NCP Circumsicion

Circumcision
Circumcision is a surgical procedure in which the prepuce (foreskin) of the penis is separated from the glans, and a portion is excised. This elective procedure is performed in the United States based on parental choice for reasons related to hygiene, religion, tradition, social norms, and culture. It is usually performed at 12–24 hr of age or when the infant is considered physically stable. Frequency of this procedure has declined in recent years to approximately 62%.
NEONATAL ASSESSMENT DATA BASE
Circulation
Vital signs WNL, no signs of cold stress
Administration of vitamin K
Food/Fluid
Weight at least 2500 g (5 lb 8 oz)
Safety
Temperature WNL
Free of congenital anomalies; no family history of bleeding disorders or history of “proud flesh” scar formation (especially in black families)
Sexuality
Infant full-term (based on Dubowitz criteria)
Genitalia normal, with no evidence of hypospadias or epispadias; testes descended, and scrotal sac free of hydrocele; prepuce, still developing at birth, normally nonretractable
DIAGNOSTIC STUDIES
CBC: Rules out presence of anemia.
Clotting Studies: Identify coagulation problems.
NURSING PRIORITIES
  1. Provide parents with sufficient information to make an informed choice.
  2. Promote comfort and healing.
  3. Identify and minimize postoperative complications.
  4. Instruct parent(s) in proper care of circumcised infant.
discharge criteria
  1. Void appropriately past procedure.
  2. Free of complications.
  3. Parent(s) understand care needs and signs/symptoms requiring further evaluation.
NURSING DIAGNOSIS:                                                               KNOWLEDGE deficit [Learning Need], regarding surgical procedure, prognosis,
and treatment
May Be Related To:                                                                        Lack of exposure, misinterpretation, unfamiliarity with information resources
Possibly Evidenced By:                                                                   Request for information, verbalization of concerns/misconceptions, inaccurate follow-
through of instructions
DESIRED OUTCOMES/EVALUATION                                    Make informed decision.
CRITERIA—PARENT(S) WILL:                                               Demonstrate proper technique of care following procedure.
Verbalize understanding of signs of complications.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Ascertain parents’ understanding of the                                                 Provides a basis for discussion and identifies need
procedure. Determine cultural/religious influences.                               for further information. While cultural/religious
beliefs may dictate circumcision be performed, some
studies have shown that many women do not know
the meaning of the word or whether their husbands
are circumcised.
Review information about the advantages and                                       The routine practice of circumcision has been
disadvantages of circumcision.                                                               questioned, and the position of the American
Academy of Pediatrics (1989) is that there are both
potential medical benefits and advantages as well as
disadvantages and risks. Proponents believe that
circumcision may reduce risk of cancer of the penis
and prostate in men and of the cervix in women; that it
has prophylactic effects against a number of diseases,
including herpes; that it facilitates hygiene; and that an
uncircumcised boy may feel different from his peers.
Opponents believe that the cancer link is not proved
by scientific studies and that hygiene is more of a
factor in cancer prevention than is circumcision; that
the long-term effects of pain and stress are not known;
and that complications are a significant concern.
Discuss anticipated infant behaviors following                                      Changes in sleep patterns, fussiness, and/or
procedure.                                                                                               refusal of feedings usually persist for 2–3 hr
following procedure. However, studies indicate that
elevated cortisol levels associated with stress of the
procedure can interfere with the newborn’s ability to
regulate sleep-wake cycles for some time following
circumcision.
Note any special requests made by parents.                                           Parents may want to be present during the procedure
or may have specific religious or cultural preferences.
Provide information about the healing process                                      Prevents complications associated with infection;
and proper care (e.g., cleaning, diapering,                                             promotes infant’s comfort. Refer to ND: Pain
positioning, use of petroleum gauze dressing or                                    [acute]. Note: If plastic bell method is used to
bacterial ointment). Discuss the need to check                                      cover the glans, petroleum gauze is not needed.
infant frequently to prevent gauze from drying
out and sticking to site of circumcision. Suggest
soaking gauze with warm, sterile water before
removing it.
Discuss potential complications, e.g., hemorrhage,                               Ensures prompt identifications and treatment of
infection, or other signs warranting notification of                                problems.
healthcare provider.
NURSING DIAGNOSIS:                                                               PAIN [acute]
May Be Related To:                                                                        Trauma to/edema of tender tissues
Possibly Evidenced By:                                                                   Crying, irritability, changes in sleep pattern, refusal to eat
DESIRED OUTCOMES/EVALUATION                                    Appear relaxed, appropriately consolable.
CRITERIA—NEONATE WILL:                                                 Resume normal sleeping and eating patterns.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Provide pacifier (dipped in sugar, if desired),                                        Provides distraction and sense of reassurance to
stroke lightly, and talk gently to infant                                                   soothe the infant.
during procedure. Observe infant response.
Remove infant from restraints immediately                                           A sense of uneasiness occurs because of
following procedure. Calm infant by holding,                                       positioning and restraint. Acute pain occurs at the
cuddling, dressing, and talking to him.                                                  time of surgical procedure, because the foreskin
Encourage parents to feed and cuddle infant.                                         contains numerous nerve endings. Change of
position, freedom of movement, and tactile activities
refocus infant’s attention and comfort infant. Feeding
may promote relaxation. Note: Infant’s turning head
away, increased restlessness, hiccuping suggest
overstimulation, which may further distress the
infant.
Apply petroleum jelly and gauze dressing loosely                                 Protects against adherence to diaper and direct
around glans, as appropriate. Leave in place for                                    contact with urine.
at least 24 hr.
Position infant on side or back, not on abdomen.                                  Prevents friction or pressure on the penis. Plastic
Loose diaper or use no diaper at all for 24–72 hr                                   rim remains in place for 5–7 days. Plastic bell falls
following procedure. Note continued placement                                   off by itself when glans is healed. Note: Removal
of plastic rim following circumcision with plastic                                 of the bell by the healthcare provider may be
bell.                                                                                                         required.
Avoid use of soaps on penis; clean with clear water.                             Soap may cause irritation, increasing discomfort, and
may cause plastic bell to fall off prematurely.
Protect the surgical site from alcohol when caring                                Alcohol may cause stinging, adding to infant’s
for umbilicus.                                                                                          discomfort.
Apply a small amount of bland or petroleum-based                              Prevents the area from sticking to diaper.
ointment on the affected area or on the dressing
that may be covering the site at each diaper
change or at least 4–5 times a day for 24–48 hr.
Note infant’s behavior following procedure.                                          Acute pain following the procedure may last
approximately 30 min, whereas discomfort related to
trauma, edema, and irritation from clothing may last
for up to 7 days until healing is completed.
Collaborative
Assist with dorsal penile nerve block with 1%                                      Although it is not used routinely, anesthesia
lidocaine without epinephrine or chloroprocaine                                    abolishes the pain and distress manifested in the
(Nesacine).                                                                                              unmedicated infant by changes in hormone levels
and cardiovascular system, vigorous crying, attempts
to wriggle from restraints, and trembling. Nesacine
has a faster onset of action. Note: Risk of nerve
damage exists if injection is not carefully
placed, and the risks of elevated blood levels of
lidocaine are as yet unstudied.
Apply topical agents, e.g., EMLAcream                                                Topical agent applied 1-2 hr before procedure may be
(lidocaine and prilocaine) to penis.                                                        as effective as nerve block without associated risks.
Administer acetaminophen drops as indicated.                                       Helps ease acute pain, enhances effects of calming
behaviors.
NURSING DIAGNOSIS:                                                               URINARY ELIMINATION, altered
May Be Related To:                                                                        Tissue injury/inflammation, or development of urethral fistula
Possibly Evidenced By:                                                                   Edema, difficulty voiding
DESIRED OUTCOMES/EVALUATION                                    Void within 6–8 hr following circumcision.
CRITERIA—NEONATE WILL:                                                 Establish normal elimination pattern.
PARENT(S) WILL:                                                                        Prevent/minimize edema.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Record time of first voiding following procedure.                                 Trauma to the urinary meatus from the procedure
Note amount and adequacy of stream and                                              may result in delayed voidings, blocked urinary
presence of hematuria.                                                                            passage, or interrupted stream.
Loosely diaper the newborn and position on                                          Reduces pressure on affected site.
side or back.
Avoid placing petroleum jelly over the meatus.                                     Excessive amounts of petroleum jelly may block
meatus, requiring greater effort to empty bladder.
Place warm, wet washcloth over the bladder area                                  Relaxes musculature and may encourage voiding.
if voiding has not occurred within 6–8 hr
following procedure.
Notify healthcare provider if infant fails to void                                    Failure to void may indicate urethral fistula,
within 12 hr following procedure.                                                          necessitating further evaluation.
NURSING DIAGNOSIS:                                                               INJURY, risk for hemorrhage
Risk Factors May Include:                                                             Decrease in clotting factors immediately after birth (do not return to prebirth levels until the end of the 1st wk); previously unidentified problems with bleeding and clotting
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Be free of injury; no evidence of hemorrhage.
CRITERIA—NEONATE WILL:
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Delay surgical procedure until at least 12–24 hr                                    Postponing circumcision from the time
following birth.                                                                                       immediately following birth to 12 or more hr
following birth helps prevent complications
associated with physiological instability, cold stress,
undetected congenital anomaly, and illness.
Observe infant every hour for first 12 hr after                                       Aids in early detection of persistent bleeding.
the procedure.                                                                                         Note: Excessive blood loss may be an initial indicator
of bleeding/coagulation problems, such as
hemophilia.
Apply gentle, direct pressure to bleeding site,                                       Promotes vasoconstriction to stop bleeding.
using a sterile gauze pad.
Apply sterile petroleum gauze dressing to site                                       Acts as a pressure dressing to control bleeding and
immediately following procedure and with                                            prevent surgical site from adhering to the diaper,
each diaper change, if plastic bell method is not                                    which could cause further irritation or loss of
used. Moisten gauze with water if it adheres                                         stable clot.
to surgical site.
Collaborative
Apply Gelfoam to bleeding areas.                                                          Gelfoam acts as a local hemostatic agent to promote
platelet adhesion and clotting.
Assist with placement of suture(s), as needed.                                       May be necessary to control bleeding.
NURSING DIAGNOSIS:                                                               INFECTION, risk for
Risk Factors May Include:                                                             Immature immune system, invasive procedure/tissue trauma, environmental exposure
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes and actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display timely healing of circumcision site within
CRITERIA—NEONATE WILL:                                                 1 wk.
Be free of signs of infection.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Clean penis gently with warm, sterile water or                                      Removes urine/feces from penis; helps promote
dilute hydrogen peroxide, and apply fresh sterile                                  healing. Note: Excessive scrubbing may irritate the
petroleum gauze with each diaper change.                                             site and provide entry for bacteria.
Note appearance of whitish yellow exudate                                           Exudate is usually noted 24–48 hr following
around the glans. Do not remove.                                                           procedure. It is a normal sign of the granulation
process and eventually disappears on its own.
Observe penis for signs of infection at each diaper                                Early detection of infection can prevent
change, (e.g., erythema or purulent exudate).                                        generalized sepsis from occurring.
Ensure that plastic bell is still firmly attached,
if used.
Collaborative
Obtain culture of exudate, if present.                                                     Identifies pathogens, appropriate treatment choices.
Monitor results of laboratory studies, e.g., CBC.                                   Helps confirm presence or resolution of infectious
process.
Administer local or systemic antibiotic, as indicated.                            Treats infection; prevents systemic involvement.
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