room. As the baby needsadequate rest , I didn’t wake her while he issleeping.

Nutrition and taking food – Baby was kept Nilorally before operation and many days afteroperation, so Parenteral fluids was given withappropriate dose, and after few days of operationsupervised breast feeding was done

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Contd…

Psychological environment:

The effect of mind and body is inter-related. Tokeep parents psychologically well, all proceduresperformed on baby is well explained. I engaged ontalking and expressing ideas, feelings. I helpedparents to understand about disease condition,treatment procedure, diagnosis and treatmentprocedure and prognosis as well as during caring ofbaby I talked with baby and in ward minimal musicas also provided.

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Contd…

Social environment:

Another important factor is the person’s socialenvironment in which she lived. The hospital shouldbe well managed, i.e. organized, clean and withappropriate supplies show client and environment inbalance and expending unnecessary energy beingstressed by environment. The patient’s totalenvironment includes her family and communitywhere he comes from. So, I recognized her as asocially valuable person. I allowed relatives andvisitors during visiting hours.

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Nursing Process applied during patient care

• Assessment

• Nursing Diagnosis

• Expected outcome

• Planning/ Intervention

62

Contd….

Nursing Assessment

Obtain parents' history, especially on birth and physical assessment

• Cyanosis


• Repeated cough



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Nursing Diagnoses

Preoperative

• Risk for aspiration of saliva related to closed congenitalanatomical structure as evidenced by frequent coughing

• Ineffective airway clearance related present congenitalanomalies as evidence by nasal flaring

• Fluid volume deficit related to inability to take oral fluids(Breast milk) as evidence by NPO status and structuralanomaly

• Imbalanced Nutrition: Less Than Body Requirementsrelated to Nil per oral status for long period of time

• Fear and anxiety of the mothers and visitors related tocritical situation of neonate, as evidence by mothers looksanxious and continue crying

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Diagnoses Contd….

Postoperative

• Acute pain related to surgical procedures as evidence by child is continuously crying

• Pain related to secondary suture as evidence by frequent crying of patient.

• Ineffective airway clearance related to surgical intervention

• Risk for infection related to long term hospital stay as evidence 1010 F body temperature

• Risk for aspiration of breast milk related to improper mother breast feeding technique as evidence bybaby continue cough during feeing time

• Imbalanced nutrition less than body requirement related to NPO status

• Impaired tissues integrity related to long term bed ridden as evidence by dry and reddish skin belowscapula

• Fear and anxiety of the parents related to critical situation of neonate, as evidence by mothers looksanxious and asking repeatedly regarding outcome surgery

• Knowledge deficit related to home base care as evidence by mothers asking so many questionrepeatedly regarding post management of disease and complication

• Risk for delayed growth and development related to prolonged hospitalization, medications anddeprived sufficient breast milk.

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Progress note

On first in emergency (2073-09-25):

• Patient admitted in emergency department of KCH, due tounavailability of bed at SICU patient surgery was kept inwaiting list

• History taken from mother and grandmother

• Vitals are recorded.

• Physical examination done

• I/V antibiotic given

• Baby is in NPO status with IV fluid 1/5NS

• counseling was done regarding the disease & its prognosis.

• The parents were told about the operation procedure also.

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1st SICU admission day (2073-09-26):

• The child was admitted in SICU after available of bed

• Patient general condition looks ill and weak

• Patient looks dehydrated

• Plan for OT on (9-27)

• All consent was taken

• Mother and relatives was informed about risk and benefits of disease treatment and possible complications.

• All the investigation report was collected and attached to the file.

• Vitals taken and recorded

• Patient kept on NPO

• Suctioned frequently

• Maintained position (lateral or prone) to prevent aspiration

67

Operation day (2073-09-27):

• The baby was stable T - 98.40F, HR-128/min, Resp. - 32/min.

• Morning care was provided• Pre-operative preparation was done• Patient transferred to OT• Observed operative procedure• Received again at SICU at 3.05pm• Post operative pain management was

done by providing injection Pathedine1.5mg IV

• I/V Antibiotic given• NPO continue

Contd..

• First postoperative day (2073-09-28)

• Vital signs are taken & recorded.

• NPO continue• NG continue• I/V fluid continues with with

KCL and Injection Eldervit• Injection Astamine 15ml IV OD

for 5day and 10ml iv injection albumin for 3 day added and given

• Antibiotic continue• Stool passed

2nd postoperative day (2073-09-29):• I/V fluid continue• Antibiotic continue• Stopped injection Vit K• NG continue • Vitals are taken & recorded i.e.

T - 97.40F, HR- 128/min, Resp. – 30/min.

• NPO continue • Urine and stool passed • Soakage from operation site so

dressing was changed

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Contd..

3rd postoperative day (2073-09-30):• The baby’s vitals were stable i.e. T

- 98.40F, HR- 128/min, Resp. -32/min.

• I/V fluid continue • NG feeding started with 5ml 10%

dextrose• Antibiotic continue and injection

Albumin stopped• Feeding tolerated by the baby.• Chest x-ray done (signs of

pneumonia seen)• Urine and stool passed. • Planning for dressing tomorrow

and ingestion of Methylene blue for confirmation of leakage

4th postoperative day (2073-10-01):• The baby’s vitals were stable. T -

98.40F, HR- 114/min, Resp. -36/min.

• Antibiotic and IV fluid continue • NG removed and oral sips stared• Urine and stool passed. • Methylene Blue could not

ingested because chest drain was removed

• Dressing was changed, wound seems healing

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Contd..

5th postoperative day (2073-10-02)• Vital stable .i.e. T - 98.60F, HR-

108/min, Resp. - 32/min.• I/V Antibiotic continue and

stopped injection Astamine• Plan for supervised breast feeding

from evening• Nebulization with Asthalin started•

6th postoperative day (2073-10-03)• Vital stable i.e T - 98.80F, HR-

132/min, Resp. - 30/min.• Iv fluid stopped• Supervised breast feeding two

hourly started• Ordered investigation send and

report collected• Nebulization with Asthalin

continue• Report shows that platelets count

was dropped to 20,000C.mm• Plan for physician consultation

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Contd..

7th postoperative day (2073-10-4)• Patient G/C looks ill• Patient body temperature

elevated up to 102 degree• Saturation drop up to 78 %,

so Oxygen started via head box at 6 liter per minute

• Continue breastfeeding with IVF added (4ml/kg)

• Paracetamol suppository added SOS

•

8th postoperative day (2073-10-5)• Patient G/C looks ill• Vital stable i.e. T - 98.60F,

HR- 130/min, Resp. -32/min.

• Breastfeeding and IVF continue

• Saturation maintained at 6 liter oxygen, so continue

• Dressing and Iv site changed

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Contd..9th postoperative day (2073-10-6)

• Patient G/C looks ill

• Vital stable i.e. T - 97.40F, HR-144/min, Resp. - 34/min.

• Breastfeeding and IVF continue

• Saturation maintained at 6 literoxygen, so continue

• Ordered investigation send and reportcollected

• Report shows (Hb 10.7 gm%,platelets 20,000, uric acid-0.8mg%,potassium- 3.0mmol/L) so physicianconsultation done

• Physician ordered to continueMeropenum, ordered to transfuse PRP15ml/kg body weight, syrup Calvit1ml

• Plan for ECHO and repeat CBC aftertransfusion

• Urine stool passed

10th postoperative day (2073-10-7)

• Patient G/C looks ill and notimproving

• Vital i.e T - 97.40F, HR- 144/min,Resp. - 34/min

• Saturation was dropped so oxygenincreased to 8 lit

• Iv site changed

• Alternate suture removed

• Nebulization with asthalin continue

• Loose stool passed three times,increased Breast feeding

• PRP transfused at Night

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Contd..


• Patient G/C looks ill

• Drip stop

• oxygen continue via head box

• Repeat CBC count send andreport collected (Hb- 10.2gm%and platelets 28000Cmm)

• Plan for ECHO

• Oxygen and breast feedingcontinue


• Patient general condition not improving

• Vitals, T-101 P-140 R-34

• Oxygen continue

• Breast feeding continue

• Syrup Niko added TDS and SOS

• Plan for Echo

• Report of pus culture collected

• Continue inj Meropenim

• All suture out and after dressing plan for secondary suture

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Contd…

13th postoperative day

(2073-10-10)

Patient general condition

not improving

Date for Echo taken

Shifted to post operative

ward


Echo done( Tiny ASD with mild Tricuspid regurgitation)

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Plan of discharge teaching

• Immunization

• Chest physiotherapy

• Feeding and nutrition

• Care of wound

• Growth and development

• Follow up

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Learning from study

• In-depth knowledge about disease, pathophysiology,signs/symptoms, treatment, and nursing management of the EA withTEF.

• Skill in physical examination and history taking.

• Policy and management of hospital to admit the patient in Surgicalward and SICU.

• Able to find out the existing problems and potential problemsthrough various assessments and plan to solve those problems.

• Total care of the patient with specific disease condition.

• Various diagnostic procedures to identify specific condition.

• Application of nursing theory to plan the care of the child

• Learnt the normal development task of the child with comparisonwith this child.

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Case study on Esophageal Atresia with Tracheo esophageal Fistula

Health & Medicine

Transcript of Case study on Esophageal Atresia with Tracheo esophageal Fistula