long-term care for children who have ingested corrosive substances

Long-TermCare for ChildrenWho Have Ingested Corrosive

Substances Darleen Papin, R.N., B.S., M. A?

Each year, over 5000 children, most of them under 5 years old, accidentally ingest corrosive substances. In many instances, the ingestions occur because adults have placed corrosive substances in containers such as soda pop bottles, cups, and jars that are usually associated with fmd . The curious child, exploring his environment, mistakes the substance for food and ingests it. The corrosive nature of the substance and the amount ingested will ultimately determine the type of injury incurred by the child. There are three basic categories of corrosive substances that children com- monly ingest. These include acids, bases (or alkalies), and bleaches. A recent medical article advises that “strong acids such as acetic, nitric, or sulfuric produce coagulative necrosis of tissue whereas strong alkali substances such as ammonia or lye tend to produce a more severe lique- faction necrosis that may penetrate through the wall of the esophagus”

Ideally, the goal of nursing intervention is to prevent the child from ingesting any substance that will harm him; therefore, parent education and anticipatory guidance is vital for accident prevention. The nurse must stress the importance of using “Mr. Yuk” stickers on any substance that can harm the child; even a very young child can learn to recognize and

(p. 499.1

*Nursing Education Coordinator, Minneapolis Children’s Health Center and Hospital, Inc., Minneapolis, Minnesota 55404.

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56 Issues in Comprehensive Pediatric Nursing

avoid containers bearing the Mr. Yuk sticker. Parents must be cautioned to use containers with child proof caps and to never use food containers to house toxic o r corrosive substances or, for that matter, any substance that should not be ingested. If the child does accidentally ingest such substances, the parents must be taught t o take the container of corrosive substance and the child to the nearest emergency room. They must also be instructed not t o give syrup of ipecac or induce vomiting. If the child will drink it, milk or water should be given immediately. Both these liquids dilute corrosive substances. In addition, milk acts as a demulcent.

Lye, which is found in washing powder, drain cleaners, and paint re- mover, is one of the most common corrosive agents ingested by children. The remainder of this article discusses the medical and nursing management of children who have ingested lye, usually in the form of drain cleaner. The long-term effects of the ingestion are directly related to the concentration of the substance ingested, the amount ingested, the damage t o tissue, and the medical intervention given. Some common complications after ingestion are scar tissue formation in and around the mouth that may later require plastic surgery and esophageal scar tissue formation that may require colonic replacement of the esophagus.

lNITIAL HOSPITALIZATION

When the child is admitted, it is imperative that a detailed history of circumstances surrounding the ingestion be obtained. Questions to be asked include: ( 1 ) What substance was taken? (2) Who was with the child‘? ( 3 ) Who was the caretaker at the time of the ingestion? and (4) What qymptoms has the child experienced since the ingestion? Questions regarding the caretaker help the nurse to plan interventions that reduce parent or caretaker anxiety and deal with guilt resulting from the inges- t ion incident.

Most children complain of intense burning pain immediately after the ingestion of a single mouthful of a corrosive agent such as lye. They may drool, hold their throat, and have difficulty swallowing. There may be burns around the mouth, in the mouth, on the tongue, and in the pharynx. The rnucous membranes are white immediately after the ingestion, but later become more brown with considerable ulcerations and edema. The edema may impair breathing and in severe cases the child may be in h o c k o n admission. According to one pediatrics textbook, “all children with serious esophageal burns have one or more of the following symptoms: visual burns of the oral cavity, hypersalivation, retching and/or vomiting, setrocternal or epigastric pain, cardiovascular collapse and/or airway sten- CJSlS’’ (p. 807).2

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Ingestion of Corrosive Substances 57

Medical Management Initial treatment involves preventing or reversing a cardiovascular col-

lapse. Parenteral therapy is indicated to provide fluids, electrolytes, and a route for administration of medication. A broad spectrum antibiotic is usually given to prevent infection in the burn area due lo contamination by saliva. Corticosteroids are usually given to reduce the inflammation and edema as well as to keep stricture formation to a minimum. If the child is experiencing any respiratory distress due to epiglottic, pharyngeal, or laryngeal edema, a tracheostomy may be needed. The child will receive nothing by mouth until he is able to handle secretions and an esophagoscopy has been performed to assess the extent and degree of burns. Nursing Care

Care of the child during initial hospitalization involves considerable nursing assessment and intervention both for the child’s physical and psychological needs and the parents’ psychological needs. One of the primary physical goals is to maintain an adequate airway. Any signs of respiratory distress such as rapid, noisy, grunting, or labored respirations should be reported to the physician immediately. Pulse, respiratory rate, and blood pressure should be taken hourly until stable, then as deemed necessary by the primary nurse. If the child has a tracheostomy, suction and clean as often as necessary or at least every 4 hours to keep airway patent. Sterile suction catheters and technique must be used for each suctioning to prevent infection. After the child begins to take fluids continue to monitor respiratory status especially when the child is swallowing. If the child begins to experience choking, coughing, or circumoral cyanosis after taking fluids, he may have developed a tracheoesophageal fistula as a result of severe esophageal burns. In this situation, notify the physician and give the child nothing by mouth. If a tracheoesophageal fistula has occurred, the child will be given a gastrostomy for feeding purposes.

Another goal during the child’s initial hospitalization is to provide adequate nutrition. Initially the child will receive most of his fluids and nutrients through parenteral fluids. As soon as the child is able to handle his own secretions and an esophagoscopy has been performed, he may be allowed clear liquids, and his diet can be advanced as tolerated. Since many of these children are toddlers, fluids from a bottle may be more appealing than fluids from a cup. The bottle may also give the young toddler a feeling of security. Popsicles, ice chips, and sips of cold fluid such as apple juice provide mouth comfort and keep the mucous membrane moist. The child should be on accurate intake and given bland, nonirritating food and fluids. When the child’s oral intake is sufficient,

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5 8 Issues in Comprehensive Pediatric Nursing

the IV may be discontinued and the medications given orally. I t is necessary for the nurse to observe the appearance of the oral burns and edema once a shift. ‘This information should then be recorded on the child’s medical record,

Many physicians request that a string be passed through the esophagus to the stomach. This procedure can be accomplished by passing the string during the esophagoscopy or by having the child swallow a small lead bead connected to silk suture. After the string is in place the nurse must make sure it is taped securely to the child’s cheek so that he can not bite it off. In some cases, the child may require arm cuff restraints to prevent him from pulling the string out. The physician primarily uses the string ;is a guide to pass esophageal bougies during dilatation. If the lead bead becomes dislodged or the string is bitten off, the child’s stools should be observed until 1 hese items are eliminated.

Another goal of nursing care is to allay the child’s anxiety and to help hjm cope with the crisis of hospitalization. The patient, if a toddler, is too young to understand why he is in the hospital, and his admission, due to its emergency nature, denies him the time or opportunity to be pre- pared for the experience. The most common psychological trauma of the toddler is separation anxiety. The young child is often fearful of strangers, and as a result of necessary painful intrusive procedures, his sense of trust is severely altered. During the initial hospitalization the child may cope with the new situation by regressing or by displaying be- havior in terms of the three stages of separation anxiety: protest, dispair, and denial. The child may also interpret his hospitalization as punishment for misdeeds. Comments such as “I won’t be bad” or I’m sorry” clearly indicate that the child views his hospitalization as a punishment. fi? order to relieve the child’s distress and meet his psychological needs nursing intervention must be started at the time of admission. A primary nurse should be assigned to the child in order to provide continuity of care and to coordinate the health care team.

Parents must be encouraged to stay with their child at all times or to visit as frequently as possible. The presence of the mother prevents the child from feeling deserted in the unfamiliar hospital environment. Parents must also be encouraged to ventilate their feelings about the accidental ingestion and to establish methods to cope with their guilt. The respon- bihility of assisting parents is shared by the nurse, the hospital chaplain, and the mental health professional. Anxiety is contagious. An anxious fretful mother will transfer these feelings to the child; therefore, relieving the parents’ anxiety is necessary in order to provide optimal care to the child. Parents also need to feel they are still important to and needed by their child. Much of the care can be done by parents so the child’s experiences are similar to those at home. The child also needs play as a way of expressing his feelings and learning to cope with the hospitaliza-

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tion experience. Therapeutic play, using techniques that reflect the child’s feelings as observed during his play, may help the child cope with the ingestion experience and the procedures constituting the medical treatment. Diversionary play such as stimulating toys, books, and diverse activities provide an environment conducive to helping the child at his own level of growth and development. Parents can be encouraged to bring the child’s favorite toys from home and to play with him. Visits from siblings can also contribute to making the child’s hospitalization as positive an experience as possible. If the parent is unable to visit frequently or “room- in” with the child, a caring individual such as a volunteer or the primary nurse should spend time holding, comforting, and playing with the child.

The final nursing goal during the initial hospitalization is to provide parent education and discharge planning. Discharge planning and in- struction begin at the time of the hospital admission. From the outset, parents should be encouraged to be active participants in the care of their child. Parents must be informed of the progress their child is making and of the long-range possibility of esophageal dilatation or plastic surgery. If the child has a string, the parents must be taught the importance of making sure the string stays in place. If arm cuffs are needed to keep the child from pulling on the string, parents must be taught how to cor- rectly apply the cuffs and the importance of removing them to allow the child to play and exercise his arms under adult supervision. Parents must be reminded to observe the child at home for any difficulties in swallowing solids or fluids. If the child has a tracheostomy or gastrostomy parents should be instructed in the care involved. If the child is to be discharged on medication, the parents must learn how to administer the medication at home. If the child is taking steroids, it may be necessary to crush the tablet and mix it with a small amount of chocolate syrup or applesauce to be given with meals. If the child is taking a broad spectrum antibiotic, the parents should be reminded to administer it for the prescribed length of time, keep the liquid refrigerated, and administer it to the child 1 hour before meals or 2 hours after meals. If the child has a gastrostomy, the same principles are involved: mix steroids with fluid such as juice or milk, dilute antibiotics with water, and give 1 hour before or 2 hours after meals. A public health nurse may be able to facilitate the family’s adjustment to caring for their child at home; therefore, referral should be made before the child is discharged. It is also important to review the child’s normal growth and development with the parents in order to assist them in making the home environment as safe and stimulating as possible.

ESOPHAGEAL DILATATION

For moderate to severe esophageal burns, frequent dilatations of the esophagus are necessary to prevent stricture or to dilate areas of stric-

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ture. llilatations are done as often as deemed necessary by the physician. One regime is “dilating daily for the first week, every second day for the second week, then a twice weekly, weekly, twice monthly, monthly, then bimonthly intervals” (p. 299)3 for as long as necessary. Many children require dilatation for at least a year after the ingestion. Parents may have difficulty understanding why dilatations are necessary even when the child has no signs or symptoms of stricture. The primary nurse should impress on the parents that this follow-up is required so that severe strictures do not develop.

The dilatation procedure is performed under general anesthesia or heavy sedation. Bougies (i.e., flexible cylindrical instruments of ascending sizes) ;ire used to dilate the esophagus. Antegrade dilatation may be done through ;in esophagoscope, or retrograde dilatation may be done using a bougie guided by a string passed through a gastrostomy. Frequently a combina- tion of antegrade and retrograde dilatation is needed to dilate long strictures. The dilatation is facilitated by passing the Tucker bougie over the silk suture string that goes from the child’s mouth, down the esophagus, ;ind into the stomach. Nursing Care

Predilatation nursing care involves parent/child teaching, routine preparation for surgery, and assessment of the child’s or parents’ needs. It is especially difficult for the child and the parent to continually be admitted to the hospital when the child may be having no obvious symptoms associated with strictures. The admission may be stressful to the child in the sense that he may perceive the hospitalization as “punishment.” For the parents, the frequent admissions may serve as a constant reminder of the ingestion incident thus reviving feelings of guilt, blame, and depression. If at all possible the child should be admitted to the same unit and have the same primary nurse at each admission. The resulting continuity of care and relationship with the parents will help the nurse assess the parents’ coping skill and the interaction pattern of the family unit. If the child has been at home with a tracheostomy or gastrostomy the primary nurse must assess how the family is managing the care. The nurse should tell the family what will happen the day of surgery and then allow the child to express his feelings about this. The nurse should reassure the child that he has not been “bad” and offer simple explanations about what he will experience.

After the dilatation procedure it is imperative to observe the child for airway obstruction. The nurse should report symptoms such as noisy respirations. grunting, a markedly elevated respiratory rate, or restlessness to the physician.

The child may act as if he has a sore throat. The nurse should allow the child t o take fluids as soon as he can handle his secretions. If no comp-

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lications occur, the child is usually discharged the day after the dilatation procedure. The most common complication of esophageal dilatation is perforation of the esophagus at the area of stricture. Signs and symptoms of perforation occur within a few hours and consist of fever, tachypnea, and tachycardia. If an esophageal perforation occurs, the child will be given nothing by mouth. A gastrostomy may be done if the child does not already have one, or the child may be placed on hyperalimentation either by deep line or peripheral cannulation. If the child has a cannula (either deep line or peripheral) he must be appropriately restrained to prevent the cannula from being dislodged. Physical nursing care is the same as for any patient on hyperalimentation, but psychological care is quite different, due to the childs’ age and stage of growth and development.

If the child with an esophageal performation requires a gastrostomy , parents will need to be instructed about care at home. This care will include meticulous skin care around the stoma to prevent skin breakdown or infection. The area around the stoma should be washed with soap and water, and no dressing needs to be applied. If the skin becomes excoriated, petroleum jelly ointment or a heat lamp may promote healing. The gastrostomy tube must be firmly anchored to prevent the stoma from widen- ing and thus increasing the amount of formula or feeding oozing around the catheter. The catheter should be firmly fixed with tape or a cut nipple and silk suture. Gastrostomy feedings should be at room temperature, and the amount and caloric content should be calculated to allow for the child’s growth.

If the child must return home with a gastrostomy, or if the parents indicate difficulty managing the child in the home, a public health nurse may be needed. A public health nurse may be able to assess and facilitate return to as normal a life style as possible for the family as a unit. If the parents are experiencing difficulty within the family unit, marital conflict, or depression, a mental health professional should be asked to see them. If financial difficulties are present, a social worker should be requested to assist the family. Other useful resources include Crippled Children’s Services and Family Social Service. A support group for parents of children with chronic illness may offer additional help to the family and assist the parents in dealing with the child’s physical problems and psychological concerns.

ESOPHAGEAL REPLACEMENT

The child with esophageal strictures resistant to or too severe for dilatation might require surgery that would bypass the esophagus thus providing a new food passage connecting the cervical esophagus and the stomach. This surgery is accomplished in one or more procedures depending on the

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severity of the esophageal scar tissue formation and the preference of the surgeon.

One method of esophageal bypass uses the right half of the colon with a short segment of attached ileum. The colon segment is tunneled in a substernal extrapleural path from the abdomen to the neck. The distal colon is attached to the anterior wall of the stomach and the cervical esophagus is anastomosed to the cecum or ascending colon.

A variation of the above procedure for esophageal replacement may also be preformed. Instead of joining the cervical esophagus with the ascending colon, the cervical esophagus is brought out through the skin to form an esophagostomy, and the ascending colon is brought out through the skin to form a mucous fistula. The child who requires esophageal replacement usually already has a gastrostomy .

Preoperative Nursing Care The child admitted for esophageal replacement requires considerable

physical and psychological preparation for the surgery. The child needs to thoroughly understand what will occur in surgery and in the postoperative period in intensive care. Nurses must adapt preoperative teaching to the age of the child and his stage of growth and development. One can have the child play out his experience and draw exactly where and what will be operated upon. If the child will have more than one incision, dressing, or opening this should be explained ahead of time and the child allowed to put dressings on the appropriate places on a doll. For the older child an anatomical model can also be an effective teaching tool. The child and parents should be given a tour of the intensive care unit and, if possible, introduced to the nurse who will be caring for the child in this unit. A11 tubes and apparatus must be explained to the child. One can allow the child to try out the IPPB (intermittent positive pressure breathing) machine and practice coughing and deep breathing. If the child has a tracheostoniy, the nurse should explain that a different type of tube might be used during surgery and for the first day or so in intensive care if the child will be on the respirator. Also, explain that there will be no actual feedings for approximately 4 days after surgery, but rather the child will be fed through an IV tube in his arm. The child should see the monitor and be allowed to put electrodes on his chest and to watch the pattern thus formed. Since the child is going to be concerned about going to the bathroom after surgery, explain that he will have a small tube in his bladder that will drain into a bag. If at all possible show and allow the child to handle the bag and catheter. It is also helpful to intro- duce the child to a child with a catheter so that he can see the equipment in operation. The child should be informed that the catheter will be inserted after he i s in surgery. It is also very important to reassure

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the child that although there will be pain associated with the surgery, medication will be given to keep him comfortable. Finally, encourage the child to tell the nurse when he is having pain and emphasize activities the child can do to help himself get better and feel a little more in control of his situation.

Patients requiring esophageal replacement need a thorough bowel preparation before surgery. This includes a laxative per gastrostomy and antibiotics per gastrostomy until surgery to destroy intestinal bacteria. The night before surgery and the morning of surgery the child will have normal saline enemas until clear. The enema procedure needs to be thoroughly explained to the child, and appropriate privacy should be provided. For 24 hours preoperatively the child is given clear liquids only by gastrostomy.

Another aspect of preoperative care includes relieving anxiety the child may have about the surgery. Children of various ages have specific fears related to their stage of growth and development. This is, for the toddler, a fear of separation or abandonment and for the child 18 months to 3 years, the fantasy that he is being punished for misdeeds. The child 3 to 6 years old fantasizes that he will have lasting damage because of forbid- den wishes. The 6 to 1 1-year-old child fears a loss of control, and the 12 to 16 year old has a fear of being crazy. The fantasies of the child must be addressed by the primary nurse or a mental health professional.

In addition’ to fears related to growth and development, some children fear they will die in surgery. It is important to encourage the child to ventilate these feelings. Parents also may be extremely fearful about the surgery. In addition to the primary nurse supporting the family, a mental health professional and the hospital chaplain may be able to offer additional counseling. The chaplain, mental health professional, or primary nurse should keep in contact with the parents during the child’s surgery to keep them informed and to offer support.

Postoperative Nursing Care Immediately after surgery the child will be in intensive care. Parents

need to be able to see the child as soon as possible after he arrives in the unit. The nurses from the intensive care unit need to be available to give the parents information about the various items of equipment surrounding the child, and the primary nurse must be able to support the parents when they see the child for the first time. No matter how much preparation the parents have, it is shocking for them to see their child with tubes, wires, and monitors. Parents need to be encouraged to visit the child and participate in the child’s care. Holding a hand, stroking the brow, or just sitting by the bed can greatly relieve a child’s anxiety and gives the parents the feeling they have not deserted their child. Frequent reinforcement of parental efforts is necessary in order to assure them of how important

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64 issues in Comprehensive Pediatric Nursing

their presence is t o the child. This also encourages their involvement in the care of their child. Parents should be shown specific care techniques and comfort measures such as back rubs, mouth care, and skin care.

Maintenance of lung function is of paramount importance to the child after replacement surgery. The child will have chest tubes t o prevent fluid retention in the chest cavity, t o keep the lungs fully expanded, and to remove any fluid from the chest that might be present due to a leak at the site of anastomosis. The child with a tracheostomy will have a cuffed tra- ciieostomy tube and will be on a respirator.Thechi1d without a tracheostomy may be on a respirator with an endotracheal tube. IPPB treatments will he done every 4 hours. The child will be turned every 2 hours. After the child IS off thc respirator he will turn, cough, and deep breathe every 2 hours and have IPPB treatments every 4 hours. For comfort the child may have the head of the bed elevated 15 to 20 degrees. This elevation also helps pool secretions at the tip of the catheter in the back of the throat to facilitate removal.

I t 1s also necessary to maintain the patient’s nutrition. For approximately 4 days the child will receive nutrition via the intravenous route. The child will need a maintenance IV with electrolytes and potassium chio- t-idc. Gastrostomy drainage will be replaced with a 5 percent dextrose solution in .33 to .45 percent normal saline containing potassium chlo- ride.

The child having the two-stage surgery will have a nasal tube to the back of the throat connected to intermittent suction. The gastrostomy will also he connected to intermittent suction for 4 days until bowel sounds are apparent, and in order that the stomach stays decompressed t o prevent strain on the suture line. The gastrostomy tube will be irrigated every 1 to 2 hours with normal saline t o ensure the patency of the tube.

Oral hygiene will be necessary in the immediate postoperative period. Many of the children who have ingested lye or other corrosive substances have had severe burns and scar tissue formation in the mouth necessitat- ing dental appliances. These appliances should be replaced as soon as possible after surgery. Swabbing with glycerine/lemon or allowing the child to rinsc with mouthwash solution can promote oral comfort for the child. The child may also brush his teeth with or without toothpaste followed hy ;i thorough rinsing of the mouth to maintain dental hygiene.

Another postoperative goal is to assess the condition of the graft and prevent infection. Complications that are common after esophageal replacement surgery include infection in the anastomosis sites, wound infection, and necrosis of the colon graft. In order to assess whether necrosis is occurring the nurse must observe the child for signs or symptoms of sepsis Broad spectrum antibiotics will be given intravenously as a propliy- lactic measure to prevent infection. The nurse should note the drainage

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and appearance of the esophagostomy stoma and the mucous fistula to assess if any infection is developing.

Pain relief is necessary after such extensive surgery. Morphine (adminis- tered intravenously) should be given freely so the child will not suffer unnecessarily. Keeping the child comfortable will also help relieve anxiety. Having the pain relieved allows the child to utilize his energies to move more freely and be more cooperative with lung care. The child should be allowed to exert as much control over his situation as possible. He should also be permitted to make some choices regarding his care. This approach helps maintain the child’s independence and usually results in the child retaining a feeling of self-control.

Four or five days postoperatively the gastrostomy is connected to straight drainage for a day and then elevated 4 to 6 inches above the abdomen for a day. After these procedures have been completed, gastrostomy feedings are resumed. The first gastrostomy feeding will be continuous Pedialyte drip. The amount will depend on the age and weight of the child. If it is tolerated, the drip will be increased, and the content pro- gressed to full liquid, then a blended soft diet. When the child is able to tolerate enough by gastrostomy to meet nutritional demands, the IV may be discontinued, and the antibiotics given by gastrostomy.

When the nasal tube is removed from the back of the throat, the child may have more drainage of saliva from the esophagostomy. It is imperative to change the dressing frequently and note the condition of the skin. The dressing over the mucous fistula will also need to be changed often enough to prevent irritation of the skin and infection. The area around the gastrostomy stoma requires meticulous care to prevent skin irritation and ex- coriation. Stoma care will need to be continued during the hospitalization and at home until the second stage is performed. Nurses should describe drainage from the gastrostomy, esophagostomy , and mucous fistula on the medical record.

When the child’s condition is stable, and he no longer requires intensive care, he can be returned to the general pediatric unit to continue his re- cuperation. Vital signs should be taken every 4 hours. Gastrostomy feeding may be given 4 times a day with snacks in between. Since the child has had a gastrostomy previously, he will have definite ideas about what feedings or snacks he wants. Allow him to make these choices. The child may have milk or soda by gastrostomy if he so desires.

Activities appropriate to the child’s level of growth and development, interaction with peers, and family support can contribute to meeting the psychosocial needs of the child. Family presence continues to play an important part in helping the child cope with the hospitalization experience. During the recuperative phase, the child may become depressed regarding a variety of thmgs such as the appearance of his incision, the esophagos-

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tomy, and being away from home. Intervention by the primary nurse can help both the child and parents deal with the child’s feelings. Siblings may also need to be involved with the child. They may have many questions regarding their brother or sister and may be frightened at the sight of the esophagostomy.

The most prevalent complication of the grafted colon is breakdown at the site of anastomosis. If this occurs, the child must have surgery to remove the necrotic graft. This can be physically difficult for the child as well as psychologically devastating. Emotionally the child is forced to cope with two major surgeries within a short period of time knowing full well that within another 6 months to a year the procedure will undoubt- edly be performed again. If the surgery does need to be repeated, the left side o f the colon can be used.

Discharge planning is necessary to prepare the parents for the care of their child at home. Although the parents have been doing gastrostomy feedings at home already, review of gastrostomy care as well as the child’s nutrition requirements should be given. Parents also need to be taught how to care for the esophagostomy at home. The dressing covering the esophagostomy should be changed as often as necessary to prevent ex- coriation, irritation, or infection of the stoma or surrounding skin. Parents must observe skin condition carefully and should report any signs of in- tection to the physician. The dressing over the mucous fistula is also changed as necessary to maintain skin integrity.

Approximately 3 to 6 months after the first stage surgery, the second stage can be performed. In this surgery the esophagus and upper part of the esophagostomy is closed, the mucous fistula is closed, and the esophagus and upper part of the colon graft are anastomosed to provide a work- able esophagus for the child. After surgery, the child will have a naso- gastric tube in order to keep the stomach depressed and allow the site of anastomosis to heal. The child will require frequent lung care such as coughing, deep breathing, and IPPB to maintain optimum lung function and to prevent pooling of secretions causing pneumonia. Intravenous fluids will be given until the child is able to tolerate fluids orally and per gastrostomy. Oral fluids are begun within 3 days postoperatively and are given in gradual amounts, beginning with clear liquids and progressing as tolerated by the child. When the child returns to the general pediatric area he will continue on both oral and gastrostomy feedings until he can take enough by mouth to maintain nutritional status. The child may complain of burping and a strong odor of stool to his breath for the first month. According to one pediatric textbook, “this is due to the propulsive action of the colon which will soon function with the esophagus which has a peristaltic action” (p. 652).4 Mouth care is especially important to the child during this stage. The child should brush his teeth after meals

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and be offered mouth rinses before and between meals as needed or de- sired by the child.

Discharge planning also includes dietary management and observation for stricture at the site of anastomosis. Parents should be told to observe the child for difficulty in swallowing, pronounced coughing, or inability to swallow solids. If signs of stricture occur, have the parents notify the physician as dilatation may be necessary. The gastrostomy will be left in place until the child is ingesting enough orally to maintain his nutritional status. The gastrostomy is then also available if strictures occur, and the child has difficulty with oral feedings. After the child has healed and is tolerating food and fluids orally (ie., about 6 months postoperatively), the child is readmitted for esophagoscopy to determine the status of the esophagus. If no strictures are present, the gastrostomy is closed. One difficulty of optimum postoperative recovery is maintaining the child’s nutrition at home. The child often has food preferences much like a child beginning solids for the first time. The parents and child must have con- sultations with the dietitian to discuss maintaining adequate amounts of protein and to stress the types of foods to be eaten as well as total calories. Some children, for example, refuse meats, so other foods high in protein must be substituted.

ORAL SURGERY AND DENTAL CARE

Although esophageal replacement is the most dramatic aspect of treatment, the child will often also require numerous oral surgeries and dental intervention due to scar tissue formation in the mouth. Teeth may not be able to erupt through the scar tissue on gums. In severe cases, the tongue may actually fuse to the inner aspect of the lower jaw. The gingiva may also fuse to the mucous membrane lining the cheeks and lips. If the child has had burns around the mouth itself, the lips can fuse together if left untreated.

The child may require oral surgery to remove scar tissue inhibiting the eruption of the teeth. After the teeth erupt, the child may need to be fitted with a dental splint that is used to support the teeth in the gum tissue.

If the child has burns around the mouth, plastic surgery may be required in order for him to open and close his mouth, use his lips to form speech sounds, and use his mouth for expressions such as smiling. The goal of the surgery is to provide the most normal appearance possible. Contractures due to scar tissue formation can give the child’s lower face a grotesque “monsterlike” appearance thus increasing the child’s psychological trauma.

Extensive psychological trauma may occur in the child with long-term

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effects of ingestion. The child should be helped to live with stares from strangers and teasing of peers as well as the multiple hospitalizations required by the medical surgical intervention.

SUMMARY

A child who only requires esophageal dilatation may have 12 to 15 admissions whereas a child who requires esophageal replacement may have 20 or more admissions. How a child maintains psychological equilibrium depends on how successfully he can cope with the multiple stressors tlu-ust upon him. However, it is not just the child who is affected by the long-term nature of the corrosive substances ingestion, the financial as well as emotional nature of the problem places severe stress on the family as a unit. The primary nurse, in providing family-centered care, must assess the multiple family stressors and intervene. This nurse should also act as a coordinator in order to assist the family in dealing with various other health care disciplines and to facilitate communication between the various health care professionals.

REFERENCES

1. Campbell, R., Burnett, H.F., Ranson, J.M., and Williams, G.D.: Treatment of corrosive burns of the esophagus. Arch. Sur. 112:495, 1977.

2 . Nelson, W., Vaughn 111, V., and McKay, R.J.: Textbook of Pediatrics. Phila- delphia, W.B. Saunders, 1975, p. 807.

3. Muhlendahl, K.E., Oberdisse, U., and Krienke, E.G.: Local injuries by accidental ingestion of corrosive substances by children. Arch. Toxicol. 39:299, 1978.

4. Scipien, G., e t al: Comprehensive Pediatric Nursing. New York, McGraw-Hill, 1975, p. 652.

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long-term care for children who have ingested corrosive substances

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