planning of nursing care planning of the

Question

Planning of Nursing Care
Planning of the nursing care depends on the decision of the surgery. The surgery may be performed in two stages depending upon the degree of the defect. So when the surgery has been decided nurse has to prepare the parents and child for surgery.
Implementation of Nursing Care
The surgery can be performed in two stages:

1.  The chordee correction to straighten the penis and 
2.  Urethroplasty to move the meatus distally and to improve the penis cosmetically and functionally.

Principles of Treatment and Nursing Care

In almost all repairs the prepuce is required as a source of extra skin. Circumcision of the neonate should therefore not be performed.

Surgical Correction
This should be carried out before the child starts school to avoid social and emotional problems. The objectives of the treatment are to provide a urethra of a adequate length and calibre, opening at the tip of the glans; to provide an unobstructed orifice directed forward to prevent splashing and to provide a penis which is straight enough to permit normal sexual intercourse. The correction of the deformity is usually in two stages. The first operation is performed when the child is 3 years old to correct the chordee. The aim is to straighten the penis and prepare the way for urethroplasty. The second operation is performed some months later to bring the orifice as close as possible to the tip of the glans. This requires diversion of the urinary flow, usually through a urethrostomy temporarily created in the perineum, through which a Foley's catheter is inserted into the bladder. This allows healing of the wound. The skin of the penis is in-turned to construct a new urinary tube. 

Pre-operative Preparation  

The nursing care includes preparing parents of the child for the type of surgery to be done. The parents need to be assured that surgery should be performed in early childhood so that it will not have any effect on the child's self image. They should also
be prepared for appearance of operation area postoperatively.

Postoperative Care

a) The child will be on bed rest until the catheter is removed. Care must be taken that he does not pull out the catheter. Restraint may be necessary but should be avoided if possible.
b) Both penile and donor site wounds are kept clean and dry. Swabs should be taken if infection is suspected.
c) Catheter care must to provided to prevent Urinary tract Infection.
d) Examination of urine for bacterial content,
e) Adequate fluid intake to maintain renal flow and dilute toxins.
F) Removal of skin sutures after 5 to 7 days.
g) The child is discharged home once the catheter has been removed and he is passing urine satisfactorily. parents are advised about any problems regarding the wound or if the child has any difficulty passing urine.

The management of child for the second stage operation is such the same as that for the first stage.

1. In some units a catheter is inserted into the bladder either through a urethrostomy temporarily created in the perineum or by suprapubic catheterisation, This allows healing of the newly constructed urethra. The cathetre is removed on the tenth day and the sinus closes spontaneously in 3 to 4 days, 
2. Catheter care will be necessary 
3. A foam or light cotton dressing may have been applied to the penis. This should be left undisturbed unless there is excessive bruising in the area which would indicate the presence of a haematoma. Oedema of the glans penis and especially of the prepuce is quite common but it resolves in a few days. 
4. Observation of urinary flow is important when the child starts to pass urine through the newly constructed urethra. If he experiences difficulty a warm bath may help him to relax and he can be asked to void urine into the bathroom. This often helps to restore confidence in his.ability to pass urine and generally there is no further difficulty in voiding.
5. Observation of complications. Blockage of the catheter may occur. It can be avoided by 4 hourly catheter care and by introducing a urinary antiseptic such as cotrimoxazole. If a haematoma occurs, the child may have to return to theatre for evacuation of the haematoma. There may also be a breakdown of the repair of the urethra resulting in a fistula. In this case urine will be passed through the abnormal opening and further repair will be required four to six months later. There may also be narrowing of the new meatal opening and stricture of the urethra. This will require periodic dilatation with graduated bougies. 
6. Support and guidance for the parents is very important. The condition will have been fully discussed with them but they still require reassurance and information following the correction. Since the child is young, it is advisable that a parent should be staying with him and every encouragement given to participate in the care.