Case study on Esophageal Atresia with Tracheo esophageal Fistula

1. ESOPHAGEAL ATRESIA WITH TRACHEO- ESOPHAGEAL FISTULA (EA with TEF)

Pabitra Sharma MN 2nd year CMC 1

2. Objective General objective To conduct the in depth case study by using nursing process.
Specific objectives • To collect information regarding the bio-demography and present/past
history of the case. • To obtain detail knowledge about disease condition EA/TEF including signs
and symptoms causes, medical surgical and nursing management, pharmacological and
complications. • To obtain knowledge upon various diagnostic procedures performed regarding
the disease. 2

3. 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

4. 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

5. 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

6. 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

7. 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 Treacheo Esophageal Fistula Ward: Surgical Intensive Care
Unit (SICU) 7

8. 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

9. 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
10. History of Present Illness According to mother, baby was born at PHCC after term gestation.
Baby seems normal immediately after birth and cry immediately. But after 30 minute of birth
when mother tries for feeding she observed excessive salivation from baby’s mouths and baby
turn to bluish when she feed baby. After feeding baby immediately vomits and baby had
difficulties in breathing. After that they bought baby at Nepalgunj hospital, where she diagnosed
as EA with TEF. Later they bought baby here (KCH) for further surgical management. 10

11. Contd.. History of Past Illness No any other problems except atresia and fistula 11

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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
20. Disease Profile Embryology The esophagus and trachea both develop from the primitive
foregut. In a 4- to 6-week-old embryo, the caudal part of the foregut forms a ventral diverticulum
that evolves into the trachea. The longitudinal tracheo-esophageal fold fuses to form a septum
that divides the foregut into a ventral laryngo tracheal tube and a dorsal esophagus. The posterior
deviation of the tracheo esophageal septum causes incomplete separation of the esophagus from
the laryngo tracheal tube and results in a TEF. 20

21. 21

22. Disease Esophageal atresia is a serious birth defect in which the esophagus, the long tube that
connects the mouth to the 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 that occurs as a fetus is forming in its mother's
uterus. When a baby with a TE fistula swallows, the liquid can pass through the abnormal
connection between the esophagus and the trachea. When this happens, liquid gets into the
baby's lungs. 22

23. Incidence • TOF occurs in around every 3500 birth • In KCH total 5 cases of EA with TEF
with in 3 month of 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 have another anomalies (cardiac 14.7-28%) • 2% risk of recurrence is present when a
sibling is affected • Increase in advanced maternal age 23

24. Etiology Exact causes still unknown Some believed theories • Esophageal occlusion and
failure of recanalization • Spontaneous deviation of tracheo-esophageL septum • Abnormal
migration of putative tracheo- esophageal septum • Mechanical obstruction • Teratogens –
Doxorubicin, Methimazole 24

25. 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

26. Classifications In 1929 E.C Vogt, a radiologist classified the anomaly 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

27. 27

28. 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

29. Types Type C in this type, Esophagus Atresia I present. The proximal end of esophagus is a
blind pouch and distal segment of esophagus is connected by fistula to trachea. This is the
commonest type, and present in about 87% of cases.(case study patient also diagnosed with type
C EA with TEF after surgical procedure) Type D it is the rarest type that occurs in 0.7% cases. In
this type, both upper and lower segment of esophagus communicate with trachea 29

30. 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

31. 31

32. Contd.. 32

33. Contd.. 33

34. Clinical Manifestation IN Book 1. Violent response occurs on feeding (3 C) • Infant coughs
and chokes • Fluid returns through nose and mouth • Cyanosis occur • The infants struggles 2.
Excessive secretions coming out of nose and constant drooling of saliva In Patient 3 ‘C’ • Cough
and chokes frequently • Cyanosis after feeding • Difficulty in breathing • Continuous secretion
coming out from mouth and nose 34

35. Clinical Manifestation In book 3. Frothy saliva 4. Abdominal distension occurs in presence
of type III, IV and V fistula 5. Intermittent unexplained cyanosis and laryngospasms caused by
aspiration of accumulated saliva in blind esophagus pouch 6. Pneumonia may occur due to
overflow of 7. Milk and saliva from esophagus through fistula into the lungs In patient • Frothy
saliva was present • Abdominal distension • Intermittent cyanosis • Not seen before surgery
(signs of pneumonia seen after 3 days of surgery) 35

36. Association of co –complication • Cardiovascular 35% • Genitourinary 24% •

Gastrointestinal 24% • Neurologic 12% • Musculoskeletal 20% 36

37. 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

38. 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

39. 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 39
40. Diagnosis In book History taking • History of continuous drooling • Cyanosis • Vomiting
after each feeding • Repeated cough • Abdominal distension • Nasal flaring and grunting •
(Coughing, choking and cyanosis= ‘C’) In patient History taking • History of continuous
drooling • Cyanosis • Vomiting after each feeding • Repeated cough • Nasal flaring and grunting
• Abdominal distension (after 24 hour of birth) 40

41. Diagnosis Contd…. In book Clinical examination • NG tube insertion Inability to pass a NG
tube into stomach because it meets resistance 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

42. Diagnosis Contd…. In book Radiologic examination The EA/TEF can be suspected
prenatally if • USG examinations- reveals polyhydraminous, absence of a fluid-filled stomach, a
small abdomen, lower than expected fetal weight, and a distended esophageal pouch • Fetal
MRI- may be used to confirm the presence of EA/TEF In patient • USG done, but there was no
any evidence of polyhydraminous (As per history by mother) • Not performed 42

43. 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 43

44. Management In patient Medical Management • Management to prevent further aspiration and
pneumonitis • Start broad spectrum antibiotic and chest physiotherapy • A sump catheter/double
lumen replogle catheter for continuous low pressure negative suction • Positioning of infants to
prevent reflux: upright sitting/head up or prone position • Vit K analog should be given • Routine
ET intubation should be avoided • 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 44

45. 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 45
46. 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 46

47. 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 47

48. 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

49. Nursing Management • Respiratory assessment • Airway management • Thermoregulations •

Fluid and electrolyte management • Potential nutritional support 49

50. Complications • Tracheomalacia • Anastomotic leak • Strictures • Dysphagia • Respiratory

distress • Gastro-esophageal reflux 50

51. 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% 51

52. 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% 52

53. 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. 53

54. Contd.. The environment is viewed as all the external conditions and influences that affect
the life and death and development of organisms. Environment is capable of preventing,
suppressing or contributing to disease, accidents or death. She identified ventilation and warmth,
light, noise, variety, bed and bedding, cleanliness of rooms and walls, and nutrition as major
areas of the environment the nurse can control. When one or more aspects of the environment are
out of balance, the clients must use increased energy to canter the environmental stress. These
stress drawn the client of energy needed for healing. These aspects of the physical environment
is also influenced by the social and psychological environment of the individual. 54

55. 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. 55

56. 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. 56

57. 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. 57

58. Contd… Ventilation and warming – A steady supply of fresh air was the most important
principles so nursing. The temperature of the room should be also maintained. The patient should
not be too warm and too cold. Baby was kept warm under warmer and changed Napkin when it
was soiled in order to prevent from heat loss. Temperature was monitored every 2 hourly.
Mother was counseled to keep baby under sunlight after shifting to surgical ward. 58

59. Contd… Noise – Noise is another environmental element. I try to keep the noise at minimal
level by limiting the number of visitors in the room. As the baby needs adequate rest , I didn’t
wake her while he is sleeping. Nutrition and taking food – Baby was kept Nil orally before
operation and many days after operation, so Parenteral fluids was given with appropriate dose,
and after few days of operation supervised breast feeding was done 59

60. Contd… Psychological environment: The effect of mind and body is inter-related. To keep
parents psychologically well, all procedures performed on baby is well explained. I engaged on
talking and expressing ideas, feelings. I helped parents to understand about disease condition,
treatment procedure, diagnosis and treatment procedure and prognosis as well as during caring of
baby I talked with baby and in ward minimal music as also provided. 60

61. Contd… Social environment: Another important factor is the person’s social environment in
which she lived. The hospital should be well managed, i.e. organized, clean and with appropriate
supplies show client and environment in balance and expending unnecessary energy being
stressed by environment. The patient’s total environment includes her family and community
where he comes from. So, I recognized her as a socially valuable person. I allowed relatives and
visitors during visiting hours. 61

62. Nursing Process applied during patient care • Assessment • Nursing Diagnosis • Expected
outcome • Planning/ Intervention 62

63. Contd…. Nursing Assessment Obtain parents' history, especially on birth and physical
assessment • Cyanosis • Vomiting after each feeding • Repeated cough • Abdominal distension •
Nasal flaring and grunting 63

64. Nursing Diagnoses Preoperative • Risk for aspiration of saliva related to closed congenital
anatomical structure as evidenced by frequent coughing • Ineffective airway clearance related
present congenital anomalies as evidence by nasal flaring • Fluid volume deficit related to
inability to take oral fluids (Breast milk) as evidence by NPO status and structural anomaly •
Imbalanced Nutrition: Less Than Body Requirements related to Nil per oral status for long
period of time • Fear and anxiety of the mothers and visitors related to critical situation of
neonate, as evidence by mothers looks anxious and continue crying 64

65. 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 by baby 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
below scapula • Fear and anxiety of the parents related to critical situation of neonate, as
evidence by mothers looks anxious and asking repeatedly regarding outcome surgery •
Knowledge deficit related to home base care as evidence by mothers asking so many question
repeatedly regarding post management of disease and complication • Risk for delayed growth
and development related to prolonged hospitalization, medications and deprived sufficient breast
milk. 65

66. Progress note On first in emergency (2073-09-25): • Patient admitted in emergency

department of KCH, due to unavailability of bed at SICU patient surgery was kept in waiting 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.
66

67. 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 Pathedine 1.5mg IV • I/V Antibiotic given • NPO continue

68. 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 68

69. 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 69

70. 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 70

71. 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 71

72. 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 liter oxygen, so continue • Ordered investigation send and report collected • Report shows
(Hb 10.7 gm%, platelets 20,000, uric acid-0.8mg%, potassium- 3.0mmol/L) so physician
consultation done • Physician ordered to continue Meropenum, ordered to transfuse PRP
15ml/kg body weight, syrup Calvit 1ml • Plan for ECHO and repeat CBC after transfusion •
Urine stool passed 10th postoperative day (2073-10-7) • Patient G/C looks ill and not improving
• Vital i.e T - 97.40F, HR- 144/min, Resp. - 34/min • Saturation was dropped so oxygen
increased 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 72

73. Contd.. 11th postoperative day (2073-10-8) • Patient G/C looks ill • Drip stop • oxygen
continue via head box • Repeat CBC count send and report collected (Hb- 10.2gm% and platelets
28000Cmm) • Plan for ECHO • Oxygen and breast feeding continue 12th postoperative day
(2073-10-9) • 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 73

74. Contd… 13th postoperative day (2073-10-10) Patient general condition not improving Date
for Echo taken Shifted to post operative ward 14th postoperative day (2073-10-11) Echo done(
Tiny ASD with mild Tricuspid regurgitation) 74

75. Plan of discharge teaching • Immunization • Chest physiotherapy • Feeding and nutrition •
Care of wound • Growth and development • Follow up 75

76. Learning from study • In-depth knowledge about disease, pathophysiology, signs/symptoms,
treatment, and nursing management of the EA with TEF. • Skill in physical examination and
history taking. • Policy and management of hospital to admit the patient in Surgical ward and
SICU. • Able to find out the existing problems and potential problems through 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
comparison with this child. 76

77. 77

1.