Elimination

I. Tracheoesophageal Fistula: A tracheoesophageal fistula (TEF) occurs when there is an abnormal connection
between the trachea and esophagus. This condition is often associated with esophageal atresia, a birth defect in which
the esophagus ends in a blind pouch, rather than connecting to the stomach.

A. Pathophysiology
• The defect affects occurs in approximately 1 in
4500 neonates
• Results from failure of the esophagus to develop
as a continuous tube during the 4th and 5th
weeks' gestation
• In esophageal atresia, the foregut fails to
lengthen, separate, and fuse into two parallel
tubes (the esophagus and trachea) during fetal
development. Instead, the esophagus may end in
a blind pouch or develop as a pouch connected
to the trachea by a fistula (tracheoesophageal
fistula)
• Often associated with a maternal history of
polyhydramnios
• May be a component of multiple congenital
defects: VACTERL or VATER (Vertebral
defects, imperforate Anus, Cardiac defects,
TracheoEsophageal fistula, Renal &/or Radial
dysplasia, and Limb defects)

B. Clinical Manifestations
• Symptoms in the newborn include excessive salivation and drooling, often accompanied by three classic signs
for this defect: cyanosis, choking, and coughing. Sneezing may also be noted.
• Excessive oral secretions. Characteristically, the neonate born with esophageal atresia drools and has
substantial mucus, with excessive oral secretions.
• Choking upon feeding. If suckling at the breast or bottle is allowed, the baby appears to choke and may have
difficulty maintaining an airway; significant respiratory distress may result.
• Seal-bark cough. In the delivery room, the affected infant may have the sonorous seal-bark cough that
indicates concomitant tracheomalacia.
• During feeding, fluid returns through the infant’s nose and mouth.
• Severe apnea and respiratory distress can occur from the Aspiration of feedings.
• Depending on the type of defect, the infant’s abdomen may be distended because of air trapping.
C. Diagnostic Evaluation
• Prenatal ultrasound with maternal polyhydramnios
• After birth, the passage of a radiopaque NG tube is attempted. If
the tube meets resistance, a chest and abdominal radiograph can
confirm the presence of esophageal atresia.
• Radiologic examination may also reveal associated anomalies.
• Early diagnosis is essential to prevent aspiration of secretions,
which can lead to pneumonia

D. Planning/Treatment

1. Primary Repair
• Primary repair (complete everything in a single surgery) is preferred when possible and involves connecting the two ends
of the esophagus and ligating the fistula if present.
2. Staged Repairs
• If primary repair of the esophageal atresia is not possible, then these patients will require staged repairs and a G-tube will
be placed.
• Several procedures have been developed that allow for stretching of the esophagus over a period of time. Once the length
of the esophagus is adequate, the two ends are reconnected in a delayed primary repair. The child will generally remain
in the hospital setting until the repair.
• Potential postoperative complications include gastroesophageal reflux,
aspiration, stricture formation, leak at the area of anatamosis, and
tracheomalacia.
• The prognosis is usually good with surgery; however, some conditions are
complicated, requiring repeated surgeries and long-term management.
• In the event that the two ends of the esophagus cannot be reconnected,
colonic, jejunal, or gastric segments may be used to lengthen the esophagus

E. Interventions

1. Pre-operatively
• NG Tube to low intermittent suction to drain fluid from fistula
• Have suction readily available to remove any secretions that accumulate in the nasopharyngeal airway
• Place the infant with the head of the bed slightly elevated (30°) to minimize aspiration of secretions into the trachea
• NPO

2. Post-operatively
• Administer IV fluids and broad-spectrum antibiotics
• Frequent vital signs
• Strict intake and output
• Oxygenation support
• TPN may be needed until gastrostomy or oral feedings are tolerated.
• Monitoring and assessment of feeding tolerance is ongoing. Feedings are introduced slowly and in small amounts.
• Assess for respiratory difficulty during reintroduction of feedings.
• Monitor weight, growth, and developmental achievements

Parents require emotional support throughout the infant’s hospitalization. Clearly explain all procedures. Encourage parents to bond
with the infant by stroking and talking to the infant. Eliciting questions and allowing parents to participate in the infant’s care,
especially feeding (when permitted), can facilitate bonding and help to prepare parents for care of the infant after discharge. Teach the
parents about gastrostomy tube care and feedings if applicable, signs of infection, and how to prevent postoperative complications.
II. Pyloric Stenosis: occurs when circular muscle of pyloric canal hypertrophies and impedes gastric emptying into duodenum.
Inflammation and edema develop and lead to obstruction.

A. Pathophysiology
• The narrowing of the pyloric orifice, directly affects the structure
and function of the digestive tract, preventing food within the
stomach from passing through the pylorus into the duodenum.
• This impairs digestion and absorption of food, resulting in
dehydration and malnutrition.
• Generally, affects infants within the first month of life, causing
regurgitation and poor feeding. Rare in adults.
• Risk Factors: 1st born Caucasian males, genetic predisposition,
hypergastrinemia (too much gastrin in blood), use of prostaglandin
E to treat ductus arteriosus, and oral erythromycin at less than 1
month of age

B. Clinical Manifestations
• Previously healthy infant with progressive, projectile, nonbilious vomiting; may become blood-tinged from repeated
irritation of esophagus from vomiting
• Persistent hunger: after vomiting, the baby is hungry and may want to feed again.
• Dehydration: Sunken fontanelles, dry mucous membranes,
lack of tears, poor skin turgor, decreased urine output
• ↓ Na, ↓ K, ↓ Cl and ↑ Hct, ↑ Hgb, ↑ BUN
• Irritability and crying that is inconsolable
• Metabolic Alkalosis: Ph > 7.45 and HCO3 > 26
• Fails to gain weight or lose weight; At risk for Failure to
Thrive
• Fewer and smaller stools; constipation
• Movable, palpable, firm, olive-sized mass in RUQ
• Visible, deep, peristaltic waves from LUQ to RUQ
immediately before vomiting
• Hyperactive bowel sounds

C. Diagnostic evaluation
• An abdominal ultrasound to determine the diameter and length of the pyloric muscle usually performed to confirm the
diagnosis
• An upper gastrointestinal (UGI) study may also be performed. If the infant has pyloric stenosis, the UGI study will reveal a
narrowing of the pyloric channel that prevents the passage of the contrast medium.
• Blood tests determine if the child is dehydrated or has an electrolyte or acid-base imbalance.

D. Assessment
• Observe the infant’s abdomen for the presence of peristaltic waves.
• Bowel sounds are hyperactive on auscultation. Auscultate before palpating the abdomen since palpation can cause a change
in bowel patterns. Palpation reveals an olive-shaped mass in the right upper quadrant of the abdomen.
• Assess the infant’s history of vomiting, vital signs, weight, and nutritional status.
• Assess skin turgor, anterior fontanelle, urinary output (weigh diapers), urine specific gravity, and mucous membranes for
signs of dehydration.
• Describe vomiting episodes and estimate emesis amount.
• Be alert for signs of an electrolyte and/or acid–base imbalance.
• Assess parental anxiety related to the child’s condition.
• The child usually appears hungry. Crying and general discomfort are frequently observed.
E. Interventions

Pyloromyotomy Surgery: Surgery is performed as soon as possible after the infant’s fluid and electrolyte balance is restored.
Laparoscopic pyloromyotomy is the preferred surgical method to correct pyloric stenosis. In a pyloromyotomy, the pyloric muscle is
split to allow the passage of food and fluid. The prognosis is good. The infant is usually taking fluids within a few hours following
surgery and discharged on full-strength formula within 24 hours after surgery.

1. Pre-operatively:
• Maintain NPO status
• Correct metabolic alkalosis
• Monitor intake and output (weigh diapers to measure infants' output of urine and stool)
• Administer IV therapy to correct fluid and electrolyte imbalances and to maintain hydration
• Correct metabolic alkalosis
• Maintain NG tube patency and monitor NG output (if NG tube is needed to decompress the stomach)
• Monitor weight daily
• During the preoperative period, the infant is hungry and cries often. The infant is swaddled to maintain warmth and
provide comfort. Encourage the parents to hold and cuddle the infant. Provide a pacifier to meet the infant’s need to
suck.

2. Post-operatively
• Monitor for the return of bowel sounds
• Daily weights
• IV therapy with electrolytes
• Strict intake and output
• Initiate small frequent feedings of clear liquids (Pedialyte) as prescribed within four to six hours after surgery; follow
strict diet regimen of gradual advancement of feedings until normal formula feedings have been resumed. Burp every 1
ounce of feed
• The incision is covered with collodion or Steri-strips and should be kept clean and dry. Inspect the incision site for
redness, swelling, or discharge. Monitor the infant’s temperature every 4 hours.
• Auscultate the lungs to assess for any adventitious sounds.
• Keep child in high fowlers position (car seat)
• The infant may be uncomfortable because of the surgical incision.
Analgesics can be administered to relieve discomfort as ordered.
• Instruct parents to avoid pressure on the incision. When diapering the
infant, slide the diaper gently under the buttocks rather than lifting the
legs.
• Swaddling, rocking, and use of a pacifier provide comfort to the infant.

3. Education
• Encourage them to participate in the infant’s care and to discuss their
fears and concerns.
• Provide simple and clear explanations about the infant’s condition and
care.
• Advise parents that occasional vomiting after surgery may occur.
• Instruct parents to observe the incision for redness, swelling, or
discharge and to notify the healthcare provider immediately if these
occur or if the infant develops a fever.
• To reduce the possibility of infection, advise parents to fold the
infant’s diaper so that it does not touch the incision.
• Provide instructions about feeding to ensure the infant’s intake.
III. Intussusception: Intussusception occurs when one portion of the intestine prolapses and then invaginates or telescopes into another.
It is one of the most frequent causes of intestinal obstruction during infancy

A. Pathophysiology
• Ninety percent of intussusception cases in
children are idiopathic because a direct
cause is not generally identified.
• Although the exact cause is unknown,
there is frequently a current or recent
enteritis or upper respiratory infection
• The most common site of intussusception
is the ileocecal valve.
• Telescoping of the intestine obstructs the
passage of stool. The walls of the intestine
rub together, causing inflammation, edema, and decreased blood flow. This can lead to bowel wall edema, necrosis, and
perforation
• Risk Factors: more common under the age of 1 year, more common in males, and an increased risk with Cystic Fibrosis and
celiac disease

B. Clinical Manifestations
• The onset of intussusception is usually abrupt. A previously healthy infant or child suddenly experiences acute abdominal pain
with vomiting and passage of brown stool.
• There may be periods of comfort between acute episodes of pain.
• As the condition worsens, painful episodes increase.
• The child may have bilious emesis and a palpable abdominal mass.
• The stools become red and resemble currant jelly because of the mix of blood and mucus

C. Diagnostic Evaluation
• Diagnosis is made on the basis of the history and confirmed by radiographs and ultrasound of the abdomen.
• A contrast enema using air or barium can be both diagnostic and therapeutic. An air (or pneumatic) enema reduces the
intussusception in approximately 90% of cases and is considered safer than a barium enema because of the decreased risk of
perforation. May resolve with air/barium enema or spontaneously

D. Interventions

Surgical Reduction: A nasogastric tube is inserted for gastric decompression. If reduction of the intussusception does not occur
during the contrast enema, surgical intervention to reduce the invaginated bowel and remove any necrotic tissue is necessary.
Surgery is generally successful in correcting the problem; however, intussusception can recur after hydrostatic reduction or surgical
correction.

A. Pre-operative
• Replacing fluids and correcting fluid and electrolyte imbalances
• May require an NG tube for suctioning either to decompress the abdomen or to help with vomiting
• Monitor for stools: if patient produces a brown stool, call HCP immediately, because the condition may have resolved
itself

B. Post-Operative
• monitoring for early signs of infection
• managing the child’s pain
• maintaining nasogastric tube patency.
• Assess vital signs, check for abdominal distention, and assess for return of bowel function.
• Feeding protocols vary among practitioners. Generally, after normal bowel function returns, clear liquid feeding, or
breastfeeding can resume. Feedings are then advanced as the infant or child tolerates them.

Not all children will present with the classic triad of symptoms: abdominal pain, abdominal mass and bloody stools. Pain is
sudden and acute. Child screaming and drawing legs up towards chest. Vomiting, lethargy, tender distended abdomen, palpable
sausage like mass in upper right quadrant, empty lower right quadrant (Dance sign). Any child presenting screaming from pain,
irritability, vomiting diarrhea/constipation, fever, dehydration and shock should be evaluated and nurses should be aware of
alternate presentations. Potentially life threatening.
IV. Hirschsprung's Disease: Hirschsprung disease, also known as congenital aganglionic megacolon, is a congenital
anomaly in which inadequate motility causes mechanical obstruction of the intestine. Hirschsprung disease can occur as
a single anomaly or in combination with other anomalies such as congenital heart defects, Down syndrome, and urinary
tract anomalies .

A. Pathophysiology
• Hirschsprung disease is the congenital absence of
ganglion cells (nerve cells) in the wall of a variable
segment of rectum and colon.
• Believed to be a familial, congenital defect, with
higher incidence in children with congenital heart
defects and chromosomal abnormalities such as
Down syndrome.
• The absence of autonomic parasympathetic ganglion
cells in the colon prevents peristalsis at that portion
of the intestine, resulting in the accumulation of
intestinal contents and abdominal distention.
• In most cases, the area lacking ganglion cells is
limited to the rectosigmoid region of the colon

B. Clinical Manifestations
• Newborns generally include abdominal distention, feeding intolerance, bilious vomiting, and failure
to pass meconium within the first 24 to 48 hours after birth.
• Infant may have failure to gain weight, abdominal distention, episodes of explosive watery
diarrhea/vomiting, signs of enterocolitis, malnutrition, and chronic severe constipation (difficult and
infrequent defecation with passage of hard, dry stool)
• Child may have chronic constipation, passage of ribbon-like-foul-smelling stool, abdominal
distention, palpable fecal mass, visible peristalsis, poorly nourished, anemic, lethargic, explosive
stool after rectal exam
• Enterocolitis (inflammation of the intestines) is a complication of Hirschsprung disease that can be
fatal if not recognized and treated early. Symptoms of enterocolitis include fever, foul smelling
and/or bloody diarrhea (frequent, watery stools), abdominal pain, and vomiting.

C. Diagnostic Evaluation
• Diagnosis is made on the basis of the history, bowel patterns, radiographic contrast studies, and
rectal biopsy for presence or absence of ganglion cells.
• The rectum is small in size on palpation and does not contain stool. Abdominal radiographs
generally show a distended bowel with dilated bowel loops throughout the abdomen.
• Water-soluble contrast studies reveal a transition zone between the normal and aganglionic bowel.
• Rectal biopsy revealing the absence of ganglionic cells and the presence of hypertrophic nerve
bundles has proven to be the most reliable test for confirmation of the diagnosis

Nursing assessment in the newborn period includes careful observation for the passage of meconium. Because newborns are often
discharged within 24 hours of birth, tell parents to notify the healthcare provider if no stool is passed or the abdomen becomes
distended. When the disease is diagnosed later in infancy or in childhood, obtain a thorough history of weight gain, nutritional intake,
and bowel elimination habits.

When Hirschsprung disease is diagnosed, nursing care includes monitoring for infection, managing pain, maintaining hydration,
measuring abdominal circumference to detect any distention, and providing support to the child and family.
D. Interventions

Anorectal Pull Through: The primary repair of Hirschsprung disease is

to remove the aganglionic portion of the bowel using a pull-through
procedure. A primary repair may not be possible in the presence of
extensive dilated proximal bowel, enterocolitis, or bowel perforation. In
that case, a temporary colostomy is created and is closed when the
definitive surgery takes place

1. Pre-operative
• Improve nutritional status to prepare for surgery
• NPO except for medications (will probably receive IV
meds)
• Bowel cleansing, Rectal irrigations may be performed to
evacuate the bowel prior to surgery, sterilization
(Vancomycin PO Q4hrs)
• Intake and Output
• Abdominal girth
• NG tube
• Educate family on what to expect with a colostomy and
how to care for it

2. Post-operative
• NPO until bowel sounds return or flatus is passed
• Prevent distention (NG bowel decompression)
• Maintain intravenous fluids and nasogastric tube.
• Monitor intake and output.
• Prevent infection
• Administer pain medications as prescribed and assess at least every hour for evidence of pain utilizing a pain scale and
documenting assessment.
• If a colostomy was performed, the stoma should be assessed frequently as well as the return of bowel function
• Assess stoma (if present) for color, bleeding, breakdown of surrounding skin; provide meticulous skin care, use
appropriately sized stoma supplies
• Assess anal area after pull-through for presence of stool, redness, drainage; do not place anything in rectum (such as
thermometer or suppository) and place sign over bed alerting staff of this
• Notify healthcare provider of any fever, unusual drainage, redness, or odor

3. Education
• Explain surgical repair and recovery process
• Teach parents how to assess for distention and obstruction and importance of reporting these findings to healthcare
provider
• Encourage preschool and early school-aged children to draw pictures, use dolls, and play to express concerns about
bodily appearance, irrigations, and colostomy
• Teach ostomy care in immediate postoperative period and encourage parents to participate and give return demonstration
while in hospital; encourage child to learn and assume care as soon as appropriate
• Children occasionally develop constipation and parents may need guidance to adapt the diet and fluid intake to manage
this complication. Because some children develop malabsorption, be alert for signs of poor growth or malnutrition.
V. Small Bowel Obstruction: Failure of bowel contents to be moved
forward.

A. Pathophysiology
• Obstructions most often occur in the ileum where the intestinal
diameter is the smallest
• Peristalsis increases in the intestine above the blockage, leading to
increased secretions, edema, and increased capillary permeability and
resulting in fluid and electrolyte imbalances
1. Mechanical obstruction:
• results from forces outside of intestines (adhesions, hernia, fibrosis)
• blockage in lumen (fecal impaction, edema, stricture, volvulus,
intussusception)
• problems within the intestine (tumors or inflammatory bowel disease)
2. Nonmechanical (functional) obstruction:
• Paralytic ileus results from impairment of muscle tone or nervous system innervation preventing forward movement of
intestinal contents (anesthesia, abdominal surgery, spinal injuries, peritonitis, vascular insufficiency)

B. Clinical Manifestations
• Early in bowel obstruction, bowel sounds may be high-
pitched and tinkling proximal to obstruction and
hypoactive or silent distal to obstruction
• Late in bowel obstruction bowel sounds decrease and
become absent
• Abdominal distention, visible peristalsis, and colicky
pain may be present; pain becomes more intense as
obstruction progresses
• Vomiting is common with a small bowel obstruction
and may have a fecal odor; vomiting is a late sign with
a large-bowel obstruction, if it occurs at all
• Vital signs may be normal in early obstruction but
signs of shock (tachycardia, fever, tachypnea,
hypotension) can occur as obstruction progresses

C. Diagnostic Evaluation
• Flat and upright abdominal x-ray
• CT Scans

D. Interventions
• Prepare client for insertion of nasogastric or nasointestinal tube and possibility of surgery: exploratory laparotomy, colon
resection, colostomy, lysis of adhesions, thrombectomy, or embolectomy
• Prepare client for insertion of nasogastric or nasointestinal tube; monitor amount and characteristics of drainage after insertion;
used to decompress bowel of fluid/air; Salem sump suction (keeps stomach mucosa intact)
• Assess NG for proper placement every 4 hours
• Maintain NPO status until peristalsis returns
• Provide IV therapy as prescribed to replace fluid and electrolytes
• Monitor VS including I&O; early detection of hypovolemic shock can prevent complications (bowel ischemia and necrosis)
• Monitor Intake and Output, Vital signs and daily weights (Careful with renal or cardiac patients: fluid overload)
• Auscultate bowel sounds: Peristalsis good as indicated by active bowel sounds
• Monitor flat. s and passage of stool
• TPN/Lipids as needed-->clear liquids--->regular diet
• Provide mouth care to minimize effect of fecal-type secretions
• Monitor level of pain; sudden change in nature of pain may indicate complications (ischemia and necrosis)
• Medication therapy: analgesics are generally limited because opioids decrease GI motility, which further compromises bowel
• Antibiotics as warranted
VI. Biliary Atresia: Biliary atresia
results when the extrahepatic bile
ducts fail to develop or are closed.
A progressive inflammatory
process that causes both
intrahepatic and extrahepatic bile
duct fibrosis. The disorder leads to
cholestasis, cirrhosis, portal
hypertension, end-stage liver
disease, and death by 2 years of age
if left untreated

A. Pathophysiology
• Obstruction of
extrahepatic bile ducts
causes obstruction of
the normal flow of bile
out of liver and into
gallbladder and small
intestine
• Bile plugs form and cause bile accumulation in liver
• Inflammation, edema, and irreversible hepatic injury occur
• Because of lack of bile in intestines, fat and fat-soluble vitamins cannot be absorbed vitamins cannot be
absorbed, this leads to malnutrition, deficiencies of fat-soluble vitamins, and growth failure
• Without treatment this disease is fatal
• Treatment involves surgery (Kasai procedure), which may correct obstruction; liver transplantation may
be required due to progressive cirrhosis

B. Clinical Manifestations
• Initially, the newborn is asymptomatic.
• Jaundice may not be detected until 2 to 3 weeks after birth; increased bilirubin levels
• Abdominal distention, hepatomegaly, splenomegaly
• Easy bruising, change in clotting factors, prolonged bleeding time from liver damage
• Severe pruritus (intense itching).
• Stools have putty-like consistency and are white or clay colored because of the absence of bile pigments.
• Possible steatorrhea
• Tea-colored urine (due to Excretion of bilirubin and bile salts)
• Failure to Thrive and severe malnutrition (can't break down ADEK fat soluble vitamins without bile
acids)

C. Diagnostic Evaluation: diagnosis is based on the history, physical examination, and laboratory evaluation.
Laboratory findings reveal elevated bilirubin and serum aminotransferase and alkaline phosphatase levels,
prolonged prothrombin time, and increased ammonia levels.
• Labs:
↑Bilirubin (0.3-1)
↑ALT (4-36 units/L) Alanine aminotransferase
↑AST (0-35 units/L) Aspartate aminotransferase
↑ALP (30-120 units/L) Alkaline phosphatase
↑PTT (60-70 seconds) Prothrombin time
• Important to assess neurological status with high levels of ammonia
• Percutaneous liver biopsy suggests biliary atresia, and an exploratory laparotomy and
intraoperative cholangiography (x-ray of the bile duct to identify obstruction) confirms
the diagnosis
D. Interventions
Kasai Procedure: Treatment involves surgery to
attempt correction of the obstruction
(hepatoportoenterostomy) and supportive care. In a
hepatoportoenterostomy (Kasai procedure), a segment
of the intestine is anastomosed to the porta hepatis. The
primary purpose of this procedure is to promote bile
flow from the liver. Intravenous antibiotics are
administered in the postoperative period to prevent
cholangitis. Prophylaxis with oral antibiotics is
continued for 1 to 2 years after surgery

While bile flow is achieved with the Kasai procedure in

many children with biliary atresia, approximately 70%
to 80% of children having this surgery will eventually
need a liver transplant. Advances in transplantation
surgery now make it possible to perform partial liver
transplants from living donor resections. This enables
transplantation to be performed before the child
develops end-stage liver disease

• High calorie, low fat diet: ↑Calories, ↑Carbs, ↓Fat, ↓Na, high quality protein (if ammonia levels get to high
protein must be decreased because protein will cause ammonia levels to rise-hyperammonemia) (Low
sodium if ascites)
• Infants: High calorie formula with fats that are digested without bile (Portagen, Neutramigen, Pregestimil);
add MCT (medium chain triglycerides) oil or polycose to formula, or use TPN
• Strict daily weights
• Fat -soluble vitamins (A, D, E, K) Must be given as a medication, can't absorb from formula
• Cholestyramine (bile acid binding drug) and antihistamines to help decrease itching.
• Ursodeoxycholic acid (Actigall) may be given to the child to promote bile flow
• Monitor stool pattern and characteristics of urine
• Provide tepid baths to reduce itching and pat skin dry (not rub) to reduce further skin irritation; colloidal
oatmeal baths
• IM vitamin K before any invasive procedures
• Establish an open, caring relationship with family
VII. Epispadias: congenital defect in which the urinary meatus is not at
the end of the penis but on the upper side of the penile shaft. Less
common than hypospadias but is often associated with exstrophy of
bladder (part of the bladder is located outside of the body). Simple
Epispadias represents a congenital anomaly which is characterized
by short phallus with marked upward curvature (dorsal chordae).
Usually occurs with other involvement and is rare. Epispadias and
bladder exstrophy are the same condition, but epispadias is the
milder expression of the condition. The opening may be small, or a
fissure may extend the entire length of the penis. Females with
epispadias have a cleft of the ventral urethra that generally extends
to the bladder neck

Staged Surgical Reduction: beginning 1 to 2 days after birth to

correct exstrophy of bladder that often comes with Epispadias.

• Closure of bladder and anterior abdominal wall are completed

during first 48–72 hours of life
• Correction is usually a staged surgical correction, with
epispadias repair at about 9 months of age
(if present) and bladder neck reconstruction with ureteral
reimplantation when bladder capacity reaches 80–90 mL
• Pre-operative (preventing infection and trauma): involves
covering bladder with sterile plastic wrap and maintaining integrity of surrounding skin using skin sealant to protect from
excoriating effects of urine
• Postoperative (immobilize wound and pelvis ): may involve Bryant’s traction to facilitate healing, avoiding abduction of legs
(puts stress on surgical area), changing dressings as prescribed; monitoring urine output and characteristics, and watching for
signs of obstruction, bladder spasms, and urine or blood draining from meatus
.
VIII. Hypospadias: the urethral meatus can be located anywhere along the course of
the urethra on the ventral surface of the penile shaft, from the perineum to the
tip of the glans. Most cases are mild, with the meatus slightly off center from
the tip of the penis; in severe cases, the meatus is located on the scrotum.
Hypospadias often occurs in conjunction with congenital chordee, a fibrous
line of tissue that results in ventral curvature of the penile shaft. Associated
defects may include inguinal hernia, cryptorchidism (undescended testes), and
partial absence of the foreskin

• Delay Circumcision until surgery to repair the hypospadias is performed. It

may be necessary for the foreskin to be used during the procedure
• Hypospadias is corrected surgically, usually during the first year of life.
• Surgery is usually performed in a single operation, often as an outpatient
procedure. and is recommended between 6 and 12 months of age. The goals
of surgical repair are:
1. placement of the urethral meatus at the end of the glans penis with satisfactory caliber and configuration for a urinary
stream (enabling the child to void in a standing position)
2. release of chordee to straighten the penis (enabling future sexual function)
3. satisfactory cosmetic appearance of the penis.
4. A urethral stent (a device used to maintain patency of the urethral canal) or catheter is placed to maintain patency of the
new urethral canal opening. The stent or catheter may drain directly into the diaper, using a double-diapering technique,
or into a closed drainage collection bag.

Post Operatively
• Care focuses on protecting the surgical site from injury. The infant or child returns from surgery with the penis wrapped in a
simple dressing, and a urethral stent or catheter for urinary drainage. Plan care to ensure that the stent does not get removed.
• Encourage fluid intake to maintain adequate urinary output and record strict HOURLY intake and output. This is essential to
detect postoperative complications. If there is no urine drainage for 1 hour, contact HCP immediately
• Pain may be associated with bladder spasms. Anticholinergic medications such as oxybutynin may be prescribed.
Acetaminophen or other medications may also be given for pain. Antibiotics are often prescribed until the stent is out.
• Discharge teaching should include instructions for parents about care of the reconstructed area, double diapering to protect
the operative site, fluid intake, medication administration, and signs and symptoms of infection
Home Care following Hypospadias Surgery

• After surgery, you can expect soreness, bruising and swelling. This is normal. It will get better with time. His urine may be light
pink, and you may see some spots of blood on his diaper.
• Your child will have one of two different types of dressings after surgery:
• One type of dressing is clear plastic that wraps all the way around the penis. This dressing may come off shortly after surgery. This is
okay, as long as there is no bleeding. If the dressing has not come off after 3-5 days, then remove it. Sometimes it is useful to get the
dressing wet or quickly soak the dressing and penis under water to help loosen it. If the dressing starts to bunch at the base of the
penis, then please remove it. Starting the day after surgery please apply bacitracin to the tip of the catheter where it meets the penis 3
times daily. This will help to slowly loosen the dressing and make it easier to remove later. Do not remove the catheter. If you have
questions or concerns about the dressing please call.
• The other type of dressing is a flat dressing that pushes the penis flat against the tummy and it is covered by the bandage so that the
penis cannot be seen. For this dressing it is okay to remove 3-4 days following surgery. Simply peel the dressing off but do not remove
the catheter. The dressing may get some blood on it or look pink or red. This is normal.
• After the dressing comes off, please apply bacitracin to the incision and stitches (if present) 2 to 3 times per day for 2 weeks.

Care of the Tube

• The small tube in the penis goes all the way into the bladder. It will drip urine continuously. With each diaper change, the outer
diaper should be wet. If you watch the tube for 3-5 minutes and do not see urine draining, call the clinic (weekdays) or paging operator
(nights, weekends). You will be instructed on how to aspirate the tube with a syringe you were sent home with. When you raise the
end of the tube above the level of the bladder, the urine in the tube should flow back into the bladder.
• It is common for there to be some blood in urine draining from the tube. As long as the tube is draining this is fine and will go away
over time.
• With each inner diaper change, apply a small amount of antibiotic ointment to the area where the tube comes out from the penis.
After the transparent dressing is removed, apply a small amount of antibiotic ointment to the surgery area also.
• The tube is tied to the head of the penis with a suture. Do not attempt to remove the tube. The new urethra heals over the tube, so it is
essential that the tube stay in place during the healing process. The tube should drain into the outside diaper. This will keep the penis
dry as it heals after the surgery.
• Prevent your son from grabbing his penis when you change his diaper.

Bathing
• At home sponge bathe your child until the tube is removed. It is okay to have water run over the dressing.
• Keep the penis clean and dry between sponge baths.
• If stool comes in contact with the surgery area, clean the area immediately with a gentle soap and water.
• If stool gets under the dressing and can’t be cleaned then remove the dressing immediately.

Activity
• No roughhousing or tumbling for 14 days or longer if the catheter is still in place. Keep the child at home with low activity until the
tube is removed.
• The child cannot play with straddle toys for 14 days and this includes bikes, walkers, swings, jumpers, etc.
• You should still put your child in their car seat normally following surgery.

Diet
• Your child may eat a normal diet. Start off with clear liquids, like juices, popsicles, water, or ice. Start solid food slowly after this
with a little bit at a time. It is not unusual for the child to throw up in the first day after surgery and this is from the medicines used to
make them sleepy during the surgery.
• Your child should have bowel movements (poop). Give your child juice, fruit and vegetables so that they do not get constipated
(cannot have a bowel movement). Your child should not strain or push when trying to have a bowel movement. If they do not have a
bowel movement within 1 day after surgery, you may give your child a child’s glycerin suppository in their bottom, (rectum). You can
buy these at the drug store without a prescription.
• You can also use MiraLAX as directed, to help with bowel movements. This can be used in addition to the suppository.

Medications
• If a pain medication is prescribed for your child, give it to him for severe pain only. This medication is usually not needed one to two
days after surgery. If the pain is less severe, then using Tylenol and Motrin may help. It is okay to give Motrin with the prescription
pain medication, but it is not okay to give Tylenol with the prescription pain medication since both medications contain Tylenol.
• Your child will also receive an antibiotic following surgery. Please give this until it is completed.
• The drainage tube may make your child have bladder spasms (cramping). He may cry or pull his legs up to his chest when this
happens. The doctor may give you Ditropan, a medicine to help with this. This should be given every 8 hours for the first day, then
only when needed.
Diapers
• The purpose of the double diaper is to keep the penis dry and drain the urine into the outside diaper.
• Change the outside diaper every 3-4 hours or sooner if wet.
• Change the inside diaper when it is wet or is soiled with stool (at least three times a day).
• The inside diaper may be the size your child usually wears. The outside diaper should be one size larger than the inside diaper.

Things to Check For

• Swelling (a small amount is normal)
• Oozing of blood or active bleeding (a small amount is normal) • Bad odor
• Pus

When to Call
• Fever of 101F degrees or higher.
• If the tube comes out partially or totally.
• If urine does not drain from the tube.
• If the dressing becomes bunched up at the base of the penis and you are unable to remove it.
• Bleeding more than 2 inches in diameter on the diaper or underwear.
• Concerns for infection at the site of surgery.
 Practice Questions

1. A 10-month-old female infant with biliary atresia is being discharged after a Kasai procedure. Which
statement, if made by the parents, indicates that teaching with regard to prognosis has been understood? #23
P ch 59
a) "We are glad was found so early; now every- thing will be fine.”
b) “We will stop her liver medicine now that she is being discharged.”
c) “We are happy to be able to stop that special formula and many of those vitamins.”
d) “We know that even though surgery is over, she will likely need a liver transplant.”

2. Which laboratory test would the nurse expect to be pre- scribed for a child with dehydration caused by
vomiting and diarrhea? Select all that apply. #24 P ch 59
a) Serum sodium
b) Urine specific gravity
c) Serum ammonia
d) Serum amylase
e) Blood urea nitrogen (BUN)

3. A child with Hirschsprung’s disease is being discharged after a Soave endorectal pull-through procedure for
colostomy closure. Which item should the nurse include in the discharge teaching plan? #27 P ch 59
a) Stools may be infrequent and uncomfortable for the first few weeks.
b) It will be necessary to perform weekly rectal irrigations for approximately 6 weeks.
c) Report fever, increasing pain or discomfort, or redness of the incision to the surgeon.
d) Stools will be fatty for a week or so and then gradually return to normal.

4. A newborn is diagnosed with exstrophy of the bladder. The nurse should assess the infant for which
additional defects? Select all that apply #1 CNPT ch 7
a) Hypospadias
b) epispadias
c) cryptorchidism
d) undescended testicles
e) bilateral inguinal hernias

5. Which nursing concern should be a priority for the nurse who is assigned to care for an infant with
unrepaired exstrophy of the bladder? #7 CNPT ch 7
a) Distressed infant behavior
b) difficulty in parental coping
c) possible urinary retention
d) potential for infection

6. The nurse instructs the parents about post-operative feeding after their infants pyloromyotomy. The nurse
should conclude that the parents understand the instructions when the parents state that they will take
which action? #2 CNPT ch 13
a) Avoid burping the baby after feeding to prevent vomiting
b) rock the baby to sleep after feeding to keep the infant calm
c) slowly increase the volume offered according to health care providers prescription
d) maintain the infant on anti-emetics to prevent vomiting
7. While gathering admission data on a 16th month old the nurse notes all of the following abnormal findings.
Which findings should the nurse interpret as that being directly related to Hirschsprung disease? Select all
that apply #4 CNPT ch 13
a) Pale colored vomitus
b) child not toilet trained yet
c) poor weight gain since birth
d) intermittent sharp pain in lower abdomen
e) chronic severe Constipation

8. The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother asks why this vomitus
looks different from that experience by her other children when they have the flu. The nurse should offer
which explanation about why the emesis does not contain bile? #2 CN ch 13
a) The GI system is still immature in newborns and infants
b) the obstruction occurs before the location where bile enters the gastrointestinal system
c) the emesis occurs because of passive regurgitation in this disorder
d) the bile duct itself is obstructed, leading to an absence of bile and emesis

9. An infant return from initial surgery for Hirschsprung disease. The general post-operative nursing care plan
contains the following interventions. Because of the type of surgery this infant underwent, which
intervention should the nurse eliminate? #8 CHN ch. 13
a) Maintain the child on NPO status until bowel sounds return
b) monitor rectal temperature every four hours
c) reunite the parents with a child as soon as possible
d) assess the surgical site every two hours

10. A client has a nasogastric tube in place for gastric decompression and reports increasing nausea. Which
action should the nurse take first? #2 MSPT ch 8
a) advance the tube 2 centimeters
b) place client in a recumbent position
c) irrigate with 20 milliliters of saline
d) obtain abdominal X ray to assess placement

11. The nurse is caring for a client who is receiving enteral feedings via a nasoduodenal tube. Upon entering the
clients room, which should the nurse assess to determine that the clients airway is protected? Select all that
apply #7 MSPT ch 8
a) Bowel sounds
b) breath sounds
c) gag reflex
d) clients position
e) rate of feeding

12. A client is admitted to the hospital with a mechanical small bowel obstruction. Which finding by the nurse
would indicate that the obstruction is in the early stages? #10 MSPT ch 8
a) High pitched tinkling bowel sounds
b) soft rumbling bowel sounds
c) no bowel sounds auscultated
d) normal bowel sounds heard in all four quadrants