Case Study:

Fistulectomy
Group 6:
Bulatao, Lesley Charmaine C.
Cabudoc, Maricar G.
Comilang, Janielle Lyn M.
Constante, Quolette M.
Dela Cruz, Rhealyn N.
Ebuenga, Allyssa O.
Espanueva, Gaylen C.
Fabon, Yvette Stephanie Nichol B.
Franco, Ma. Eliza Joy L.
Fuentes, Raquel F.
Introduction
 An anal fistula is an abnormal connection
between the epithelialised surface of the anal
canal and (usually) the perianal skin. Anal
fistulae originate from the anal glands, which
are located between the two layers of the
anal sphincters and which drain into the anal
canal. If the outlet of these glands becomes
blocked, an abscess can form which can
eventually point to the skin surface. The tract
formed by this process is the fistula.
 Abscesses can recur if the fistula seals
over, allowing the accumulation of pus. It then
points to the surface again, and the process
repeats. Anal fistulas do not generally harm
and they often do not hurt, but they can be
irritating because of the pus-drain (and, it is
not unknown for formed stools to be passed
through the fistula); additionally, recurrent
abscesses may lead to significant short term
morbidity from pain, and create nudes for
systemic spread of infection. A fistula is a
tiny channel or tract that develops in the
presence of inflammation and infection. It
may or may not be associated with an abscess,
but like abscesses, certain illnesses such as
Crohn’s disease can cause fistulas to develop.
 The channel usually runs from the rectum
to an opening in the skin around the anus.
However, sometimes the fistula opening
develops elsewhere. For example, in women
with Crohn’s disease or obstetric injuries, the
fistula could open into the vagina or bladder.
Since fistulas are infected channels, there is
usually some drainage. Often a draining fistula
is not painful, but it can irritate the skin
around it. An abscess and fistula often occur
together. If the opening of the fistula seals
over before the fistula is cured, an abscess
may develop behind it.
 An anal fistula is almost always the result of a
previous abscess. Just inside the anus are small
glands. When these glands get clogged, they may
become infected and an abscess can develop. A
fistula is a small tunnel that forms under the skin
and connects a previously infected anal gland to
the skin on the buttocks outside the anus. After
an abscess has been drained; a tunnel may persist
connecting the anal gland from which the abscess
arose to the skin. If this occurs, persistent
drainage from the outside opening may indicate
the persistence of this tunnel. If the outside
opening of the tunnel heals, recurrent abscess
may develop. Symptoms related to the fistula
include irritation of skin around the anus,
drainage of pus (which often relieves the pain),
fever, and feeling poorly in general.
 Surgery is necessary to cure an anal
fistula. Although fistula surgery is usually
relatively straightforward, the potential for
complication exists, and is preferably
performed by a specialist in colon and rectal
surgery. It may be performed at the same
time as the abscess surgery, although fistulas
often develop four to six weeks after an
abscess is drained, sometimes even months or
years later.
 Fistula surgery usually involves opening up
the fistula tunnel. Often this will require
cutting a small portion of the anal sphincter,
the muscle that helps to control bowel
movements. Joining the external and internal
openings of the tunnel and con-verging it to a
groove will then allow it to heal from the
inside out. Most of the time, fistula surgery
can be performed on an outpatient basis.
Treatment of a deep or extensive fistula may
require a short hospital stay. Discomfort
after fistula surgery can be mild to moderate
for the first week and can be controlled with
pain pills.
 The amount of time lost from work or
school is usually minimal. Treatment of an
abscess or fistula is followed by a period of
time at home, when soaking the affected area
in warm water (sitz bath) is recommended
three or four times a day. Stool softeners or
a bulk fiber laxative may also be
recommended. It may be necessary to wear a
gauze pad or mini-pad to prevent the drainage
from soiling clothes. Bowel movements will not
affect healing.
 CASE
ABSTRACT
 This is the case of Patient X, a 34 year old
male who was admitted last September 3,
2009, under the service of Dr. R. Lopez of
Valuecare. He came to the hospital with a
chief complaint of hematochezia and painful
bowel elimination.
Three weeks prior to admission, Patient X
experienced hematochezia. He noted painful
defecation, however describes having
constipation or diarrhea. He decided to seek
consult and was admitted to undergo
proctosigmoidoscopy.
 He was initially diagnosed with an anal
fistula and was to be forwarded to the OR for
proctosigmoidoscopy and fistulectomy on
September 4, 2009 at 7 a.m. Meanwhile,
Patient X was hooked to a liter of D5LR which
was to run for 8 hours. He was also advised
to be on NPO and for urine collection. His
attending physician ordered CBC, urinalysis
and x-ray.
The following morning, at 6:35 a.m.,
Patient X was wheeled to the OR table,
inducted with spinal anesthesia and was placed
on lithotomy for proctosigmoidoscopy. At
7:35, Dr. Lopez confirmed the anal fistula. At
8:00 a.m., Dr. Lopez and Dr. Publico started
the fistulectomy, the procedure was well
tolerated and Patient X was brought to the
Recovery Room for further management.
 At the Recovery Room, Patient X was
inserted with a Foley Catheter for urine
collection and was transferred to room. He
was hooked to a liter of D5NM + Ketorolac 60
mg to run for 6 hours and was placed on diet
as tolerated. A few hours later, the foley
catheter was removed and he was able to void
freely. The sack on the surgical site was
removed later on.
On September 5, 2009 at 5:40 a.m. the
IVF was discontinued upon request and on
September 6, 2009, Patient X was discharged
ambulatory.
 Physical
Assessment
GENERAL DATA
1. General Information
Name: D.Y. Age: 34 y/o
Gender: Male

Chief complaint: Hematochezia

Admitting diagnosis: Proctosigmoidoscopy
Fistulectomy
2. Vital Signs
 Temperature: 36.4
 Pulse Rate: 62
 Respiratory rate: 16
 Blood Pressure: 100/70
3. General Survey
3.1 Anthropometric Measurement
 Height: 5’5”
 Weight: 72kg

3.2 General Appearance

The patient shows sign of distress,
conscious and coherent. He is oriented to the place,
person, and time. He is well-developed, looks
according to his age. Well- nourished and calm.
4. Skin
 The patient’s skin is brown, smooth and fair,
without any abnormalities found. He has good
skin turgor and is warm to touch.
5. Head
 The patient’s head size is proportion to the size
of his body and with a normocephalic shape. The
hairs are evenly distributed. There is no
presence of dandruff or scar. The face is
symmetrical and with negative facial musculture.
The patient’s eyes are symmetrical. Eyebrows
and eyelashes are evenly distributed. Pale
conjunctiva. Anicteric sclera. The cornea and lens
are clear. Pupil sizes are equal. The visual acquity
is good (20/20).
6. Ears
 The ears of the patient are symmetrical, soft
and pliable, and at the level of the outer cantus
of the eye. There is no presence of discharges on
the ear canal. Able to hear sounds on both ears.
7. Nose
 Patient’s nose is smooth, nasolobial fold is
symmetrical, septum is located in the midline, no
presence of nasal discharge seen. Patent nostrils.
8. Mouth and Pharynx
 The lips are pinkish in color and moist, no
presence of cracks or lesions. Tongue is found at
the midline and can move freely. Complete teeth
without presence of cavity. Gums and buccal
mucosa are pinkish in color, smooth and moist.
Uvula is on the midline. There is no presence of
inflammation of tonsils.
9. Neck
 Patient’s neck moves freely. Trachea is located in
the midline. Cervical lymph nodes are non-
palpable. There is no presence of masses.
10. Chest and Lungs
 Patient’s chest is cylindrical with regular
breathing pattern. Lung expansion is symmetrical
and no retractions.
11. Heart
 The precordium is flat. Apical pulse is located at
the fifth intercostal space left mid-clavicular
line. Heart rhythm is regular.
12. Abdomen
 Patient’s abdomen appears globular and without
presence of scars/lesions, with a presence of
tenderness upon palpation.
13. Genitals
 Not assessed, the patient refused to.
14. Anus and rectum
 Not assessed, the patient refused to.
15. Back and Extremities
 Nail and nail beds are pinkish with no sign of
inflammation. Decreased ROM upon surgery.
Spine is on the midline. Coordinated gait.
Anatomy & Physiology:
Digestive Functions
Th
e
D
Sy ige
s t st
em iv
e
Digestive functions
 Ingestion occurs when foods enter the
digestive tract through mouth.
 Mechanical processing is the physical
manipulation of solid foods, first by the
tongue and the teeth and then by swirling
and mixing motions of the digestive tract.
 Digestion refers to the chemical breakdown
of food into small organic fragments that
can be absorbed by the digestive epithelium.
 Secretion aids digestion through the release
of water, acids, enzymes and buffers by the
digestive tract and accessory organs.
 Absorption is the movement of small organic
molecules, electrolytes, vitamins, and water
across the digestive tract.
 Excretion is the elimination of waste
products from the body. Within the
digestive tract, these waste products are
compacted and discharge through the
process of defecation
 e s
u r
a t
F e
a l
gic
o l o
i s t
H
Four Major Layers of Digestive
Tract
1. Mucosa
 Inner lining.
 An example of a mucous membrane.
 Consist of an epithelial surface moistened
by glandular layer of loose connective
tissue, the lamina propria.
 Increase the surface area available for
absorption
 Permit expansion after a large meal.
 Forms fingerlike projections, called villi.
 Outer portion of the mucosa contains a
narrow band of smooth muscle and
elastic fibers
 Muscularis mucosae, move the mucosal
folds and villi.
2. Submucosa
 Second layer of loose connective tissue
that surrounds the muscularis mucosae.
 Contains large blood vessels and
lymphatics as well as network of nerve
fibers, sensory neurons and
parasympathetic motor neurons.
 This neural tissue submucosal plexus
helps control and coordinate the
contractions of smooth muscle layer and
also helps regulate the secretion of the
digestive glands.
3. Muscularis externa
 Collection of smooth muscle cells arranged
in an inner circular layer and an outer
longitudinal layer.
 Contractions of these layers in various
combinations agitate or propel materials
along the digestive tract.
 These are autonomic reflex movements
controlled primarily by a network of nerve,
the myenteric plexus, sandwiched between
the inner and outer smooth muscle layers.
 Parasympathetic stimulation increases
muscular tone and activity, and
sympathetic stimulation promotes
muscular inhibition and relaxation.
4. Serosa
 A serous membrane
 Covers the muscularis externa along most
portions of the digestive tract inside the
peritoneal cavity
 The parietal and visceral peritoneum that lines
the inner surfaces of the body wall.
 The parietal and visceral peritoneum are
connected by double sheets of serous
membrane called mesenteries, loose connective
tissue sandwiched between epithelia provides
an access route for the passage of blood
vessels, nerves and lymphatics servicing the
digestive tract.
 v e
sti
i g e
D
o f
n t a l s
m e r i
v e at e
M o M
h e
T
Peristalsis and Segmentation
Peristalsis
 Waves of muscular contractions that move along
the length of the digestive tract.
 During a peristaltic movement, the circular
muscles first contract behind the digestive
contents. Then longitudinal muscles contract,
shortening adjacent segments. A wave of
contraction in the circular muscles then forces
the materials in the desired direction.
Segmentation
 Movements that churn and fragment
digestive materials.
 This action results in a thorough mixing
of the contents with intestinal
secretions. Because they do not follow a
set pattern, segmentation movements do
not propel materials in a particular
direction.
The Stomach
 Located within the left upper quadrant of
the abdominopelvic cavity.
 Receives food from the esophagus.
 The stomach has four primary functions the
temporary storage of ingested food, the
mechanical breakdown or resistant
materials, the beginning of digestion by
breaking chemical bonds through the action
of enzymes and acids, and the production of
intrinsic factor, a compound necessary for
absorption of vitamin B12.
 The agitation of ingested materials with
gastric juices secreted by the glands of the
stomach produces a viscous, soupy mixture
called chyme.
 The principal anatomical landmark of the
stomach is a muscular organ with the shape
of an expanded J.
 The esophagus connects to the stomach at
the cardia.
 The bulge of the stomach superior to the
cardia is the fundus of the stomach.
 The large area between the fundus and the
curve of the J is the gastric body.
 Pylorus the curve of the J connects the
stomach with the small intestine.
 A muscular pyloric sphincter regulates the
flow of the chyme between the stomach and
the small intestine.
 The stomach resembles a muscular tube with
narrow and constricted lumen. When full, it
can expand to contain 1-1.5 liters.
 This degree of expansion is possible because
the stomach wall contains a number of
prominent ridges and folds called rugae.
 The visceral peritoneum covering the outer
surface of the stomach is continuous with a
pair of mesenteries. The greater omentum
extends below that hangovers and protects
abdominal viscera. The much smaller lesser
omentum extends from the lesser curvature
to the liver.
 Stomach is lined by an epithelium dominated
by mucous cells. These secreted mucus
produced helps protect the lining from the
acids, enzymes, and abrasive materials it
contains.
 Gastric pits shallow depressions and
open onto the gastric surface. Each
gastric pit communicates with the
gastric glands that extends deep into
the underlying lamina propria. These
glands are dominated by two types of
secretory cells: parietal cells and
chief cells. Together these cells
secrete about 1500 ml of gastric juice
each day.
 Chief cells secrete pepsinogen, an
inactive form of the enzyme pepsin.
Regulation of Gastric Activity
• The cephalic phase the sight, smell, taste or
thought of food initiates at the cephalic
phase of gastric secretion directed by the
CNS, prepares the stomach to received food.
Under the control of vagus nerve,
parasympathetic fibers innervate parietal
cells, chief cells, and mucous cells of the
stomach.
• The gastric phase begins with the arrival of
food in the stomach. Stimulation of stretch
receptors in the stomach wall and
chemoreceptors in the mucosa triggers the
release of a hormone, gastrin, into the
circulatory system.
3. The intestinal phase begins when chyme
starts to enter the small intestine. The
purpose of this phase is to control rate of
gastric emptying and ensure that the
secretory, digestive, and absorptive
functions of the small intestine can proceed
efficiently.
Digestion in the stomach
 The stomach performs preliminary
digestion of proteins by pepsin and, for a
variable period, permits the digestion of
carbohydrates by salivary amylase.
 This enzyme remains active until pH
throughout the material in the stomach
falls below 4.5, usually within 1-2 hours
after a meal. As the stomach contents
become more fluid and the pH approaches
2.0, pepsin activity increases and protein
disassembly begins.
 Protein digestion is not completed in the
stomach, but there is usually enough time
for pepsin to breakdown complex proteins
into smaller peptide and polypeptide
chains before the chyme enters the small
intestine.
The Small Intestine
 About 6 meters (20 ft) long and has a
diameter ranging from 4 cm at the stomach
to about 2.5 cm at the junction with the
large intestine. It has three subdivisions:
the duodenum, the jejunum, and the ileum.
 The duodenum is the 25 cm (1 ft) closest to
the stomach. This portion receives chyme
from the stomach and exocrine secretions
from the pancreas and liver.
 The jejunum, which is supported by a sheet
of mesentery, is about 2.5 meters (8 ft) in
length. The bulk of chemical digestion and
nutrient absorption occurs in the jejunum.
 The jejunum leads us to the third segment,
the ileum. The ileum ends at the sphincter,
the ileocecal valve, which controls the flow
of chyme from the ileum into the cecum of
the large intestine.
 Plicae intestinal lining bears a series of
transverse folds.
 Villi lining of the intestine is also thrown into
series of fingerlike projections.
 Small intestine were a simple tube with
smooth walls, it have a total absorptive area
around 3300 square centimeters, or roughly
3.6 square feet.
 Lacteal refers to the pale, cloudy
appearance of the lymph in these channels.
Intestinal Movements
 Two examples are the gastroenteric reflex and the
gastroileal reflex.
 Gastroenteric reflex initiated by distention, which
immediately accelerates glandular secretion and
peristaltic activity in all segments.
 Gastroileal reflex is a response to circulating levels
of hormone gastrin.
 Intestinal juice moistens the intestinal contents,
assists in buffering acids, and dissolves both
digestive enzymes provided by the pancreas and the
products of digestion.
Intestinal hormones
 Secretin is released when the pH falls in the
duodenum, occurs when acid chyme arrives from
the stomach. The effect is to increase the
secretion of water and buffers by the pancreas
and liver
 Cholecystokenin is secreted when chyme arrive
in the duodenum, especially when it contains
lipids and partially digested proteins, targets
the pancreas and liver, accelerates the
production and secretion of all types of
digestive enzymes.
 Gastric inhibitory peptide is released when
fats and glucose enter the small intestine. This
peptide hormone inhibits gastric activity and
causes the release of insulin from pancreatic
islets.
The Large Intestine
 The horseshoe-shaped large intestine begins
at the end of the ileum and ends at the anus.
 Lies below the stomach and liver.
 The principal functions of large intestine
include reabsorption of water and
compaction of feces, the absorption of
important vitamins liberated by bilateral
action, and the storing of fecal material
prior to defecation.
 The large intestine often called the large
bowel.
 It has an average length of approximately 1.5
meters (5 ft) and a width of 7.5 cm (3 in).
 It is divided into three major regions: the pouch
like cecum, the first portion of the large intestine;
the colon, the largest portion of the large intestine;
and the rectum the last 15 cm (6 in) of the large
intestine and the end of the digestive tract.
 Large intestine absorbs a variety of other
substances from the chyme Vitamins (2) bilirubin
products bile salts toxins
 Movement from the transverse colon through the
rest of the large intestine results from the
powerful peristaltic contractions, called mass
movement.
The Cecum
 Material arriving from the ileum first enters
an expanded chamber called cecum.
 Ileocecal valve a muscular sphincter guards
the connection between the ileum and the
cecum.
 It usually has the shape of a rounded sac
and the slender veniform appendix attaches
to the cecum along its posteromedial
surface.
 Appendix is almost 9 cm( 3.5 in)
The Colon
 The most striking external feature of the colon
is the pouches, or hustrae, that permit
considerable distension and elongation.
 Longitudinal bands of muscle, the Taenia coli,
are visible on the outer surface of colon just
beneath the serosa.
 The ascending colon begins at the ileocecal
valve. It ascends along the right side of the
peritoneal cavity until it reaches the inferior
margin of the liver.
 Transverse colon, colon turns horizontally,
continues toward the left side, passing below
the stomach and following the curve of the
body wall.
 Descending colon turns inferiorly.
 The descending colon continues along the
left side until it curves and recurves as the
sigmoid colon.
The Rectum
 Forms the end of the digestive tract.
 Anorectal canal last portion of the rectum
contains small longitudinal folds joined by
the transverse folds that mark the boundary
between columnar epithelium of the rectum
and a stratified squamous epithelium similar
to that found in the oral cavity.
 Anus the opening of the anorectal canal, the
epidermis becomes keratinized and identical
to that on the surface of the skin.
 The circular muscle layer of the
muscularis externa in this region forms
the internal anal sphincter.
 The external anal sphincter guards
the exit of the anorectal canal. Consist
of muscle fibers, is under voluntary
control.
Pathology and
Physiology
History of ↓ H20 Intake Activity:
Constipation Power Lifting

HARDENING OF THE STOOL

DIFFICULTY IN EXPULSION OF STOOL

VALSALVA MANEUVER

INTRA-ABDOMEN PRESSURE

COMPRESSION OF LOWER DIGESTIVE TRACT

 ↑ PRESSURE IN RECTUM

PASSAGE OF HARDENED STOOL

CAUSES FRICTION TO LINING

PREDISPOSITION TO ANAL GLAND INFECTION IN THE

INTERSPHINTERIC PLANE

FORMS ABSCESS IN THE PERI-ANAL AREA

FORM A CHRONIC TRACT ( FISTULA-IN-ANO)

↑ INFLAMMATORY RESPONSE DUE TO INFECTION

↑ WBC NEUTROPHILS

RELEASE OF CHEM. MEDIATORS

HISTAMINE & PROSTAGLANDIN SEROTONIN

PAIN FEVER
Clinical presentation
History (in order of prevalence)
• Perianal discharge-intermittent or constant
• Perianal pain-worse during defecation, may be
constant
• Swelling /lump in the perianal area
• Bleeding in the perianal area
• Diarrhea
• Discoloration of skin surrounding the fistula
• External opening in the perianal discharging
• Fever
Past medical history
 Important points in the history that may suggest
a complex fistula include the following:
 Inflammatory bowel disease
Diverticulitis
History of trauma
Previous radiation therapy for prostate or
rectal cancer
Tuberculosis
Immune suppression-Steroid therapy, HIV
infection
Review of symptoms
• -Abdominal pain
• -Weight loss
• -Change in bowel habits
Physical examination
• Physical examination findings remain
the mainstay of diagnosis
Classification of fistula in-ano
• Parks classification system (all are in
relation to the sphincters)
• The Parks classification system defines
4 types of fistula-in-ano that result
from cryptoglandular infections.
1.Intersphincteric-commonest-70%
Common course - Via internal sphincter to the
intersphincteric space and then to the perineum.
They result from perianal abscesses
2. Transsphincteric -25%
Common course - Low via internal and external
sphincters into the ischiorectal fossa and then to
the perineum. Originate from ischiorectal
abscesses
3.Suprasphincteric -5%
Common course - Via intersphincteric space
superiorly to above puborectalis muscle into
ischiorectal fossa and then to perineum. Result
from supralevator abscesses
4. Extrasphincteric-1%
• Bypass the anal canal and sphincter
mechanism, passing through the ischiorectal
fossa and levator ani muscle, and open high in
the rectum
Current procedural terminology
codes classification
1.Subcutaneous
2.Submuscular (intersphincteric, low
transsphincteric)
3.Complex, recurrent (high transsphincteric,
suprasphincteric and extrasphincteric,
multiple tracts, recurrent)
Laboratory
 Examination Date Result Normal Significance
done Values
Urinalysis Sept. 3, 2009
Color Yellow Yellow Normal
Transparency Turbid Clear Turbid is a
manifestation of
pus in the urine.
Reaction (pH) 6.0 4.8-7.8 Normal
Pus cells 10-15 0-8 Indicates UTI
anywhere from
the kidneys to
the urethra.
RBC 8-12 0-5 Hematuria
potentially a sign
of a bladder
infection.
Amorp. Urates Few
Bacteria Few Negative or Bacteria in urine
rare sediment reflect
genito urinary
tract infection or
contamination of
external genitalia.
Examination done Date Result Normal Values Significance

Mucus threads Moderate Is a normal

finding in the
urine.
Squamous Few Presence of
squamous cells
may mean that
the sample is not
as pure as it it
needs to be.
Spec. grav. 1.020 1.015-1.025 Normal

Sugar Negative Negative Normal

Protein Trace Negative Proteinuria

suggest renal
failure.
Complete Blood Sept. 3, 2009
Count
Hemoglobin 143 140-170gm/L Normal

Hematocrit 0.43 0.41-0.51 Normal

RBC count 4.76 4.60-5..20 Normal

WBC count 5.9 4.50-11.00 Normal

Platelet count Adequate 200.00-400.00 Normal

 Examination Date Result Normal Significance
done Values
Differential
count
Segmenters 0.60 0.55-0.65 Normal
Lymphocytes 0.35 0.25-0.35 Normal
Eosinophils 0.05 0.02-0.05 Normal

X-RAY Sept. 3, 2009 Findings:

The lungs are clear and well expanded.
There is no evidence of acute pulmonary
infiltration non consolidation.
The heart is normal.
There is no engorgement of the pulmonary
vascularities.
The ribs, soft tissue outlines and the
diaphragm are likewise unremarkable.
Impression:
 Normal chest findings.
Drug Study
 Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities

Plasil Antacids, 1 amp x 1 TIV Dopamine Disturbanc Give at least

anti-emetic dose antagonist es of GI 30 mins.. Before
agents, anti- that acts by motility meals and at
ulcerants increasing bedtime.
receptor Assess mental
sensitivity and status during
response of treatment.
upper GIT Instruct pt. to
tissues to avoid hazardous
acerthylcoline. activities for at
least 2 hours.
Advice pt to
avoid alcohol and
other
depressant that
enhance
sedating
properties of
this drug.
Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities

Ranitidin Antacids, 1 amp x 1 TIV Completely selected Assess pt. for

e anti- emetic, dose inhibits action cases of abdominal pain.
anti- of histamine persistent Note for
ulcerants on the H2 at dyspepsia, presence of
receptor site stress blood in emesis,
of parietal ulceration, stool or gastric
cells. & in aspirate.
Decreasing patients May be added
gastric acid at risk of to total
secretions. acid parenteral
aspiration nutrition
during solution.
anesth
Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities
Co Antibiotic 625 mg/ PO An antibiotic skin & soft Instruct
amoxiclav tab q 8hrs that is a tissue patient to
 x 6 doses infections,
combination immediately
UTI, pre &
of a penicillin post- report signs or
(amoxicillin) surgical symptoms of
and a procedure hypersensitivity
substance s, bone & reaction, such
called joint as rash, fever,
clavulanic or chills.
acid. It kills Monitor
bacteria, by patient
interfering carefully for
with their signs and
ability to symptoms of
form cell hypersensitivity
walls. The reaction.
bacteria Monitor
therefore patient’s vital
break up and signs before,
die. during and after
medication.
Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities

Flanax non-steroidal 550 mg/ PO Reversibly Relief of Advice the pt.

forte anti- tab q 8 hrs inhibits mild to to take this
inflammatory x 3 doses cyclooxygenas medication
moderatel
and ant e-1 and 2 exactly as
y severe
rheumatic (COX-1 and 2) directed; do not
products enzymes, pain & increase dose
which result in fever w/ without
decreased or w/o consulting
formation of accompany physician. Do
prostaglandin ing not crush
precursors; tablets
inflammati
has Instruct
antipyretic, on eg
client to take
analgesic, and musculosk with food or
anti- eletal milk to reduce
inflammatory trauma, GI distress.
properties post-op
pain &
post-
dental
extraction
.
Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities
Tell pt. that
she may
experience
drowsiness,
dizziness,
lightheadednes
s, or headache
also, nausea,
vomiting, or
heartburn
Instruct pt.
to report DOB,
chest pain, skin
rash and
itching.
Name of Classification Dosage/ Route Mechanism of Indication Nursing
Drug frequency action responsibilities

Fibrosine Laxatives and 1 sachet in 1 PO Is a stimulant Fiber Instruct patient

sachets purgatives glass of laxative. It supplemen to report if she/
water TID x acts directly t to he develop
2 days on the bowels, maintain nausea, vomiting,
stimulating the regularity or stomach pain.
bowel muscles of bowel Instruct patient
to cause a movement. to stop laxative
bowel and inform nurse
movement. or physician if
she/ he
experienced
Rectal bleeding
or failure to have
a bowel movement
within 12 hours
after use of a
laxative, may be a
sign of a serious
condition.
 r e
C a
i n g
rs a n
N u P l
PRE-OP
 Assessment Diagnosis Planning Nursing Evaluation
Interventions
Subjective: Acute pain related After 1 hour of Performed a Goal has been
“Masakit kapag to actual tissue nursing comprehensive partially met.
ako ay damage intervention, the determined The client
dumudumi”, as client will whether the client is experienced
verbalized by the experience lesser experiencing pain lesser pain.
patient pain. the tine of initial
pain in rectal interview.
region
assessed pain in
a client using a self
Objective: report 0-10
a pain rating of numerical pain
7 on a scale of 0- rating scale
10 assessed and
Irritable document the
Confused intensity of pain and
change in pulse discomfort.
rate
increase and
decrease in
respiratory rate
Assessment Diagnosis Planning Nursing Evaluation
Interventions
asked the client
to describe
appetite, bowel
elimination and
ability to rest and
sleep.
obtained a
prescription to
administer by the
doctor.
 Assessment Diagnosis Planning Nursing Evaluation
Interventions
Subjective: Constipation After 1 hour of Assessed Goal has
“Nahihirapan related to nursing usual pattern of been partially
ako dumumi” as discomfort intervention the defecation met.
verbalized by during client will relief including time The client has
the patient defecation from discomfort of day, amount experienced
of constipation and frequency lesser pain
of stool from the
Objective:
Assessed discomfort of
Bright red
history of bowel constipation.
blood with stool habits
 (+) flatus Palpated for
Abdominal abdominal
tenderness distention,
percuss for
dullness and
auscultate for
bowel sounds
Assessment Diagnosis Planning Nursing Evaluation
Interventions
Encouraged
the client to
heed defecation
warning signs
Checked for
impaction of
feces in bowel
Provide
privacy for
defecation
Administer
stool softeners
ordered by the
doctor
POSTOP
Assessment Diagnosis Planning Nursing Evaluation
Interventions
Subjective: High risk for After 2 hours Independent After 2 hours of
infection r/t of Establish Nursing
Objective: inadequate nursing Rapport intervention
Open wound primary intervention Teach patient the patient will be
the to wash hands able to gain
defense as
patient will often, knowledge in
manifested by
gain
broken skin especially infection control
knowledge in as
before
infection evidenced by his
toileting,
control
Before and discussion in
as evidenced wound
after meals.
by care. Therefore,
discussing the the
wound care. goal was met
Assessment Diagnosis Planning Nursing Evaluation
Interventions
  Discuss to
patient the
following signs
of infection:
redness,
swelling,
increased pain,
or purulent
drainage on the
site and fever
Demonstrate
and allow
return
demonstration
of wound care
 ON
T I G E
U A AR
AL C H
E V I S
D N
N D P L A
A
MEDICATION
Take Home Med.
 Fibrosine Sachet
 1 sachet in 1 glass of water 3 times a day.
EXERCISE
 Avoid heavy lifting, straining and strenuous
exercise for two weeks at a minimum (i.e.,
weightlifting, jogging, swimming, etc.)
TREATMENT
 Fistulectomy - in a fistulectomy, the surgeon makes
an incision in the fistula tract, opening it up and
merging it with the anal canal. This allows the
tissues to heal from the inside out.For very small
fistulas, a fistulotomy may be performed in a
doctor’s office, using only local anesthesia. Larger
fistulas, however, require surgery under spinal or
general anesthesia, and are typically performed in a
hospital or surgery center. Patients typically
experience mild or moderate discomfort or pain
following this procedure, with a recovery time of
one to four weeks.
HEALTH TEACHING
 Maintain a liquid diet for two days after the
procedure (i.e., soup, Jell-O, etc.)
 Eat a high fiber diet after two days
 Use the bathroom once a day. A warm bath
may help your symptoms.
 Take over-the-counter pain medicine as
needed
 Shower standing up and bathe the area with
water to soothe and keep it clean.
 Do not sit in the bathtub
 Do not use topical steroids or topical agents
such as Preparation H
 Expect some drainage for two to four weeks
after the procedure as the Surgisis AFP
plug is incorporated and the fistula tract is
closed.
 Using stool softeners and adhering to good
hygiene, such as sitz baths after every
bowel movement, decreases discomfort and
helps for recovery.
OPD
 For anal fissures, the WASH regimen is indicated.
 For anal fistulas, outpatient follow-up with a
surgeon is indicated if consultation did not take
place at the time of presentation.
 Botulinum toxin injection has been shown to be an
effective alternative to surgery for the treatment
of uncomplicated idiopathic anal fissure.
 Topical application of clove oil cream has
demonstrated significant benefit in patients with
chronic anal fissure.
 The application of topical 0.5% nifedipine ointment
has been used as a chemical sphincterotomy agent.
It has been shown to offer a significant healing
rate for acute anal fissure and may prevent it from
becoming a chronic fissure.
DIET
 A high-fiber diet causes a large, soft, bulky stool
that passes through the bowel easily and quickly.
Because of this action, some digestive tract
disorders may be avoided, halted, or even reversed
simply by following a high-fiber diet. A softer,
larger stool helps prevent constipation and
straining. This can help avoid or relieve
hemorrhoids. More bulk means less pressure in the
colon, which is important in the treatment of
irritable bowel syndrome and diverticulosis (defects
in the weakened walls of the colon). In addition,
fiber appears to be important in treating diabetes,
elevated cholesterol, colon polyps, and cancer of the
colon.