A Care Study of Anorectal Malformation With Recto Urinary Fisula
A Care Study of Anorectal Malformation With Recto Urinary Fisula
A Care Study of Anorectal Malformation With Recto Urinary Fisula
BY
INDEX NUMBER:......................
SCHOOL OF NURSING
AMAMBRA STATE.
MAY, 2022.
A CARE STUDY OF MASTER U.S WITH ANORECTAL MALFORMATION AND RECTO URINARY FISULA
BY
INDEX NUMBER:.....................
PRESENTED TO
SCHOOL OF NURSING,
ANAMBRA STATE.
MAY,2022.
CERTIFICATION
This is to certify that this care study was written by the student nurse Nnadi ogechukwu Vivian with
INDEX Number......................................under the supervision of Mrs Nwafor I.E and has been
approved by school of nursing Nnamdi Azikiwe University Teaching Hospital Nnewi.
................................. ...................................Mr
s Nwafor I.E. Date
............................. ................................
(Principal)
............................... ...............................
A case study of a 24 days old baby Master U.S with diagnosis of anorectal malformation with recto
urinary fistula. She was admitted on the 8th of April,2020 into the pediatric extension ward in Nnamdi
Azikiwe University Teaching Hospital Nnewi.He was presented with abdominal pain and distention,
inability to pass stool,fever and irritability.
Baby was diagnosed of Anorectal malformation with recto urinary fistula. Laboratory investigations
were carried out. He was managed with analgesics, antibiotics and haematinics. Anoplasty was done
to create an opening for the baby to pass stool. Due medical and nursing management were rendered
and baby recovered without any complication and was discharged home on 16th April,2022. Mother
was encouraged, advice on discharge was given and encouraged to come for follow up care.
Baby was brought back for check up by the mother on 28th April,2022 and was seen at the
pediatric extension unit by Dr. N.K . There was no new complaint. He passes stool normally and
tolerates oral feeding ( breast milk). On examination,baby was stable ,not pale and afebrile. The
incision site healed well.
DEDICATION
This care study is dedicated to God almighty for his guidance, immeasurable love,care, generosity
and unmerited favours.
I also dedicate this study to my amiable family whose support and encouragement made my
education a success.
Acknowledgement
My profound gratitude goes to God almighty for his infinite mrecirsand love to me throughout the
period of this study.
My special thanks to the principal, school of nursing, Nnamdi Azikiwe University Teaching Hospital
Nnewi Mrs Aralu J C.and the entire staff of the school for their support towards the success of this study.
I want to appreciate my supervisor Mrs Nwafor I.E for devoting her time to read, correct and advice me
throughout this study and also to my welfare officer Mrs okeke Mabel for her motherly advice
throughout my course of studies.
My profound thanks goes to my loving parents Mr and Mrs Nnadi for unending love and support
My gratitude also goes to Mr ononiwu .O.for their contribution and support. Special thanks to my
siblings,chinedu,chinenye,Oluchi and chisom for their care, Love,and prayers.To all my friends,thank you
for always being for me.I want to thank everyone who contributed immersely to the success of this
study most especially my patient Baby U.S, author whose books I consulted.
Cover page.
Title page
Certification page
Abstract
Dedication
Acknowledgement
Table of contents
CHARPTER ONE
Introduction
Definition of term
Incidence
Aetiology
Pathophysiology
Clinical manifestation
Diagnostic measures
General management
Medical management
Surgical management
Nursing management
CHARPTER TWO
Case report
Nursing assessment
i History taking
Bio data
IV Diagnosis
Medical diagnosis
vii Planning
Medical plan
Surgical plan
Nursing plan
viii Implementation
ix Evaluation
CHARPTER Three
Drug study
Rehabilitation/health care
Summary
Follow up care
Reference
Appendix
CHARPTER ONE
INTRODUCTION
Anorectal malformation are birth defect in which the anus and rectum (the lower end of the
digestive tract) don't develop properly,the rectum is malformed and the anus ended in a blind pouch. It
had incidence in both gender and in all races.
Recto urinary fistula is a connection between the rectum or anus and the urethra,which is the
tube that empties the bladder and allows you to urinate. This fistula forms secondary to surgery or
trauma.
The cause of this condition is unknown but it has been linked to alterations of the
embroyonic/fetal development. Genetic and family history tends to play some role in the development
of this condition
Patient with anorectal malformation often presents with stool coming out from the vagina/
penis,urine coming out of the anus, lack of stool, trouble having bowel movement or constipation.
The clinical manifestation may Include Abdominal pain, abdominal distention, vomiting which may
lead to loss of electrote and alkalosis.mild dyspnea may occur due to increased intra thoracic pressure
caused by distended colon.
The health care provider will do a physical examination when the baby is born. The provider will
look at the child's anusto sweet if it is open. The child may also have have an imaging test such as
abdominal X-ray, abdominal ultrasound,CT Scan,MRI, Lower gastrointestinal series also
rrttrrttttttthvcvvv
a) This is the intramural part of the urethra and varies between 0.5cm and 1.5cm in length
depending on the fullness of the bladder. It crosses through the prostate gland. There are
several openings; the ejaculatory duct where the fluid from the prostatic uricle,which is merely
an indention. These openings are collectively called verumontanum.
b) Membranous urethra: A small ( 1 or 2cm) portion passing through the external urethral
sphincter. This is the narrower part of the urethra. It is located in the deep perineal pouch. The
bulbo urethra gland (cowpea's gland) are found posterior to this region but open in the spongy
urethre.
c) Spongy urethra( or penile urethra): Runs along the length of the penis in it Ventra ( underneath)
surface. It is about 15 - 16cm in length and travels through the corpus spongiosium. The duct
from the urethra gland( glands of litre) enter here. The openings of the bulbo urethra gland are
also found here, the urethral lumen runs effectively parallel to the penis except at the narrow
point. The external urethral meatus,where it is vertical.
Structure
It has a thin layer of smooth muscle tissues and lined with mucous membrane which is
continuous with that of bladder.
The inner lining, the mucosa is thrown into folds and contains opening of lacunal into which
the glands of litic open.
Sorrounding the mucosa is lamina propria containing many elastic fibre and bloody vessel,
outside of which is an indefinite muscular layer.
Sphincters
Blood supply
Venous drainage
Nerve supply
Pudendal nerve.
Lymph
Functions
PATHOPHYSIOLOGY
Anorectal malformation or imperforate anus is a birth defect in which the rectum is malformed and
the anus is blind ( blind pouch) . In ability of the stomach and intestine to empty it's content when due
through the anal canal, triggers series of gastrointestinal events, whose clinical manifestation depends
on duration of the obstruction.
Normally,6-8 litre of fluids enter the small bowel daily,most of the fluids enter the small intestines
and is absorbed before it reaches the colon and the rectum. However,in a congenital Anorectal
malformation,the total content of the colon (stool) has no way out of the body causing distention.
During the 6th week of fetal development, the hindgut comes into contact with the cloacal
membrane. The hindgut is divided into a central urogenital and dorsal rectal component. By the 8th
week, the dorsal ½ perforates to the exterior. In Anorectal malformation,the process is arrested during
the critical period.
Classification of anorectal variants is based in the relationship between the rectum and puborectalis
muscle;supralevator ( high) and translevator (low) malformations.
Cloaca is a complex defect where the rectum, urethra and the vagina drain into a common channel
that communicates with peritonium.
The fistula communicating from the rectum to the external opening (peroneal fistula) or to the
urogenital system is present in 90%of cases
Females: Most common defects is a recto vestibular fistula where the rectum opens into the
vestibule.
Males: most common defects is a recto urinary fistula from the rectum to the lower posterior
urethra (bulbar)or upper posterior urethra (prostatic).
CLINICAL MANIFESTATION
Abdominal pain.
Abdominal distention.
Vomiting.
Stool coming out of vagina or penis.
Trouble having bowel movement or constipation.
Pain In the lower abdomen and pelvis area .
DIAGNOSTIC MEASURES
Physical examination: This is done to confirm the presence of the central abdominal distention.
Abdominal radiography: it shows intra peritoneal air from bowel perforation.
Abdominal ultrasound: This is done to show the level of accumulated gastric contents.
Barium enema: shows and obstruction.
Rectal examination: confirms blind ended pouch in the peritoneum.
M.R.I( magnetic Resonance Imaging: To detect abnormal anatomical and physiological process
of the body. pictures of the internal organs.
C.T Scan( Computed tomography) : Also used to capture images within the body which uses a
small amount of radiation to create pictures of the inside of the body.
GENERAL MANAGEMENT
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
Colostomy: an operation where the large intestine is directed through an opening in the abdomen and
waste excreted.
Anoplasty: a surgical opreration ( reconstruction) to repair or create an anus allowing passage for stoool
and gastric contents.
NURSING MANAGEMENT.
Assessment
History taking: history of signs and symptoms,age,sex, address, family medical history should be
taken from patient ( mother ) or relatives.
Monitor and record vital signs.
Monitor for signs of complications.
Assess the level of pain.
Assess relevant laboratory findings.
Physical examination:
On inspection: preform head to toe examination.
Head: check for alopecia, discoloration.
Eye: check for paleness, jaundice.
Nose: check for nasal discharge.
Abdomen: check for abdominal distention
Limbs: check for any deformity.
Rectum: check for inflammation/ infection.
Palpation: palpate to check to assess the level of pain in the chest.
Check if abdomen is enlarged and painful.
Rectum: Asses for level of pain in the anal region and surrounding area.
Auscultation: assess the respiratory sound
Auscultate for bowel sound in the abdomen.
Percute to detect sounds heard in the lungs.
Planning.
Pre operative
To prevent infection.
To relieve pain.
To allay anxiety.
Post operative.
Implementation
Pre operative:
To prevent infection:
To relieve pain.:
To allay anxiety:
Post operative
To relieve pain:
Place patient on complete bed rest in a comfortable position to prevent strain to the operation
site.
Relieve pressure on the opreration site.
Administer prescribed analgesics.
To prevent infection
Evaluation
CASE REPORT.
Baby was delivered on 6th of April,2022 via SVD at Chizoba Hospital Awada Obosi but was notified
not to have passed meconium or stool after > 24 hours of life. This is despite aunty noticing that the
child kept making straining effort. On closer check, he was noticed not to have anal opening
neccesitatng their calling the attention of the child's doctor who examined the child and referred them
to Nnamdi Azikiwe University Teaching Hospital (NAUTH) for expert care.
NURSING ASSESSMENT
History taking
Bio data
Sex: Male
Age: 24 days
Religion: Christianity
Tribe: Igbo
Nationality: Nigerian
Occupation: Minor
Informant: Mother
Consultant: Prof N. K
Medical diagnosis: Anorectal malformation with recto urinary
Baby U.S is the 4th child in a monogamous family with 4 children ( 3 boys, 1girl). Elder siblings are
alive and well. Father is a business man at Onitsha and mother is a teacher (secondary). source of
drinking water is satchet water.
Parent live together with siblings in a bedroom flat,well fenced, ventilated and enough space for
movement.
Pregnancy was desired and achieved spontanously. Mother was booked for ANC at 5 months of
gestation at Chizoba Hospital. She was regular with the routine drugs and ANC visit. Had bleeding per
vagina at 5th week of gestation which she did not had any treatment. Thereafter, pregnancy profound
to term. She received two doses of T.T and I.P.T for malaria.
Labour was spontaneous and profound to SVD of a male neonate weighing 4kg. There is history of
ingestion of alcohol in the course of pregnancy. No history of exposure to X-rays.
Baby's problem was noticed by aunt ( mother's sister) hours after birth. She noticed a blind ended
anus as baby was unable to pass meconium. Baby started vomiting a day after birth,vomitus was
accompanied with freshly eaten food (breast milk) and baby's abdomen was distended.
PHYSICAL EXAMINATION
Limbs: No deformity
Palpation
Percussion:
Chest: Resonance: high pitched sound heard in the lungs
Auscultation
SYSTEMIC REVIEW
Central nervous system: patient was concious and no sign of nervous system deficit.
Intergumentary system: skin not pale, not jaundiced, warm to touch at temperature of 37.4°c.
Cardiovascular system system: Apex beat 164 b/m,pulse rate 140c/m.no murmur.
Respiratory system: The chest was clinically clear,ribs moves with respiration.Respiratory rate 70c/m.
LABORATORY INVESTIGATIONS
Na+ : 142mmol/l.
K+: 3.8mol/l
HCO3-: 15
Cl: 94
Urea: 3.4
Abdominal x-ray: x-ray showed normal recto anal junction with a blind ended anal pouch. This shows
signs of obstruction at the terminal anal region.
DIAGNOSIS
Medical diagnosis
NURSING DIAGNOSIS
Pre operative
Post operative
Planning
Medical plan
NURSING PLAN
Implementation
8/04/2022. 7pm
Baby U.S was admitted into pediatrics extension ward under Prof. N.K at about 7pm. On physical
examination, he had abdominal swelling and pain. Vital signs read: temperature 37.4°c,Apex
beat 170b/m, respiration 70c/m.
At 8pm intravenous fluid( Dextrose 4.3% + 3mls of vit- B complex) was given. Nasogastic tube
was passed and gastric contents was sunctioned and baby prepared for surgery.
At 8:55 on baby was taken to the theatre.Anoplasty was done which was successful. He
returned to the ward at about 11: 45pm. Vital signs read temperature 38.5° c, Apex beat
162b/m, respiration 72c/m. Baby was exposed and tepid sponged prescribed drugs was given.
Baby was concious and in a fair condition.
Evaluation
Baby was successfully managed . Pain was relieved, abdomen is normal. His vital signs were all
normal. Prescribed drugs were administered. Patient suffered no complications throughout his
period of hospitalization.
CHAPTER THREE
DRUG STUDY
Ceftazidi Antibio It inhibits Post 1-2g Hypersensi Intraven Hyperse Use if caution if
ne tics the operative ever tivity ous nsitivity patient is
( fortum) synthesis antibiotics, y 8- reaction,m Intramus to drugs hypersensitive to
of bacteria bronchitis, 12 outh sores, cular or it's penicillin.
cell , pneumonia, hour diarrhoea, compon Check injection
mitosis and meningitis, s. abdominal ents. site for absess
growth of pharyngitis, 100 pain,rashes Renal Instruct patient
bacteria. septicemia. mg/ . failure. mother to report
kg side effects.
wt in Observe signs
child and symptoms
ren. of anaphylaxis
during first dose.
Metronid Antimic It alters the Giadiasis,Se 2.5 Drowsiness Orally Hyperse Not to be given
azole robial synthesis ptic mls , uricaria, Intreven nsitivity to patient with
of the cell abortion, dizziness, ous to drugs CNS diseases or
wall Gingivitis, rashes, Supposi or it's blood dyscrasia
permiabilit Appendiciti darkening tion compon Don't use if high
y with loss s, Amioebic, of urine, ents. fever occurs
of dysentery, hypersensi CNS Administer after
intracellula post tivity diseases meal to reduce
r operative reaction Blood gastrointestinal
constituent antibiotics dyspraxi distress
s. a GiveI.V injection
Pregnan slowly
cy and
lactatin
g
mother
s
Paraceta Antipyr It alters the Pain,Fever, 2.5 Skin rashes, Orally Liver Avoid giving
mol etics response Toothache,j mls bronchospa Intramus diseases overs dose to
Analges on the oint sm, rarely cular renal patient.
ics regulating pain,headac thrombocyt impairm
center in he,Muscle openia ent
the ache
hypothala
mus and
raises the
pain
threshold.
Vitamin c Antiscu It helps in Tissues 2.5 Gastrointes Orally Nill Advice mother
rvy the alkalosis, mls tinal onthe diatary
synthesis fracture, disturbance sources of
bof wound s though vitamin c eg
intracellula healing side effects oranges
r. process,im are rare Sense of correct
Substance muno doses
including suppression Observe for any
clagen gastrointestinal
matrix of disturbances.
tooth,
bone and
intercellula
r cement of
capillary
endotheliu
m.
Merone Antibio They Meningiti, 100 Severe Intraven Hyperse Use caution if
m tics inhibits intra mg stomach ous nsitivity patient is
btge abdominal pain, to drugs hypersensitive to
synthesis infection,pn convulsions and it's drugs.
of bacteria eumonia,se ,pale compon Avoid over
cell wall by psis,anthrax skin,shortn ents. dosage of drugs
enhancing ess of and watch out
the effect breath,cilo for side effects.
of the d, hands
enzymes and feet
called shock.
autolysins
including
murein
hydrolase
present in
bacteria
cell wall.
Tropami Amino Streic Nutritional 40ml Dark urine, Intraven Heptic Find out if
ne acids blocking support of s dry ous coma patient is
model, infant mouth,fast patient hypersensitive to
actvates anand heart beat, with the drug and it's
ATPase young chest untreat components
activity and pediatric pain,cough, ed Should not be
Muscle patient , anuria. administered to
contraction requiring hoarseness patient under
s. TPN via ,nausea & the
either vomiting,se contraindication
central or wizure,sto s.
peripheral mach pain.
infusion
route.
Vitamin k Anti It helps to Vitamin k 2.5 Stomach Intrader Hyperse Watch patient
bleedin make deficiency, mls upset, mal nsitivity for
g, various malabsorpti diarrhea Orally. to hypersensitivity
against proteins on vitamin reaction,
poor that are syndrome, k,liver Administer right
bone needed for biliary diseases dose and watch
develop blood aresia, , kidney out for side
ment clotting hepatic diseases effects.
and the failure,hem .
building mirhagic
bones( for diseases of
blood newborn.
clotting)a
new
carbonic
model that
mimics the
proton
abstration
from the
gamma
position of
protein
bound
glutamate
Vitamin Appetiz The Adjustment 2.5 No side Orally Nill Serve correct
B er cyanocabar and mls Effects dose
complex Heama min.it treatment Advice mother
tininics contains of broad on other sources
vitamin the spectrum of vitamin B.
maturation antibiotics,
of supplement
erythrocyte ation of
during diet.
erythropoi
esis. It is
for proper
functioning
of the
nerves and
muscl
PRE OPERATIVE NURSING CARE PLAN FOR BABY U.S WITH ANORECTAL MALFORMATION WITH
RECTO URINARY FISULA.
2. Acute pain Patient will 1. Monitor vital 1. Vital signs helps to Patient
related to show reduction signs i.e the know the baseline showed
abdominal of pain within respiration, data. reduction of
distention 1-2hours of temperature 2. Early recognition of pain within
evidence by nursing care. pulse,apex signs and symptoms 1hour 30
restlessness. beat of pain, allow for mins of
2. Asses for signs proper dectection nursing
and symptoms and intervention and intervention.
of pain and pain control.
restlessness. 3. Application of hot
3. Apply hot compress helps to
compress on dilate blood vessels
abdominal thereby increasing
region. blood flow and
4. Provide patient prevent ischaemia.
with 4. Provision of
diversional diversional therapy
therapy eg toys will divert patient
and lullaby. mind out of pain.
5. Give 5. Administration of
prescribed analgesics depresses
analgesics e.g the pain centre in the
paracetamol brain thereby
2.5mls 6hrly. reducing pain.
Risk for infection Patient will not 1. Monitor vital 1. Monitor vital Patient did
related to surgical show any signs signs i.e signs helps to not show
incision is of infection respiration, know the any signs of
throughout the temperature baseline data and infection
post operative pulse apex beat deviation from throughout
period of 2. Observe for normal and the post
hospitalization signs and detect onset of operative
symptoms of infection as body period of
infection. temperature hospitalizati
3. Change rises. on
dressing when 2. This will prompt
soiled and detection and
when due. intervention.
4. Give prescribed 3. Changing of
antibiotics e.g soiled dressing
ceftazidine prevents
300mg 12 transmission of
hourly. infection.
4. Antibiotics
prevents the
invasion of
microorganisms.
REHABILITATION
The family should be involved in the care of the patient after hospitalization. Rehabilitation of patient
include
The family should adjust in the way they handle the baby do as not to apply undue pressure to
the anus and abdomen.
They should be enlightened on the importance of copious fluid intake to avoid impaction of
feacal matters.
They should be advised to avoid undue pressure in the abdominal region and pelvic muscles.
HEALTH EDUCATION
The importance of health education to the patient's family is to correct any bias misconception
about follow up care and also to help to avoid any complication when they are discharged.They are
educated to:
To take high nutritional diet rich in protein, vitamin and calories preferably breast milk.
The importance of personal hygiene to prevent infection especially when cleaning the perineal
area.
The need to provide emotional support to the child like pampering, cuddling e.t.c
To ensure baby receives adequate immunization as stated in the National Program on
Immunization Schedule.
Keep appointment date for follow up care.
To give prescribed drugs as instructed and report to the hospital immidiatly if side effects occur.
To return to the hospital if they observe any sign of infection like fever, redness and swelling of
incision site or any form of drainage from the incision site.
SUMMARY
Baby U.S a 24days old baby was admitted into the pediatric extension department of Nnamdi
Azikiwe University Teaching Hospital Nnewi on 7th April,2022. In company of mother, father and
siblings.
Baby presented with absence of anal orifice after birth as evidenced by inability to pass meconium,
abdominal distention for two days and vomiting which started a day after birth. Vomitus which was
accompanied with freshly eaten food ( breast milk) . On admission,a medical diagnosis of Anorectal
malformation with recto vestibular fistula was made and baby was booked for emergency analplasty.
Several investigations were done to confirm the diagnosis. Medical and surgical treatment were given,as
well as proper nursing care. Baby's condition improved and he was discharged home on 16/04/2022. On
discharge,oral drugs was prescribed. Check up date of two weeks was given ,due advice,health
education were also given to the patient's mother. The mother was encouraged to feed baby well as
baby's condition was satisfactory.
Follow up care.
Baby was brought back for check up by mother on 28th, April,2022.andvwas seen at pediatric extension
unit by Dr.N.K. There was no new complaint. He passed stool normally and tolerates oral feeding( breast
milk). On examination, baby was stable, not pale and afebrile. The incision site healed well.
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Barba,F.W ( 2014). Baillier's Dictionary for nurses and health care workers 26th edition.
Brender,G.B,Janice,L.H & Kerry,C (2014). Brunner & syddarth's textbook of medical surgical nursing.13th
edition, Lippincott- Raven publishers Limited.
Chukwurah,C.J (2018). Easy way to understand Nursing process ISNL ( NANDA - I, NOC & NIC).
Ronald, K.M &Jen L.D. Anorectal malformation, causes, treatment and complications. Retrived from
htt// www.google.com./.
Waugh,A & Grant(2004) Ross and Wilson. Anatomy and physiology in health and illness (12th edition
published by Churchill living stone.