Kamis, 05 Mei 2011
CHAPTER I THEORETICAL REVIEW 1. Definition Anorectal malformations (imperforate anus) is a congenital malformation in which the rectum has no outlet. Anus absent, abnormal or ectopic. Common anorectal disorders in men and women show the relationship of low and high anorectal disorders among intestinal, muscular levator ani, skin, urethra and vagina. (Wong, 2003) 2. Classification: Classification of anorectal according to the incident, among others: a. What often in men 1. Pirenium fistula (cutaneous) The simplest is defective in both sexes. Patients have a small hole located in the perineum, the anterior of the center, near the external sphincter in the male scrotum / vulva in women. 2. Fistula rektrovesika In patients with fistula rektrovesika, rectum associated with urinary tract in the neck as high as vesika urinaria. 3. Fistula rektrouretra In the case rektrouretra fistula, rectum associated with the bottom of the urethra (bulbar urethra) or the top of the urethra (prostatic urethra). 4. Imperforate anus without Vistula Has the same characteristics in both sexes rectum closed at all and is usually found approximately 2 cm above the perineal skin 5. Atresium rectum It is a rare, only 1% of the anomaly anorektum It has the same defect padakedua sex characteristics. Unique mark on this flaw is that the patient has anul & anal canal is normal. There is obstruction of about 2 cm above the skin
b. What often in women 1. Persistent cloaca In the case of persistent cloaca, the rectum, vagina and urethra meet together in a single channel. Perineum has a hole which is located slightly behind the clitoris. 2. Vestibular fistula Is a defect that is often found in women. Rectum empties into the female genital vestibula slightly beyond the lining of the virgin.
Classification of anorectal malformations based on relationships of the rectum with muscle puborektal: a. Abnormalities low position (low anomalies) At this location the rectum connects to the muscle puborektal, spinter developing internal and external functions normally, no association with genitourinary tract. b. Abnormalities of the location being (intermedieat anomalies) The rectum is located under the muscle puborektal, there is the anal cavity, and normal external spinter position. c. Abnormalities location (high anomalies) End of the rectum lies above the muscle puborektal, there were no internal spinter and there is a relationship with the male genitourinary fistula rektouretra, in women rectovaginal.
Anorectal malformations consist of a variety of forms. Some forms include the following: 1. Congenital anal stenosis 2. Membrane anal atresia. 3. Anal agenesis 4. Rectal atresia 5. Rectoperitoneal fistula 6. Rectovaginal fistula (Nelson,)
3.Etiologi The cause of this disease are: 1. Anal malformations Impaired growth and fusion and the formation of the bulge embryonic anus. 2. Malformations Rectum Impaired separation cloaca into rectum and urogenital sinus and anorectal developmental disorder septum that separates it (happened fistel) (Mansjoer, 2000)
4. Clinical Manifestation Anorectal malformations have clinical manifestations as follows:. 1. Abdominal bloating, vomiting arise later. 2. Vomit fluid initially green and then mixed with feces .. 3. Spastic colon. 4. increased bowel sounds. 5. Abdominal distension. 6. Exit either the vagina or meconium with urine (depending on the location fistel). 7. Meconium out of the rectum, such as toothpaste. (Betz, 2002)
5. Pathophysiology Congenital abnormalities of the anus caused by impaired growth, fusion and formation of the bulge embryonic anus. So also on rectal malformation cloacal separation started from the disorder so the rectum and urogenital sinus and progress unorektal septum that separates it.Second-fistel fistel malforamsi form that inhibits spending meconium causing intestinal obstruction colonic visible picture flatulence, abdominal distension, vomiting with liquid initially green and then mixed with feces. Abdominal distension that occurs causing intra-abdominal pressure to torakal so that clients have trouble breathing pattern. Failure expenditure so that meconium causes reflux vomiting colonic abnormalities supported the anus and rectum. This is disturbing pattern of fecal elimination. Malformations should be treated first to a temporary measure with a new colostomy definitive surgery was then performed according to the location defeknya. Bed rest post-surgery patients will eventually lead to activity intolerance. Presence on tissue injury will cause pain and high risk of infection because the wound is an entry-germs part. It also caused damage to skin integrity. Anesthesia is given also affect the decline in organ function, eg decreased respiratory system, decrease in heart function and decrease in intestinal peristalsis. (Nelson, 1999)
6. Examination Support 1. Digital rectal examination, the rectal atresia finger did not go over 1-2 cm. 2. Protosigmoidoskopi, anoscopy, inverted lateral radiographs. 3. Urogram intravenous; sistourethrogram: miksi done on time must be done because of frequent urinary malformations traktuf accompany this anomaly. 4. Rontgenologis vertebral column: to know the disorder that accompanies the vertebral anomalies. 5. Examination of inspection and palpation in early perineal area. 6. Ultrasound: can be used to determine the location of the rectal pouch.7. Needle aspiration to detect rectal pouch by way of a needle on it while doing aspirations; if meconium was not out when the needle is
7. Management Treatment is performed in patients with anorectal disease maformasi there are two kinds, namely with a temporary measure and definitive action, as follows: 1. While action a) The action depends on high or low spontaneous atresia. Children fasted for surgery soon. If there is suspected rectal malformation, the baby should be immediately sent to the surgeon that performed acute transverse colostomy. There are 2 places that are recommended wear colostomy in neonates and infants is transversokolostomi and sigmoidkolostomi. Especially for the female cloacal defect types other than well done vaginostomi colostomy and urinary diversion if necessary (after the bigger kids from 1 to 1.5 years). b) In the male anus malformation type done Covered anal incision / cut only on the black line on her skin, then slowly widened and if there is a hole followed by a Vaseline-coated kelingkin pushed in until palpable / protruding end of the rectum and rectum ends at the incision without stitches. At low defect lies directly definitive therapy is anorektoplasti posterior sagittal (PSARP), the remaining temporary colostomy performed.
2. Definitive Action a) definitive surgery is intended to remove the obstruction and maintain contact kontinensi. To malformation of the rectum after the baby is 6 months old do-ano-vaginal-uretroplasti rekto posterior sagittal (PSAVURP). b) The anus malformation further corrective action depends on defect; 1) At the anal malformations that do not exist but there appear to be anal fistel Dimple Dimple dianal incision made through the middle of the sphincter ani eksternus. 2) If fistel ano uretralis Dimple anal therapy should not be directly penetrated but first fistel ano uretralis tersbeut tied. If the case can not be considered and treated as a case of malformation of the rectum. c) In anorectal agenesis at high kelainana after the baby's weight reached 10 kg should be corrected with surgery sakroperineal or abdomino perineal where the distal colon is pulled into muskulus aneterior puborektalis and sewn into perinuem. In this anomaly, the sphincter ani eksternus inadequate and there is no sphincter internus, so kontinensi faecal depend on muscular function pubo rectal. As a result of children with high abnormality without muskolatur muskulatur or bad, continence may be obtained by slow but with intensive training by using existing muscle, muscle toning and then with levator plasti, advice on diet and maintaining a "neorektum" blank, progress can be achieved. (Wong, 1999)
9. Complication a) Acidosis hiperkloremia b) prolonged urinary tract infection c) Damage to the urethra (due to surgical procedures) d) Long-term complications: 1. Anal mucosal eversion 2. Stenosis (due to contraction of scar tissue from the anastomosis) 3. Impaction and constipation (due to the sigmoid dilatasinya) 4. Problems or delays on those related to toilet training 5. Incontinence (from anal stenosis or impaction) 6. Anorectal mucosal prolapse (causes incontinence and persistent seepage) 7. Recurrent fistula (due to voltage diarea surgery and infection) (Betz, 2000)
CHAPTER II APPLICATION ASKEP
I. Nursing Concepts A. Assessment a. Pre Op Assessment Physical examination: a) Regional perineum - Inspection of the perineal area carefully at an early stage - To find the relationship to the skin fistula - To find the mouth or anus of an ectopic stenatik - To improve the form of long-term foreign - To see the meconium (whether out of the vagina or out with the urine?) - To see the black lines that define the location fistel and therapeutic care. b) Abdomen - Checking for signs of intestinal obstruction (abdominal distention) - Observe any abdominal distension - Measure abdominal circumference - Listen to bowel sounds (4 koadran) - Abdominal Percussion - Palpation of the abdomen (possible bowel spasm) c) Assess the hydration and nutritional status - Weigh the body weight per day - Observe the projective vomiting (vomiting characteristic) d) TTV - Measure the temperature of the body (usually an increase) - Measure the respiratory frequency (occurrence Tachypnoea or dyspnea) - Measure pulse (tachycardia occurrence) - Observation manifestation of anorectal malformations - Digital rectal examination of the rectum which seemed normal, but when not to go over 1-2 cm means there is atresia of the rectum. - Check with the catheter to the urethra and differentiate fistel fistel vesika.
b. Post Op Assessment 1. Assess the integrity of the skin covering the texture, color, skin temperature. 2. Observe any signs of infection 3. Observe the pattern of elimination and the general condition of the patient.
A. Nursing Diagnosis B. Nursing Interventions C. Rational D. Evaluation 1. Pre Operative a) The balance of fluid and electrolyte disorders associated with vomiting. Objective: The client shows the electrolyte fluid balance after the act of nursing for 2 x 24 hours, with the criteria: a balance of input and output, elastic skin turgor, normal TTV (temperature: 36.5 to 37, RR: 35x/menit)not obtained abdominal distension. Intervention: a. Input-Output Measure the amount of fluid. Rationalization: Identify the imbalance. b. Inspection of skin turgor. Rationalization: On the state dejidrasi skin turgor is inelastic. c. Measure vital signs. Rationalization: state of dehydration are identified thanks to changes in TTV: tachycardia, hypotension, increase in temperature. d. Inspection of abdominal distension. Rationalization: Increased abdominal pressure is characterized by abdominal distenai e. Collaboration given IV fluids. Rationalization: Menganti fluid and electrolyte loss.
b) Impaired breathing patterns associated with suppression torakal secondary to abdominal distension. Objective: The pattern of normal breath / fulfilled after the action of nursing for 3 x 24 hours with the criteria results: normal RR (30 - 60 x / min), regular, not using a respirator muscles, not ditujukkannya use of nostrils in breathing.
Intervention: a. Position the child in a comfortable position with the use of pillow 30 °.Rationalization: for maximum ventilation efficiency b. Record TTV and heart rhythm Rationalization: tachycardia, dysrhythmias and changes in pressure can indicate the effect of systemic hypoxia on cardiac function. c. Give O2 as needed Rationalization: to improve and prevent hypoxia d. Auscultation of breath sounds breath sounds noted adventisius like: krekel, wheezing. Rationalization: usually decreased breath sounds. e. Inspection of cyanosis. Rationalization: Indicates that there is a lack of oxygen to the tissues
c) Anxiety in the elderly associated with action / surgical procedures. Objectives: Parents express acceptance of actions / procedures (reduced anxiety), after the action has been nursing for 1 x 24 hours, with families able to reveal the outcome criteria of pain, acceptance of surgery, and understand the surgical procedure.
Intervention: a. Identification of ignorance. Rationalization: By providing clarity of the family for a little quiet. b. Increasing support to families' actions or the actions they will prosdur right ". Rationalization: With the support will reduce anxiety. c. Explaining the procedure on time. Rationalization: Increase the sense of optimism with surgery. 2. Post Operation a) Ineffective breathing pattern related to decreased lung capacity secondary to the administration of anesthesia. Objective: Respiratory effective return after nursing action for 2 x 24 hours with the criteria results: clients do not experience cyanosis, no hypoxia, respiration rate is normal (30 - 60 x / min) and regular. No snoring sound. Intervention: a. Record speed / depth of breathing, auscultation of breath sounds, observe the pale, cyanosis. Rationalization: breathing snoring / reduce ventilation and anesthesia can lead to hypoxia. b. Position client with head elevated 30 °. Rationalization: It can promote optimal lung expansion and to minimize pressure on the abdominal contents into the thoracic cavity. c. Change positions periodically Rationalization: Increase the air filling the entire segment of the lung. d. Give O2 as needed Rationalization: Maximizing O2 preparation for gas exchange and reduced work of breathing.
b) pain associated with blood vessel vasodilatation secondary to surgery. Objectives: Pain is lost or reduced after the action has been nursing for 2 x 24 hours. With the criteria result: clients are not worried and tense again, the client is not crying, facial expressions fair (not withstand the pain). Intervention: a. Assess and record an increase in pain Rationalization: Used to determine the client's pain to determine measures of pain reduction. b. Avoid palpation of the area unless necessary surgery Rationalization: To avoid the increase in postoperative pain c. Provide a comfortable and quiet environment. Rationalization: Reduction of pain stimulus. d. Collaborative provision of analgesia as required and monitor their effectiveness. Rationalization: Used to pharmacotherapy for pain.
c) High risk of infection associated with tissue injury at surgery. Objective: No infection occurred after the act of nursing for 3 x 24 hours.With the outcome criteria: normal temperature, 36.5 ° C - 37 ° C, there were no signs of inflammation (red, swollen, hot area of the wound), dry and clean bandages. Intervention: a. Take temperature every 4 hours Rationalization: The increase in body temperature indicates the occurrence of systemic infection. b. Use of septic and aseptic technique medical Rationalization: Prevent the occurrence of infection and sepsis. c. Perform wound care carefully to keep the wound clean Rationalization: To minimize the risk of infection. d. Change wound dressing after 3 days post operation in "dry-dry" by the way; betadin dialas wound and cover with dry gauze. Rationalization: The dressing can meningkatkankelembaban and slow healing of wounds. e. Collaboration of antimicrobials / antibiotics as needed. Rationalization: Used for the prevention of systemic infection.
d) Activity intolerance related to lactic acid accumulation secondary to bed rest. Objective: Tolerance of increased activity after the action has been nursing for 2 x 24 hours with the results criteria; after the move client does not experience fatigue is evidenced by (RR: 30 - 60 x / min, pulse: 120 - 140x / min). Intervention: a. Check your child's tolerance level of physical Rationalization: It can be used to determine the child's level of fatigue. b. Give period of rest and sleep according to the condition Rationalization: Rest used to save energy and fatigue can be reduced. c. Provide a quiet and comfortable environment Rationalization: a quiet environment to increase the range of break clients to save energy.
e) Damage to the integrity of the skin associated with the existence of tissue injury. Objectives: After action has been nursing for 4 x 24 hours does not get damaged skin integrity, with the criteria results: increased persembuhan wounds, signs of infection-free. Intervention: a. Inspection of the color of the wound size. Rationalization: Reddish swollen identify any damage to skin integrity. b. Clean the skin surface by using hydrogen / water soap soft dg / petrolatum. Rationalization: petrolatum clean up feces attached. c. Use aseptic dressing technique. Rationalization: Reduce skin irritation.
f) Amendments to the growth and development related to the physical and process weakened the ability of hospitalization. Objective: The collapse is achieved according to age after the action has been nursing for 2 x 24 hours with the criteria: the patient showed improved physical characteristics, sensory development, behavior socialization, cognitive development.
Intervention: a. Assess the level of child development in all areas of function. Rationalization: important to know whether the child has reached the fall.b. Teach parents about normal perkembngan task group children according to age. Rationalization: the family (mother) to nurse the child for at home, are expected to monitor the development of children at all times. c. Provide an opportunity for a sick child to fulfill the task perkambangan appropriate age group. Rationalization: Prevent the occurrence of regression because shospitalisasi process. (Doengoes, 1999)
Treatment can be done is: 1. Actions while depending on the type aberration a) In malforamsi anus made an incision on the type of anal Covered. b) On kolostimi malformation of the rectum performed immediately. c) The location of the low defect made new PSAVRP remaining temporary colostomy performed.
2. Definitive action a) Malformations 6 months old when the surgery PSAVURP. b) Malformations anus without incision dianal fistel with Dimple. c) agenesis and high anorectal abnormalities of the baby is 20 pounds be corrected with surgery or abdominoperineal sakroperineal. d) When the high abnormality muskulatur no or bad can be done first intensive training using the existing muscles, muscle toning and then with levatorplasti, and advice on diet and memelhara "neorektum remain empty."
Nursing problems that arise: 1. Ineffective breathing pattern associated with decreased secondary lung capacity of anesthesia. 2. Pain associated with vasodilatation of blood vessels secondary to surgery. 3. High risk of infection associated with the existence of tissue injury in surgery. 4. Damage to the integrity of the skin associated with the existence of tissue injury. 5. Parental anxiety associated with the action / surgical procedures. 6. Changes in growth and development related to the physical and process weakened the ability of hospitalization.
CHAPTER V M E N U T U P
A. CONCLUSION. 1. Anorectal malformations (imperforate anus) is a congenital malformation in which the rectum has no outlet. Anus absent, abnormal or ectopic. Common anorectal disorders in men and women show the relationship of low and high anorectal disorders among intestinal, muscular levator ani, skin, urethra and vagina. (Wong, 2003) 2. The cause of this disease are: 1. Anal malformations Impaired growth and fusion and the formation of the bulge embryonic anus. 2. Malformations Rectum Impaired separation cloaca into rectum and urogenital sinus and anorectal developmental disorder septum that separates it (happened fistel) (Mansjoer, 2000) 3. Nursing problems that arise: a) ineffective breathing pattern associated with decreased secondary lung capacity of anesthesia. b) pain associated with blood vessel vasodilatation secondary to surgery. c) High risk of infection associated with tissue injury in surgery. d) Damage to the integrity of the skin associated with the existence of tissue injury. e) Anxiety parents associated with the action / surgical procedures. f) Changes in growth and development related to the physical and process weakened the ability of hospitalization.
B. ADVICE.
1. In applying the nursing care of children with anorectal malformations required assessment, concepts and theories by a nurse. 2. Information or health education is useful for a client with lung cancer for example, reduce or stop smoking, pay attention to the work environment associated with pollution. 3. Psychological support is very useful to clients.
REFERENCES
Doengoes, 1999. Nursing care plan. Edition 3. EGC, Jakarta. Mansjoer, Arif. 2000. Capita Selekta Medicine. Media Aesculapius, Jakarta. Ngastiyah. 1995. Child Care Hospital. EGC, Jakarta. Nelson, 1999. Pediatrics. EGC, Jakarta. Silbernagl, Stefan. Color Atlas & Text Physiology. 2000. Hippocrates, Jakarta. Syaifuddin, 1997. Anatomy Physiology. EGC, Jakarta. Syamsudin, R. Song. Textbook of Surgery. EGC, Jakarta. Wong, Dona L. 2003. Guidelines for Pediatric Nursing. EGC, Jakarta
b. What often in women 1. Persistent cloaca In the case of persistent cloaca, the rectum, vagina and urethra meet together in a single channel. Perineum has a hole which is located slightly behind the clitoris. 2. Vestibular fistula Is a defect that is often found in women. Rectum empties into the female genital vestibula slightly beyond the lining of the virgin.
Classification of anorectal malformations based on relationships of the rectum with muscle puborektal: a. Abnormalities low position (low anomalies) At this location the rectum connects to the muscle puborektal, spinter developing internal and external functions normally, no association with genitourinary tract. b. Abnormalities of the location being (intermedieat anomalies) The rectum is located under the muscle puborektal, there is the anal cavity, and normal external spinter position. c. Abnormalities location (high anomalies) End of the rectum lies above the muscle puborektal, there were no internal spinter and there is a relationship with the male genitourinary fistula rektouretra, in women rectovaginal.
Anorectal malformations consist of a variety of forms. Some forms include the following: 1. Congenital anal stenosis 2. Membrane anal atresia. 3. Anal agenesis 4. Rectal atresia 5. Rectoperitoneal fistula 6. Rectovaginal fistula (Nelson,)
3.Etiologi The cause of this disease are: 1. Anal malformations Impaired growth and fusion and the formation of the bulge embryonic anus. 2. Malformations Rectum Impaired separation cloaca into rectum and urogenital sinus and anorectal developmental disorder septum that separates it (happened fistel) (Mansjoer, 2000)
4. Clinical Manifestation Anorectal malformations have clinical manifestations as follows:. 1. Abdominal bloating, vomiting arise later. 2. Vomit fluid initially green and then mixed with feces .. 3. Spastic colon. 4. increased bowel sounds. 5. Abdominal distension. 6. Exit either the vagina or meconium with urine (depending on the location fistel). 7. Meconium out of the rectum, such as toothpaste. (Betz, 2002)
5. Pathophysiology Congenital abnormalities of the anus caused by impaired growth, fusion and formation of the bulge embryonic anus. So also on rectal malformation cloacal separation started from the disorder so the rectum and urogenital sinus and progress unorektal septum that separates it.Second-fistel fistel malforamsi form that inhibits spending meconium causing intestinal obstruction colonic visible picture flatulence, abdominal distension, vomiting with liquid initially green and then mixed with feces. Abdominal distension that occurs causing intra-abdominal pressure to torakal so that clients have trouble breathing pattern. Failure expenditure so that meconium causes reflux vomiting colonic abnormalities supported the anus and rectum. This is disturbing pattern of fecal elimination. Malformations should be treated first to a temporary measure with a new colostomy definitive surgery was then performed according to the location defeknya. Bed rest post-surgery patients will eventually lead to activity intolerance. Presence on tissue injury will cause pain and high risk of infection because the wound is an entry-germs part. It also caused damage to skin integrity. Anesthesia is given also affect the decline in organ function, eg decreased respiratory system, decrease in heart function and decrease in intestinal peristalsis. (Nelson, 1999)
6. Examination Support 1. Digital rectal examination, the rectal atresia finger did not go over 1-2 cm. 2. Protosigmoidoskopi, anoscopy, inverted lateral radiographs. 3. Urogram intravenous; sistourethrogram: miksi done on time must be done because of frequent urinary malformations traktuf accompany this anomaly. 4. Rontgenologis vertebral column: to know the disorder that accompanies the vertebral anomalies. 5. Examination of inspection and palpation in early perineal area. 6. Ultrasound: can be used to determine the location of the rectal pouch.7. Needle aspiration to detect rectal pouch by way of a needle on it while doing aspirations; if meconium was not out when the needle is
7. Management Treatment is performed in patients with anorectal disease maformasi there are two kinds, namely with a temporary measure and definitive action, as follows: 1. While action a) The action depends on high or low spontaneous atresia. Children fasted for surgery soon. If there is suspected rectal malformation, the baby should be immediately sent to the surgeon that performed acute transverse colostomy. There are 2 places that are recommended wear colostomy in neonates and infants is transversokolostomi and sigmoidkolostomi. Especially for the female cloacal defect types other than well done vaginostomi colostomy and urinary diversion if necessary (after the bigger kids from 1 to 1.5 years). b) In the male anus malformation type done Covered anal incision / cut only on the black line on her skin, then slowly widened and if there is a hole followed by a Vaseline-coated kelingkin pushed in until palpable / protruding end of the rectum and rectum ends at the incision without stitches. At low defect lies directly definitive therapy is anorektoplasti posterior sagittal (PSARP), the remaining temporary colostomy performed.
2. Definitive Action a) definitive surgery is intended to remove the obstruction and maintain contact kontinensi. To malformation of the rectum after the baby is 6 months old do-ano-vaginal-uretroplasti rekto posterior sagittal (PSAVURP). b) The anus malformation further corrective action depends on defect; 1) At the anal malformations that do not exist but there appear to be anal fistel Dimple Dimple dianal incision made through the middle of the sphincter ani eksternus. 2) If fistel ano uretralis Dimple anal therapy should not be directly penetrated but first fistel ano uretralis tersbeut tied. If the case can not be considered and treated as a case of malformation of the rectum. c) In anorectal agenesis at high kelainana after the baby's weight reached 10 kg should be corrected with surgery sakroperineal or abdomino perineal where the distal colon is pulled into muskulus aneterior puborektalis and sewn into perinuem. In this anomaly, the sphincter ani eksternus inadequate and there is no sphincter internus, so kontinensi faecal depend on muscular function pubo rectal. As a result of children with high abnormality without muskolatur muskulatur or bad, continence may be obtained by slow but with intensive training by using existing muscle, muscle toning and then with levator plasti, advice on diet and maintaining a "neorektum" blank, progress can be achieved. (Wong, 1999)
9. Complication a) Acidosis hiperkloremia b) prolonged urinary tract infection c) Damage to the urethra (due to surgical procedures) d) Long-term complications: 1. Anal mucosal eversion 2. Stenosis (due to contraction of scar tissue from the anastomosis) 3. Impaction and constipation (due to the sigmoid dilatasinya) 4. Problems or delays on those related to toilet training 5. Incontinence (from anal stenosis or impaction) 6. Anorectal mucosal prolapse (causes incontinence and persistent seepage) 7. Recurrent fistula (due to voltage diarea surgery and infection) (Betz, 2000)
CHAPTER II APPLICATION ASKEP
I. Nursing Concepts A. Assessment a. Pre Op Assessment Physical examination: a) Regional perineum - Inspection of the perineal area carefully at an early stage - To find the relationship to the skin fistula - To find the mouth or anus of an ectopic stenatik - To improve the form of long-term foreign - To see the meconium (whether out of the vagina or out with the urine?) - To see the black lines that define the location fistel and therapeutic care. b) Abdomen - Checking for signs of intestinal obstruction (abdominal distention) - Observe any abdominal distension - Measure abdominal circumference - Listen to bowel sounds (4 koadran) - Abdominal Percussion - Palpation of the abdomen (possible bowel spasm) c) Assess the hydration and nutritional status - Weigh the body weight per day - Observe the projective vomiting (vomiting characteristic) d) TTV - Measure the temperature of the body (usually an increase) - Measure the respiratory frequency (occurrence Tachypnoea or dyspnea) - Measure pulse (tachycardia occurrence) - Observation manifestation of anorectal malformations - Digital rectal examination of the rectum which seemed normal, but when not to go over 1-2 cm means there is atresia of the rectum. - Check with the catheter to the urethra and differentiate fistel fistel vesika.
b. Post Op Assessment 1. Assess the integrity of the skin covering the texture, color, skin temperature. 2. Observe any signs of infection 3. Observe the pattern of elimination and the general condition of the patient.
A. Nursing Diagnosis B. Nursing Interventions C. Rational D. Evaluation 1. Pre Operative a) The balance of fluid and electrolyte disorders associated with vomiting. Objective: The client shows the electrolyte fluid balance after the act of nursing for 2 x 24 hours, with the criteria: a balance of input and output, elastic skin turgor, normal TTV (temperature: 36.5 to 37, RR: 35x/menit)not obtained abdominal distension. Intervention: a. Input-Output Measure the amount of fluid. Rationalization: Identify the imbalance. b. Inspection of skin turgor. Rationalization: On the state dejidrasi skin turgor is inelastic. c. Measure vital signs. Rationalization: state of dehydration are identified thanks to changes in TTV: tachycardia, hypotension, increase in temperature. d. Inspection of abdominal distension. Rationalization: Increased abdominal pressure is characterized by abdominal distenai e. Collaboration given IV fluids. Rationalization: Menganti fluid and electrolyte loss.
b) Impaired breathing patterns associated with suppression torakal secondary to abdominal distension. Objective: The pattern of normal breath / fulfilled after the action of nursing for 3 x 24 hours with the criteria results: normal RR (30 - 60 x / min), regular, not using a respirator muscles, not ditujukkannya use of nostrils in breathing.
Intervention: a. Position the child in a comfortable position with the use of pillow 30 °.Rationalization: for maximum ventilation efficiency b. Record TTV and heart rhythm Rationalization: tachycardia, dysrhythmias and changes in pressure can indicate the effect of systemic hypoxia on cardiac function. c. Give O2 as needed Rationalization: to improve and prevent hypoxia d. Auscultation of breath sounds breath sounds noted adventisius like: krekel, wheezing. Rationalization: usually decreased breath sounds. e. Inspection of cyanosis. Rationalization: Indicates that there is a lack of oxygen to the tissues
c) Anxiety in the elderly associated with action / surgical procedures. Objectives: Parents express acceptance of actions / procedures (reduced anxiety), after the action has been nursing for 1 x 24 hours, with families able to reveal the outcome criteria of pain, acceptance of surgery, and understand the surgical procedure.
Intervention: a. Identification of ignorance. Rationalization: By providing clarity of the family for a little quiet. b. Increasing support to families' actions or the actions they will prosdur right ". Rationalization: With the support will reduce anxiety. c. Explaining the procedure on time. Rationalization: Increase the sense of optimism with surgery. 2. Post Operation a) Ineffective breathing pattern related to decreased lung capacity secondary to the administration of anesthesia. Objective: Respiratory effective return after nursing action for 2 x 24 hours with the criteria results: clients do not experience cyanosis, no hypoxia, respiration rate is normal (30 - 60 x / min) and regular. No snoring sound. Intervention: a. Record speed / depth of breathing, auscultation of breath sounds, observe the pale, cyanosis. Rationalization: breathing snoring / reduce ventilation and anesthesia can lead to hypoxia. b. Position client with head elevated 30 °. Rationalization: It can promote optimal lung expansion and to minimize pressure on the abdominal contents into the thoracic cavity. c. Change positions periodically Rationalization: Increase the air filling the entire segment of the lung. d. Give O2 as needed Rationalization: Maximizing O2 preparation for gas exchange and reduced work of breathing.
b) pain associated with blood vessel vasodilatation secondary to surgery. Objectives: Pain is lost or reduced after the action has been nursing for 2 x 24 hours. With the criteria result: clients are not worried and tense again, the client is not crying, facial expressions fair (not withstand the pain). Intervention: a. Assess and record an increase in pain Rationalization: Used to determine the client's pain to determine measures of pain reduction. b. Avoid palpation of the area unless necessary surgery Rationalization: To avoid the increase in postoperative pain c. Provide a comfortable and quiet environment. Rationalization: Reduction of pain stimulus. d. Collaborative provision of analgesia as required and monitor their effectiveness. Rationalization: Used to pharmacotherapy for pain.
c) High risk of infection associated with tissue injury at surgery. Objective: No infection occurred after the act of nursing for 3 x 24 hours.With the outcome criteria: normal temperature, 36.5 ° C - 37 ° C, there were no signs of inflammation (red, swollen, hot area of the wound), dry and clean bandages. Intervention: a. Take temperature every 4 hours Rationalization: The increase in body temperature indicates the occurrence of systemic infection. b. Use of septic and aseptic technique medical Rationalization: Prevent the occurrence of infection and sepsis. c. Perform wound care carefully to keep the wound clean Rationalization: To minimize the risk of infection. d. Change wound dressing after 3 days post operation in "dry-dry" by the way; betadin dialas wound and cover with dry gauze. Rationalization: The dressing can meningkatkankelembaban and slow healing of wounds. e. Collaboration of antimicrobials / antibiotics as needed. Rationalization: Used for the prevention of systemic infection.
d) Activity intolerance related to lactic acid accumulation secondary to bed rest. Objective: Tolerance of increased activity after the action has been nursing for 2 x 24 hours with the results criteria; after the move client does not experience fatigue is evidenced by (RR: 30 - 60 x / min, pulse: 120 - 140x / min). Intervention: a. Check your child's tolerance level of physical Rationalization: It can be used to determine the child's level of fatigue. b. Give period of rest and sleep according to the condition Rationalization: Rest used to save energy and fatigue can be reduced. c. Provide a quiet and comfortable environment Rationalization: a quiet environment to increase the range of break clients to save energy.
e) Damage to the integrity of the skin associated with the existence of tissue injury. Objectives: After action has been nursing for 4 x 24 hours does not get damaged skin integrity, with the criteria results: increased persembuhan wounds, signs of infection-free. Intervention: a. Inspection of the color of the wound size. Rationalization: Reddish swollen identify any damage to skin integrity. b. Clean the skin surface by using hydrogen / water soap soft dg / petrolatum. Rationalization: petrolatum clean up feces attached. c. Use aseptic dressing technique. Rationalization: Reduce skin irritation.
f) Amendments to the growth and development related to the physical and process weakened the ability of hospitalization. Objective: The collapse is achieved according to age after the action has been nursing for 2 x 24 hours with the criteria: the patient showed improved physical characteristics, sensory development, behavior socialization, cognitive development.
Intervention: a. Assess the level of child development in all areas of function. Rationalization: important to know whether the child has reached the fall.b. Teach parents about normal perkembngan task group children according to age. Rationalization: the family (mother) to nurse the child for at home, are expected to monitor the development of children at all times. c. Provide an opportunity for a sick child to fulfill the task perkambangan appropriate age group. Rationalization: Prevent the occurrence of regression because shospitalisasi process. (Doengoes, 1999)
Treatment can be done is: 1. Actions while depending on the type aberration a) In malforamsi anus made an incision on the type of anal Covered. b) On kolostimi malformation of the rectum performed immediately. c) The location of the low defect made new PSAVRP remaining temporary colostomy performed.
2. Definitive action a) Malformations 6 months old when the surgery PSAVURP. b) Malformations anus without incision dianal fistel with Dimple. c) agenesis and high anorectal abnormalities of the baby is 20 pounds be corrected with surgery or abdominoperineal sakroperineal. d) When the high abnormality muskulatur no or bad can be done first intensive training using the existing muscles, muscle toning and then with levatorplasti, and advice on diet and memelhara "neorektum remain empty."
Nursing problems that arise: 1. Ineffective breathing pattern associated with decreased secondary lung capacity of anesthesia. 2. Pain associated with vasodilatation of blood vessels secondary to surgery. 3. High risk of infection associated with the existence of tissue injury in surgery. 4. Damage to the integrity of the skin associated with the existence of tissue injury. 5. Parental anxiety associated with the action / surgical procedures. 6. Changes in growth and development related to the physical and process weakened the ability of hospitalization.
CHAPTER V M E N U T U P
A. CONCLUSION. 1. Anorectal malformations (imperforate anus) is a congenital malformation in which the rectum has no outlet. Anus absent, abnormal or ectopic. Common anorectal disorders in men and women show the relationship of low and high anorectal disorders among intestinal, muscular levator ani, skin, urethra and vagina. (Wong, 2003) 2. The cause of this disease are: 1. Anal malformations Impaired growth and fusion and the formation of the bulge embryonic anus. 2. Malformations Rectum Impaired separation cloaca into rectum and urogenital sinus and anorectal developmental disorder septum that separates it (happened fistel) (Mansjoer, 2000) 3. Nursing problems that arise: a) ineffective breathing pattern associated with decreased secondary lung capacity of anesthesia. b) pain associated with blood vessel vasodilatation secondary to surgery. c) High risk of infection associated with tissue injury in surgery. d) Damage to the integrity of the skin associated with the existence of tissue injury. e) Anxiety parents associated with the action / surgical procedures. f) Changes in growth and development related to the physical and process weakened the ability of hospitalization.
B. ADVICE.
1. In applying the nursing care of children with anorectal malformations required assessment, concepts and theories by a nurse. 2. Information or health education is useful for a client with lung cancer for example, reduce or stop smoking, pay attention to the work environment associated with pollution. 3. Psychological support is very useful to clients.
REFERENCES
Doengoes, 1999. Nursing care plan. Edition 3. EGC, Jakarta. Mansjoer, Arif. 2000. Capita Selekta Medicine. Media Aesculapius, Jakarta. Ngastiyah. 1995. Child Care Hospital. EGC, Jakarta. Nelson, 1999. Pediatrics. EGC, Jakarta. Silbernagl, Stefan. Color Atlas & Text Physiology. 2000. Hippocrates, Jakarta. Syaifuddin, 1997. Anatomy Physiology. EGC, Jakarta. Syamsudin, R. Song. Textbook of Surgery. EGC, Jakarta. Wong, Dona L. 2003. Guidelines for Pediatric Nursing. EGC, Jakarta
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