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• Patient profile
• Reason for admission

• Past medical history

• Past surgical history
• What is hemorrhoid
• Etiology & patophysiology

• Clinical manifestation
• Investigation

• Diagnosis finding
• Medical & surgical treatment

• Pre-operative management
• Post-operative management

• Nursing intervention
• Health teaching

• Conclusion

I would like to thank Mr Goh Hin An for giving me

opportunity to use his case’s for my case study.from this
case study,I’ve learnt a lots of things about hemorrhoid
especially about the causes and treatment.
Thanks also to tutors for giving me guide line for doing this
case study.
For friends which helping me,special thanks for you
all,hopefully you all also done well for your case study.

NAME : Goh Hin An @ Ah An
AGE : 63 years
SEX : Male
RN : 00847295
PHYSICIAN : Dr.Vijeyasingam


H/O PR bleeding –fresh blood since 5pm 2/8/08,staining
@ stools
Constipation 3/7
On admission :conscious,alert
Bp :140/90mmhg T :36.4°c P:78bpm R:20/min
RBS :12.1mmol

Hypertension Tung Shin Hospital for 20 years,on Adalat

LA 30mg daily.
Diabetic – on diet control


Piles for 20 years,under treatment rubber banding 5 years
ago and more recently last month at Tung Shin Hospital.


To understand hemorrhoids, we need to review the
anatomy of the digestive system (start backward - from the

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
On top of the rectum lies the large intestine (also known
as the colon or bowel). It is six foot in length, and is
divided into four components: the sigmoid colon, the
descending colon, the transverse colon, and the
ascending colon. The ascending colon is connected to the
small intestine by a structure called the ceccum.The
digestive process of food stops at the small intestine and
the fecal waste water-removal process starts at the
ascending colon. Fecal matter starts as liquid waste at the
cecum and ends up as solid waste in the sigmoid colon.

What are hemorrhoids?

The term hemorrhoids refers to a condition in which the

veins around the anus or lower rectum are swollen and

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. These lumps can turn hard
if blood clot develops, and become painful thrombosed
hemorrhoids. Since the anus has many nerve endings,
external hemorrhoids can be very painful or itchy.
Sometimes, the clot may even break out of the hemorrhoid
by itself or dissolve back into normal blood circulation.
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. Sometimes, the
sphincter muscle can close shut in a spasm and trap this
prolapsed hemorrhoid outside the anus. This cuts off the
blood circulation, and creates a strangulated hemorrhoid.
Some prolapsed hemorrhoids can be manually "pushed"
back inside the anus. Advanced cases of prolapsed
hemorrhoids, however, must be surgically treated.
Prolapsed and strangulated hemorrhoid are a serious
medical condition that requires immediate attention. Also,
bleeding of any amount should be checked by a doctor
since it may be an indication of more serious conditions,
such as colorectal cancer


We all have hemorrhoidal veins in the anus, anal canal,
and rectum. These veins do not have valves, which would
normally help support and distribute the weight of the
blood. Many factors can cause undue pressures on these
veins, which can then cause these veins to become
distended and swollen hemorrhoids.
Below are some factors that can cause hemorrhoids:

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.
It is interesting that some have argued that the design of
the sitting toilet actually contributes to straining -
hemorrhoids are virtually unknown in countries with squat

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
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.
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. For example, in the days and weeks after
vaginal delivery, some women regularly postpone bowel
movements because of tenderness in the anus and
perianal area.

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. While occassionally postponing bowel
movement does no harm, doing it regularly can contribute
to hemorrhoids.

Here's why: the longer fecal matter remains in the colon,

the drier it becomes and therefore the harder it is to pass
without straining. Repeated inhbition of the urge to
defecate can also result in weaker signals to the rectal
muscles to pass stool. Eventually, it may be difficult to
pass stool naturally without some straining.

Also, a colon filled with fecal matters is heavy and exerts

pressure on the blood vessels and veins of the anus and
rectum. This can cause these veins to swell and become
There are several diseases that can actually lead to the
development of hemorrhoids. Of these, the most serious is
rectal cancer, which causes a false "call of nature", thus
encouraging the patient to go to the bathroom and strain

Enlargement of the liver, often found in people who abuse

alcohol, can create extra pressure on the hemorrhoidal
veins. Other digestive diseases, such as intestinal tumor
and irritable bowel syndrome, can interefere with normal
elimination or cause constipation.
Lastly, although heart attack does not cause hemorrhoids,
it does increase venous pressure and therefore can make
an existing hemorrhoid worse.
Bouts of diarrhea
Diarrhea is the body's way of getting rid of bacteria from its
digestive system. It is commonly caused by contaminated
food. However, diarrhea can also be caused by an allergic
reaction to food and milk, by stress and anxiety, as well as
by an adverse reaction to medication and laxatives.
In the case of diarrhea, the expulsive force of the watery
stool can damage rectal veins and lead to hemorrhoids.
Paradoxically, the opposite of diarrhea can also lead to
hemorrhoids! Constipation is defined as infrequent bowel
movements or the difficulty in passing stool. The longer
the stool remains in the colon, the drier it gets. After a
certain point, usually a fair amount of straining is required
to pass the dry and hard stool.
A common condition in the elderly, constipation is one of
the major causes of hemorrhoids in this segment of the
Extreme physical exertion
Laborers and weightlifters often hold their breath or grunt
while lifting heavy objects. This forces air downward in the
lungs and exerts 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
Prolonged sitting or standing and lack of exercise
Sedentary lifestyle, lack of exercise, as well as jobs which
require prolonged periods of sitting and standing can lead
to, or exacerbate, existing hemorrhoids.


Hemorrhoidal symptoms are divided into internal and
external sources.
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.
Internal hemorrhoids most commonly cause painless
bleeding with bowel movements. The covering epithelium
is damaged by the hard bowel movement and the
underlying veins bleed. With spasm of the sphincter
complex elevating pressure, the internal hemorrhoidal
veins can spurt.
Internal hemorrhoids can deposit mucus onto the perianal
tissue with prolapse. This mucus with microscopic stool
contents can cause a localized dermatitis, which is called
pruritus ani. Generally, hemorrhoids are merely the vehicle
by which the offending elements reach the perianal tissue.
Hemorrhoids are not the primary offenders.
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. Recurrence occurs
approximately 40-50% of the time, at the same site. This
occurs at the same site because the underlying damaged
vein remains present. Simply removing the blood clot and
leaving the weakened vein in place, compared with
excision of the offending vein with the clot, will predispose
to recurrence.
External hemorrhoids can also cause trouble with hygiene.
The excess redundant skin left after an acute thrombosis
(skin tags) is actually accountable for these problems.
External hemorrhoidal veins found under the perianal skin
obviously cannot cause hygiene problems; however,
excess skin in the perianal area can mechanically interfere
with cleansing.
Lab Studies

• Hematocrit testing is suggested if excessive bleeding

with concomitant anemia is suspected.
• Coagulation studies are indicated if the history and
physical examination suggest coagulopathy.
Imaging Studies

• Barium enema study or virtual colonoscopy is

suggested if proximal colonic and intestinal diseases
must be excluded and if endoscopy is not helpful.


Urea 5.7mmol/L 5.2-8.0mmol/L
(normall range)
Sodium 138mmol/l 137-150mmol/l
(normall range)
Potassium 3.7mmol/L 3.5-5.3mmol/L
(normall range)
Chloride 97mmol/L 99-111mmol/L
(normall range)


Red cell count 4.0×10^12/L 4.5-6.0×10^12/L
(normal range)
Haemoglobin 13.1g/dL 13.7-18.0g/dL
(normal range)
Haematocrit 40% 40-54%
(normal range)
MCV 99fL 82-100fL
(normal range)
MCH 33pg 27-32pg
(normal range)
MCHC 33g/dL 32-36g/dL
(normal range)
Platelet 151×10^9/L 150-400×10^9/L
(normal range)
White cell count 7.0×10^9/L 4.0-11.0×10^9/L
(normal range)

Neutrophils 50.1% 40-75%
(normal range)
Lymphocytes 17.4% 15-45%
(normal range)
Monocytes 5.3% 2-10%
(normal range)
Eosinophils 2.7% 1-6%
(normal range)
basophil 0.3% 0-1%
(normal range)


Medical and Surgical Treatments for Hemorrhoid

Fortunately for many people, hemorrhoids can heal by

themselves and all that is needed is temporary relief from
their symptoms. For these people, self-care of this
condition is usually sufficient.
Aggravation of hemorrhoids can be avoided using similar
steps to that used for preventing them. These steps
• Eat fiber-rich food
• Drink plenty of water
• Do not postpone bowel movement
• Do not strain during defecation
• Exercise
In order to alleviate the symptoms of hemorrhoids, you
Take a warm sitz bath
A sitz bath of warm water for 10 to 15 minutes, either in
the bathtub or in a special basin that is placed on top of
the toilet, can provide a quick relief from the swelling and
pain of hemorrhoids. The bath water should be warm or
hot, but not burning hot. Also, do not add soap, Epsom
salt, bath oil, or anything else as they can irritate the

Use a cold or warm compress

In the last months of pregnancy, a sitz bath is not
recommended as water can seep into the vagina. Instead,
a cold or warm compress can be used.
Use a moist wipe
Instead of toilet paper, try a moistened wipe to clean
yourself after going to the bathroom. Some commercially
available wipes are medicated with witch hazel, a natural
astringent that can reduce the swelling and ease the pain
of hemorrhoids.
Use a bidet
If available, you can use a bidet or stream of warm water
to clean yourself after bowel movement.
Use stool softener and lubricant
A hard, dry stool can be difficult to pass, and may irritate
the hemorrhoids to cause bleeding. A fiber-based stool
softener can be used to create a stool that is bulkier,
moister, and easier to pass.
Another way to make it easier to pass stool is to use
finger to lubricate the anal opening and canal with
petroleum jelly or other lubricants such as K-Y Jelly.

Use over-the-counter analgesics or suppositories

Topical hemorrhoid creams and suppositories work as
lubricants to reduce friction and ease the irritation of
hemorrhoids. They usually contain ingredients such as
cocoa butter, lanolin, glycerin, cod-liver oil, and vegetable
Some have additional ingredients that deaden pain
sensation, to give a potent but temporary relief. Usually,
these analgesics contain benzocaine, lidocaine, or other
-caine derivatives.
Other creams may contain astringents such as tannic acid,
bismuth, and witch hazel to reduce swelling. Medicated
creams, available with your doctor's prescription, may
contain steroids to reduce inflammation.
Note that some people are allergic to the ingredients in
these analgesics and astringents. Using them may
actually worsen hemorrhoids.

An advanced or severe case of hemorrhoids often can

only be treated by surgical procedures. These treatments

Anal Dilation
Although this technique is no longer commonly used,
when properly used, anal dilation can help relieve the pain
and promote healing of hemorrhoids. In this anal dilation
procedure, the anal sphincter muscle is stretched or
dilated to prevent hemorrhoids from increasing rectal
pressure, as well as to reduce the need of straining to
pass stool.
Because of its potential side effect of fecal incontinence or
anal leakage, this procedure not be used for eldery
patients or those with weak sphincter muscle.

Rubber Band Ligation

Basically, the idea behind this method has not changed
since Hippocrates tied thread around an internal
hemorrhoid to cut off its blood circulation. The doctor
would use an applicator to apply a special rubber band
onto the base of the hemorrhoid.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. It can be done without any special
preparation, in doctor's room. In case of multiple
hemorrhoids,doctor would normally ligate or band them
one at a time over a period of time. 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.
Stapled Hemorrhoidectomy
Stapled hemorrhoidectomy is the newest surgical
technique for treating hemorrhoids. Stapled
hemorrhoidectomy is a misnomer since the surgery does
not remove the hemorrhoids but, rather, the abnormally lax
and expanded hemorrhoidal supporting tissue that has
allowed the hemorrhoids to prolapse 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
Internal Hemorrhoids in Anal Canal
Hollow Tube Inserted into the Anal Canal and
Pushing up the Hemorrhoids
Suturing the Anal Canal through the Hollow
Bringing Expanded Hemorrhoidal Supporting
Tissue into the Hollow Tube by Pulling on
Hemorrhoids Pulled Back Above Anal Canal
after Stapling and Removal of Hemorrhoidal
Supporting Tissue
During stapled hemorrhoidectomy, the arterial blood
vessels that travel within the expanded hemorrhoidal
tissue and feed the hemorrhoidal vessels are cut, thereby
reducing the blood flow to the hemorrhoidal vessels and
reducing the size of the hemorrhoids. During the healing of
the cut tissues around the staples, scar tissue forms, and
this scar tissue anchors the hemorrhoidal cushions in their
normal position higher in the anal canal. The staples are
needed only until the tissue heals. They then fall off and
pass in the stool unnoticed after several weeks. Stapled
hemorrhoidectomy is designed primarily to treat internal
hemorrhoids, but if external hemorrhoids are present, they
may be reduced as well.
Stapled hemorrhoidectomy is faster than traditional
hemorrhoidectomy, taking approximately 30 minutes. It is
associated with much less pain than traditional
hemorrhoidectomy and patients usually return earlier to
work. Patients often sense a fullness or pressure within
the rectum as if they need to defecate, but this usually
resolves within several days. The risks of stapled
hemorrhoidectomy include bleeding, infection, anal
fissuring (tearing of the lining of the anal canal), narrowing
of the anal or rectal wall due to scarring, persistence of
internal or external hemorrhoids, and, rarely, trauma to the
rectal wall.

√ Diagnosis finding

√ Diet
• Low residual diet × 2/7
• Fluid diet one day before operation
√ Fasting 12MN
√ Rectal lavaj
√ Shaving if necessary
√ Consent

• IM pethidine 50 mg tds / prn
• IVD 2pint D 5%, 2 pint Dextrose Saline in 24

Problem :Pain and discomfort related to
surgical wound
Objective : To reduce and minimize the pain
Nursing intervention :
1.Asses level of pain according to pain scale level
by asking the patient for further management.
2.Monitor vital sign to detect any abnormality such
as blood pressure more than 140/90mmhg and
3.Position patient on side lying position to reduce
the pressure at surgical wound so that it’s can
help to reduce the pain.
4. Teach patient how to do breathing exercise to
reduce the pain
5.Give diversional theraphy such as watching
television,reading magazine so that patient do
not focus on the pain.
6.Plan nursing care effectively to minimize
disturbance so that patient can rest well.
7.Give analgesic such as IM Pethidine 50 mg as
ordered by doctor to reduce the pain.
8.Asses effectiveness of the analgesic after 30
minutes to make sure the dosage is enough for
the pain.
9.Inform doctor if pain still persist after analgesic
to prevent any complication.

Evaluation :patient didn’t complain discomfort and


Problem :potential bleeding related to surgical

Objective:to prevent any signs and symptoms of
Nursing intervention :
1.Inspect dressing site for any bleeding and
perform pressure dressing if bleeding occurs.
2.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.
3.Advise patient to take diet that are high in fiber
such as fruits and vegetables in avoidance of
4.Advise patient to drink a lots of water at least 2
liter/day in avoidance of constipation.
5.give stool softener such as liquid paraffin
15mls tds @ ON as ordered by doctor in
avoidence patient straining during passing
6.Advise patient not to strain during passing
motion to prevent any bleeding.
7.Tell patient to use soft tissue for wiping to
prevent any bleeding.
Evaluation :no signs and symptoms of bleeding

There are simple steps to avoid getting hemorrhoids.
Even if you already have them, these tips should
help in preventing hemorrhoid flare-ups:
Eat more fibers and drink more water
A typical Western diet is high in animal fat and
protein, and is often made with refined flours with
little fiber content. This fiber-poor diet makes for
stool that is smaller, drier, and harder to pass as
compared to fiber-rich food.
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.
For the elderly, there are fiber-rich food that are not
crunchy or hard to chew, such as oatmeal, steamed
vegetables and stewed fruits. Drinking water during
a meal, instead of between meals, can also help
make fiber-rich food easier to digest.
It may take sometime for your body to get used to
roughage, so it is sometimes best to change your
diet gradually - start by eating more roughage over a
period of several weeks.
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.
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. So, don't wait
when you get the urge to defecate.
Don't read on the toilet - a normal bowel movement
only takes between 2 to 5 minutes.
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.
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
Aging can weaken the anal sphincter muscle.
Indeed, many elderly men and women have trouble
passing stool because of this reason. Instead of
using laxatives, which can make constipation worse,
you can try "buttock" press exercises - tighten the
buttock muscles for several second and then relax
them in a repeated cycle. This will strengthen the
sphincter muscle.
The buttock press can be done several times a day
and practically anywhere - while sitting or standing.
It is an especially good exercise for the elderly,
pregnant women, and for those who cannot do
strenuous exercise.

• Lewis Medical Surgical Nursing

• Lemone Medical Surgical