Postoperation Care After Pull-Through /

PSARP Surgery for Anorectal

Malformations / Imperforate Anus
Two weeks after the Pull-Through (PSARP) surgery, the stitches are removed and the
antibiotic ointment is discontinued.

At this time, the process of anal dilations is initiated. The dilations prevent anal structures
from forming because of the scar tissue around the anus.

It is imperative for the family to adhere to the guidelines given to them. The surgeon
generally passes the first dilator and then the surgeon or pediatric surgical nurse teaches
the parents the dilation process.

Position the child with the knees flexed close to the chest. Lubricate the tip of the anal
dilator and insert it three to four centimeters into the rectum.

Repeat this procedure twice a day for approximately 30 seconds each time. Every week
advance to the next size dilator. After six to eight weeks the "desired size" is reached. Then,
colostomy closure is planned.

Patients who undergo a posterior sagittal operation generally have a smooth post operative
course. The incision is relatively painless considering the extent of surgery that was done.

We attribute this to the fact that the operation is done through a midline incision and most
probably no nerve endings are divided.

Foley catheters in those cases with urinary fistula must remain in place between five and 14
days. Five days will be adequate for a typical rectourethral bulbar fistula, and up to two
weeks are needed for a complicated or complex cloaca.

In service cloacas, a formal suprapubic cystostomy is recommended rather than inserting a

Foley catheter. We believe that the presence of a foreign body in the urethra for longer
periods of time
will not only fail to prevent strictures, but may act as a foreign body, causing irritation and
increasing the inflammatory rectourethral fistulas in males.

If the catheter comes out before five days, it is better to leave it out rather than risk tearing
the sutures in the posterior urethra by trying to recatheterize the child. Most patients will
void spontaneously without further consequences.

On a few occasions, when the patient cannot void, then a percutaneous suprapubic tube
can be inserted and left in place for three to five days.

Bacitracin ointment is used three times a day on the wound site. Antibiotics, including
ampicillin and gentamicin, should be administered intravenously, usually 24 to 72 hours.

After that period, provided the patient is doing well and no manifestation of infection is seen,
we suggest stopping the intravenous antibiotics and continuing with ampicillin by mouth.

In specific cases in which the colostomy was not completely diverting and therefore gross
fecal contamination occurred during the operation, we give a more aggressive treatment
with ampicillin, gentamicin and clindamycin for one week postop.

Those patients whose abdomen was also opened in order to repair a very high defect, in
addition to the postop care already described, may need a nasogastric tube for a variable
period, usually 48 to 96 hours, until there is evidence that the bowel is working well.

A child who underwent a posterior sagittal operation without having had the abdomen
opened, may receive oral feedings on the day of surgery. They can be discharged after 48
hours, whereas the patients with laparotomy may spend a few more days in the hospital.

Contact the Colorectal Center at Cincinnati Children's

For more information or to request an appointment for the Colorectal Center at Cincinnati
Children's Hospital Medical Center, please contact us.

NURSING DIAGNOSIS: Self-Care deficit: (specify)May be related to

Depression, discouragement, loss of mobility, general debilitation; perceptual/cognitive impairment

Possibly evidenced by

Inability to manage ADLs; unkempt appearance

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Self-Care: Activities of Daily Living (ADL)

(NOC)

Peform self-care activities within level of own ability.Demonstrate techniques/lifestyle changes to meet
own needs.Use resources effectively.

ACTIONS/INTERVENTIONS

Self-Care Assistance (NIC)

Independent

Determine current capabilities (0–4 scale) and barriers to participation in care.Involve patient in
formulation of plan of care at level of ability.Encourage self-care. Work with present abilities; do not
pressure patient beyond capabilities. Provide adequate time for patient to complete tasks. Have
expectation of improvement and assist as needed.Provide and promote privacy, including during
bathing/showering.Use specialized equipment as needed, e.g., tub transfer seat, grab bars, raised toilet
seat.Give tub bath, using a two-person or mechanical lift if necessary. Use shower chair and spray
attachment, as appropriate. Avoid chilling.Shampoo/style hair as needed. Provide/assist with
manicure.Encourage use of barber/beauty salon if patient is able.Acquire clothing with modified
fasteners as indicated.Encourage/assist with routine mouth/teeth care daily.

Collaborative

Consult with physical/occupational therapists and rehabilitation specialist.

RATIONALE

Identifies need for/level of interventions required.Enhances sense of control and aids in cooperation and
maintenance of independence.Doing for oneself enhances feeling of self-worth. Failure can produce
discouragement and depression.Modesty may lead to reluctance to participate in care or perform
activities in the presence of others.Enhances ability to move/perform activities safely.Provides safety for
those who cannot get into the tub alone. Shower may be more feasible for some patients, though it may
be less beneficial/desirable to the patient. Elderly/debilitated patients are more prone to chilling.Aids in
maintaining appearance. Shampooing may be required more/less frequently than bathing
schedule.Enhances self-image and self-esteem, preserving dignity of the patient.Use of Velcro instead of
buttons/shoe laces can facilitate process of dressing/undressing.Reduces risk of gum disease/tooth loss;
promotes proper fitting of dentures.Useful in establishing exercise/activity program and in identifying
assistive devices to meet individual needs/facilitate independence

NURSING DIAGNOSIS: Skin Integrity, risk for impairedRisk factors may include

General debilitation; reduced mobility; changes in skin and muscle mass associated with aging,
sensory/motor deficitsAltered circulation; edema; poor nutritionExcretions/secretions (bladder and
bowel incontinence)Problems with self-care

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Risk Control (NOC)

Maintain intact skin.Identify individual risk factors.Demonstrate behaviors/techniques to prevent skin

breakdown/facilitate healing.

ACTIONS/INTERVENTIONS

Skin Surveillance (NIC)

Independent

Inspect skin, tissues, and mucous membranes routinely.Anticipate and use preventive measures in
patients who are at risk for skin breakdown, such as anyone who is thin, obese, aging, or
debilitated.Assess nutritional status and initiate corrective measures as indicated. Provide balanced diet,
e.g., adequate protein, vitamins, and minerals.Maintain strict skin hygiene, using mild, nondetergent
soap (if any), drying gently and thoroughly, and lubricating with lotion or emollient.Change position
frequently in bed and chair. Recommend 10 min of exercise each hour and/or perform passive ROM.

RATIONALE

Provides opportunity for early intervention in potential high-risk population, who may have thin, less
elastic, and more fragile skin and tissues.Decubitus ulcers are difficult to heal, and prevention is the best
treatment.A positive nitrogen balance and improved nutritional state can help prevent skin breakdown
and promote ulcer healing.

Note:
 May need additional calories and protein if draining ulcer present.A daily bath is usually not necessary
in elderly patients because there is atrophy of sebaceous and sweat glands, and bathing may create dry-
skin problems. However, as epidermis thins with age, cleansing and use of lubricants is needed to keep
skin soft/pliable and protect susceptible skin from breakdown.Improved circulation, muscle tone, and
joint motion and promotes patient participation

ACTIONS/INTERVENTIONS

Skin Surveillance (NIC)

Independent

Use a rotation schedule in turning patient. Use draw/turn sheet. Pay close attention to patient’s comfort
level.Massage bony prominences gently with lotion or cream.Keep sheets and bedclothes clean, dry, and
free from wrinkles, crumbs, and other irritating material.Use elbow/heel protectors, foam/water or gel
pads, sheepskin for positioning in bed and when up in chair.Provide for safety during ambulation, using
appropriate adaptive devices, e.g., walker, cane.Limit exposure to temperature extremes/use of heating
pad or ice pack.Examine feet and nails routinely and provide foot and nail care as indicated:Keep nails
cut short and smooth;Use lotion, softening cream on feet;Check for fissures between toes, swab with
hydrogen peroxide or dust with antiseptic powder, and place a wisp of cotton between the toes;Rub
feet with witch hazel or a mentholated preparation and have patient wear lightweight cotton stockings.

RATIONALE

Allows for longer periods free of pressure; prevents shearing or tearing motions that can damage fragile
tissues.

Note:

Use of prone position depends on patient tolerance and should be maintained for only a short
time.Enhances circulation to tissues, increases vascular tone, and reduces tissue edema.

Note:

Contraindicated if area is pink/red because cellular damage may occur. Gentle massage around area
may stimulate circulation to impaired tissues.Avoids friction/abrasions of skin.Reduces risk of tissue
abrasions and decreases pressure that can impair cellular blood flow. Promotes circulation of air along
skin surface to dissipate heat/moisture.Loss of muscle strength and flexibility and physical disease
process/debilitation may result in impaired coordination.Decreased sensitivity to pain/heat/cold
increases risk of tissue trauma.Foot problems are common among patients who are elderly, diabetic,
bedfast, and/or debilitated.Jagged, rough nails can cause tissue damage/infection.Prevents
drying/cracking of skin; promotes maintenance of healthy skin.Prevents spread of infection and/or
tissue injury.Even though rash may not be present, burning and itching may be a problem.

Note:

Witch hazel may be contraindicated if skin is dry.

ACTIONS/INTERVENTIONS

Skin Surveillance (NIC)

Collaborative

Inspect skin surface/folds (especially when incontinence pad/pants are used) and bony prominences
routinely. Increase preventive measures when reddened areas are noticed.Continue regimen for
redness and irritation when break in skin occurs.Observe for decubitus ulcer development, and treat
immediately according to protocol.

Collaborative

Provide waterbed, alternating pressure/egg-crate or gel mattress, and pad for chair.Monitor Hb/Hct and
blood glucose levels.Refer to podiatrist as indicated.Provide whirlpool treatments as appropriate.Assist
with topical applications; hydrogel dressings; skin barrier dressings (Duoderm, Op-Site); collagenase
therapy; absorbable gelatin sponges (Gelfoam); aerosol sprays.Administer nutritional supplements and
vitamins as indicated.Prepare for/assist with skin grafting (Refer to CP: Burns, ND: Skin Integrity,
impaired.)

RATIONALE

Skin breakdown can occur quickly with potential for infection and necrosis, possibly involving muscle
and bone. There is increased risk of redness/irritation around legs due to elastic bands in adult
diapers/incontinence pads.Aggressive measures are important because decubitus ulcers can develop in
a matter of a few hours.Timely intervention may prevent extensive damage.Provides protection and
improved circulation by decreasing amount of pressure on tissues.Anemia, dehydration, and elevated
glucose levels are factors in skin breakdown and can impair healing.May need professional care for such
problems as ingrown toenails, corns, bony changes, skin/tissue ulceration.Increases circulation and has a
debriding action.Although there are differing opinions about the efficacy of these agents, individual or
combination use may enhance healing.Aids in healing/cellular regeneration.May be needed to close
large ulcers.

NURSING DIAGNOSIS: Mobility, impaired physicalMay be related to

Decreased strength and endurance, neuromuscular impairmentPain/discomfortPerceptual/cognitive
impairment

Possibly evidenced by

Impaired coordination, limited ROM; decreased muscle mass, strength, controlReluctance to attempt
movement; inability to purposefully move

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Mobility Level (NOC)

Maintain/increase strength and function of affected body parts.Verbalize willingness to, and participate
in, desired activities.Demonstrate techniques/behaviors that enable continuation or resumption of
activities.

ACTIONS/INTERVENTIONSIndependent

Determine functional ability (0–4 scale) and reasons for impairment.Note emotional/behavioral
responses to altered ability.Plan activities/visits with adequate rest periods as necessary.Encourage
participation in self-care, occupational/recreational activities.Provide chairs with firm, high seats and
lifting chairs when indicated.

Fall Prevention (NIC)

Assist with transfers and ambulation if indicated; show patient/SO ways to move safely.Obtain
supportive shoes and well-fitting, nonskid slippers.Remove extraneous furniture from pathways.

RATIONALE

Identifies need for/degree of intervention required.Physical changes and loss of independence often
create feelings of anger, frustration, and depression that may be manifested as reluctance to engage in
activity.Prevents fatigue; conserves energy for continued participation.Promotes independence and self-
esteem; may enhance willingness to participate.Facilitates rising from seated position.Prevents
accidental falls/injury, especially in the patient with altered gait, generalized weakness, orthostatic
hypotension, fatigue and vision disturbances.Assists patient to walk with a firm step/maintain sense of
balance and prevents slipping.Prevents patient from bumping into furniture and reduces risk of
falling/injuring self

NURSING DIAGNOSIS: Mobility, impaired physicalMay be related to

Decreased strength and endurance, neuromuscular impairmentPain/discomfortPerceptual/cognitive

impairment

Possibly evidenced by
Impaired coordination, limited ROM; decreased muscle mass, strength, controlReluctance to attempt
movement; inability to purposefully move

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Mobility Level (NOC)

Maintain/increase strength and function of affected body parts.Verbalize willingness to, and participate
in, desired activities.Demonstrate techniques/behaviors that enable continuation or resumption of
activities.

ACTIONS/INTERVENTIONSIndependent

Determine functional ability (0–4 scale) and reasons for impairment.Note emotional/behavioral
responses to altered ability.Plan activities/visits with adequate rest periods as necessary.Encourage
participation in self-care, occupational/recreational activities.Provide chairs with firm, high seats and
lifting chairs when indicated.

Fall Prevention (NIC)

Assist with transfers and ambulation if indicated; show patient/SO ways to move safely.Obtain
supportive shoes and well-fitting, nonskid slippers.Remove extraneous furniture from pathways.

RATIONALE

Identifies need for/degree of intervention required.Physical changes and loss of independence often
create feelings of anger, frustration, and depression that may be manifested as reluctance to engage in
activity.Prevents fatigue; conserves energy for continued participation.Promotes independence and self-
esteem; may enhance willingness to participate.Facilitates rising from seated position.Prevents
accidental falls/injury, especially in the patient with altered gait, generalized weakness, orthostatic
hypotension, fatigue and vision disturbances.Assists patient to walk with a firm step/maintain sense of
balance and prevents slipping.Prevents patient from bumping into furniture and reduces risk of
falling/injuring self