9.6 Hernia and Cleft Lip/Palate Flashcards
Hernia
- Protrusion of an organ through abdominal wall
- This is an issue because the portion protruding can become strangulated (not getting blood supply)
Umbilical Hernia
- Most common
- Issues of umbilical ring where bowel protrudes out
Intervention
- Is the hernia reducible? (Can you push on the area of herniation back into the patient without pain) - If yes then push it back in
- If no, then the area can be inflamed and not getting proper blood flow, which requires surgery.
Inguinal Hernia
- Hernia protrudes into scrotum
Diaphragmatic Hernia
- Abdominal contents protrude upwards through diaphragm into thoracic cavity
- Issue because it pushes on heart, lungs and airways which can lead to lung disease, GERD, and developmental delays
Cleft Lip and Palate
- Most common craniofacial malformation
Cleft Lip
- Failure of maxillary and medial nasal processes to fuse together (should be complete by 7-8 weeks gestation)
Cleft Palate
- Failure of palatal shells to fuse (normally occurs at 7-12 weeks gestation)
Cause
- Combination of genetics and environment (smoking, alcohol, steroid/drug use during pregnancy)
Cleft Lip/Palate Differences
Cleft Palate
- Involves soft/hard palate (roof of mouth)
Cleft Lip
- Unliteral (under a nostril) or Bilateral
- Degree of cleft can be from a small notch to going all the way up into the floor of the nose.
DIAGNOSIS
Cleft lip - Visual Exam
Cleft Palate - Palpate the palate
Complications
- Altered nutrition (cannot create good suction around nipple when feeding)
Management
- Multidisciplinary approach (pediatrician, plastic surgeon, speech therapist, orthodontist)
- Goal is to close the cleft
- Optimize nutrition
Feeding Techniques for Cleft Lip/Palate
Breastfeeding
- Breast conforms better to odd shape of lips (breast feeding is a lot easier than bottle feeding)
Bottle feeding
- Orthodontist may make a obturator (device fitted to the child’s defect to create a better suction on the bottle)
- Feeding through different types of nipples (such as longer nipple) or feed through a syringe.
- Hold infants cheeks together to help them get a better seal
- Speech therapy and nutrition helps determine which is the most appropriate gadget to use.
Extra notes
- Burp baby after every 15-30 mL of formula (due to swallowing air)
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Surgical Correction for Cleft Lip/Palate
Cleft Lip
- Z-plasty (sutures in a z like pattern done at 6-12 weeks of age)
Cleft Palate
- Palatoplasty
- No extra tissue to repair so it is harder to repair than a cleft lip
- Done at 12-18 months of age (done before speech develops)
Post-Op Care
- Goal is to protect the surgical site
- NEVER PLACE ON STOMACH DUE TO EXTRA PRESSURE ON SURGICAL SITE
- Put on side, back or infant seed
- Elbow restraints (no-no’s) - to prevent them from pulling on sutures
- Wound care to prevent infection
- Pain control (Tylenol or Motrin)
Post-Op Cleft Lip
- They will have logan bars or steri-strips to hold their surgical site together
- Make sure to clean suture lines with saline water
- Apply Neosporin if ordered.
Nursing Interventions
- Protect Airway
- Protect surgical site (no pacifiers, straws)
- Frequent swallowing may be a sign of bleeding
- If infant is upset (they are at risk of rupturing sutures) so keep them as calm as possible
- Infants are typically nose breathers but they will not be able to breathe through their nose due to inflammation from the surgery. (They will need to mouth breath which may cause distress)
Order of Interventions
Priority for Interventions
- Apply cool mist 24 hours
- Gently suction oropharynx and nasopharynx avoiding suture lines
- Medicate for pain as ordered
- Apply elbow immobilizers (removed every 2 hours)
- Cleanse suture line with normal saline
- Encourage parents to hold and soothe child
