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University of Baguio

General Luna Road


Baguio City

A
Clinical Paper
On

Perianal Abscess
Presented to Mrs. Christine Diaz
Clinical Instructor

In Partial Fulfillment
Of the Requirements for
NCM103

By:

Czarina Kaye D.R. Villarosa


NMB-III
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TABLE OF CONTENTS
TITLE PAGE.
TABLE OF CONTENTS..
I. INTRODUCTION.....................................................................................................................1
II. PATIENTS PROFILE2
A. BIBLIOGRAPHICAL DATA..2
B. HISTORY......2
B.1. PAST MEDICAL HISTORY..2
B.2. PRESENT MEDICAL HISTORY...2
III. THIRTEEN (13) AREAS OF ASSESSMENT

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I. Patients Profile
A. Biographical Data
Mr. X is male patient admitted at Baguio General Hospital Medical Center surgery
ward.He was born on June 12,2005 in First Gate, Ucab, Itogon, Benguet. He was a Filipino
citizen. He belongs in Roman Catholic church. Both his parents has no occupation thats why he
stayed in his grandparents. He was a pupil
B. Patient History
1. History of Present Illness
10 days percutaneous transluminal angioplasty
, the patient was apparently well until he was hit by motorcycle. The patient was brought to the
nearby hospital. Operation was done and he was sent home after 5 days of hospital stay. Until 2
days percutaneous transluminal angioplasty the patient was noted to have pus and certain smell
coming out on the affected area, no consultation was done until they decided to bring the child in
our institution, hence was subsequently admitted skin avulsion on left foot.
2. Past Medical History
Prior to admission,the patient was asked to have complete blood count and urinalysis. He
also undergo in skin test. It was found out that he has no allergies to food and drug.
3. Family History
The patients family has no history of hypertension, diabetes mellitus, coronary artery
disease.

4. Social and Environmental History


The patient was not a smoker. He did not also drink alcohol beverages.

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III. 13 AREAS OF ASSESSMENT


I.

Psychological status

Mr. Gatchilian is a driver.bread winner of the family. In the hospital, his daughter is staying
with him. No significant others went to the hospital to visit him. Harmonious relationship and
open communication was observed within the family. The patient and his daugther also
communicate effectively with healthcare personnel such as physicians, staff nurses and student
nurses.
II.

Mental and Emotional Status

Before hospitalization, the patient mentioned that he is having a good relationship with his
family and friends.
During hospitalization, Mr. Gatchalian is irritable at times at the student nurse who endorsed
to me. During our shift he had been kind and willing to cooperate with the nursing interventions
that I do.
Mr. Gatchalian is conscious. He is aware on his time of meals,and his time of sleep. He was
attentive and able to answer some question being asked.
III.

Environmetal Status

According to the Mr. Gatchalian, he is living in a semi concrete house having two rooms, one
bathroom,a living room and kitchen. The house is well ventilated. There is no hazard mentioned,
the house is located along the highway.
Patients room has adequate lighting and warm terperature. Theere were 15 beds in the room
including his bed. The room is cleaned and mapped every shift,reducing the production of
microorganism aiming to decrease possibilities of acquiring further nosocomial infections leading
to other illnesses. Furthermore, the bed is approximately 6 meters away from the nurses station
for faster intervention in case of emergency.
IV.

Sensory Status

Mr. Gatchalian verbalized that he has no illnesses or disturbances in her senses. He has pink
conjuctiva and has normal vision,he could hear our voice efficiently.There is no lesion or

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abnormal discharges in his ears and nose. He can also distinguish different taste.Mr. Gatchalian
was able to differenciate warm from cold.
V.

Motor status
Prior to admission, Mr. Gatchalian

was efficiently attending to his work.During

hospitalization, Mr. Gatchalian needs minimal help of his activities of daily living.he has limited
body movements. Moreover patient has easy fatigability on minimal activity.
VI.

Nutritional Status

Prior to admission, Mr. Gatchalian verbalized that he has a normal eating pattern of three
times a day. On admission he was ordered diet as tolerated.
According to the patient he consumes foods which are nutritious.
VII.

Elimination Status

Before hospitalization, the patient verbalized that she usually urinate 4 to 6 times a day and
having a clear to turbid urine and no discomfort during urination.
Mr. Gatchalian urinates one to two time every shift. He claimed no abnormalities in urination
such as dysuria.
VIII. Fluid and Electrolyte Balance
Mr. Gatchalian has daily habit of having one cup of noodles every morning.He also completes
five to eight glasses of water daily.
On admission, he had ordered nothing per orem the day of his operation.An IVF of PNSSIL x
31gtts per minute was given.
When he was assessed by the health care providers he has a good skin turgor. Supplemental
electrolytes were given.
IX. Circulatory Status
Mr. Gatchalian is not in cardio pulmonary distress. His cardiac rate ranges from 97 to 112 beats
per minute. He has a capillary refill of 2 to 3 seconds. Upon auscultation there were no murmur
sounds noted and there was regular rhythm.

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X.

Respiratory Status
Before hospitalization, he was reported that he has no coughs and colds that causes nasal
congestion but proper intervention was given,he did not report any further respiratory
complication. Patient respiratory rate ranges fromm 24 to 28 cycles per minute.

XI.

Temperature
The patient has normal body temperature ranging from 36.6 to 37.3 degrees Celsius.per

axilla.
XII.

Integumentary Status

The patient has brown to light brown skin color.There are no presence of skin avulsion.
XIII. Comfort and Rest status
According toMr. Gatchalian, he sleeps 8 to 10 hours prior to admission. Mr. Gatchalian
awakes every time vital signs were taken.

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IV. Laboratory Findings and Interpretation


1. Clinical Pathology
Parameter
WBC
Lymph#
Mid#
Gran#
Lymph%
Mid%
Gran%
HGH
RBC
HCT

Result
6.4x10 /L
1.6x10 /L
0.4x10 /L
4.4x10 /L
25.3%
6%
68.7%
135glc
4.47x10 /L
.419l L/L

Reference range
4.0 - 12
0.8 - 4
0.1 - 0 .9
2.0 7.0
20.0 40.0
3.0 9.0
50.0 - 70.0
115.0 145.0
4.0 - 5.36
.330 - .436

MCV(H)
MCH
MCHC
RDW CV
ROW SD
PLT
MPV (l)
PDW
PCT (H)

93.9 1L
30.2 pg
322 g /L
13.1%
44.37L
419x10 /L
6.8 IL
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.284%

76.0 90.0
25.0 - 31.0
320.0 360.0
11.5 - 14.5
35.0 - 56.0
140.0 - 440.0
7.0 - 11.0
15.0 - 17.0
.108 - .282

Remarks: Midcells may include less frequently occurring and rare correlating to monocytes,
eosinophils, basophils, and other precursors of white blood cell.
2. Urinalysis Result Form
Physical Examination
Color : light yellow
Chemical Examination
Ph: 6.0
Specific gravity: 1.015
Microscopic Examination
Pus cells
Red blood cell
Yeast cell
Bacteria
Epithelial cells
Mucus threads
Amorphous materials

Appearance: slightly turbid


Sugar: negative
Result
1-2 /hpf
0-1 /hpf
none/hpf
none/hpf
rare/lpf
few/lfp
occasional/lfp

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Protein: negative

V. ANATOMY AND PHYSIOLOGY


Definition
A perianal abscess represents an infection of the soft tissues surrounding the anal canal,
with formation of a discrete abscess cavity. The severity and depth of the abscess are quite
variable, and the abscess cavity is often associated with formation of a fistulous tract. For that
reason, along with perianal abscess, perianal fistula also is discussed in this article.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and
Intestine Center. Also, see eMedicine's patient education articles Anal Abscess and Rectal Pain.
Problem
An anorectal abscess originates from an infection arising in the cryptoglandular
epithelium lining the anal canal. The internal anal sphincter is believed to serve normally as a
barrier to infection passing from the gut lumen to the deep perirectal tissues. This barrier can be
breached through the crypts of Morgagni, which can penetrate through the internal sphincter into
the intersphincteric space. Once infection gains access to the intersphincteric space, it has easy
access to the adjacent perirectal spaces. Extension of the infection can involve the intersphincteric
space, ischiorectal space, or even the supralevator space. In some instances, the abscess remains
contained within the intersphincteric space. The variety of anatomic sequelae of the primary
infection is translated into va Types of Anorectal Abscesses
Patients with a perianal abscess typically complain of dull perianal discomfort and
pruritus. Their perianal pain often is exacerbated by movement and increased perineal pressure
from sitting or defecation. Physical examination demonstrates a small, erythematous, welldefined, fluctuant, subcutaneous mass near the anal orifice.
Patients with an ischiorectal abscess often present with systemic fevers, chills, and severe
perirectal pain and fullness consistent with the more advanced nature of this process. External
signs are minimal and may include erythema, induration, or fluctuancy. On digital rectal
examination (DRE), a fluctuant, indurated mass may be encountered. Optimal physical
assessment of an ischiorectal abscess may require anesthesia to alleviate patient discomfort that
would otherwise limit the extent of the examination.
Patients with an intersphincteric abscess present with rectal pain and exhibit localized
tenderness on DRE. Physical examination may fail to identify an intersphincteric abscess.
Although rare, supralevator abscesses present a similar diagnostic challenge. As a result, clinical
suspicion of an intersphincteric or supralevator abscess may require confirmation through
computed tomography (CT) scanning, magnetic resonance imaging (MRI), or anal
ultrasonography. Use of the last modality is limited to confirming the presence of an
intersphincteric abscess.
Classification of anorectal abscess
Abscesses are classified based on their anatomic location. The most commonly described
locations are perianal, ischiorectal, intersphincteric, and supralevator. The image below illustrates
the different anatomic locations of anorectal abscesses.

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Illustration of the major types of anorectal abscesses (submucosal not pictured).


Perianal abscesses represent the most common type of anorectal abscesses, accounting
for approximately 60% of reported cases. These superficial collections of purulent material are
located beneath the skin of the anal canal and do not transverse the external sphincter.
The next most common types of abscesses, in descending order of frequency, are
ischiorectal, intersphincteric, and supralevator. An ischiorectal abscess forms when suppuration
transverses the external sphincter into the ischiorectal space. Intersphincteric abscesses result
from suppuration contained between the internal and external anal sphincters. A supralevator
abscess results either from primary disease in the pelvis (eg, appendicitis, diverticular disease,
gynecologic sepsis) or from suppuration extending cranially from an origin in the intersphincteric
space, through the longitudinal muscle of the rectum and reaching above the levators.
Horseshoe abscesses, while rare, result from circumferential infiltration of pus within the
intersphincteric planes.
The Goodsall rule for perianal fistulas
The Goodsall rule states that the external opening of a fistulous tract located anterior to a
transverse line drawn across the anal verge is associated with a straight radial tract of the fistula
into the anal canal/rectum. Conversely, an external opening posterior to the transverse line
follows a curved, fistulous tract to the posterior midline of the rectal lumen. This rule is important
for planning surgical treatment of the fistula and is illustrated in the images below.

Diagram illustrating the Goodsall rule for anorectal fistulas. Fistulas that exit in the posterior half
of the rectum generally follow a curved course toward the posterior midline, while those that exit
in the anterior half of the rectum usually follow a radial course to the dentate line.

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Illustration of the Goodsall rule for anorectal fistulas. Note the curved nature of the posterior
fistulas and the radial (straight) orientation of the anterior fistulas.
Frequency
The peak incidence of anorectal abscesses is in the third and fourth decades of life. Men
are affected more frequently than are women, with a male-to-female predominance of 2:1 to 3:1.
Approximately 30% of patients with anorectal abscesses report a previous history of similar
abscesses that either resolved spontaneously or required surgical intervention.
A higher incidence of abscess formation appears to correspond with the spring and
summer seasons. While demographics point to a clear disparity in the occurrence of anal
abscesses with respect to age and sex, no obvious pattern exists among various countries or
regions of the world. Although suggested, a direct relationship between the formation of anorectal
abscesses and bowel habits, frequent diarrhea, and poor personal hygiene remains unproved.
The occurrence of perianal abscesses in infants also is quite common. The exact
mechanism is poorly understood but does not appear to be related to constipation. Fortunately,
this condition is quite benign in infants, rarely requiring any operative intervention in these
patients other than simple drainage.1
Etiology
Perirectal abscesses and fistulas represent anorectal disorders arising predominately from
the obstruction of anal crypts. Infection of the now static glandular secretions results in
suppuration and abscess formation within the anal gland. Typically, the abscess forms initially in
the intersphincteric space and then spreads along adjacent potential spaces.
Indications
As a rule, the presence of an abscess is an indication for incision and drainage. Watchful
waiting while administering antibiotics is inadequate.
Contraindications
Clinical suspicion of anorectal abscess warrants aggressive identification and surgical
drainage. Delayed surgical intervention results in chronic tissue destruction, fibrosis, and stricture
formation and may impair anal continence. Delayed incision and drainage of an anorectal abscess
is contraindicated.
.
VI. Pathophysiology
As mentioned above, perirectal abscesses and fistulas represent anorectal disorders that arise
predominately from the obstruction of anal crypts. Normal anatomy demonstrates anywhere from
4-10 anal glands drained by respective crypts at the level of the dentate line. Anal glands
normally function to lubricate the anal canal. Obstruction of anal crypts results in stasis of
glandular secretions and, when subsequently infected, suppuration and abscess formation within
the anal gland results. The abscess typically forms in the intersphincteric space and can spread
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along various potential spaces.


Common organisms implicated in abscess formation include Escherichia coli, Enterococcus
species, and Bacteroides species; however, no specific bacterium has been identified as a unique
cause of abscesses.
Less common causes of anorectal abscess that must be considered in the differential diagnosis
include tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis,
lymphogranuloma venereum, Crohn's disease, trauma, leukemia, and lymphoma. These may
result in the development of atypical fistula-in-ano or complicated fistulas that fail to respond to
conventional surgical treatment.
Presentation
The classic locations of anorectal abscesses listed in order of decreasing frequency are as follows:
perianal 60%, ischiorectal 20%, intersphincteric 5%, supralevator 4%, and submucosal 1%. These
major types are illustrated in the image below. Clinical presentation correlates with the anatomic
location of the abscess.

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VI. Nursing Care Plan


Assessment

Explanation of the problem

Subjective:
Nahihirapa
n ako
makatae
dahil sa
dressing sa
puwet ko

Short term goal:


Perianal Abscess Secondary to
fistula ruptured in the anus.

Surgical Incision Site

Objective:
>grimaces
>guarding
behavior
>irritable at
times
>with intact
dry dressing
in the anal

Objective

Altered Bowel Movement

After 8 hours of nursing


interventions, patient will
verbalized feeling of
comfort.
a) Patient can sleep
well not feeling of
ache in the stomach
b) Patient can pass out
stool little by Little.
Long term goal:
After 3 days of nursing
interventions the patient
Bowel Movement will
normalized by:

Diagnosis:
Perianal
Abscess
Secondary to
ruptured of
fistula in the

a) Patient will have


normal elimination
pattern.
b) Patient can eliminate
without strains in the
dressing.

Nursing Intervention
Dx >
Identify
Factors that May
cause/contribute
constipation

Determined his
motivation to
begin an exercise
program

Tx > Maintained
and regulated
above IVF as
ordered.
Kept patient
comfortable and
warm
Position Patient in
Side Lying
Position
Tx > Encourage
increased fliud
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Rationale
Assessing causative
factors is an
essential step in
teaching and
planning for
improved bowel
elimination.
Individuals who
have been sucessful
in an exercise
program can assisst
Mr. Gatchalian by
providing
incentives.
Correct infusion of
IVF inside patients
body.
Promotion of rest
and sleep
Alleviate pain

Sufficient fluid
intake is necessary

Evaluation
Short term goal
After 8 hours of nursing
interventions goal met by:
a) Patient sleep during the
whole shift.
b) Patient pass out stool.
Long term goal
After 3 days of nursing
interventions goal partially met
by:
a) Patient able to pass out
stool without any strain
in the dressing.
b) Patient is still
constipated.

anus

intake unless
contraindicated
Encouraged and
Instructed in
providing diet high
in bulk/fiber and
adequate fluids

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for Bowel
Absorption.
Easy Elimination

VII. Drug Study


Drug

Action

Indication

Contraindication

Cautious use

Adverse effects

Nursing Responsibilities

Generic name:
Oxacillin Sodium

Semisynthetic,
acid
stable,penicillina
se resistant
isoxazolyl
penicillin

Oxacillin is
indicated in the
treatment of
infections caused
by penicillinase
producing
staphylococci
which have
demonstrated
susceptibility to
the drug.
Cultures and
susceptibility
tests should be
performed
initially to
determine the
causative
organism and its
susceptibility to
the drug.

A history of a
hypersensitivity
(anaphylactic) reaction to
any penicillin is a
contraindication. Solutions
containing dextrose may be
contraindicated in patients
with known allergy to corn
or corn products

History of or suspected
atopy or
allergy,premature
infants,
neonates,lactation

Thrombophlebitis,s
uperinfection,whee
zing,sneezing,fever,
anaphylaxis,nausea,
vomiting,flatulence,
rash,diarrhea

Assessments and drug effects

Brand name:
Bactocill
Classification:
Antiinfective,antib
iotic penicillin
Route:
Intravenous
Dosage:
250 mg every 8
hours

>Ask the patient prior to first


dose about hypersensitivity
reactions to
penicillins,cephalosporins,and
other allergies.
>Withhold next drug dose and
report the onset of
hypersensitivity reactions and
superinfections
Patient and family education
>Take oral medication around the
clock

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Drug

Action

Indication

Contraindication

Cautious use

Adverse effects

Nuring Responsibilities

Generic name:
Ketorolac

The primary
mechanism of
action
responsible for
ketorolac's antiinflammatory,
antipyretic and
analgesic effects
is the inhibition
of prostaglandin
synthesis by
competitive
blocking of the
enzyme
cyclooxygenase
(COX). Like
most NSAIDs,
ketorolac is a
non-selective
COX inhibitor

he safety and
effectiveness of
single doses of
keterolac have
been established
in pediatric
patients between
the ages of 2 and
16 years.
ketorolac, as a
single injectable
dose, has been
shown to be
effective in the
management of
moderately
severe acute pain
that requires
analgesia at the
opioid level,
usually in the
postoperative
setting.

Hypersensitivity to
ketorolac, individuals with
complet or partial syndrome
of nasal
polyps,angioedema,and
bronchosplastic reaction to
aspirin or other NSAIDS.

History of peptic
ulcers,impaired renal or
hepatic function,older
adults, debilitated
patients,pregnancy
category B.Safety and
effectiveness in
children is stablished.

Drowsiness,dizzene
ss,headache,nausea,
GI
pain,hemorrhage,ed
ema,sweating,pain
at injection site

>Correct hypovolemia prior to


administration of ketorolaac
>Do not drive or engage in
potentially hazardous activities
until response is drug is known.
>Do not use other NSAID while
taking this drug.

Brand name:
Toradol
Classification:
CNS agent,
NSAID,
analgesic,antipyret
ic
Route:
IV
Dosage:
15 mg every 6
hours and PRN for
pain

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Drug

Action

Indication

Contraindication

Cautious use

Adverse effects

Nursing responsibilities

Generic name:
Ascorbic Acid

Water soluble
vitamin
essential for
synthesis and n
Maintainace
and collagen
and intercellular
ground
substance of
body tissue,
cells,blood
vessels,
cartilage,bones,t
eeth,skin and
tendons. Unlike
most
mammals,huma
ns are unable to
synthesize
ascorbic acid in
the
body,therefore
it must be
consumed daily.

To acidify
urine,to prevent
and treat cancer,
idiopathic
methemoglobine
mia. Widely use
as an antioxidant
in formulation in
parenteral
tetracycline and
other drugs

Use of sodium ascorbate in


patients on sodium
restrition,use of calcium
ascorbate in patients receiving
digitalis

Excessive doses in
patints with G6PD
deficiency,hemocromat
osis,sickle cell
anemia,patients are
prone to gout or renal
canaculi.

Nausea,vomiting,he
art
burn,diarrhea,abdo
minal cramps,acute
haemolytic
anemia,mild sore at
injection
site,dizzeness,

Assessment

Brand name:
Ascorbicap
Classification:
Vitamin
Route:
Oral
Dosage:
1 tablespoon once
a day

>Monitor for S and S of acute


haemolytic anemia, sickle cell
crisis.
Patient and family education
>Vitamin C increases the
absoption of iron when taken at
the same time as iron rich foods.
Take large doses of vit. C in
divided amount because the body
uses only what is needed at a
particular and excretes in urine.

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Drug

Action

Indication

Contraindication

Cautious use

Adverse effects

Generic
name:
Nalbuphine
Hydrochlorid
e

Synthetic narcotic
analgesic with agonist
and weak antagonins
properties. Analgesic
potency is about 3 or
4 time greater than
that of pentazocine
and approximately
equal to that produce
by equivalent doses
or morphine. On a
weak basis produces
respiratoy depression
about equl to that of
morphine,however, in
contrast to morphine
doses lesser than 30
mg produce low
futher respiratory
depression .
Antagonistic potency
is approximately one
forth that of naloxone
and about 10 time
greater than that of
pentaxocine.

Symptomatic
relief of
moderate to
severe pain.
Also
preoperative
sedation
analgesia and as
a suipplement
surgical
anesthesia.

History of hypersensitivity to
drug.

History of emotional
instability or drug
abuse, head injury,
increase intracranial
pressure, impaired
respiration, impaired
kidney or liver
function.

Hypertension,
>Assess respiratory status before
hypotension,
drug administration
bradycardia,tachyca Monitor ambulatory
rdia,
dizzeness,blured
vision,burning
sensation

Brand name:
Nubain
Classification
: CNS agent
agent,
analgesic,
narcotic
agonist
antagonist
Route:
IV
Dosage:
3 mg every 4
hours and
PRN

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Nursing responsibilities

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