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Anorectal malformation

pediatric nursing

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Anorectal malformation

  1. 1. Presented by Mrs. Arifa T N Second year M.Sc Nursing MIMS CON
  2. 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. 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. 4. Anorectal malformations are congenital malformation caused by abnormal development of the rectum and anus.
  5. 5.  Generally any congenital malformation can cause ARM  Family history unusual  Autosomal recessive when genetically linked  Incidence 1/5000 live births
  6. 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. 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
  8. 8.  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
  9. 9.  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
  10. 10.  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.
  11. 11.  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
  12. 12. 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
  13. 13.  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
  14. 14.  UTI  Intestinal obstruction  Fecal impaction  Colostomy related problems  Recurrence of fistula  Anal stenosis  Post operative complications
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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
  20. 20.  Information on dietary modifications and administrationof medications is included in counseling  Quality of life enhanced for the child and family
  21. 21.  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.
  22. 22.  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

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pediatric nursing

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