INTRODUCTION

A 63 years old male, Mr. V.R. was brought to the hospital by his wife for complaints of fresh blood in the stool and constipation. The patient is conscious and coherent prior to admission. He was diagnosed of hemorrhoids and staple hemorrhoidectomy.

PATHOPHYSIOLOGY

The anus is the end-point of the digestive system. It contains sweat and oil glands, hair follicles, as well as many nerve endings, which make it very sensitive to pain and erotic stimulation. The anal opening is an oval opening located about an inch in front of the spine. When closed, the anus is about an inch in circumference however, the external sphincter muscle that circles it can stretch to about five times the size. Inside the anal opening is the anal canal. It is approximately two inches deep, with an encircling internal sphincter muscle that controls the passage of stool in the elimination process On top of the anal canal, there is a ring of tissue fold arranged in zigzag or sawtooth pattern called the dentate line. Underneath this line lies some vestigial glands - in our evolutionary ancestors, these glands secrete odors that attract mates. Now, however, these glands are empty and unused. About an inch above the dentate line is the rectum, or the last holding place for feces in the elimination process. The rectum is

approximately six inches long, with folds called the valves of Houston. These valves serve as shelves where the feces rest between bowel movements. When the stool becomes heavy, the valve presses against the rectal wall, which results in the "the call of nature" signal or the urge to defecate.

HEMORRHOIDS
What are hemorrhoids? The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed.

Source: www.images.google.com There are two types of hemorrhoids: External hemorrhoids Hemorrhoids located outside of the anus are called external hemorrhoids. Here, swollen veins cause a soft lump around the anal opening. Internal hemorrhoids Internal hemorrhoids are located inside the rectum or anal canal, and are usually not painful. This is because the anal canal does not have many nerve endings. Indeed, most people are not aware that they have internal hemorrhoids until a hard stool rubbing against them cause these hemorrhoids to rupture and bleed. Left untreated, some internal hemorrhoids can "prolapse" or be pushed out of the anal opening.

SOME FACTORS THAT CAN CAUSE HEMORRHOIDS

1. Straining during bowel movement One of the most frequent causes of hemorrhoids is straining during bowel movements. Forcing for too long or too hard, because of diarrhea, constipation, or bad bathroom habits (such as reading on the toilet) is actually attributed to the majority of hemorrhoids cases. 2. Genetics Inherited characteristics such as weak vein walls can result in tendencies to develop hemorrhoids. Heredity alone, however, does not usually lead to a hemorrhoid without additional factor(s), such as a bad bathroom habit or a job that requires standing or sitting for prolonged periods. 3. Diet Foods that are lacking in fibers actually create stool that is harder to pass. This results in straining during a bowel movement, and thus hemorrhoids. 4. Pregnancy Another of the most common causes of hemorrhoids in women is pregnancy: the extra weight of the uterus adds great pressure on the rectal veins. For women who already have hemorrhoids, pregnancy can definitely make their hemorrhoid condition worse. Even women who do not develop hemorrhoids during pregnancy can still get them because of long and arduous labor and delivery, or because of constipation that arise after childbirth. 5. Postponing bowel movement Sometimes when "nature calls", there is no toilet nearby. Usually, by postponing bowel movement, the urge to defecate goes away and does not return until after eating another meal. 6. Extreme physical exertion Laborers and weightlifters often hold their breath or grunt while lifting heavy objects. These forces air downward in the lungs and exert pressure on the diaphragm, which in turn exerts pressure on the abdominal organs and rectal veins. Note that weightlifters can also get hemorrhoids because they eat a lot of animal proteins in order to gain bulk and mass. Source: http://en.wikipedia.org/wiki/hemorrhoid

CLINICAL MANIFESTATIONS
Internal hemorrhoids cannot cause cutaneous pain, as they are above the dentate line and are not innervated by cutaneous nerves. They can bleed, prolapse and cause perianal itching and irritation. Irritation and itching is caused by deposition of an irritant onto the sensitive perianal skin. Internal hemorrhoids can cause perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain. This consternation of symptomsis referred to as acute hemorrhoidal crisis. It usually requires emergent treatment. External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, for example, physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With resolution of the thrombosis, the stretched anoderm persists as excess skin or skin tags. External thromboses can occasionally erode the overlying skin and cause bleeding.

HISTORY
Mr. V.R. is hypertensive and diabetic. He is on a diet control. He is on piles for twenty years, under treatment rubber banding 5 years ago and more recently last month at T.H hospital.

NURSING PHYSICAL ASSESSMENT

According to the diagnostic findings, Urea-5.7mmol/L, sodium- 138mmol/l, potassium- 3.7mmol/L, chloride- 97mmol/L. On his full blood count, the red cell count- 4.010^12/L, hemoglobin- 13.1g/dL, Haematocrit- 40%, MCV- 99fL, MCH33pg, Platelet- 15110^9/L, White cell count- 7.010^9/L. ECG shows normal.

RELATED TREATMENTS
Mr. V.R. is receiving rubber band ligation. The band will cut off blood circulation to the hemorrhoid, which will shrivel and fall off in about one week along with the band. This medical procedure is usually done for bleeding internal and prolapsed hemorrhoids. Typically, separate hemorrhoids are treated about one month apart. Because there are few nerve endings in the anal canal, this procedure is usually not painful. However, some people do experience discomfort and a dull ache after the procedure. To avoid further irritating the hemorrhoid, it is recommended that you drink plenty of water, eat a fiber-rich diet, and take a stool softener. In rare instances, side effects and complications such as clotting of an external hemorrhoid and bleeding can happen. Staple hemorrhoidectomy- is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoid supporting tissue that has allowed the hemorrhoids to prolapsed downward. For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue.

NURSING CARE PLAN NURSING DIAGNOSIS AND PATIENT GOAL

1. Problem: Pain and discomfort related to surgical wound. The goal is to reduce and minimize the pain. 2. Potential bleeding related to surgical wound. The goal is to prevent any signs and symptoms of bleeding.

NURSING INTERVENTIONS
1. Pain and discomfort: (Lewis Medical Surgical Nursing) a. Asses level of pain according to pain scale level by asking the patient for further management. b. Monitor vital sign to detect any abnormality such as blood pressure more than 140/90mmhg and tachycardia c. Position patient on side lying position to reduce the pressure at surgical wound so that its can help to reduce the pain. d. Teach patient how to do breathing exercise to reduce the pain e. Give diversional theraphy such as watching television,reading magazine so that patient do not focus on the pain. f. Plan nursing care effectively to minimize disturbance so that patient can rest well. 2. Problem: Potential bleeding related to surgical wound. (Brunner & Suddarth Medical-Surgical Nursing) a. Inspect dressing site for any bleeding and perform pressure dressing if bleeding occurs. b. Monitor vital signs such as blood pressure and pulse to detect any sign and symptom of bleeding such as blood pressure more than 140/90 mmhg and pulse more than 100 bpm. c. Advise patient to take diet that are high in fiber such as fruits and vegetables in avoidance of constipation. d. Advise patient to drink a lots of water at least 2 liter/day in avoidance of constipation. e. Advise patient not to strain during passing motion to prevent any bleeding. f. Tell patient to use soft tissue for wiping to prevent any bleeding.

EVALUATION
The patient gets better and didnt complain discomfort and pain. And has no signs and symptoms of bleeding occurs.

RECOMMENDATION
The patient should: a. Eat more fibers and drink more water To avoid hemorrhoids, add fiber to your regular diet by eating raw vegetables and fruits, as well as adding oatmeal. It is particularly good because it helps make the stool soft, moist, and easier to pass. Drinking a lot of water can also help make stool softer, especially if you are eating fiber-rich food. b. Changing Bad Bathroom Habits Straining on the toilet puts a great pressure on the rectal and anal veins causing them to distend and swell in a hemorrhoid. When "nature calls" normal bowel movement should be easy - if defecation is difficult, don't strain. Instead, wait a while and then try again. People who exercise are also less prone to developing hemorrhoids. Exercising can also make you thirstier, so you naturally drink more water. It can also help improve your metabolism and aid digestion. Postponing bowel movement regularly can also help reduce the capability of the abdominal muscle to push out stool. It can also cause the stool to harden, and thus become harder to pass. c. Exercise Sitting or standing for long periods of time puts pressure on the rectal veins, so if your job requires you to sit or stand, be sure to take frequent breaks and move around to prevent hemorrhoids.

OUR LADY OF FATIMA UNIVERSITY COLLEGE OF NURSING REGALADO, QUEZON CITY

SUBMMITTED BY: CONNIE T. SEGUNDO BSN 3Y1-10 SUBMMITTED TO: MS. CATHERINE CABRERA, RN