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A Case Study Hypospadias

JRRMMC Batch 33 Group 8

The study focuses on the actual case of a 4 year old boy with hypospadias. In line with this, the group aims to identify and analyze the occurrence, the signs and symptoms, as well as its etiologic and pathologic factors and the diagnostics and interventions needed for this kind of condition. Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus (the opening, or male external urethral orifice). Instead of opening at the tip of the glans of the penis, a hypospadic urethra opens anywhere along a line running from the tip along the of the shaft to the junction of the penis and scrotum or perineum

A distal hypospadias may be suspected even in an uncircumcised boy from an abnormally formed foreskin and downward tilt of the glans. Hypospadias repair is, however, controversial because it is genital surgery. Some people regard it as unnecessary interference with a child's body and a traumatic experience with psychological consequences extending into adult life. Others maintain that boys with untreated hypospadias are far more likely than those who have had surgery to develop fears about intimate relationships and sexuality.

Hypospadias is one of the most common birth defects of the male genitalia but widely varying incidences have been reported from different countries, from as low as 1 in 4000 to as high as 1 in 125 boys. The incidence of hypospadias around the world has been increasing in recent decades. Two surveillance studies reported that the incidence had increased from about 1 in 500 total births (1 in 250 boys) in the 1970s to 1 in 250 total births (1 in 125 boys) in the 1990s. Although a slight worldwide increase in hypospadias was reported in the 1980 - 2005, studies in different countries and regions have yielded conflicting results and some registries have reported decreases. The availability and cooperation of the client and its relatives help us come up choosing the case.


To describe the congenital defect process of hypospadias. To illustrate the pathophysiology of hypospadias. To determine the importance of the treatment and management of the congenital defect. To formulate specific and appropriate nursing care plan. To evaluate the effectiveness of the interventions and detect any progress of the clients condition.


Personal Data
Name: Patient X Age: 4 years old Birthday: March 31, 2007 Religion: Roman Catholic Weight: 23kg Date of Admission: July 13, 2011 Diagnosis: Hypospadias Operation: Repair of Hypospadias; Circumcision, Urethroplasty and Glanuloplasty Date of Operation: July 14, 2011 Date of Discharge: July 18, 2011 Source of Data: Mother


History of Present Illness

Chief Complaint: Abnormal Urination When the child was at 4 months of age, his mother noticed an abnormal direction of the urine every time he void. The mother seeks for medical assistance and immediately went to Jose R. Reyes Memorial Medical Center; the physician explained the condition and advised to comeback after 3 years for surgery.

III. Past Medical History

The mother denies any serious illnesses, except for mild fever, cough, colds, measles, chickenpox, mumps and no known allergies noted. When asked about the vaccinations he has received during childhood, his mother claimed that he received complete immunization.

IV. Family History

Urinary Tract Infection Hypospadias

Hypertension Asthma






Social and Personal History

According to the mother, the patient has initiative to study, eat, play and the like. The mother verbalized mahilig yan maglaro, madami syang friends. The parents are aware of the abnormal location of urethral orifice of their child thus, the patient has regular micturation.

VI. Nursing Assessment

Date Assessed: July 19, 2011  Time: 10:00 AM  General Survey: The patient is post operative, conscious and afebrile.  PR: 98 RR: 28 T: 36.4


Physical Assessment
Normal Findings Equally distributed Actual Findings Equally distributed Thick, silky and resilient hair White sclera, no White sclera, no discharge, lids close symmetrically, pupil Eyes constricts when illuminated, both eyes move in unison Symmetrical, pinna Ears recoils after it is folded, No aural discharges, Symmetrical, pinna recoils after it is folded, No discharges, Within normal range discharge, lids close symmetrically, pupil constricts when illuminated, both eyes move in unison Within normal range Interpretation Within normal range



Thick, silky and resilient hair


Physical Assessment
Symmetric and straight, no nasal discharges Uniform pink color Uniform pink color lips, Uniform pink color lips, Within normal range Symmetric and straight, Within normal range


moist mucous membrane Muscles equal in size; head centered; no neck vein

moist mucous membrane Muscles equal in size; head centered; no neck vein engorgement, No palpable lymph nodes Within normal range


engorgement, No palpable lymph nodes Good complexion,

Good complexion, good skin turgor and elastic

Within normal range


good skin turgor and elastic


Physical Assessment
Intact, With suprapubic tube cystoscopy on hypogastric region Urethral meatus is Surgical incision site

Abdomen (-) tenderness,

No enlargement or tenderness,

located underside of the

Size is relative to body penile Genital size, Urethral meatus positioned at the tip of the penis Various to some degree with the Extremities person s physical activity, Intact With IV catheter on the left hand With urethra stent in the Hypospadias

IV fluid replacement


Developmental Theory

Erick Ericsons Psychosocial Theory: INITIATIVE VS GUILT

Before Hospitalization During Hospitalization Interpretation and Analysis
According to the mother, the The patient has restrictions in Interpretation: Since the patient is hospitalized patient has initiative to study, doing things he wants to do his activities of daily living is limited. But his eat, play and the like. The due to his condition (with social interaction wasn t affected because he is mother verbalized mahilig intravenous fluid, suprapubic still interacting with other people. yan maglaro, madami syang friends.

tube cystoscopy, with filler at Analysis: Stage 3 - Initiative vs. Guilt Children who are successful at this stage feel the urethra.) capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt and lack of initiative. Reference: http://psychology.about.com/od/psychosocialt heories/a/psychosocial_2.htm


Developmental Theory

Sigmund Freuds Psychosexual Theory: PHALLIC STAGE/OEDIPAL COMPLEX

Before Hospitalization During Hospitalization Interpretation and Analysis He is more attached to his He still depends on his Interpretation: Since he is a 4 year old boy, he is mother rather than his father mother. in the stage of the so called oedipal complex. Analysis: Freud also believed that boys begin to view their fathers as a rival for the mother s affections. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the father. Reference: http://psychology.about.com/od/theoriesofperso nality/ss/psychosexualdev_4.htm


Developmental Theory

Jean Piagets Cognitive Development Theory: PRE-OPERATIONAL (2-7y/o)

Before Hospitalization During Hospitalization When asked about his He is mischievous Interpretation: The patient is expressing his point of view, showing how egocentric he is at his age. Analysis: The belief that you are the centre of the universe and everything revolves around you: the corresponding inability to see the world as someone else does and adapt to it. Not moral "selfishness", just an early stage of psychological development. Reference: http://www.learningandteaching.info/learning/piaget.htm Interpretation and Analysis

cognitive development the and cheerful. mother verbalized, siya

Nagpapakitang gilas

lalo na pag may bisita kame sa bahay.


Developmental Theory

Lawrence Kohlbergs Moral Development Theory: PRE-CONVENTIONAL/OBEDIENCE & PUNISHMENT

Before Hospitalization The mother During Hospitalization Interpretation and Analysis verbalized, He obeys his father Interpretation: He is afraid of punishment that s why he naman yan command whenever follows his parent s rules.


kasi takot yan sa tatay nya. there s a procedure to Analysis: The first level of moral thinking is that generally Disiplinado kasi yun . be done. found at the elementary school level. In the first stage of this level, people behave according to socially acceptable norms because they are told to do so by some authority figure (e.g., parent or teacher). This obedience is compelled by the threat or application of punishment. Reference: http://www.csudh.edu/dearhabermas/kohlberg01bk.htm

VIII. Pathophysiology:

The term, hypospadias, means under [hypo] the rent [spadon]. Hypospadias can occur anywhere along the urethral groove. In mild forms, the urethra opens just under the corona glandis. This is called coronal hypospadias


Increased Maternal Age Cause is unknown Family History


The genitals develop a masculine phenotype primarily under the testosterone As the phallus grow, the open urethral groove extends from its base to the level of the corona

Urethral opening



Repair of Hypospadias

IX. Drugs study

Brand/Generic Name Dosage/ Frequency Classification Mechanism of Action Inhibits enzymes involved in formation of peptidoglycan layer of bacterial cell wall Indication Contraindication Side Effect Nursing Responsibility

Generic name: 156mg/5ml 5ml Co-amoxiclav BID Brand name: Per Natravox


Skin and soft Hypersensitivity to tissue penicillins. infection

Hand washing before & Superficial after the procedure tooth discolorati Observe 10 Rights when on giving medication Nausea Watch out for any untoward reaction of the drug, if its occur intervene and refer it immediately Teaching points: Informed the parent or the significant other that tooth discoloration is expected but can be removed by brushing teeth.

Brand/ Generic Name

Dosage/ Frequency

Classificatio n

Mechanism of Action



Side Effect

Nursing Responsibility

Generic name: Mupirocin Ointment Brand name: Bactroban Ointment

On affected side Once daily

Antibacterial It blocks the activity of an Agent enzyme called isoleucyl-tRNA synthetase within the bacteria. This enzyme is necessary in order for the bacteria to make proteins. Without the ability to make proteins, the bacteria die.

Treatment for impetigo due to Staphylococ cus aureus and Streptococc us pyogenes.

Contraindicated with Hypersensitivity to any of its components.


Burning sensation Stinging Itching Rash Erythema Dry skin Swelling



Hand washing before & after the procedure Observe 10 Rights when giving medication Watch out for any untoward reaction of the drug, if its occur intervene it immediately Teaching points: Apply small/thin amount to affected area, may be covered with a gauze dressing Daily wound care

Brand/ Generic Name

Dosage/ Frequency


Mechanism of Action



Side Effect

Nursing Responsibility

Generic 250 mg/5ml Acetaminoph name: 5ml every 6 en Paracetamol hours for Brand name: fever and Biogesic pain

Antipyretic: Reduces fever by acting directly on hypothalamic heat-regualating center to cause vasodilation and sweating which helps dissipate heat Analgesic

Mild to moderate pain Fever

Hypersensitivity to Acetaminophen

Skin Rashes


Hand washing before & after the procedure Observe 10 Rights when giving medication Refer to physician for any untoward reaction of the drug.


Nursing Care Plan

Nursing Diagnosis Risk for Infection Related To Insufficient Knowledge To Avoid Exposure To Pathogens Planning After 5-7 days of nursing intervention, the patient will show negative signs of infection.

Assessment A risk diagnosis is not evidenced by signs and symptom, as the problem has not occurred and nursing interventions are directed at prevention. Objectives:  Surgical Incision Site (suprapubic catheter & stent)


Nursing Care Plan cont.

Rationale y The first line defense against heath care associated infection. y To reduce risk of cross contamination Evaluation After 5-7 days of nursing intervention, the patient shows negative signs of infection.

Intervention y Stressed proper hand hygiene by all care givers between therapies and the client. y Changed surgical/ other wound dressing, as indicated, using proper technique for changing/ disposing of contaminated materials. y Monitored client s visitors/caregivers for respiratory illnesses. Offered masks and tissues to visitors who are coughing/sneezing. y Encouraged early ambulation and deep breathing exercises. y Emphasized necessities of taking antibiotics as ordered.

To limit exposures, thus reduce cross contamination

y y

For early mobilization Premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug resistant strains.


Nursing Care Plan cont.

DIAGNOSIS Impaired Skin Integrity Related To Mechanical Factor Specifically Trauma: Surgery PLANNING After 5-7 days of nursing intervention, the patient s wound will display timely healing without complication.

ASSESSMENT Subjective: y Reported irritability at the surgical site Objectives: y Disruption of skin surface (suture)


Nursing Care Plan cont.

RATIONALE y To monitor progress of wound healing. y To assist body s natural healing process.
y To protect the wound or surrounding tissue y To prevent further skin irritation.

INTERVENTION y Observed for complications. y Kept the area clean and dry, carefully dressed wounds. y Used appropriate wound dressing. y Applied Mupirocin Ointment on the affected site as ordered.

EVALUATION After 5-7 days of nursing intervention, the patient s wound displayed timely healing without complication.

XI. Discharge Planning

Medications Instructed the mother to follow all the prescribed medications. Take home medications are as follows: Co-amoxiclav 156mg/5ml give 5 ml twice a day for 7 days, Paracetamol 250mg/5ml give 5ml every 6 hours for pain. Instructed the mother that the patient do not have to stay in bed at all times, but he needs to be watched closely. He may walk and play quietly. Discouraged the patient to use straddle toys, walkers, or bicycles as doctors order. Application of anti-bacterial medication like Mupirocin Ointment to the area to prevent infections. Always do proper hand washing and proper hygiene. Instructed for daily wound care to prevent infection. Avoid strenuous activities that would lead to bleeding and have adequate rest for timely wound healing. Follow up appointment July 26,2011 @ Out Patient Department to monitor the progress of the treatment. Advised the mother to give her son fruit juice, soups and crackers to help prevent stomach upset. It is important that his son drinks plenty of fluids. Give him foods high in fiber, such as cereal or fruit to prevent constipation. Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord by showing love and respect to the people around you.


Treatment Health Teaching

Out-Patient Diet