pediatric nursing

1. Presented by
Mrs. Arifa T N
Second year M.Sc Nursing
MIMS CON

2.  Anorectal malformations refer to anomalies of the rectum and distal anus,
the urinary tract, and the genital tract.
 They have an incidence of approximately 1 in 5000 live births worldwide
 These malformations may range from simple imperforate anal to include
other associated complex anomalies of genitourinary (GU) and pelvic
organs,
 Which may require extensive treatment for fecal, urinary, and sexual
function.
 The term imperforate anus (absence of the anal opening)

3.  Anorectal malformations are frequently associated with other
anomalies. Some babies have VACTERL conditions.
 VACTERL refers to the presence of three or more of the following
anomalies:
 Vertebral anomalies,
 Anal atresia,
 Congenital heart disease,
 Tracheoesophageal fistula,
 Renal anomalies, and
 Limb defects
 Boys with an imperforate anus frequently have a rectourethral
fistula and girls generally have a rectovestibular fistula.

4. Anorectal malformations are congenital malformation
caused by abnormal development of the rectum and anus.

5.  Generally any congenital malformation can cause ARM
 Family history unusual
 Autosomal recessive when genetically linked
 Incidence 1/5000 live births

6.  The major part of the anus and rectum develops during 4th to 6th
weeks of IUL
 The cloaca becomes the common channel for developing the urinary,
genital and rectal system
 The division of cloaca occurs at 6th week forms the an anterior
urogenital sinus and posterior intestinal channel by the urorectal
septum.
 Failure or any interception in the division of cloaca into the
urogenital tract and the rectum results in the high and intermediate
type of anomalies.

7.  Infant with out normal anus
 With a visible abnormal opening
 Anal stenosis
 Ano perineal fistula
 Anovestibular fistula
 with an invisible but manifested opening of the bowel
 Rectovagianal fistuala
 Recto urethral fistula
 Rectovesicular fistula
 No manifested opening of the bowel
 Persistant anal membrane
 Rectal atresia

16.  No or abnormally formed anal opening
 Failure to pass meconium within the first 24 hours of birth may
be indicative of imperforate anus
 Fistula
 Presence of mechonium in urine
 Progressive abdominal distension
 Vomiting
 Rectal tube cannot be inserted

17.  Imperforate anus
 Anal stenosis
 Anal agenesis
 Rectal agenesis
 Recto perineal fistula
 Rectovaginal fistula
 Cloacal malformations in girls, in which the urinary tract,
vagina, and rectum fuse together, forming a common
channel

19.  Physical examination
 Cystoscopy
 An IV pyelogram and a voiding cystourethrogram are
performed to evaluate associated anomalies involving the
urinary tract.
 Other diagnostic examinations that may be performed
include pelvic MRI, radiography, ultrasonography, and
fluoroscopic examination of pelvic anatomic contents and
lower spinal anatomy.

20.  Newborn is stabilized andkept NPO for further evaluation
 IV fluids are provided to maintain glucose and fluid and
electrolyte balance.
 Current recommendation is that surgery be delayed at
least 24 hours to properly evaluate for the presence of a
fistula and possibly other anomalies

21. Surgical
 Varies according to the defect
 Low ARM
 Rectal cut back anoplasty or Y-V plasty
 Dialation of fistula
 High ARM
 Colostomy
 Posterior sagittal anorectoplasty (PSARP) or other pull-
through with colostomy

22.  This surgery generally occur between 3 to 6 months of
age, although timing varies among surgeons.
 When the operative site has healed, approximately 2
weeks after surgery, anal dilations are begun.
 When the desired size of the anal opening has been
achieved, the colostomy is closed

36.  UTI
 Intestinal obstruction
 Fecal impaction
 Colostomy related problems
 Recurrence of fistula
 Anal stenosis
 Post operative complications

37.  Assisting in identification of anorectal malformations
 A newborn that does not pass stool within 24 hours after birth or
has meconium that appears at a location other than the anal
opening requires further assessment.
 Preoperative care includes diagnostic evaluation,
 GI decompression,
 Bowel preparation, and
 IV fluids

38.  Acute pain
 Impaired skin integrity
 Body image disturbance
 Interrupted family process
 Parental anxiety
 Knowledge deficit
 Risk for infection
 Risk fluid volume deficit
 Risk for electrolyte imbalance
 Risk for complications
Pre-post operative nursing diagnosis

39.  General preoperative care
 Postoperative nursing care after anoplasty is primarily directed
toward healing the surgical site without other complications.
 A program of anal dilations is usually initiated then the child
returns for the 2-week checkup
 Feedings are started soon after surgical repair, and
breastfeeding is encouraged because it causes less
constipation

40.  In neonates with anomalies such as cloaca (female),
rectourethral prostatic fistula (males), and vestibular fistula
(females), a descending colostomy is performed to allow fecal
elimination and avoid fecal contamination of the distal
imperforate section and subsequent urinary tract infection in
infants with urorectal fistulas.
 Postoperative nursing care is directed toward
 Maintaining appropriate skin care at the stoma sites (both distal and
proximal),
 Managing postoperative pain, and
 Administering iv fluids and antibiotics.
 Postoperative ng decompression may be required with laparotomy, and
 Maintenance of appropriate drainage

41.  The PSARP is a common surgical procedure for the repair of
anorectal malformations in infants approximately 1 to 2 months
after the initial colostomy
 Preoperative PSARP care often involves
 Irrigation of the distal stoma to prevent fecal contamination of the
operative site
 Parents must be given accurate yet simple information regarding the
infant's appearance postoperatively and expectations as to their level of
involvement in the child's care
 Parents are instructed in perineal and wound care or care of the
colostomy as needed
 Anal dilations may be necessary for some infants
 Parents should observe stooling patterns and observe for signs of anal
stricture or complications

42.  Information on dietary modifications and administrationof
medications is included in counseling
 Quality of life enhanced for the child and family

43.  Long-term follow-up is essential for children with complex
malformations
 Toilet training is delayed, and complete continence is seldom
achieved at the usual age of 2 to 3 years
 Bowel habit training,
 Bowel management irrigation programs,
 Diet modification, and
 Administration of stool softeners or fiber help children improve bowel
function and social continence
 Daily bowel irrigations (if not acheived)
 Support and reassurance are important during the slow
progression to normal, socially acceptable function.

44.  The child’s pain is effectively managed
 Incisions heal without signs of infection.
 Fluid and electrolyte balance is maintained.
 Adequate bowel function is demonstrated.
 The parents demonstrate an understanding of ostomy
care and other treatment protocols