Chapter 23: Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) Flashcards
Esophageal Atresia (EA)
the failure of the esophagus to develop a continuous passage (no connection of trachea and esophagus)
- characterized by the presence of blind pouch
- the proximal and/ or distal portions of the esophagus may or may not be connected to the trachea by a fistula (TEF)
- EA without a fistula occurs about 10% of the time
Tracheoesophageal Fistula (TEF)
creates an abnormal communication between the trachea and the esophagus
-anomalies are caused by defective separation, incomplete fusion, or failure of the structure to hollow out
>when a fistula is present, it is between distal esophagus and the airway 85% of the time
-TEF often associated with other anomalies, which may involve the kidneys, heart, limbs, or spine
-commonly associated with polyhydramnios (the presence of excess amniotic fluid in the amniotic sac) that is r/t the presence of a gastrointestinal obstruction
-occurs during fetal development when the tracheoesophageal groove fails to close, resulting in incomplete separation of the trachea and esophagus
Signs + Symtoms
-excessive drooling and secretions
-frothing and bubbling of the mouth and nose
-cyanosis
-respiratory distress
-choking with attempted feeding
-inability to pass orogastric tub into the stomach
>clinical symptoms may intensify with feeding leading to regurgitation, choking, and aspiration
-in cases of isolated TEF, symptoms may occur later in life with the child having chronic respiratory problems and abdominal distention b/c of air building up in the stomach
>b/c EA and TEF have been associated with other congenital anomalies that occur in the musculoskeletal, GI, cardiac, and GU systems, a thorough assessment by nurse is necessary
Diagnosis
-prenatal sonogram
-if not diagnosed with prenatal sonogram, diagnosed soon after birth or during infancy b/c TEF is life-threatening
-confirmed by observing an early onset of respiratory distress accompanied by S/S, as well as inability to pass a nasogastric or orogastric tube
-confirmatory diagnosis made through radiography
>Barium should not be used b/c the risk of aspiration, though a small amount of dilute water-soluble agent can be used for contrast
-chest films are taken to determine the patency of the esophagus or the presence and level of the blind pouch
Focus on Safety: Checking the Mother’s Obstetric Hx
when the nurse is caring for a newborn and observes the baby to be drooling excessively, and/or having persistent choking spells and color changes with feedings, it is important to check the mothers obstetric hx
-if there is a history of polyhydramnios, the nurse must report the observed symptoms to the baby’s pediatrician; these symptoms are highly suspicious of EA and TEF
Nursing Diagnoses for EA with or without TEF
- ineffective airway clearance r/t excessive secretions
- altered nutrition: less than body requirement r/t inadequate ingestion of nutrients
- high risk for infection r/t accumulation of secretion in the lungs
- altered family processes r/t frequent hospitalizations/prolonged sickness
- impaired family social interaction r/t situational crisis
- high risk of aspiration r/t excessive drooling and poor swallowing and inability to clear secretions
Prevention
- may not be prevented
- good prenatal care provides an opportunity to promote optimal prenatal development
Nursing Assessment: a child diagnosed with EA or TEF
the nurse watches for subtle changes in the child’s color, respiration, behavior, heart rate, and general health
- subtle change often occur before technology is able to recognize these changes; essential to have emergency equipment ready at the bedside; child has uncanny ability to compensate
- when the child is no longer able to compensate, the child “crashes” and then may then have a poor probability of recovery
Nursing Care
-immediately after birth, treatment is aimed at maintaining a patent airway and preventing aspiration of secretions
>although EA and TEF are surgical emergencies, discretion is used about performing immediate surgical corrections
-highly compromised neonates, such as those who are premature, those with concurrent congenital anomalies, and those who are poor physical condition, should not be operated on immediately
Surgical Care
after life-sustaining measures are given, surgical corrections may come in stages that may be palliative in nature (e.g. gastrostomy and drainage of esophageal pouch)
-goal of surgery is to close the fistula and attach the two sections of the esophagus
>artificial ventilation may be required in the beginning, and the child can be weaned off the artificial ventilation as the condition improves; endotracheal (ET) intubation is often avoided because it may worsen abdominal distention b/c of the connection between the trachea and esophagus
Before Surgical Correction
- neonate is not given oral feedings, but IV (parenteral) fluids instead
- positions neonate at 30 to 45 degree elevation of the head to protect the trachea from secretions, and the head is turned to the side to prevent aspiration and drain secretions
- suctioning is done regularly and at frequent intervals
- a nasogastric or orogastric tube with continuous, low suctioning is likely to be placed by the health-care provider into the blind pouch and monitored for patency; tube should not be irrigated b/c this may cause aspiration; hydration and fluid and electrolyte balance is monitored
- often antibiotic therapy is started b/c aspiration pneumonia is inevitable
Immediately After Surgical Correction
- must monitor vital signs at regular intervals
- site requiring correction is usually the thoracic cavity, so the nurse expects the baby to return with a chest tube and possibly still intubated with a ET tube; infants with chest tubes are carefully handled to avoid dislodging of the tube
- suctioning of the oropharyngeal area is kept to a minimum to avoid disruption of the surgical repair
Postopratively
- vigilant assessments on all body systems to detect any complications or new problems
- b/c the child may have low blood counts and a decrease in fluid volume, the nurse must regulate plasma or blood transfusion and the IV infusions adequately
- to maintain adequate nutrition, gavage feeding may be initiated by the 2nd or 3rd postoperative day; gavage feedings administered slowly while watching for any untoward manifestations, such as aspiration
- requires prolonged hospitalization, so the family must be informed about the lengthy hospital stay and the myriad of ongoing treatments
- after recovered, child may be discharged to parents; emphasize need for follow-up visits to ensure no complications or problems present
Chest Tubes
removal of air, fluid, or blood from the pleural, pericardial, or mediastinal spaces may be facilitated by the placement of chest tubes
-purpose of closed chest suction is to remove air and fluid from the thoracic cavity and to improve postoperative lung re-expansion, as well as to treat pneumothorax
-chest tube connected to a closed drainage system
-the closed drainage system consists of an underwater seal, a collection chamber, and suction chamber in a single unit, which is connected to sterile tubing and a suction device
-suction is applied as prescribed by the primary care provider; ordered at -15 to -20 cm H20
>to function properly, the chest drainage system needs to be placed a minimum of 1 foot (30 cm) below the level of the lungs
Nursing Considerations for a Chest Tube
-explain procedure to child and parents
-note character, consistency, and amount of drainage in the collection chamber
-note integrity of the tubing and chest tubes every 2 to 4 hours
-carefully coil the tubing and secure to the edge of the bed, avoiding pressure or kinks in the tubing
-mark drainage level according to policy
-never clamp the tube when moving or transporting the child
-encourage coughing and deep breathing according to the policy
-check rate and quality of respirations and auscultate the lungs according to policy
-instruct the child and parents to report any breathing difficulty
notify the primary care provider of changes in color, decreased oxygen saturation, rapid or shallow breathing, chest pain, or excessive bleeding
-check the chest tube dressing according to policy
-do not routinely milk or strip the chest tubes because it can cause negative pressure, which may damage lung tissue
-document observations, routine care, dressing appearance, drainage, and functioning of the chest drainage system according to policy
