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.

Hemorrhoids - Page | 3

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.

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

o 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.

The mucosa has a large number of goblet cells but does not have any villi. The

Hemorrhoids - Page | 5

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.

III. THE PATIENT AND HIS ILLNESS

Hemorrhoids - Page | 6

Hemorrhoids - Page | 7

Tenesmus

Increases intra-abdominal pressure Increases hemorrhoidal venous pressure

Non-modifiable

factors

Age (20-50y.o)

Gender

Family history

Pregnancy

Modifiable factors

Obesity

Sedentary lifestyle

Constipation

Chronic Diarrhea

Poor bathroom habits

Postponing bowel movement

Intake of fiber-deprived diet

Cirrhosis of the liver

Prolonged sitting or standing

Distention of the hemorrhoidal veins

Rectal ampulla is filled with formed stool

Venous obstruction

Repeated pressure and obstruction Prolonged pressure and obstruction

B.1. Definition of the disease

Hemorrhoids - Page | 8

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

Extreme edema

Inflammation

Stapled Hemorrhoidectomy

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.

B.2. Predisposing / Precipitating factors

Hemorrhoids - Page | 9

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.

Prolonged sitting or standing- It increases intra-abdominal pressure

and also causes relative venous return.

Hemorrhoids - Page | 10

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

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.

Hemorrhoids - Page | 11

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.

IV. CLINICAL INTERVENTION

Hemorrhoids - Page | 12

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.

Hemorrhoids - Page | 14

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 non-

surgical 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

numbness or a 10ml syringe filled with 1% lidocaine with a 25 gauge, 1 ¼ inch

needle.

Hemorrhoids - Page | 17

o Sterile tray for the procedure:

o Sterile drape covering a Mayo stand

o 2 inches of 4x4 gauze

o 3 hemostats (mosquito )

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.

Hemorrhoids - Page | 18

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

thumb and index finger. Some forceps have cross-hatched tips or serrated tips

(often called 'mouse's teeth').

Hemorrhoids - Page | 19

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.

Hemorrhoids - Page | 21

FACILITIES

`

`

1.4. Perioperative tasks and responsibilities of the Nurse

Hemorrhoids - Page | 22

P

A

T

I

E

N

T

SURGEON

ASSISTANT

BACK TABLE

Surgical

Light

Surgical

Light

SUTURE NURSE

SUCTIONMACHINE

EmergencyCart

Defibrillator Machine

ANESTHESIOLOGIST

CIRCULATING NURSE

SCRUB NURSE

MAYO TABLE

SUPPLY CABINET

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

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

Hemorrhoids - Page | 24

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.

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

Hemorrhoids - Page | 25

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

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.

Hemorrhoids - Page | 26

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.

***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

Hemorrhoids - Page | 27

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.

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

Hemorrhoids - Page | 28

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.

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.

Hemorrhoids - Page | 29

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.

Aescin improves tone in vein walls, thereby strengthening the support structure

of the vein. Double blind studies have shown that supplementation with horse-

chestnut helps relieve the pain and swelling associated with chronic venous

insufficiency.

Hemorrhoids - Page | 30

1.7 Nursing Care Plans

a. Acute Pain (pre-operative)Assessment Nursing

DiagnosisScientific Explanation

Objectives Nursing interventions

Rationale Expected Outcome

S> ØO> 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)

Acute Pain Tenesmus increases intra-abdominal 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

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 skillsAnd diversional activities as indicated for individual situation.

-take client’s vital signs

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

-note location of surgical procedures

- assess for referred pain

- use pain rating scale appropriate for

- to obtain baseline data

- to assess contributing factors

- this can influence the amount of post-operative pain experienced

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

- to evaluate client’s response to pain

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.

Hemorrhoids - Page | 31

- 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

- note when pain occurs

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

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

- altered during acute pain

- to medicate prophylactically as appropriate

- to promote nonpharmacological pain management

- to distract attention and reduce tension

Hemorrhoids - Page | 32

- administer analgesics as indicated to maximum dose

- document client’s response to analgesics

- encourage adequate rest periods

- to maintain acceptable level of pain

- to determine increase or decrease dosage of analgesics

- to reduce fatigue

Hemorrhoids - Page | 33

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

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

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

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

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.

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

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

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

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

> Ascertain understanding of individual nutritional needs

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

> In order to know appropriate intervention needed

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

> To determine what information to provide client/SO

> To appeal to clients likes and dislikes.

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

Hemorrhoids - Page | 34

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

> Determine psychological factors/ perform psychological assessment

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

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

> To assess body image and congruency with reality

> Provides comparative baseline

Hemorrhoids - Page | 35

c. Constipation (pre-operative)Assessment Nursing

DiagnosisScientific Explanation

Objectives Nursing Interventions

Rationale Expected Outcome

S> ØO>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

Constipation r/t hemorrhoids

Tenesmus increases intra-abdominal 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

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

-take client’s vital signs

- determine fluid intake

- review daily dietary regimen

- evaluate client’s medication regimen

- note activity level

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

- to obtain baseline data

- to determine client’s hydration status

- to determine fiber sufficiency

- which could cause/. Exacerbate constipation

- sedentary lifestyle may affect elimination patterns

- provides baseline data for comparison

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

Hemorrhoids - Page | 36

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

- promote adequate fluid intake

- encourage activity within individual limitations

- apply lubricant/ anesthetic ointment to anus

- provide sitz bath after defectaion

- discuss client’s current medication regimen

- to improve consistency

- to promote passage of soft stool

- to stimulate contraction of intestines

- to facilitate return of acceptable bowel pattern

- for soothing effect at rectal area

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

bowel program

Hemorrhoids - Page | 37

d. Risk for Urinary Retention (post-operative)Assessment Nursing

DiagnosisScientific Explanation

Objectives Nursing Interventions

Rationale Expected Outcome

S> ØO>The patient may manifest:- bladder distention- small frequent voiding/ absence of urine output- residual urine (150mL or more)- dysuria

Risk for urinary Retention

Tenesmus increases intra-abdominal 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

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

- 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

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

- to promote prevention techniques-To maintain low bladder pressure

- to wash off bacteria, avoid infections.- to promote urination

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

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.

Hemorrhoids - Page | 38

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

Hemorrhoids - Page | 39

e. Deficient KnowledgeAssessment Nursing

DiagnosisScientific Explanation

Objective Nursing Interventions

Rationale Expected Outcome

S> ØO> The client may manifest:-Inaccurate follow through of instruction-inappropriate/ exaggerated behavior- misguided knowledge regarding disease condition- use of inappropriate interventions for disease condition

Deficient Knowledge

Absence or deficiency of cognitive information necessary for clients/SO to make informed choices regarding condition/ treatment. Due to common heresay and primitive knowledge about hemorrhoids which are retained and passed on to families, and lack of initiative, knowledge

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 hemorrhoidectomy

Long Tern;After 3 days of interventions client will:-practice correct wiping of anal area which should

- ascertain level of knowledge includingAnticipatory needs

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

- provide positive reinforcement

- identify information that needs to be remembered

- to assess readiness to learn and individual learning needs

- to assess client’s motivation

- can encourage continuation of efforts

- client can become sel-reliant

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

Hemorrhoids - Page | 40

and resources to seek medical assistance.

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

-to promote comfort

- to reduce pain

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

Hemorrhoids - Page | 41

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.

Hemorrhoids - Page | 42

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

Hemorrhoids - Page | 43

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

Hemorrhoids - Page | 44

"... 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 | 45

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-Varicose-

Veins.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.

Hemorrhoids - Page | 46