I.

Introduction

A precise definition of hemorrhoids does not exist, but they can be described as masses or
clumps ("cushions") of tissue within the anal canal that contain blood vessels and the
surrounding, supporting tissue made up of muscle and elastic fibers. The anal canal is the last
four centimeters through which stool passes as it goes from the rectum to the outside world. The
anus is the opening of the anal canal to the outside world.

Although most people think hemorrhoids are abnormal, they are present in everyone. It is
only when the hemorrhoidal cushions enlarge that hemorrhoids can cause problems and be
considered abnormal or a disease.

There are two types of hemorrhoids, external and internal which are differentiated via their
position with respect to the dentate line.

External hemorrhoids are those that occur outside the anal verge (the distal end of the anal
canal). Specifically they are varicosities of the veins draining the territory of the inferior rectal
arteries, which are branches of the internal pudendal artery. They are sometimes painful, and
often accompanied by swelling and irritation. Itching, although often thought to be a symptom of
external hemorrhoids, is more commonly due to skin irritation. External hemorrhoids are prone
to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a
thrombosed hemorrhoid.
Internal hemorrhoids are those that occur inside the rectum. Specifically they are varicosities
of veins draining the territory of branches of the superior rectal arteries. As this area lacks pain
receptors, internal hemorrhoids are usually not painful and most people are not aware that they
have them. Internal hemorrhoids, however, may bleed when irritated. Untreated internal
hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated
hemorrhoids. Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are
pushed outside the anus. If the anal sphincter muscle goes into spasm and traps a prolapsed
hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes
a strangulated hemorrhoid.

Internal hemorrhoids can be further graded by the degree of prolapse.

Grade I: No prolapse.
Grade II: Prolapse upon defecation but spontaneously reduce.
Grade III: Prolapse upon defecation, but must be manually reduced.
Grade IV: Prolapsed and cannot be manually reduced.

It is not known why hemorrhoids enlarge. There are several theories about the cause,
including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining to have
a bowel movement (constipation). None of these theories has strong experimental support.
Pregnancy is a clear cause of enlarged hemorrhoids though, again, the reason is not clear.
Tumors in the pelvis also cause enlargement of hemorrhoids by pressing on veins draining
upwards from the anal canal.

1
 One theory proposes that it is the shearing (pulling) force of stool, particularly hard stool,
passing through the anal canal that drags the hemorrhoidal cushions downward. Another theory
suggests that with age or an aggravating condition, the supporting tissue that is responsible for
anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the
hemorrhoidal tissue loses its mooring and slides down into the anal canal.

One physiological fact that is known about enlarged hemorrhoids that may be relevant to
understanding why they form is that the pressure is elevated in the anal sphincter, the muscle that
surrounds the anal canal and the hemorrhoids. The anal sphincter is the muscle that allows us to
control our bowel movements. It is not known, however, if this elevated pressure precedes the
development of enlarged hemorrhoids or is the result of the hemorrhoids. Perhaps during bowel
movements, increased force is required to force stool through the tighter sphincter. The increased
shearing force applied to the hemorrhoids by the passing stool may drag the hemorrhoids
downward and enlarge them.

Hemorrhoids are usually benign. In most cases, symptoms will resolve within a few days.
External hemorrhoids are painful while internal hemorrhoids usually are not.

The most common symptom of internal hemorrhoids is bright red blood covering the stool, a
condition known as hematochezia, on toilet paper, or in the toilet bowl. They may protrude
through the anus. Symptoms of external hemorrhoids include painful swelling or lump around
the anus.

Hemorrhoids are common. In the USA, the prevalence is about 4.4%. It is estimated that
approximately one half of all Americans have had this condition by the age of 50, and that 50%
to 85% of the world's population will be affected by hemorrhoids at some time in their life.
However, only a small number seek medical treatment. Annually, only about 500,000 in the U.S.
are medically treated for massive hemorrhage, with 10 to 20% of them requiring surgeries.

Our group has chosen this case because as said in statistical reports, only a small number of
people with this condition seek for medical treatment, which makes it quite a rare case. This may
be because of the private body part involved in the condition – the anus. Although our chosen
case may be quite simple, we will make sure that we may be able to explain well the condition’s
entire whirl about.

Objectives

2
General Objectives:

After 5 days of nursing internship, this case presentation will aim to identify and
determine the general health problems and needs of the patient with an admitting diagnosis of
Internal Hemorrhoid. This presentation will also intend to help the patient promote health and
medical understanding of such conditions through the application of suitable nursing skills

Specific Objectives:

 To obtain the patient’s profile and nursing health history

 To assess his health patterns and show a relationship with his underlying condition, if
there’s any
 To assess his physical appearance and show a relationship with his underlying condition, if
there’s any
 To be able to put up a pathophysiological mechanism of the patient’s condition
 To name the laboratory examinations and procedure done to the patient and his
medications in order for us to associate it with his condition
 To formulate a nursing care plan to promote wellness to the patient
 To implement appropriate nursing interventions to promote the patient’s optimum level of
well-being
 To render nursing care and information to the patient through the application of nursing
skills
 To raise the level of awareness of the patient on health problems that he may
encounter

II. Assessment

Personal Data

Client Y was born on May 19, 1983 at the province of Sorsogon and is presently 27 years
old. He resides at Barangay San Roque, Sta. Magdalena, Sorsogon. He is a Roman Catholic and
is still single. Client Y is a member of the Armed Forces of the Philippines and is currently
ranked as a Private First Class soldier. He is a military personnel.

Chief Complaint

This is the case of Client Y, 27 years of age from Sorsogon City, Bicol who came to the
Armed Forces of the Philippines Medical Center with a chief complaint of protruding anal
mucosa.

History of Present Illness

3
 One month prior to admission, Client Y noted protrusion of his mucosa over his anal
sphincter. There were no associated bleeding or pain and the protruding mucosa was noted to be
manually reduced. According to Client Y, the mucosa protrudes upon defecation. He did not
seek consultation from any health care practitioners at first and he did not take any medications
for this as well. However, due to the persistence of his condition, he was prompted to do so.
Client Y was then examined to have Grade 3 Internal Hemorrhoids. Client Y was given Deflon
and Mefenamic Acid. He was then referred to the Armed Forces of the Philippines Medical
Center for further evaluation and management.

Past Medical History

Patient Y had no major childhood illnesses except for common cough and colds. He has
neither food nor drug allergies. According to him, he completed all the necessary immunizations
when he was young. This is the first time that Patient Y was admitted to the hospital, meaning he
also has no previous surgeries or injuries.

Family History of Illness

Patient Y stated that besides his own, the condition no longer existed in their family. The
only familial illness that the patient knows of is hypertension, which his mother has. Other than
that, he describes his family as healthy.

Functional Health Patterns (Marjorie Gordon’s)

PATTERNS OF PRIOR TO DURING ANALYSIS AND

HEALTH HOSPITALIZATIO HOSPITALIZATION INTERPRETATION
N
Health Perception  He is healthy  Feels dependent
and Health  He is a non- on the health care
Management Pattern smoker team
 He drinks  He expects that he
alcoholic would be cured
beverages while in the
occasionally, once hospital
or twice every  Expects the
two weeks medical staff to
 Does not believe assist and help
in albularyos him in every way
 Takes OTC drugs they could
in case of illness
Nutritional and  No problem with  No significant High fiber foods
Metabolic Pattern his appetite changes except promote fecal
 Eats 3 rice meals during the evacuation.

4
 per day and operative period Adequate fluid
sometimes snacks  Encouraged to eat intake prevents stool
 Drinks around 1 high fiber foods from being
liter of water and to increase excessively dry and
everyday fluid intake hard
 No food or eating (pp. 1057-1058,
discomforts Medical Surgical
 No significant Nursing: Total
dental problem Patient Care,
Harkness and
Dincher)
Elimination Pattern  Defecates once  Defecated once in Hemorrhoids result
every two or three two days from numerous
days  Stool is said to be factors including
 Stool is slightly not as hard as constipation
hard before (p. 1093, Medical
 Normal urinary Surgical Nursing:
elimination Total Patient Care,
pattern Harkness and
Dincher)

Activity – Exercise  Exercises  Was instructed to

Pattern regularly rest and not do
 He can take full too much
self care of strenuous
himself activities first to
prevent pressure
causing bleeding
of operative site
Sleep – Rest Pattern  Approximately  No significant
does 6hrs of deep, changes
continuous sleep
 Takes nap at
times
Cognitive –  No troubles of  No troubles of
Perceptual Pattern hearing hearing
 Does not wear  Does not wear
eyeglasses or eyeglasses or
contact lenses contact lenses
Self-perception and  Perception of  Wants to get well
Self-control Pattern being healthy as soon as
 Emotionally possible for him
stable to go back to his
life outside the
hospital

5
Role – Relationship  Patient is single
Pattern  Usually socializes
with friends and
colleagues

Sexuality –  Patient has no

Reproductive offspring yet
Pattern
Coping – Stress  Consults friends  Does not feel
Pattern and family at stressed of his
times when hospitalization
patient has big
problems
Value – Belief  Hears mass  Prayed for Rendering culture-
Pattern seldom because of uncomplicated specific care is an
busyness stay in the essential goal in
hospital nursing. It leads to a
high credibility,
conformability, and
wealth of empirical
data – Madeleine
Leininger
(Theoretical
Foundations of
Nursing, Octaviano
and Balita)

Physical Assessment

Body Part Normal Findings Actual Findings Interpretation &

Analysis
Skin Inspection Skin is uniform Skin is brown Skin may be
whitish pink or dry because of
brown color insufficient fluid
No Bleeding intake
No area of No bleeding Normal fluid
increased No area of intake should be
vascularity and increased 2500 ml per day
ecchymosis vascularity and
No skin lesions ecchymosis
present except No lesions
for freckles,
birthmarks or
moles which

6
 may be flat or (pp.283-304,
elevated Health
Skin is dry Assessment &
with a minimum Physical
Palpation of perspiration. Skin is dry Examination –
Warm and Zator Estes)
equal bilaterally.
Hands and skin Warm and equal
slightly cooler bilaterally
than the rest of
the body
Skin surfaces
non-tender
Texture:
Smooth, even
and firm except
where there is
significant hair
growth
Skin turgor: Skin sprung back
When released, rapidly when
should return to pinched
original contour
rapidly
Edema not No edema
present present

Scalp and Hair Inspection Dark black to Hair appears No significant
pale blonde; may black findings
turn gray or
white; may be
chemically
changed
Terminal hair Even distribution
found in the of hair (pp.305-308,
eyebrows,, Health
eyelashes, and Assessment &
scalp, and in Physical
axilla and pubic Examination –
areas after Zator Estes)
puberty. No infestation or
No signs of lesions
infestation or
lesions.
Seborrhea/
dandruff may be

7
 present Hair is thick and
Palpation Hair may feel shiny
thin, straight,
coarse, thick or
curly. Shiny and
resilient
Nails Inspection Have a pink- Brown-cast nails No significant
cast in light- findings
skinned and
brown in dark-
skinned. Capillary refill of
Capillary refill 1.5 seconds
present (should
return to normal
2-3 sec) Surface smooth
Surface is and slightly (pp.308-311,
smooth, and rounded Health
slightly rounded Assessment &
or flat. Curved Physical
nails are normal. Examination –
Uniform nail No splinters or Zator Estes)
thickness brittle edges
throughout; no
splintering or
brittle edges.
Angle approx. Angle approx.
160° 160°
Firm nail base Firm nail base
Palpation
Eyes Inspection Symmetrical Eyes No significant
with no symmetrical findings
drooping,
infection, tumors
or other
abnormalities
Visual Acuity: Visual acuity of
20/20 20/20
Sclera: Sclera appears
White in light- white
skinned w/o (pp.350-362,
exudates, lesions Health
or foreign Assessment &
bodies. In dark- Physical
skinned, may Examination –
have brown Zator Estes)
patches

8
 Pupils: equally
round, reactive to Pupils equally
light and round, reactive to
accommodation; light and
2-6 mm accommodation;
No tearing, approx. 4 mm
swelling or No tearing,
discharge swelling or
descharge
Ears Inspection Match flesh Same color as No significant
color of the rest face findings
of the skin.
Central Central position
position. Proportional
Proportional. No redness, (pp.386-389,
Palpation No redness, swelling, or Health
lesions, swelling, tenderness Assessment &
tenderness Physical
Should not No pain assessed Examination –
complain of pain Zator Estes)
or tenderness

Nose Inspection Symmetrical, Symmetrical and No significant

midline of the in midline findings
face.
Without No swelling,
swelling, bleeding, lesions, (pp.394-397,
bleeding, lesions, or masses Health
or masses. Assessment &
Each nostril Patent nostrils Physical
patent. Examination –
No pain or No pain or Zator Estes)
Palpation discomfort discomfort noted
during palpation

Mouth Inspection Breath smells No significant

fresh. findings
Lips and Lips and
membranes pink membranes are
and moist with moist, dark flesh
no lesions or colored; no lesions
inflammation. or inflammation
Tongue is Tongue in
midline. Pink, midline and moves (pp.398-405,
moist, rough freely Health
without lesions.   Assessment &

9
 Symmetrical; Physical
moves freely. Examination –
Gums have Zator Estes)
pale-red strippled
surface.
No swelling or No swelling or
bleeding. bleeding

Neck Inspection Symmetrical Symmetrical No significant

with head in with head in findings
central position. central position
Able to move Able to move
head without head w/o(p.331, Health
discomfort or discomfort Assessment &
noticeable limits Physical
Palpation Muscles should No palpable Examination –
be symmetrical masses Zator Estes)
without palpable
masses or spasm
Chest Inspection Without Without lesions No significant
lesions; skin findings
intact. Quiet rhythmic
Quiet, and effortless
rhythmic and breathing
effortless
Palpation breathing No masses or
No pulsations, tenderness
masses, thoracic (pp.451-469,
tenderness Bronchovesicular Health
Auscultation present. breath sounds Assessment &
Normal lung Physical
tissue produces Examination –
resonant sound, Zator Estes)
diaphragm has
dull sounds.
Bronchial,
bronchovesicular
or vesicular
breath sounds

Abdomen Inspection Abdominal Abdominal No significant

contour flat or contour rounded. findings
rounded.
Symmetrical. Symmetrical.
Uniform in Uniform in color.
color or

10
 pigmentation.
No abdominal
scars.
No striae No scars; striae (pp.552-562,
Auscultation Intermittent Gurgling sounds Health
gurgling sounds in abdomen Assessment &
throughout   Physical
abdominal   Examination –
quadrants. Zator Estes)
Percussion Tympany, No friction rubs/
predominant audible bruits
sound heard
Palpation No organ
enlargement
palpable, or any
masses, bulges,
or swelling

Suprapubic Area Inspection Without Without Lesions No significant

lesions findings
Palpation Urinary Urinary bladder
bladder not not palpable (p.638,
palpable and not Fundamentals of
tender Nursing -
Kozier)
Genitalia Inspection Pubic hair Pubic hair evenly No significant
distributed in distributed findings
Palpation triangular form.
More coarse
than scalp hair. (pp.746-753,
No nits or lice. No nits or lice Health
Penis skin free No lesions or Assessment &
of lesions and inflammation Physical
inflammation. Examination –
Zator Estes)
Rectum Inspection No lesions,  In midline A dilated vein
redness Redundant mass seen as swollen,
Sphincter noted, reddish reddish-blue
intact mass signifies
Palpation Non-tender hemorrhoids
(pp. 55-56,
Medical Surgical
Nursing,
Harkness and
Dincher)
Upper Inspection Without Without lesions, No significant

11
 Extremities lesions, scars or scars or findings
inflammation inflammation (p.579,
Fundamentals of
Nursing, Kozier)

Lower Inspection Without Without lesions, No significant

Extremities lesions, scars scars findings
Palpation No edema No edema (p.579,
Fundamentals of
Nursing, Kozier)

Diagnostics
Date Performed Procedure Rationale Findings
07-08-10 X-Ray: The lower GI series
Colon and Rectum may show problems
(Barium Enema) like abnormal growths,
ulcers, polyps, and
diverticuli, and colon
cancer.
Barium coats the lining
of the colon and
rectum and makes
these organs, and any
signs of disease in
them, show up more
clearly on x-rays.
07-08-10 Complete Blood Count To measure RBC, WBC,
hemoglobin and Segmenters are
hematocrit levels If increased.
there is concern that
significant bleeding
has occurred
07-09-10 Urinalysis Urinalysis is usually Slightly turbid
done to preoperative
patients and if not
normal, should be
further examined by
Blood Glucose Test to
prevent postoperative
delayed union or non-
healing wound
07-12-10 Electro-Cardio Gram To rule out any Impression:
problems in the heart, Sinus rhythm
if there’s any prior to Bifasicular block
surgery

12
III. Anatomy

The gastrointestinal tract (GI tract), also called the digestive tract, alimentary canal
or gut, is the system of organs within multicellular animals that takes in water and food, extracts
energy and nutrients from the food, and expels the remainder as waste. The major functions of
the GI tract are digestion and excretion.

Digestion refers to the process of metabolism whereby a biological entity applies both
mechanical and chemical procedures to reduce a substance to component parts that are then
absorbed into the body and distributed throughout via the circulatory system (Silverthorn 2004).
Excretion is the process of eliminating the waste products of metabolism and other non-useful
materials.

The digestive process involves the cooperative work of many body components,
including the heart, brain, liver, and pancreas. For example, the heart directs blood to the area
and the liver and pancreas secrete digestive enzymes. The process also reflects individuality. For
instance, some individuals can digest milk or eat peanuts, while others may have an allergy to
one or both of these, and people enjoy different tastes.

The GI tract differs substantially from animal to animal. For instance, some animals have
multi-chambered stomachs, while some animals' stomachs contain a single chamber. In a normal
human adult male, the GI tract is approximately 6.5 meters (20 feet) long and consists of the
upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut,
reflecting the embryological origin of each segment of the tract.

In humans, the gastrointestinal tract is a long tube with muscular walls comprising four
different layers: inner mucosa, submucosa, muscularis externa, and the serosa (see histology
section). It is the contraction of the various types of muscles in the tract that propel the food.

The GI tract can be divided into an upper and a lower tract. The upper GI tract consists of
the mouth, pharynx, esophagus, and stomach. The lower GI tract is made up of the intestines and
the anus.

Upper gastrointestinal tract

The upper GI tract consists of the mouth, pharynx, esophagus, and stomach.

 The mouth comprises the oral mucosa, buccal mucosa, tongue, teeth, and openings of the
salivary glands. The mouth is the point of entry of the food into the GI tract and the site
where digestion begins as food is broken down and moistened in preparation for further
transit through the GI tract.
 Behind the mouth lies the pharynx, which leads to a hollow muscular tube called the
esophagus or gullet. In an adult human, the esophagus (also spelled oesphagus) is about
one inch in diameter and can range in length from 10-14 inches (NR 2007).

13
  Food is propelled down through the esophagus to the stomach by the mechanism of
peristalsis—coordinated periodic contractions of muscles in the wall of the esophagus.
The esophagus extends through the chest and pierces the diaphragm to reach the
stomach, which can hold between 2-3 liters of material in an adult human. Food typically
remains in the stomach for two to three hours.
 The stomach, in turn, leads to the small intestine.

The upper GI tract roughly corresponds to the derivatives of the foregut, with the exception
of the first part of the duodenum (see below for more details.)

Lower gastrointestinal tract

The lower GI tract comprises the intestines and anus.

 Bowel or intestine
o The small intestine, approximately 7 meters (23 feet) feet long and 3.8
centimeters (1.5 inches) in diameter, has three parts (duodenum, jejunum, and
ileum). It is where most digestion takes place. Accessory organs, such as the liver
and pancreas help the small intestine digest, and more importantly, absorb
important nutrients needed by the body. Digestion is for the most part completed
in the small intestine, and whatever remains of the bolus have not been digested
are passed onto the large intestine for final absorption and excretion.
 duodenum – the first 25 centimeters (9.84 inches)
 jejunum and ileum – combined are approximately 6 meters (19.7 feet) in
length
o The large intestine – (about 1.5 meters (5 feet) long with a diameter of about 9
centimeters (3.5 inches) also has three parts:
 cecum (the appendix is attached to the cecum)
 The colon (ascending colon, transverse colon, descending colon and
sigmoid flexure) is where feces are formed after absorption is completed
 The rectum propels feces to the final part of the GI tract, the anus
 The anus, which is under voluntary control, releases waste from the body through the
defecation process

Related organs

Accessory organs to the GI tract help in digestion by releasing powerful enzymes and
other fluids that breakdown macromacules into smaller molecules that can be absorbed by the
digestive system. Two such organs are the liver and pancreas.

The liver secretes bile into the small intestine via the biliary system, employing the gall
bladder as a reservoir. Apart from storing and concentrating bile, the gall bladder has no other
specific function. The pancreas secretes an isosmotic fluid containing bicarbonate and several
enzymes, including trypsin, chymotrypsin, lipase, pancreatic amylase, and nucleolytic enzymes
(deoxyribonuclease and ribonuclease), into the small intestine.

14
Embryology

The human embryo has three germ layers: endoderm, mesoderm, and ectoderm. These
layers differentiate and give rise to various structures.

The gut is an endoderm-derived structure. At approximately the sixteenth day of human

development, the embryo begins to fold ventrally (with the embryo's ventral surface becoming
concave) in two directions: the sides of the embryo fold in on each other and the head and tail
fold towards one another. The result is that a piece of the yolk sac, an endoderm-lined structure
in contact with the ventral aspect of the embryo, begins to be pinched off to become the primitive
gut. The yolk sac remains connected to the gut tube via the vitelline duct. Usually this structure
regresses during development; in cases where it does not, it is known as Meckel's diverticulum.

During fetal life, the primitive gut can be divided into three segments: foregut, midgut,
and hindgut. Although these terms are often used in reference to segments of the primitive gut,
they are nevertheless used regularly to describe components of the definitive gut as well.

Each segment of the primitive gut gives rise to specific gut and gut-related structures in
the adult. Components derived from the gut proper, including the stomach and colon, develop as
swellings, or dilatations, of the primitive gut. In contrast, gut-related derivatives (those structures
that derive from the primitive gut but are not part of the gut proper) in general develop as
outpouchings of the primitive gut. The blood vessels supplying these structures remain constant
throughout development (Carlson 2004).

Part Range in adult Gives rise to Arterial supply

pharynx, esophagus, stomach, upper
the pharynx, to the upper duodenum, respiratory tract (including branches of the
foregut
duodenum the lungs), liver, gallbladder, and celiac artery
pancreas
lower duodenum, to the lower duodenum, jejunum, ileum, branches of the
midgut first half of the transverse cecum, appendix, ascending colon, and superior mesenteric
colon first half of the transverse colon artery
second half of the remaining half of the transverse colon, branches of the
hindgut transverse colon, to the descending colon, rectum, and upper part inferior mesenteric
upper part of the anal canal of the anal canal artery

Source: http://www.newworldencyclopedia.org/entry/Gastrointestinal_tract

15
V. Medical and Surgical Management

Name of drug Classification Indication Dosage and route Side effects/ Nursing
adverse effect consideration

Generic Name:
Central nervous system Short term (< 5 30 mg IM/IV q6h. Side Effects:  Assess LFT’s,
Ketorolac agent, Non-steroidal days) of moderate to renal function, and
Tromethamine inflammatory drugs, severe, acute pain as Headache, coagulation profile
analgesic; antipyretic continuation therapy drowsiness,
Brand Name: from IV/IM. dizziness  Assess for history
Toradol, of CABG surgery,
Adverse effect: asthma and allergic
reaction to aspirin
Nausea, dyspepsia, or other NSAID’s.
GI pain, diarrhea,
edema  Monitor for
hypersensitivity
reactions.

16
 Name of drug Classification Indication Dosage and route Side effects/ Nursing
adverse effect consideration

Administer drug with

Generic name: non-steroidal anti Acute and long-term 100 mg PO bid; Side effect: food or after meals if
Celecoxib inflammatory drug treatment of signs may increase to 200 GI upset occurs.
and symptoms of mg/day PO bid as Headache,
Brand Name: rheumatoid arthritis needed dizziness,
Celebrex and somnolence, Establish safety
osteoarthritis insomnia, fatigue, measures if CNS,
• tiredness, dizziness visual disturbances
Reduction of the occur.
number of colorectal Adverse effect:
polyps in familial
adenomatous Rash, pruritus, Arrange for periodic
polyposis sweating, dry ophthalmologic
(FAP) mucous membranes, examination during
• stomatitis long-term therapy.
Management of
acute pain
• If overdose occurs,
Treatment of institute emergency
primary procedures—gastric
dysmenorrhea lavage, induction of
emesis, supportive
therapy.

Provide further comfort

measures to reduce pain (eg
positioning, environmental
control), and to reduce
inflammation (eg warmth,
positioning, rest)

17
 Name of drug Classification Indication Dosage and route Side effect/ adverse Nursing
effect consideration

Generic name: Analgesic Short term (< 5 Side effects: Tell the patient that
Tramadol days) of moderate to 100mg IV q6 Headache, nausea driving and
severe, acute pain as and vomiting machinery activities
Brand name: continuation therapy drowsiness should be avoided if
Ultram from IV/IM. tramadol is taken
Adverse effect:
Inform client that
Dry mouth, vertigo, medication may
visual disturbance cause CNS
depression and/or
respiratory
depression,
particularly when
combined with other
CNS depressants

18
B. Surgical Management

HEMORRHOIDECTOMY

Hemorrhoidectomy is a surgical excision of the hemorrhoid used primary only in severe

cases. General anesthesia is used in this kind of procedure. Incisions are made in the tissue
around the hemorrhoid. The swollen vein inside the hemorrhoid is tied off to prevent bleeding,
and the hemorrhoid is removed. The surgical area may be sewn closed or left open. Medicated
gauze is used to cover the wound. The tools used in this kind of surgery vary like scalpel, cautery
pencil (uses electricity) and laser. Recovery in this kind of surgery takes about 2-3 weeks.

Hemorrhoids come back about 5% of the time after hemorrhoidectomy.

Hemorrhoidectomy is done with equal success using traditional surgical tools and newer tools.

After surgery:

 Pain is expected.
 Some bleeding is normal, especially with the first bowel movement.
 May apply numbing medicines before and after bowel movements to relieve pain.

19
  Ice packs applied to the anal area may reduce swelling and pain.
 Frequent soaks in warm water (sitz baths) help relieve pain and muscle spasms.
 Take stool softeners that contain fiber to help make your bowel movements smooth.
Straining during bowel movements can cause hemorrhoids to come back.
RISKS
 Pain, bleeding, and an inability to urinate (urinary retention) are the most common side
effects of hemorrhoidectomy.

Other procedures for hemorrhoids:

 Rubber band ligation - a procedure in which elastic bands are applied onto an internal
hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7
days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line
intense pain results immediately afterwards. Cure rate has been found to be about 87%.

 Sclerotherapy - involves the injection of a sclerosing agent (such as phenol) into the

hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The
success rate at four years is 70%.

 Stapled hemorrhoidectomy - a procedure that involves resection of soft tissue proximal to

the dentate line, disrupting the blood flow to the hemorrhoids. It is generally less painful
than complete removal of hemorrhoids and was associated with faster healing compare to
a hemorrhoidectomy.

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VI. Course in the Ward

Date and Time Order Focus Evaluation Nursing Responsibilities

July 08, 2010 @ 1740H DATA Pain DATA *Side rails up

*Admitted male patient *awake
ambulatory accompanied *f/ proctosigmoidoscopy *Keep the environment
by ward man with chief Scheduling quite
complaint of protruding *Kept rested
oral mucosa *Perform pain assessment
*conscious and coherent ACTION every time the pain
*Xray and CBC done occurs (pain scale)
ACTION
*On High Fiber and Low *Accept client’s
Residue diet description of pain
*Oriented use and
regulation of the ward *Monitor Vital Signs

RESPONSE
*fl UA
*+1 FBS, BUN, Crea
*fl Lipid profile
on oral meals

21
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 09, 2010 @ 3-11am DATA Safety and Security DATA *Side rails up
*fl proctosigmoidoscopy *asleep
scheduling *keep rested *Keep the environment
*with consent sign quite
*maintained NPO ACTION
*dulcolay given *Urinalysis done *Accept client’s
*attended description of pain

ACTION *Monitor Vital Signs

*NPO

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 Date and Time Order Focus Evaluation Nursing Responsibilities

July 12, 2010 @ 7am- S Bowel Movement DATA *Side rails up

3pm *Mucous on defecation *Awake
*Keep the environment
O ACTION quite
*Correct oriented *Due available meds.
Given *Accept client’s
A *FFHP description of pain
*Internal Hemorrhoids proctosigmoidoscopy
result *Monitor Vital Signs
P *Kept Rested
*High Fowlers *High Fowlers *Give a medication at the
*ECG done right time

*Monitor I & O

23
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 12, 2010 @ 3-11 S Bowel Movement ACTION *Side rails up

*Mucous on defecation *fl ff-up
proctosiguinoidoscopy *Keep the environment
O Result quite
*Correct oriented *Fl referral to cardio
SVC *Monitor I & O
A *Attended
*Internal Hemorrhoids *High Fowlers *Accept client’s
*Low Residue Diet description of pain
P
*High Fowlers *Monitor Vital Signs
*Low Residue Diet
*Give a medication at the
right time

24
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 13, 2010 Safety and Security DATA *Side rails up

*Received patient awake
*With CBC with QPC *Keep the environment
result quite
*V/S taken and recorded
*Needs attended
*Keep Rested *Accept client’s
description of pain

ACTION *Monitor Vital Signs

*OR Scheduling
*Give a medication at the
right time

25
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 14, 2010 Safety and Security DATA *Side rails up

*Needs attended
*Keep Rested *Keep the environment
*Asleep on bed quite

*Accept client’s
ACTION description of pain
*OR Scheduling
*Meds Needed *Monitor Vital Signs

*Give a medication at the

right time

26
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 15, 2010 Safety and Security DATA *Side rails up

*Seen by Dental SVC
*Keep the environment
quite
ACTION
*Cardio Cleared *Accept client’s
description of pain

*Monitor Vital Signs

*Give a medication at the

right time

27
 Date and Time Order Focus Evaluation Nursing Responsibilities

July 18, 2010 S Bowel Movement DATA *Side rails up

*+ Bleeding mucosa *Received Patient awake
on bed *Keep the environment
O *CV distress quite
*Concern columns *Meds. Attended
MCRD *Kept rested and *Accept client’s
*+ skin tag position comfortable description of pain

P *Monitor Vital Signs

*High Fiber Diet ACTION
*For OR scheduling *Cardio Cleared *Give a medication at the
*High Fiber Diet right time
*For OR scheduling
*Note the findings

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 Date and Time Order Focus Evaluation Nursing Responsibilities

July 20, 2010 *Back to PACU Safety and Security DATA *Side rails up
*Flat on bed for 8hours *f/ with
*Monitor V/S q15 until hemmorrhoidectomy for *Keep the environment
stable then q1 today quite
*Monitor Input and
Output q1 ACTION *Perform pain assessment
*NPO temporarily *With concent for every time the pain
* IVF: D5LR IL x procedure occurs (pain scale)
30gtts./min *Pre op site rechecked
*MEDS: *Wrist tag on *Accept client’s
>Tramadol 100mg IV *Maintain on NPO description of pain
then Tramadol 50mg IV *CT, BT, PT, PTT result
q6 x 24hrs *transferred to PACU per *Monitor Vital Signs
>Tramadol 25mg IV as wheelchair
rescue dose for Pain *Give a medication at the
>Keterolac 30mg IV 16 right time
>Pantolol 40mg IV OD
while on NPO
*Once patient on diet
start Celecoxib 200mg
tab, 1 tab BID for Pain

29
VII. Nursing Care Plan

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Constipation Decreased high Short term: Independent: Short term:

“ Ilang araw na related to fiber food intake
akong hirap decreased dietary  After of 8 hours Determine stool Assist in After of 8 hours
dumumi, ayaw intake as Slowed muscle of nursing color, identifying of nursing
lumabas ng dumi manifested by contraction of the intervention the consistency, causative or intervention the
ko.” As stated by altered bowel colon patient will be frequency and contributing patient is been
the patient sound, and  able to eliminate amount factors and able to eliminate
abdominal pain. Stool move stool which are appropriate stool which are
Objectives: through the colon semi formed intervention semi formed
- abdominal pain, slowly consistency. consistency.
urgency and 
cramping Altered Long term: Bowel sounds Long term:
withdrawal of After 1 week of are generally After 1 week of
- altered bowel waste nursing Auscultate bowel decreased in nursing
sound  intervention the sounds constipation intervention the
constipation patient will be patient is now
V/S taken as able to establish Assists in able to establish
follows: normal pattern of improving stool normal pattern of
bowel consistency bowel
BP: `120/90 functioning as functioning as
PR: 78 evidenced by Encourage fluid To decreased evidenced by
RR: 23 intestinal motility intake of 2500 – gastric distress intestinal motility
T: 37.4 3000 ml/day and abdominal
within cardiac distension
intolerance

Recommend to To facilitate
avoid gas defecation when
forming food constipation is
present.

30
Dependent:

Discuss use of
stool softeners,
mild stimulants,
bulk – forming
laxative or
enemas. Monitor
effectiveness

To enhance easy
defecation

Fiber resists
Encourage to eat enzymatic
high fiber rich digestion and
food absorbs liquid in
its passage along
the intestinal
Collaborative: tract and thereby
produces bulk,
Consult with which acts as a
dietician to stimulant to
provide well defecation
balanced diet
high in fiber and
bulk.

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Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Acute pain Mechanical Short term: Independent: Short term:

“masakit ang related to post thermal and After 2 to 3 Encourage pt. to Promote After 2 to 3
tahi ko”,. As surgical incision chemical stimuli hours of nursing verbalize pain cooperation hours of nursing
stated by the as manifested by  intervention the from the client intervention the
patient facial grimace, Nociceptor patient will be Provide comfort patient has been
irritability and  able to perform such as deep This calms and able to
Objective: pain scale of Afferent nerve divertional breathing soothes the performed
- facial grimace 8/10  activities and Encourage patient divertional
- pain scale of End terminal can relief pain diversional activities and
8/10 irritability by analgesics activities To divert the relieved pain by
- irritability  attention and not analgesics
- Restlessness Brain cortex Long term: Dependent: feel any pain
- radiating pain pain After 2 to 3 days Administer Long term:
in the incision of nursing medication: After 2 to 3 days
site intervention the Toradol To lessen the of nursing
V/S taken as patient will be (analgesic) as pain intervention the
follows: able to handle ordered patient has been
BP: 120/80 pain and will High protein diet To promote able to handled
PR: 85 state pain 4/10 tissue repair pain and stated
RR: 23 pain scale of
T: 36.7 4/10

32
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: High risk for Trauma on the Short term: Independent: To gain trust and Short term:
“Namamaga ang infection related incision site After 2 hours of Established cooperation of After 2 hours of
sugat ko.” As to inadequate  nursing rapport the patient nursing
stated by the primary defense Invaded by intervention the intervention the
patient as manifested by microorganisms patient will gain Hand washing patient has
broken skin,  knowledge in Teach patient to reduces risk of gained
Objective: swelling and Broken skin infection control hand wash often infection knowledge in
- redness of the redness of the  by verbalizing before and after infection control
skin incision site Redness and of the patient the wound care and can now
- broken skin swelling procedures in To impart the pt. verbalized the
- irritability  wound care. Discuss to when the wound procedures in
- swelling of the Risk for infection patient the becomes wound care.
incision site Long term: following signs infected
After 2 to 3 days of infection such Long term:
V/S taken as of nursing as swelling and After 2 to 3 days
follows: intervention the redness of nursing
BP: 120/70 patient will intervention the
PR: 88 perform the Dependent: To reduce patient has been
RR:22 wound care and Administer infection performing the
T: 37.5 will be free from antibiotics or wound care and
infection anti infective now can be free
Cefuroxime 750 from infection
mg TIV q8

33
VIII. Health Teaching

MEDICATIONS
 Before the patient leaves the hospital, tell about what the medications are for.
 Instruct patient to follow medications that are ordered by the doctor for the patient.

EXERCISE
 Teach patient to perform ROM exercises to the patient promote good blood circulation especially on
the part that is most affected. Since the patient can’t move, teach family member and let her assist
the patient.

TREATMENT
 Advise patient to bring patient to attend a physical therapy session to improve his movements.
 Cheap physical therapy sessions are offered in barangay health centers.

HYGEINE
 To promote full recovery, advise patient’s family member to monitor hygiene, it is to prevent
infections or other related complications such as skin diseases and body odor.

OUT-PATIENT
 Advise patient to accompany patient to attend all follow up check up for his monitoring.

DIET
 Teach patient’s companion how to make osteorized feedings for the patient, with every essential
nutrient part of the feedings
 Teach patient to have a Fiber diet to help in the treatment of hemorrhoids along with the
medications prescribed by your specialist.

SPIRITUAL
 To obtain optimum health, spiritual status should always be considered.
 Advise patient and family members to get closer to God and always give thanks for another life.

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IX. Appendices

Vital Signs
Date Blood Pressure Temperature Pulse Rate Respi. Rate

July 12 100/80 36.9 70 16

120/80 36.2 64 20

July 13 120/80 35.7 70 20

120/80 35.2 73 20

July 15 110/80 35.2 70 20

Out Out Out Out

July 16 110/80 36.1 65 20

120/90 36.2 67 20

July 17 130/90 35.7 84 20

Out Out Out Out

July 22 Out Out Out Out

120/90 36.4 82 22

July 26 110/70 36.4 79 14

120/80 36.0 74 15

July 28 110/80 36.1 85 16

120/80 36.5 82 18

35