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
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.
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.
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
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
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
Permanently dilation of
hemorrhoidal
veins
Enlarged and thrombosed Bleeding and prolapsed
Severe bleeding Thrombosis Hemorrhoidal

strangulation
Iron Deficiency Intense Pain Cut off blood supply

Anemia by anal sphincter
Severe pain
Stapled
Hemorrhoidectomy
Extreme edema
Inflammation
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.
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.
• 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
• 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.
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 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.
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
• 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.
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.
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.
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').
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
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.
FACILITIES
Defibrillator
Machine
Emergency
Cart
Surgic `
ANESTHESIOLOGIST Surgic
al
Light al
Light
P
S A
` S
U A S
R I
G T S
SUCTION E T
MACHINE O A
I N
N T
E
N
SCRUB
NURSE SUTURE
T NURSE
MAYO
TABLE
BACK TABLE
CIRCULATING
NURSE
SUPPLY CABINET
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.
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
 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
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.
 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
• 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
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.
• 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.
1.7 Nursing Care Plans
a. Acute Pain (pre-operative)

Assessment Nursing Scientific Objectives Nursing Rationale Expected
Diagnosis Explanation interventions Outcome
S> Ø Acute Pain Tenesmus After 5 hours of -take client’s - to obtain baseline After 2 hours of
O> increases Nursing vital signs data Nursing
The patient intra- Interventions and Interventions and
may manifest: abdominal health teachings - note client’s - to assess Health Teachings
- observed and client will: age, contributing factors client shall have:
evidence of hemorrhoidal - report pain is developmental - reported pain is
pain venous relieved or level, and relieved or
- facial mask pressures, controlled. current controlled.
-sleep leading to - follow prescribed condition - followed
disturbance distention of pharmacological prescribed
- expressive the regimen. -note location - this can influence pharmacological
behavior hemorrhoidal - verbalize of surgical the amount of post- regimen.
(restlessness, veins. When nonpharmacologic procedures operative pain - verbalized
moaning, the rectal methods that experienced nonpharmacologic
irritability) ampulla provide relief. methods that
- diaphoresis (pouch) is - demonstrate use provide relief.
-change in filled with of relaxation skills - demonstrated
blood formed stool, And diversional - assess for - to help determine use of relaxation
pressure venous activities as referred pain possibility of skills and
- narrowed obstruction is indicated for underlying organ diversional
focus believed to individual dysfunction activities as
(impaired occur. As a situation. requiring treatment. indicated for
thought result of the individual
process, repeated and - use pain - to evaluate client’s situation.
altered time prolonged rating scale response to pain
perception) increase in appropriate for
- positioning this pressure age
to avoid pain and the
obstruction, - monitor vital - altered during
hemorrhoidal signs acute pain
veins become
permanently - note when - to medicate
dialted. As a pain occurs prophylactically as
result of the appropriate
distention,
thrombosis - provide - to promote
and bleeding comfort nonpharmacological
may also measures pain management
occur. such as:
= touch
= repositioning
= use of
heat/cold
packs
= quiet
environment
= calm
activities
= nurse’s
presence
- instruct use - to distract

of relaxation attention and
techniques reduce tension
= focused
breathing
= imaging
= music
- administer - to maintain
analgesics as acceptable level of
indicated to pain
maximum
dose
- document - to determine
client’s increase or
response to decrease dosage of
analgesics analgesics
- encourage - to reduce fatigue

adequate rest
periods
b. Imbalanced nutrition less than body requirements related to poor nutrition before surgery
Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis Explanation Outcome
S> ∅ Imbalanced Before the Short term: > Identify clients at > In order to know Short term:
nutrition less operation, patients After 40 of NI the risk for malnutrition appropriate The pt shall
O> The pt. than body are required to be pt will verbalize (e.g., intervention needed have
manifested requirements NPO for quite understand-ding hypermetabolic verbalized
>body related to some time in order of causative state, restricted understanding
malaise poor nutrition to decrease bulk in factors when intake, etc.) of causative
before the alimentary tract known and factors when
> body weight surgery. that would impede necessary > Determine ability > Factors that can known and
20% or more sterility during interventions. to chew, swallow, affect ingestion necessary
under ideal surgery this affects and taste. Note and/or digestion of interventions.
the nutritional denture fit; nutrients should be
> weak-ness status of the client presence of determine n order
of muscles therefore mechanical to intervene Long term:
required for decreasing Long term: barriers; lactose properly The pt. shall
mastication or nutritional intake. After 3 days of intolerance; cystic have
swallow-wing After the surgery NI, the pt. will fibrosis; pancreatic demonstrated
still, the patient is demonstrate disease progressive
> decreased under NPO due to progressive weight gain
subcutaneous post anesthesia weight gain > Ascertain > To determine toward goal
fats/muscle and impaired GI toward goal. understanding of what information to
mass motility. This would individual nutritional provide client/SO
therefore alter the needs
nutritional status of
a client. > Discuss eating > To appeal to
habits, including clients likes and
food preferences, dislikes.
intolerances,
aversions, etc.
> Assess drug > These factors
interactions, may be affecting
disease effects, appetite, food
allergies, use of intake, or
laxatives, diuretics. absorption
> Determine > To assess body

psychological image and
factors/ perform congruency with
psychological reality
assessment
> Assess weight, > Provides

age, body build, comparative
strength, baseline
activity/rest level
c. Constipation (pre-operative)
Diagnosis Explanation Interventions Outcome
S> Ø Constipation r/t Tenesmus After 1 hour of -take client’s - to obtain After 2 hours of
O> hemorrhoids increases intra- Health vital signs baseline data Health
The patient abdominal and Teachings the Teachings the
may manifest: hemorrhoidal client will: - determine - to determine client shall
- hard, formed venous - verbalize fluid intake client’s have:
stool pressures, understanding hydration - verbalized
- straining with leading to of etiology and status understanding
defecation distention of the appropriate of etiology and
- hypoactive/ hemorrhoidal interventions for - review daily - to determine appropriate
hyperactive veins. When individual dietary regimen fiber sufficiency interventions for
bowel sounds the rectal situation individual
- distended ampulla - evaluate - which could situation
abdomen (pouch) is filled After 5 days of client’s cause/.
-abdominal with formed Nursing medication Exacerbate After 5 days of
tenderness stool, venous Interventions regimen constipation Nursing
- palpable obstruction is client will: Intervention the
abdominal/ believed to - regain normal - note activity - sedentary client shall
rectal mass occur. As a pattern of bowel level lifestyle may have:
- percussed result of the functioning affect - regained
abdominal repeated and - demonstrate elimination normal pattern
dullness prolonged lifestyle patterns of bowel
increase in this behavior which functioning
pressure and will prevent - note color, - provides - demonstrated
the obstruction, recurrence odor, baseline data lifestyle
hemorrhoidal - participate in consistency, for comparison behavior which
veins become bowel program frequency, and will prevent
permanently amount recurrence
dialted. As a - participated in
result of the - encourage - to improve bowel program
distention, diet of fiber and consistency
thrombosis and bulk
bleeding may
also occur. - promote - to promote
The anal area adequate fluid passage of soft
is very painful, intake stool
and the client
may avoid - encourage - to stimulate
defecating, activity within contraction of
resulting in individual intestines
hard stool limitations
formation or
fecal impaction. - apply - to facilitate
lubricant/ return of
anesthetic acceptable
ointment to bowel pattern
anus
- provide sitz - for soothing

bath after effect at rectal
defectaion area
- discuss - to determine if
client’s current drugs
medication contributing to
regimen constipation
can be
changed or
discontinued
d. Risk for Urinary Retention (post-operative)
S> Ø Risk for urinary Tenesmus After 1 hour of - render health - to promote After 1 hour of
O> Retention increases intra- Health teachings to prevention Health
The patient abdominal and Teachings client client such as: techniques Teachings client
may manifest: hemorrhoidal will: = recommend -To maintain will have:
- bladder venous - verbalize the client to low bladder - verbalized
distention pressures, understanding void at frequent pressure understanding
- small frequent leading to of causative timed schedule of causative
voiding/ distention of the factors and = maintain - to wash off factors and
absence of hemorrhoidal appropriate consistent fluid bacteria, avoid appropriate
urine output veins. When interventions for intake infections. interventions for
- residual urine the rectal individual = instruct use of - to promote individual
(150mL or ampulla situation. crede’s urination situation.
more) (pouch) is filled - demonstrate maneuver - demonstrated
- dysuria with formed techniques to techniques to
stool, venous prevent - adjust fluid - prevent prevent
obstruction is retention. amount and bladder retention.
believed to timing distention
occur. As a - refrain use of - to prevent
result of the valsalva’s further trauma
repeated and maneuver in perineal area
prolonged - increase fluid - to promote
increase in this intake voiding
pressure and - provide - to allow client
the obstruction, privacy to have a
hemorrhoidal comfortable
veins become environment for
permanently urination
dialted. As a
result of the
distention,
thrombosis and
bleeding may
also occur.
May induce
perineal
trauma.
e. Deficient Knowledge
Assessment Nursing Scientific Objective Nursing Rationale Expected
S> Ø Deficient Absence or Short Term: - ascertain - to assess Short Term:
O> Knowledge deficiency of After 1 hour level of readiness to After 1 hour of
The client may cognitive Health Teaching knowledge learn and Health Teachings
manifest: information client will: including individual client shall have:
-Inaccurate necessary for - verbalize Anticipatory learning - verbalized
follow through clients/SO to understanding of needs needs understanding of
of instruction make Hemorrhoid Hemorrhoid
-inappropriate/ informed situation and - determine - to assess situation and
exaggerated choices certain lifestyle blocks to client’s certain lifestyle
behavior regarding changes to learning: motivation changes to
- misguided condition/ promote comfort =language promote comfort
knowledge treatment. and alleviate pain. =age and alleviate pain.
regarding Due to -verbalize =mental -verbalized
disease common understanding of capability understanding of
condition heresay and corrected =environment corrected
- use of primitive misconceptions misconceptions
inappropriate knowledge regarding - provide - can regarding
interventions about hemorrhoidectom positive encourage hemorrhoidectomy
for disease hemorrhoids y reinforcement continuation of
condition which are efforts Long Term:
retained and Long Tern; After 3 days of
passed on to After 3 days of - identify interventions client
families, and interventions information - client can shall have:
lack of client will: that needs to become sel- -practiced correct
be reliant
initiative, -practice correct wiping of anal
remembered
knowledge wiping of anal area which should
and resources area which should = pregnancy, not be too hard
to seek not be too hard constipation - be aware of - practiced good
medical - practice good with prolonged the causes perineal care
straining,
assistance. perineal care -prevented
obesity heart
-prevent failure, excessive
excessive prolonged straining
straining sitting or - eaten food rich in
- eat food rich in standing and fiber to prevent
fiber to prevent cirrhosis with constipation and
constipation and portal straining
hypertension
straining - known how to
raise the
- know how to incidence of manage
manage hemorrhoids prevention of
prevention of hemorrhoid
hemorrhoid = increasing occurrence or
occurrence or fluids and fiber - to soften possible
possible in diet stool and void managements
managements straining
= application of
cold packs -to promote
followed by sitz comfort
bath
= application of
topical - to reduce
anesthetics pain
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.
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
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
"... 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
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.

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I.

-Oliver Wendell Holmes, Sr.

Health is an essential part of a person; it is the fuel which gives every

Prevelance statistics about Hemorrhoids:The following statistics relate to the

A different method for the treatment of haemorrhoids was introduced back

This information about haemorrhoid Stapling gives both nurses and

Lower Gastrointestinal Tract

Rectum and Anus

Non-modifiable Modifiable factors

Age (20-50y.o) Sedentary lifestyle

Increases intra-abdominal pressure Increases hemorrhoidal venous pressure

Distention of the hemorrhoidal veins

Rectal ampulla is filled with formed stool

Repeated pressure and obstruction Prolonged pressure and obstruction

Enlarged and thrombosed Bleeding and prolapsed

Severe bleeding Thrombosis Hemorrhoidal

Iron Deficiency Intense Pain Cut off blood supply

Certain conditions may cause internal hemorrhoids to bulge, become irritated

• Trauma during childbirth

Rarely, a bulging internal hemorrhoid may thrombose, meaning a blood clot

Hemorrhoids caused by a blood clot, medically referred to as thrombosed

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

Symptoms can be made worse by straining during constipation and overly

Usually, an explanation of your symptoms is an important clue to your

Often your doctor will recommend a detailed examination of your sigmoid

Treatment for pain and itching

Treatment for constipation

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

Risk VS. Benefit of Hemorrhoidectomy

Other relatively rare risks include the following:

Benefits of patients from hemorrhoidectomy is based from a high rate of success;

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

o 1 inch of 4x4 gauze

o 1 inch of 2% lidocaine jelly (Xylocaine) placed on the corner of the

o Sterile tray for the procedure:

o Sterile drape covering a Mayo stand

o 2 inches of 4x4 gauze

o No.15 scalpel blade and handle

A needle holder, also called needle driver, is a surgical instrument, similar to a

o Adson forceps with teeth

o Curved clamps -used for holding tissues

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

PREOPERATIVE NURSING RESPONSIBILITIES:

POSTOPERATIVE NURSING RESPONSBILITIES:

 Because of swelling and the dressing, some patients have

 Patients experience pain and discomfort during the immediate

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

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

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

1.5 Expected outcomes of surgical treatment performed

1.6 Medical management of physiologic outcomes

An ice pack can help reduce swelling. Discomfort is decreased thru

Especially in the case of external hemorrhoids with a visible lump of small

• Topical corticosteroid such as hydrocortisone. (May weaken the skin and

Dietary supplements can help treat and prevent many complications of

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin

a. Acute Pain (pre-operative)

- instruct use - to distract

- encourage - to reduce fatigue

Assessment Nursing Scientific Objectives Interventions Rationale Expected

> Determine > To assess body

> Assess weight, > Provides