Revised Case Report- Hemorrhoids

I.

INTRODUCTION “There are three wicks you know to the lamp of a man's life: brain, blood, and breath. Press the brain a little, its light goes out, followed by both the others. Stop the heart a minute, and out go all three of the wicks. Choke the air out of the lungs, and presently the fluid ceases to supply the other centres of flame, and all is soon stagnation, cold, and darkness.” -Oliver Wendell Holmes, Sr.

Health is an essential part of a person; it is the fuel which gives every individual the physical drive needed to conquer a day. Without it no man can survive, a deficiency in health impairs the normal functioning of a person, it becomes a hindrance. Health pertains to the person’s body systems as a whole, it is not achieved if even only one body system is impaired, a good heart with weak lung still does not signal health, there should be harmony and balance between the systems to achieve ultimate health. Hemorrhoids Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it’s usually not serious. Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. It is possible to have have both types at the same time. The symptoms and treatment depend on which type is existent. Internal hemorrhoids With internal hemorrhoids, there is visible bright red streaks of blood on toilet paper or bright red blood in the toilet bowl after a normal bowel movement. Blood is also visible on the surface of the stool. Internal hemorrhoids often are small, swollen veins in the wall of the anal canal. But they can be large, sagging veins that bulge out of the anus all the time. They can be painful if they bulge out and are squeezed by the anal Hemorrhoids - Page | 1

muscles. They may be very painful if the blood supply to the hemorrhoid is cut off. If hemorrhoids bulge out,mucus may also be seen on the toilet paper or stool. External hemorrhoids External hemorrhoids can bleed, and then the blood pools, causing a hard painful lump. This is called a thrombosed, or clotted, hemorrhoid. Prevelance statistics about Hemorrhoids:The following statistics relate to the prevalence of Hemorrhoids: 47 per 1000 people (NHIS95);1.0% of male population self-reported having haemorrhoids in Australia 2001 ;1.1% of population self-reported having haemorrhoids in Australia 2001 ;1.2% of female population self-reported having haemorrhoids in Australia 2001 ; 209,000 people self-reported having haemorrhoids in Australia 2001;

120,000 women self-reported having

haemorrhoids in Australia 2001 ;89,000 men self-reported having haemorrhoids in Australia 2001 (ABS 2001 National Health Survey, Australia’s Health 2004, AIHW)

(retrieved

from

the

website:

http://www.wrongdiagnosis.com/h/hemorrhoids/stats.htm) A different method for the treatment of haemorrhoids was introduced back in the late 1990s, it is called “Stapling”. Stapling became a popular alternative for hemorrhoidectomy because, it entailed faster healing, lesser pain, and lesser occurrence of itching. Although a study was conducted wherein out of 269 stapling patients, 23 suffered recurrences, compared with four recurrences among 268 patients in the surgical-removal group, it showed a higher recurrence rate than that of the surgical removal procedure. With this result, the authors still considered excisional surgery as the gold standard of the surgical treatment of haemorrhoids. Excisional surgery came with no or minimal recurrences, it may not entitle faster healing and lesser pain that of Stapling but it guarantees the lesser risk of recurrence after the procedure and

Hemorrhoids - Page | 2

recovery.

The article confronts the main concern of hemorrhoid surgical

treatment which is the longterm outcome. (Source: http://www.doctorslounge.com/surgery/news/hemorrhoid_stapling_risks.shtml) This information about haemorrhoid Stapling gives both nurses and doctors knowledge about the procedure, its benefits and consequences. Through the facts they could be more knowledgeable and may give more info to their patients regarding what procedure may be beneficial to them or which procedure would the patient prefer. And for doctors, they can have better judgement and be able to suggest a suitable procedure for a patient to undergo hemorrhoidectomy. For nurses, it can help by giving them an idea as to what should they be anticipating in terms of post-surgical outcomes, and give them a plan to create their nursing care plans for a post-op hemorrhoidectomy patient, plus be able to give effective health teachings.

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II.

ANATOMY AND PHYSIOLOGY

Lower Gastrointestinal Tract The lower gastrointestinal tract comprises most of the intestines and the anus. •

Bowel or intestine

o

Small intestine, two of the three parts: 

Duodenum - Here the digestive juices from pancreas and liver mix together



Jejunum - It is the midsection of the intestine, connecting Duodenum to Ileum.

 o

Ileum - It has villi. All soluble liquid absorbs here with blood.

Large intestine, which has three parts: 

Cecum (the vermiform appendix is attached to the cecum).



Colon (ascending colon, transverse colon, descending colon and sigmoid flexure)

 •

Rectum

Anus

Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Hemorrhoids - Page | 4

Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion.

Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. Hemorrhoids - Page | 5

The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces. Rectum and Anus The rectum continues from the sigmoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control.

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III.

THE PATIENT AND HIS ILLNESS

Non-modifiable

Modifiable factors

factors

Obesity

Age (20-50y.o)

Sedentary lifestyle Constipation

Gender

Chronic Diarrhea

Family history

Poor bathroom habits

Pregnancy

Postponing bowel movement Intake of fiber-deprived diet Cirrhosis of the liver Prolonged sitting or standing

Tenesmus

Increases intra-abdominal pressure

Increases hemorrhoidal venous pressure

Distention of the hemorrhoidal veins

Rectal ampulla is filled with formed stool

Venous obstruction

Repeated pressure and obstruction

Prolonged pressure and obstruction

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Permanently dilation of hemorrhoidal veins

Enlarged and thrombosed

Bleeding and prolapsed

Severe bleeding

Thrombosis

Hemorrhoidal strangulation

Iron Deficiency Anemia

Intense Pain

Cut off blood supply by anal sphincter

Severe pain Stapled Hemorrhoidectomy Extreme edema

Inflammation

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B.1. Definition of the disease Hemorrhoids are varicose (swollen or dilated) veins located in or around the anus. Internal hemorrhoids are varicose veins that surround the rectum and, when dilated, protrude inside, sometimes extending out of the anus. Scientists aren't sure why people get hemorrhoids. They are usually not painful, but they can be bothersome. Hemorrhoid sufferers can frequently and safely push them back inside. Certain conditions may cause internal hemorrhoids to bulge, become irritated and bleed, including: •

Trauma during childbirth

•

The extra weight of pregnancy

•

Obesity

•

Chronic constipation with straining

•

Anal intercourse

Rarely, a bulging internal hemorrhoid may thrombose, meaning a blood clot may occur. External hemorrhoids are varicose veins located under the skin on the outside of the anus. They are frequently painful and usually arise when a blood clot blocks off the vein. Hemorrhoids caused by a blood clot, medically referred to as thrombosed hemorrhoids, need to be treated right away by a doctor. The doctor usually will remove the blood clot. Otherwise, most cases of hemorrhoids can be treated at home, with the most important aspect of care being good hygiene. Rarely, surgery is required to remove them.

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B.2. Predisposing / Precipitating factors Predisposing factors •

Age- 20-50 years of age typically have hemorrhoids because they are within the working age and at the same time reproductive age for women.

•

Gender- Females has greater tendency for having hemorrhoids due to trauma during childbirth and extra weight during pregnancy.

•

Family History - If the patient has several close relatives who have had hemorrhoids, the patient may be at an increased risk of hemorrhoids.

•

Pregnancy – It is due to the pressure on lower part of the body because of the extra weight of the gravid uterus especially in the third trimester.

Precipitating factors •

Obesity- It is because of the pressure due to heavy weight.

•

Sedentary lifestyle- Immobility can lead to constipation which can

cause increased abdominal pressure during bowel movement. •

Constipation- Straining during chronic constipation can cause

internal hemorrhoids to bulge. •

Chronic Diarrhea- Repeated pressure and straining can irritate the

lining of the anus. •

Poor bathroom habits- Overly aggressive wiping of the anus can

worsen hemorrhoids. •

Postponing bowel movement- Re-absorption of water in the colon

can lead to constipation and possible fecal impaction. •

Intake of fiber-deprived diet- No bulk in the food can lead to

constipation. •

Cirrhosis of the liver- It can cause pooling of blood in the vessels

around the rectum.

Hemorrhoids - Page | 10

•

Prolonged sitting or standing- It increases intra-abdominal pressure

and also causes relative venous return. B.3. Symptoms •

Pain and pressure in the anal canal- This is due to cut off blood

supply by anal sphincter and thrombosis. •

A grapelike lump on the anus- Collection of varicose (swollen or

dilated) veins located in or around the anus. •

Itching and soreness in and around the anus- This is due to the

permanently dilation of hemorrhoidal veins. •

Blood on underwear, toilet paper, the surface of the stool, or in the

toilet bowl- This happens when they are irritated during straining. Symptoms can be made worse by straining during constipation and overly aggressive wiping of the anus. Diagnosis Usually, an explanation of your symptoms is an important clue to your doctor. On examination, external hemorrhoids and bulging hemorrhoids may be visible. When hemorrhoids are not visible beyond the anus, your doctor may examine the inside of the anal canal using a lighted instrument called an anoscope. Often your doctor will recommend a detailed examination of your sigmoid colon and rectum using a lighted scope (flexible sigmoidoscopy to ensure that there is no inflammatory disease such as Crohn's disease or ulcerative colitis or cancer. Treatment for pain and itching

Hemorrhoids - Page | 11

•

Take warms soaks in the bath (sitz baths). Sit in plain warm

water for about 10 minutes several times a day. •

Apply a hemorrhoid cream or use a suppository. Follow the

directions on the package. •

Don't strain during bowel movements.

Treatment for constipation •

Increase the amount of fiber in your diet. Good sources of

fiber are fruits, vegetables, and whole grains. Five to ten servings of fruits

and

vegetables

are

recommended

each

day.

Fiber

supplements may be helpful -- examples include Metamucil and Citrucel. •

Sparingly use over-the-counter laxatives or stool softeners.

Stool softeners like Colace are relatively safe, but prolonged use of osmotic or stimulant laxatives may not be. •

Exercise regularly. Even walking regularly helps improve the

normal flow of material through the intestine. •

Empty the bowels when you feel the urge to do so.

Immediately following a meal the body will have a natural urge to defecate. That's a good time to plan a visit to the bathroom. Prevention The best way to prevent hemorrhoids is to keep bowel movements regular and stool soft. Try some of the tips for relieving constipation listed above. Also, avoid prolonged standing, sitting, and heavy lifting, and chronic coughing, straining at stool, and aggressive wiping.

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IV.

CLINICAL INTERVENTION

1.1 Description of prescribed surgical treatment performed According to Black and Hawks (2009), hemorrhoidectomy is a procedure wherein the vein is excised, and the area is either left open to heal by granulation or is closed with sutures. The open method is very painful but has a high rate of success. The suture method, although far less painful, is more likely to cause infection and result in poor healing. Complications include infection, stricture formation as the lesion heals, and hemorrhage. Hemorrhage may occur immediately after surgery or about 10 days later as a result of sloughing of tissue. Also, bleeding may not be evident because it can occur into the rectum without being passed immediately (p.722).

Hemorrhoids - Page | 13

Hemorrhoids can occur inside the rectum, or at its opening. To remove them, the surgeon feeds a gauze swab into the anus and removes it slowly. A hemorrhoid will adhere to the gauze, allowing its exposure. The outer layers of skin and tissue are removed and then the hemorrhoid itself. The tissues and skin are then repaired.

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1.2

Indication of prescribed surgical treatment Hemorrhoidectomy is indicated for hemorrhoids with persistent

itching, anal bleeding, pain, and blood clots (thrombosis) not relieved by nonsurgical treatment (fiber rich diet, laxatives, stool softener, suppositories, medications, warm baths), very large internal hemorrhoids, internal hemorrhoids that still cause symptoms after nonsurgical treatment, large external hemorrhoids that cause significant discomfort and make it difficult to keep the anal area clean, both internal and external hemorrhoids, patients who have had other treatments for hemorrhoids (such as rubber band ligation) that have failed. It is also necessary for patients with severe bleeding, intolerable pain and pruritus, and large prolapsed hemorrhoids. Risk VS. Benefit of Hemorrhoidectomy Hemorrhoidectomy has certain risks like constipation, Excessive discharge of fluid from the rectum, fever of 101°F or higher, inability to urinate or have a bowel movement, severe pain( especially when having a bowel movement), severe redness and/or swelling in the rectal area, side effects of anesthesia (e.g., spinal headache, reactions to medications, problem breathing, nausea), bleeding, infection, additional risks include possible narrowing (stricture) of the anus or stenosis, of the hemorrhoid; fistula formation; and nonhealing wounds, some patients have temporary difficulty urinating due to swelling and the dressing. Other relatively rare risks include the following: •

Early problems

•

Bleeding from the anal area

•

Collection of blood in the surgical area (hematoma)

•

Inability to control the bowel or bladder ( incontinence)

•

Infection of the surgical area

•

Stool trapped in the anal canal (fecal impaction)

•

Late problems Hemorrhoids - Page | 15

•

Narrowing (stenosis) of the anal canal

•

Recurrence of hemorrhoids

•

An abnormal passage (fistula) that forms between the anal or rectal canal and another area

•

Rectal prolapse, which happens when the rectal lining slips out of the anal opening

Benefits of patients from hemorrhoidectomy is based from a high rate of success; most patients have an uncomplicated recovery with no recurrence of the hemorrhoids. Complete recovery is typically expected with a maximum period of two weeks. 1.3

Required instruments, devices, supplies, equipment, and facilities •

Nonsterile tray for anesthesia

•

The following items are placed on a nonsterile drape covering a Mayo stand:

The mayo stand utilizes a Tru-Loc friction-knob for manual locking at desired height. It uses a lighter tray-support and stainless-steel base.It is covered and used for placing surgical instruments that may be needed by the surgeon. Hemorrhoids - Page | 16

o Sterile gloves

o 1 inch of 4x4 gauze Gauze is a type of thin fabric with a very open weave. which is used to dress or apply pressure to wounds and stop bleeding. o 4x4 gauze soaked in povidone-iodine solution

o 1 inch of 2% lidocaine jelly (Xylocaine) placed on the corner of the drape Lidocaine is a local or topical anesthetic that can be applied to the skin or to mucous membranes to reduce the immediate feeling of pain and produce

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numbness or a 10ml syringe filled with 1% lidocaine with a 25 gauge, 1 ¼ inch needle. o Sterile tray for the procedure:

o Sterile drape covering a Mayo stand

o 2 inches of 4x4 gauze

o 3 hemostats (mosquito )

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also known as an arterial forceps or a hemostatic clamp, is one of the most common tools which surgeons use during the course of an operation. Hemostats are used to prevent and control bleeding of veins and arteries.

o No.15 scalpel blade and handle A scalpel is a thin, small, very sharp knife, which is used for cutting skin and muscle in surgery,

o Needle holder A needle holder, also called needle driver, is a surgical instrument, similar to a hemostat, used by doctors and surgeons to hold a suturing needle for closing wounds during suturing and surgical procedures.

o Adson forceps with teeth Forceps are commonly held between the thumb and two or three fingers of one hand, with the top end resting on the anatomical snuff box at the base of the Hemorrhoids - Page | 19

thumb and index finger. Some forceps have cross-hatched tips or serrated tips (often called 'mouse's teeth').

o Mayo scissors Straight-bladed Mayo scissors are designed for cutting body tissues near the surface of the wound. As the straight Mayo scissor is also used for cutting sutures, or stitches, it’s also sold as suture scissors.

o Curved clamps -used for holding tissues

o 4-0 vicryl suture is an absorbable suture used for internal surgery

o Surgical stapler Hemorrhoids - Page | 20

A surgical stapler is a medical device which is used to place surgical staples. Staples are used to close wounds ranging from bowel resections to skin incisions, and they are found widely all over the world in surgical settings.

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FACILITIES Defibrillator Machine Emergency Cart Surgic al Light

` ANESTHESIOLOGIST

Surgic al Light

P `

SUCTION MACHINE

S U R G E O N

A S S I S T A N T

A T I E

SCRUB NURSE

N SUTURE NURSE

T

MAYO TABLE BACK TABLE

CIRCULATING NURSE

SUPPLY CABINET

Hemorrhoids - Page | 22

1.4. Perioperative tasks and responsibilities of the Nurse PREOPERATIVE NURSING RESPONSIBILITIES: 

Secure informed consent. 

Provide gown for the patient.



Tape for wedding ring if necessary.



Any equipment and documents required by law and hospital policy.



Assess the pre operative education received by the patient and

ensure that it is complete and understood. 

Record the patient’s pulse, temperature blood pressure respirations

and weight. 

Those patients over the age of 45 will likely have to receive a

colonoscopy or x-ray of their colon. This is to make sure that the bleeding the patient may be experiencing is not due to some other factor. 

Be sure the patient or immediate relative signed the consent for

operation 

Shave the perineum



Two enemas will be needed prior to the surgery. Laxatives and

antibiotics, however, will not likely be administered prior to the operation. 

Prepare patient physically, must had full bath



Complete the pre operative check list by asking the patient and

checking records and notes before giving any pre medication. 

Ensure that the patient has been fasting from food and drink for the

prescribed length of time. 

Check whether the patient has micturated before pre medication.



Carry out pre -op medication as ordered by the surgeon



Ensure the patient is wearing an identification bracelet with the

correct information. Hemorrhoids - Page | 23

INTRAOPERATIVE NURSING RESPONSIBILITIES: SCRUB NURSE: 

Set up sterile supplies and instruments



Assists the surgeons as needed throughout the surgery



Assists in gowning and gloving the surgical team



Assists in draping the patient and the fields



Hands instruments and, sutures, sponges etc. as needed in an

efficient manner 

Keeps operative tidy during the case



Wipes blood from instruments



Keeps close watch on needles, instruments, and sponges so that

none will be misplaced or lost during the surgery 

Keeps an accurate account of needles and instruments



Supplies sterile dressing materials



Discards soiled linen into hamper after checking it for any

instruments 

Cares for all instruments and supplies

CIRCULATING NURSE: 

Functions as the overseer of the room during the procedure to

maintain sterility 

Assists the entire team and the patient



Sends for the patient at appropriate time



Receives, greets and identifies the patient



Checks chart for completeness



Assists patient in moving safely to operating room table

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

Assist anesthesiologist when requested, stays with the patient

during induction 

Ties scrubbed members’ gown



Checks operating room lights in advance for good working order

turns lights on at appropriate time and adjust when needed 

Prepares operative site



Connects catheter to drainage bottle, or catherize if desired by the

surgeon 

Does the sponge count with the scrub nurse



Positions the client



Supplies foot stools if needed by the surgeon team



Watches forehead for perspirations



Fills out required operative records completely and legible



Remains in the room as much as possible to be constantly

available 

Watches progress of surgery, anticipates needs, reacts quickly to

emergency 

Uses equipment and supplies economically and conservatively



Gathers supplies for case and opens sterile supplies for the scrub

nurse 

Connects/ reminds those who breaks any technique



Directs cleaning of the room and preparations for the next operation

POSTOPERATIVE NURSING RESPONSBILITIES: 

After surgery, the patient is taken to the postanesthesia care unit

(PACU). Patients are closely monitored by the nursing staff and remain there until they are stable. The amount of time spent in the PACU depends on the patient's progress and the type of anesthesia received. General anesthesia must wear off and the patient must be awake and coherent before they leave the PACU. Hemorrhoids - Page | 25



Outpatients are transferred to another room to finish their recovery,

and inpatients are taken to their hospital room. The intravenous line remains in until clear liquids are taken and tolerated. This can be almost immediately following surgery, especially if local anesthesia was used. Sometimes general anesthesia induces nausea, which may delay taking oral fluids. Once clear liquids are tolerated, the diet progresses to solid foods.



Spinal anesthesia usually wears off within a few hours. During the

first hour following surgery, patients lie flat on their back to decrease the risk for an anesthesia-induced headache, which can be painful and prolonged. Before being discharged, the patient must regain full sensation in the lower part of the body.



Because of swelling and the dressing, some patients have

temporary difficulty urinating. If there is urgency, but the urine will not flow, a catheter is used to empty the bladder. Outpatients may need to stay overnight, if they are unable to urinate. Patients must be able to urinate on their own before being discharged.



Even though the anesthesia has worn off, most patients remain

groggy for the rest of the day. Patients must arrange for a family member or friend to be with them if they are being discharged the same day as the surgery.



Patients experience pain and discomfort during the immediate

postoperative period (i.e., about 10 days). Pain medication is prescribed and should be taken as directed. Sometimes relief can be achieved with an over-the-counter preparation such as Tylenol®. If a

Hemorrhoids - Page | 26

pack was inserted into the rectum following surgery, the physician usually removes it in a day or two.



An ice pack can help reduce swelling. Soaking in a sitz bath (a

shallow bath of warm water) several times a day helps ease the discomfort. Using a donut ring (cushion with a hole in the middle) can make sitting upright more comfortable.



It is important to avoid constipation at this time. So, the physician

will prescribe stool softeners and a laxative. Eating a high-fiber diet and drinking plenty of liquids also helps. A small to moderate amount of bleeding, usually when having a bowel movement, may occur for a week or two following the surgery. This is normal and should stop when the anus and rectum heal.



Complete recovery takes 6 weeks to 2 months. Most patients return

to work within 10 days. Heavy lifting should be avoided for 2 to 3 weeks. 1.5 Expected outcomes of surgical treatment performed The outcome is usually very good in the majority of cases. Patients may experience the following: •

pain after surgery as the anus tightens and relaxes.

•

temporary difficulty in urinating due to swelling and the dressing.

•

discomfort during the immediate postoperative period (i.e., about 10 days). A small to moderate amount of bleeding, usually when having a bowel

movement, may occur for a week or two following the surgery. This is normal and should stop when the anus and rectum heal. Complete recovery takes 6 weeks to 2 months. Most patients return to work within 10 days. Heavy lifting should be avoided for 2 to 3 weeks.

Hemorrhoids - Page | 27

***Postoperative Complications Most patients are satisfied with the results of the surgery and recover without any problems. Complications associated with hemorrhoidectomy are rare and include: •

Anal fistula or fissure

•

Constipation

•

Excessive bleeding

•

Excessive discharge of fluid from the rectum

•

Fever of 101°F or higher

•

Inability to urinate or have a bowel movement

•

Severe pain, especially when having a bowel movement

•

Severe redness and/or swelling in the rectal area

•

Side effects of anesthesia (e.g., spinal headache)

•

Narrowing (stenosis) of the anal canal

•

Recurrence of hemorrhoids

•

An abnormal passage (fistula) that forms between the anal or rectal canal and another area

•

Rectal prolapse, which happens when the rectal lining slips out of the anal opening

***The surgeon should be notified if any of these symptoms are experienced during the immediate postoperative period. 1.6 Medical management of physiologic outcomes For pain - The doctor may prescribe narcotics to relieve the pain. The patient should take stool softeners and attempt to avoid straining during both defecation and urination. Soaking in a warm bath can be comforting and may provide symptomatic relief. Bleeding (if postoperatively) - never apply heat because of the increased risk of hemorrhage. Hemorrhoids - Page | 28

For difficulty in urination - If there is urgency, but the urine will not flow, a catheter is used to empty the bladder. An ice pack can help reduce swelling. Discomfort is decreased thru soaking in a sitz bath (a shallow bath of warm water) several times a day helps ease the discomfort. Using a donut ring (cushion with a hole in the middle) can make sitting upright more comfortable. Postoperatively, check for signs of prolonged rectal bleeding, administer adequate analgesics, and provide sitz baths as ordered. As soon as the patient can resume oral feelings, administer a bulk medication, such as psyllium, about 1 hour after the evening meal, to ensure a daily stool. Warn against using stool-softening medications soon after hemorrhoidectomy because a firm stool acts as a natural dilator to prevental and stricture from the scar tissue (The patient may need repeated digital dilation to prevent such narrowing). Keep the wound site clean to prevent infection and irritation. Before discharge, stress the importance of regular bowel habits and good anal hygiene. Warn against too-vigorous wiping with washcloths and using harsh soaps. Encourage the use of medicated astringent pads and white toilet paper (the fixative in colored paper can irritate the skin). The anal area is very painful, and the client may avoid defacating, resultin in hard stool or fecal impaction. Encourage the client to take bulk laxatives, stool softeners, or mineral oil as prescribed to promote stool passage. Monitor the stool for consistency and blood. Counsel the client to (1) eat fiber-containing foods and drink ample fluids to prevent straining and (2) avoid laxatives as much as possible. remind the client not to sit on the toilet longer than necessary; this position impairs blood flow and puts added pressure on anal vessels.

Hemorrhoids - Page | 29

Relieve pain and encourage 15 minute warm sitz baths three or four times per day for 15 minutes. Witch hazel (a topical astringent) compresses are soothing to the mucosa. Other over-the-counter preparations may temporarily relieve pain. Hydrotherapy with a bathtub, bidet, or extend-able shower head. Especially in the case of external hemorrhoids with a visible lump of small size, the condition can be improved with warm bath causing the vessels around the rectal region to be relaxed. •

Topical corticosteroid such as hydrocortisone. (May weaken the skin and may contribute to further flare-ups.)

•

Topical vasoconstrictor such as phenylephrine.

•

Topical moisturizer.

•

Topical astringent, such as witch hazel

•

Stress the importance of regular bowel habits and good anal hygiene. Warn against too-vigorous wiping with washcloths and using harsh soaps. Encourage the use of medicated astringent pads and white toilet paper (the fixative in colored paper can irritate the skin)

•

Keep the wound site clean to prevent infection and irritation.

•

Using the squatting position for bowel movements. Dietary supplements can help treat and prevent many complications of

hemorrhoids, and natural botanicals such as Butchers Broom, Horse-chestnut, Hem-eez and bioflavonoids can be an effective addition to hemorrhoid treatment. Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory and vasoconstrictor effects that help tighten and strengthen veins. Butcher's Broom has traditionally been used to treat venous problems including hemorrhoids and varicose veins. Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin, that has anti-inflammatory, anti-edema, and venotonic actions. Hemorrhoids - Page | 30

Aescin improves tone in vein walls, thereby strengthening the support structure of the vein. Double blind studies have shown that supplementation with horsechestnut helps relieve the pain and swelling associated with chronic venous insufficiency.

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1.7 Nursing Care Plans a. Acute Pain (pre-operative) Assessment S> Ø O> The patient may manifest: - observed evidence of pain - facial mask -sleep disturbance - expressive behavior (restlessness, moaning, irritability) - diaphoresis -change in blood pressure - narrowed focus (impaired thought process, altered time perception)

Nursing Diagnosis Acute Pain

Scientific Explanation Tenesmus increases intraabdominal and hemorrhoidal venous pressures, leading to distention of the hemorrhoidal veins. When the rectal ampulla (pouch) is filled with formed stool, venous obstruction is believed to occur. As a result of the repeated and prolonged increase in

Objectives After 5 hours of Nursing Interventions and health teachings client will: - report pain is relieved or controlled. - follow prescribed pharmacological regimen. - verbalize nonpharmacologic methods that provide relief. - demonstrate use of relaxation skills And diversional activities as indicated for individual situation.

Nursing interventions -take client’s vital signs

Rationale

- note client’s age, developmental level, and current condition

- to assess contributing factors

-note location of surgical procedures

- this can influence the amount of postoperative pain experienced

- assess for referred pain

- to help determine possibility of underlying organ dysfunction requiring treatment.

- use pain rating scale appropriate for

- to evaluate client’s response to pain

- to obtain baseline data

Expected Outcome After 2 hours of Nursing Interventions and Health Teachings client shall have: - reported pain is relieved or controlled. - followed prescribed pharmacological regimen. - verbalized nonpharmacologic methods that provide relief. - demonstrated use of relaxation skills and diversional activities as indicated for individual situation.

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- positioning to avoid pain

this pressure and the obstruction, hemorrhoidal veins become permanently dialted. As a result of the distention, thrombosis and bleeding may also occur.

age - monitor vital signs

- altered during acute pain

- note when pain occurs

- to medicate prophylactically as appropriate

- provide comfort measures such as: = touch = repositioning = use of heat/cold packs = quiet environment = calm activities = nurse’s presence

- to promote nonpharmacological pain management

- instruct use of relaxation techniques = focused breathing = imaging = music

- to distract attention and reduce tension

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- administer analgesics as indicated to maximum dose

- to maintain acceptable level of pain

- document client’s response to analgesics

- to determine increase or decrease dosage of analgesics

- encourage adequate rest periods

- to reduce fatigue

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b. Imbalanced nutrition less than body requirements related to poor nutrition before surgery Assessment S> ∅ O> The pt. manifested >body malaise > body weight 20% or more under ideal > weak-ness of muscles required for mastication or swallow-wing > decreased subcutaneous fats/muscle mass

Nursing Diagnosis Imbalanced nutrition less than body requirements related to poor nutrition before surgery.

Scientific Explanation Before the operation, patients are required to be NPO for quite some time in order to decrease bulk in the alimentary tract that would impede sterility during surgery this affects the nutritional status of the client therefore decreasing nutritional intake. After the surgery still, the patient is under NPO due to post anesthesia and impaired GI motility. This would therefore alter the nutritional status of a client.

Objectives

Interventions

Rationale

Short term: After 40 of NI the pt will verbalize understand-ding of causative factors when known and necessary interventions.

> Identify clients at risk for malnutrition (e.g., hypermetabolic state, restricted intake, etc.)

> In order to know appropriate intervention needed

> Determine ability to chew, swallow, and taste. Note denture fit; presence of mechanical barriers; lactose intolerance; cystic fibrosis; pancreatic disease

> Factors that can affect ingestion and/or digestion of nutrients should be determine n order to intervene properly

> Ascertain understanding of individual nutritional needs

> To determine what information to provide client/SO

> Discuss eating habits, including food preferences, intolerances, aversions, etc.

> To appeal to clients likes and dislikes.

Long term: After 3 days of NI, the pt. will demonstrate progressive weight gain toward goal.

Expected Outcome Short term: The pt shall have verbalized understanding of causative factors when known and necessary interventions.

Long term: The pt. shall have demonstrated progressive weight gain toward goal

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> Assess drug interactions, disease effects, allergies, use of laxatives, diuretics.

> These factors may be affecting appetite, food intake, or absorption

> Determine psychological factors/ perform psychological assessment

> To assess body image and congruency with reality

> Assess weight, age, body build, strength, activity/rest level

> Provides comparative baseline

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c. Constipation (pre-operative) Assessment S> Ø O> The patient may manifest: - hard, formed stool - straining with defecation - hypoactive/ hyperactive bowel sounds - distended abdomen -abdominal tenderness - palpable abdominal/ rectal mass - percussed abdominal dullness

Nursing Diagnosis Constipation r/t hemorrhoids

Scientific Explanation Tenesmus increases intraabdominal and hemorrhoidal venous pressures, leading to distention of the hemorrhoidal veins. When the rectal ampulla (pouch) is filled with formed stool, venous obstruction is believed to occur. As a result of the repeated and prolonged increase in this pressure and the obstruction, hemorrhoidal veins become permanently dialted. As a

Objectives After 1 hour of Health Teachings the client will: - verbalize understanding of etiology and appropriate interventions for individual situation After 5 days of Nursing Interventions client will: - regain normal pattern of bowel functioning - demonstrate lifestyle behavior which will prevent recurrence - participate in bowel program

Nursing Interventions -take client’s vital signs

Rationale

- determine fluid intake

- to determine client’s hydration status

- review daily dietary regimen

- to determine fiber sufficiency

- evaluate client’s medication regimen

- which could cause/. Exacerbate constipation

- note activity level

- sedentary lifestyle may affect elimination patterns

- note color, odor, consistency, frequency, and amount

- provides baseline data for comparison

- to obtain baseline data

Expected Outcome After 2 hours of Health Teachings the client shall have: - verbalized understanding of etiology and appropriate interventions for individual situation After 5 days of Nursing Intervention the client shall have: - regained normal pattern of bowel functioning - demonstrated lifestyle behavior which will prevent recurrence - participated in

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result of the distention, thrombosis and bleeding may also occur. The anal area is very painful, and the client may avoid defecating, resulting in hard stool formation or fecal impaction.

- encourage diet of fiber and bulk

- to improve consistency

- promote adequate fluid intake

- to promote passage of soft stool

- encourage activity within individual limitations

- to stimulate contraction of intestines

- apply lubricant/ anesthetic ointment to anus

- to facilitate return of acceptable bowel pattern

- provide sitz bath after defectaion

- for soothing effect at rectal area

- discuss client’s current medication regimen

- to determine if drugs contributing to constipation can be changed or discontinued

bowel program

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d. Risk for Urinary Retention (post-operative) Assessment S> Ø O> The patient may manifest: - bladder distention - small frequent voiding/ absence of urine output - residual urine (150mL or more) - dysuria

Nursing Diagnosis Risk for urinary Retention

Scientific Explanation Tenesmus increases intraabdominal and hemorrhoidal venous pressures, leading to distention of the hemorrhoidal veins. When the rectal ampulla (pouch) is filled with formed stool, venous obstruction is believed to occur. As a result of the repeated and prolonged increase in this pressure and the obstruction, hemorrhoidal veins become permanently dialted. As a

Objectives After 1 hour of Health Teachings client will: - verbalize understanding of causative factors and appropriate interventions for individual situation. - demonstrate techniques to prevent retention.

Nursing Interventions - render health teachings to client such as: = recommend the client to void at frequent timed schedule = maintain consistent fluid intake = instruct use of crede’s maneuver

Rationale

- adjust fluid amount and timing - refrain use of valsalva’s maneuver - increase fluid intake - provide privacy

- prevent bladder distention - to prevent further trauma in perineal area - to promote voiding - to allow client to have a comfortable environment for urination

- to promote prevention techniques -To maintain low bladder pressure - to wash off bacteria, avoid infections. - to promote urination

Expected Outcome After 1 hour of Health Teachings client will have: - verbalized understanding of causative factors and appropriate interventions for individual situation. - demonstrated techniques to prevent retention.

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result of the distention, thrombosis and bleeding may also occur. May induce perineal trauma.

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e. Deficient Knowledge Assessment Nursing Scientific Diagnosis Explanation S> Ø Deficient Absence or O> Knowledge deficiency of The client may cognitive manifest: information -Inaccurate necessary for follow through clients/SO to of instruction make -inappropriate/ informed exaggerated choices behavior regarding - misguided condition/ knowledge treatment. regarding Due to disease common condition heresay and - use of primitive inappropriate knowledge interventions about for disease hemorrhoids condition which are retained and passed on to families, and lack of initiative, knowledge

Objective Short Term: After 1 hour Health Teaching client will: - verbalize understanding of Hemorrhoid situation and certain lifestyle changes to promote comfort and alleviate pain. -verbalize understanding of corrected misconceptions regarding hemorrhoidectom y Long Tern; After 3 days of interventions client will: -practice correct wiping of anal

Nursing Interventions - ascertain level of knowledge including Anticipatory needs

Rationale

- determine blocks to learning: =language =age =mental capability =environment

- to assess client’s motivation

- provide positive reinforcement

- can encourage continuation of efforts

- identify information that needs to be remembered

- to assess readiness to learn and individual learning needs

- client can become selreliant

Expected Outcome Short Term: After 1 hour of Health Teachings client shall have: - verbalized understanding of Hemorrhoid situation and certain lifestyle changes to promote comfort and alleviate pain. -verbalized understanding of corrected misconceptions regarding hemorrhoidectomy Long Term: After 3 days of interventions client shall have: -practiced correct wiping of anal area which should

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and resources to seek medical assistance.

area which should not be too hard - practice good perineal care -prevent excessive straining - eat food rich in fiber to prevent constipation and straining - know how to manage prevention of hemorrhoid occurrence or possible managements

= pregnancy, constipation with prolonged straining, obesity heart failure, prolonged sitting or standing and cirrhosis with portal hypertension raise the incidence of hemorrhoids = increasing fluids and fiber in diet = application of cold packs followed by sitz bath = application of topical anesthetics

- be aware of the causes

- to soften stool and void straining

not be too hard - practiced good perineal care -prevented excessive straining - eaten food rich in fiber to prevent constipation and straining - known how to manage prevention of hemorrhoid occurrence or possible managements

-to promote comfort

- to reduce pain

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V.

CONCLUSION The case report has enlightened the group with much information

regarding hemorrhoidectomy along the lines of: anatomy of the digestive system, pathophysiology of the disease, clinical and surgical interventions for hemorrhoidectomy, and nursing care plans of a patient with hemorrhoids. For future references, the group would know, the necessary interventions and health teachings applicable to a patient with haemorrhoids or a patient post-op or pre-op hemorrhoidectomy. Even without the actual interaction of the group with a patient with hemorrhoids, the case report still bears its benefits on the group not only, through knowledge gain but also with character gain. The case report brought to the group: patience, perseverance, logical thinking, and a thirst for knowledge, diligence, cooperation and camaraderie. For the whole part the group delighted in the completion of the case report.

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VI.

LEARNING DERIVED Hemorrhoids may not be a life-threatening disorder, but disrupts the daily

routine of a patient, and so it still is a medical concern and should not be treated lightly, since it is the nurse’s role to provide comfort and help ease the pain a client is experiencing. It gave me knowledge gain and made me less ignorant about hemorrhoids and at least I won’t be empty-handed if I ever get assigned to a patient with hemorrhoids. Doing the case report book based and without any patient interaction, was like going around a dark room, feeling your way around and not knowing when to stop, what to expect or what you are actually looking for. It held me up blind, and sort of lost since I didn’t know what to expect, but once I got some information and began learning about hemorrhoids along the way, it came moderately fine. And it was great being able to work with my group mates, and now I’ve gained new friends, and their trust. As a student nurse, aside from completing this requirement, it helped me be more knowledgeable, and enlightened to the topic of hemorrhoids. -

Bianca Patricia O. Santiago BSN III-10 Gr.37

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This work is done within the new environment with a new clinical instructor, new group mates during the new experiences we encounter each day. Hemorrhoids are familiar problems faced by many in the Philippines most especially with females primarily due to pregnancy. Though it is commonly experienced, it is rarely being talked or discussed about. Not much is known about hemorrhoids and so, misconceptions are widespread. Throughout the completion of this work, more information was provided to us. This included the causes, signs and symptoms and the managements, both medical and surgical, are being done. This case report may benefit us when the time for us to encounter such comes. If that occurs, then we could be more confident in doing our responsibilities in rendering the maximum care we can because we are somehow equipped with knowledge about hemorrhoids. It was hard for us to come up with a case report without observing a patient on actual. References from the internet and books became useful for us to complete this report and understanding it at the same time. Even though hemorrhoids are not life-threatening it is important to alleviate the pain experienced by the client. I have also learned that the best way to eliminate the condition permanently cannot be achieved after the operation but is attained by changing lifestyle most especially with the diet. As a student nurse at the present time and hopefully a registered nurse in the future, it is our responsibility to keep ourselves updated with the new trends. Everyday should be a learning moment for us to be able to provide optimum care to our patients. -Christina Marie D. Ocampo BSN III-10 Gr.37

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"... Observation and experience will teach us the ways to maintain or to bring back the state of health." -Florence nightingale Hemorrhoids whether external or internal is a condition wherein the patient must be closely monitored for pain and bleeding. I learned that in doing this case study it takes great patience and compassion to render care to the patients. Caring for patients is not a big joke, we should treat our patients the way we wanted our loved ones be treated. I learned that the pain experienced by the patient results from the hemorrhoids in their anus, now I know what this condition really is because when I was in high school my dad and untie had the same condition and they experienced the same signs like pain in the anus and even bleeding, before then they even manually inserted the hemorrhoids, good thing they dealt with it then. Dealing with patients of this condition is like dealing with chipped glass, the patients are so fragile that the care given should be effective and efficient. In doing the case study, I think time management is second to compassion in rendering one's service because the main focus should be the client. I learned that forcing ourselves to defecate should be avoided even though the effect seems good because we don’t need to worry that we will defecate in public or somewhere we aren’t comfortable. Hemorrhoids are also caused by prolonged standing or seating which I think a lot of us don’t enjoy. In this case I learned that squatting, warm sitz bath, and even fiber rich foods should be done not just by people with hemorrhoids but also people like us to avoid having hemorrhoids. Observation and experience will teach us the ways to maintain or to bring back the state of health, just like what Florence Nightingale have said, in this case I have learned thru the experience of my relatives, our case, and even our books and other reference. Observing and acting on the patient’s condition truly helps the patient, the SO, and the other Health Care Provider in improving the patient's condition. -Pamela Jane Simbulan BSN III-10 Gr.37 Hemorrhoids - Page | 46

VII. REFERENCES Websites: http://www.wellsphere.com/digestive-health-article/hemorrhoids/69667po1 http://www.surgerychannel.com/hemorrhoidectomy/post.shtml http://www.hemorrhoidsinplainenglish.com/hemorrhoid/total-hemorrhoidectomy.htm http://health.allrefer.com/health/hemorrhoid-surgery-hemorrhoid-surgery-series-2.html http://health.allrefer.com/health/hemorrhoids-info.html http://www.surgeryencyclopedia.com/Pa-St/Sclerotherapy-for-VaricoseVeins.html#ixzz0WsvkiyMW http://www.surgeryencyclopedia.com/Fi-La/Hemorrhoidectomy.html#ixzz0WslnRnWg http://www.wales.com.au/haemorrhoids_internal.html http://www.surgerychannel.com/hemorrhoidectomy/index.shtml http://www.webmd.com/a-to-z-guides/hemorrhoidectomy-for-hemorrhoids http://en.wikipedia.org/wiki/Hemorrhoidectomy http://www.proctocure.com/f9_hemorrhoidectomy.htm

Books: Black, Joyce M., et al. Medical Surgical Nursing Clinical Management of Positive Outcomes 8th edition. Singapore: Elsevier, 2009.

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