National Academy of Medical Sciences

Bir Hospital Nursing Campus

Mahabouddha, Kathmandu

CASE STUDY REPORT

ON

“Perianal Fistula”

SUBMITTED TO: SUBMITTED BY:

Ms. Kabita Pandey, Rina Udas

Senior Hospital Nursing Administrator, Roll no: 26

B.H.N.C. BSc Nursing, 2nd Year

B.H.N.C

Submitted on: 2080/09/16

 ACKNOWLEDGEMENT

The following case study report has been prepared during my clinical posting at Bir Hospital
for the partial fulfillment of nursing concept practicum. I would like to first take a moment to
express my sincerest gratitude to all those respectful people who contributed their valuable
time, knowledge and experience into the making of my report.

I would like to express my sincere gratitude towards Bir hospital nursing College (BHNC)
directors, honorable principle, nursing campus chief Ms. Bandana Pandey and management
who made us able and provided us essential equipment’s needed for our practical.

Similarly, I would like to extend my sincere and heartfelt gratitude to our coordinator Ms.
Kabita Pandey, our supervisor Ms. Sneha Shrestha and all the teachers of B.Sc. Nursing, 2nd
Year for their support and guidance throughout my case’s study.

A special thank you goes to all those in charge and staffs of Bir Hospital for their kind co-
operation and help during our practicum. I also want to thank the director, manager and all
nursing staffs, doctors, patients, and visitors for providing detail knowledge, cooperation,
inspiration and full support to complete my case study.

Additionally, I would like to express my special thanks to librarian ma’am who provided me
with essential reference materials. I would like to acknowledge all the authors whose work I
have relied on and all those that I have referenced in this report.

At last, I would like to express sincere thanks to my patient, Mr. Dilli Rawat and his family
members for their kind co-operation in providing information, allowing me to perform
procedures required in providing nursing care to complete my case study successfully. I shall
contest, as a student, I have learned a lot from this works and take full responsibility for error
and omission.

Ms. Rina Udas

Student, B.H.N.C

Roll No. 26

B.Sc. Nursing, 2nd Year

2
 CONTENTS

ACKNOWLEDGEMENT 2

CONTENTS 3

BACKGROUND 4

RATIONAL 5

OBJECTIVES 6

PATIENT PROFILE 7
History 7
Physical Examination 10

DEVELOPMENTAL TASK 15

DISEASE PROFILE 16
Perianal Fistula 16
Epidemiology 16
Pathophysiology 17
Clinical Manifestation 18
Diagnostic Investigations 18
Treatment 20
Nursing Management 20
Prognosis 21

DRUG PROFILE 21

NURSING CARE PLAN 29

STRESS MANAGEMENT 33

HEALTH TEACHING 33

OUTCOME 34

SUMMARY 34

LEARNING FROM THE STUDY 35

REFERENCES 35

3
 BACKGROUND

The curriculum of B.Sc. Nursing is structured in a way that provides us with the opportunity to
put to practical use various nursing concepts on different wards of Bir Hospital. During the
course of our clinical posting, we are assigned a case study that enables us to understand how
our theoretical knowledge can effectively be put to use in combating real life situations. This
type of case study aims at enabling nursing students to gain a profound knowledge on the
selected case and making them able to apply the concept of holistic nursing care.

This is a case study on “Perianal fistula” that I have prepared during my clinical posting, the
objective of which is to expand my knowledge on Perianal fistula and to learn the ways for
effective stress management.

I selected this case during my clinical posting and I was able to study and observe the case in
detail. I am content and satisfied for being able to provide holistic nursing care during my
patient’s course of hospital stay. The details of which I have mentioned in this report.

4
 RATIONAL

According to the curriculum of Bsc. nursing 2nd year program, we were supposed

to select a patient for the case study along with providing comprehensive care to

the patient as per the need. During our posting in Bir hospital’s surgical ward, I

got the opportunity to select a case for my case amongst various surgical cases. I

developed a keen interest on the case of “perianal Fistula” as it was present in 12

patients over the course of this year which was less in number as compared to

other cases. So I wanted to explore more about this case and broaden my

knowledge about this case. The case study can be a good opportunity to learn and

gain knowledge about the diagnosis, treatment and management of perianal

Fistula. It can also provide important information about how to recognize the

signs and symptoms of perianal fistula and how to provide care to those affected.

Hence, I selected Mr. Dilli Rawat , a case of “Perianal Fistula” as my case study.

5
 OBJECTIVES

General objective
To enable me to scientifically approach the selected case in practical situations by making use
my theoretical knowledge to better provide the patients with holistic nursing care.

Specific objectives
This case study will further enable me to
 To manage and minimize stress and provide psychological support to the patients during
hospitalization.
 To provide the patient due nursing care as that is needed during hospitalization.
 Make use of my theoretical knowledge and apply it in practical situations
 Better communicate with the patient and tend to the patient’s medical needs.
 Educate patient on health promotion, maintenance as well as prevention of complication

6
 PATIENT PROFILE
History
1. Personal Information Of The Client
Name: Dilli Rawat
Age completed in years: 75 Yrs.
Sex: Male
Address: Salyan
Religion: Hinduism
Occupation: farmer
Education Status: illiterate
Economic status: Adequate
Marital Status: Married
No. of children: 4
Ward: Male surgical ward
Date of Admission: 2080/08/10
Inpatient No.: 214961
Diagnosis: Perianal Fistula
2. Chief Complaints
At time of admission,
No any chief complains, planned hospitalization
At time of history taking,
Difficulty sleeping,
Loss of appetite

3. History Of Present Illness

Onset : 12 months back
Frequency : twice a month
Duration : few days to week
Alleviating factors: rest
Aggravating factors: physical work
4. Recent Treatment History
No any recent history of treatment

7
5. History of past illness :
A. Childhood illness: not known
B. Immunization :
a. BCG
b. DPT
c. Measles
d. Td
C. History of any drug allergy : no any history of any food allergy
D. Previous hospitalization : no previous hospitalization
E. History of any chronic illness : no any history of chronic illness
F. Family history
Disease Paternal side Maternal side
Diabetes present absent
Cancer absent absent
Cardiovascular Disorder absent absent
COPD present present
Genetic disorder absent absent

8
 Family tree

75 yrs 70 yrs
farmer housewife

50 yrs 45 yrs 48 yrs 44 yrs 47 yrs 50 yrs

52yrs 58yrs

25 yrs 23 yrs 23 yrs 20 yrs

Family tree
Index
- Male
- Female
- Expired male
- Expired female
- Patient
- Present family

9
Physical Examination

1. General Physical Examination

Vital Signs
Blood pressure: 110/70 mm of hg
Pulse: 82beat/min
Respiratory rate: 22/min
Temperature: 97.2 degree fareinheit
Anthropometric Measurement
Weight: 65kg
Height:158 cm
BMI:
PILCCOD
Pallor : absent
Icterus : absent
Lymph Nodes
 no any tenderness and palpable lymph nodes (Submental, Submandibular,
Anterior, and posterior cervical, Pre and post auricular and axillary)
 Cyanosis : absent
 Clubbing: absent
 Oedema : absent
 Dehydration : absent

2. Head And Neck Examination

a. Head
Scalp
Inspection
 Size : uniform
 Shape : symmetrical and round
 Hair : brown with white hair present
 Scalp : no any scar, pediculosis or dandruff present
On Palpation
 No any masses, lesions, tenderness & depression
b. Face
10
 Inspection
 Facial expression : tensed
 Symmetry : symmetrical
 No any swelling, puffiness or injury
c. Eye
Inspection
External eye structure
 Eye shape and symmetry: symmetrical
 Eye brows : normal
 Eyelid : drooping,
 Eye balls : symmetrical, moist and protruded
 Sclera & Conjunctiva : no any discharge
 Lacrimal glands : no any tearing and blockage
On palpation
 Lacrimal apparatus : no any tenderness or discharge
Testing eye function
 Visual acuity : present
 Accommodation : present
 Extra ocular eye movement : present
Test response to light
 Corneal light reflex :present
d. Ear Assessment
Inspection
 External ear : normal size and shape, no any discharge
 External auditory canal: wax present
 On palpation
 Auricle palpation: no any tenderness
 Mastoid process palpation: no any tenderness or palpable mass

Hearing assessment
 Whisper/ finger friction/ watch test: positive
 Tuning fork test:
Weber test: sound vibration equally perceived by both ears
Rinne test: air conduction> bone conduction
11
 e. Nose and sinus Assessment
Inspection
External nose
 Shape: symmetrical
Internal nose
 Appearances: mucosa pink and moist with uniform color and lesion
 Nasal septum: normal
Sinuses palpation
 Frontal sinuses and maxillary sinuses : no any tenderness or inflammation
Olfactory test: normal
f. Mouth and throat
 Lips: brownish, with no any swelling or bleeding
 Teeth: dental caries present, 2 molars of lower jaw absent
 Tongue: pinkish
 Uvula : normal
 Gums and mucosa: no any swelling, bleeding or infection
 Pharynx and tonsils: no any inflammation or enlargement
 Oral hygiene: maintained
g. Neck
 Appearance: normal
 Mobility and stiffness: mobile
 Trachea: midline

Inspection: no any swelling present

Palpation: no any lymph nodes or palpable masses
Auscultation: thyroid bruit heard

3. Chest (Anterior And Posterior)

Inspection
 Observation : normal, no any scars present
 Intercostal space : even and relaxed
 Chest symmetry : symmetrical
 Sternum : located at the midline

12
 Palpation
 No any pain or tenderness

Percussion
Tympanic sound
Auscultation
 Breathe sound : normal
4. Heart
 Heart sound in 4 areas (aortic, pulmonic, tricuspid and mitral) : Normal
5. Abdominal Assessment
Inspection: Normal in size with no any enlarged veins or scars
Auscultation: Bowel sound present
Percussion:
 Abdomen: tympanic sound
 Shifting dullness absent
Palpation
Light palpation: no any tenderness or masses
Deep palpation (liver, spleen and kidney): no any masses, tenderness, enlargement of liver,
spleen or kidney detected
6. Extremities
Inspection
Joint mobility present, no any tenderness, redness or swelling present
Palpation
No any swelling or tenderness
7. Neurologic
Mental status: awake, alert, oriented to person, place and time

Reflexes (deep tendon)

Reflexes present (Bicep (C5-6), triceps(C5-6), brachioradialis, knee(L2-4),ankle(S1) plantar
reflex)

8. Genital Examination
Inspection

13
Male genitalia: scrotum normal in size with no any scars or discharge present and maintenance
of perineal hygiene by patient’s verbalization
Rectal and prostrate examination: perianal fistula present evidenced by patients
verbalization and reports with watery discharge
9. Skin Examination
 Brownish color skin, rough texture, scar present on right leg
Findings of examination
Scar present on right leg, watery discharge from perianal region

14
 DEVELOPMENTAL TASK
The patient is in older age with the following achievement of developmental tasks:

S.N. According To My Book In the Patient

Adjusting to decreasing physical

Patient was well adjusted to the decreasing
1.
strength and health physical strength and health

Accepting one’s physical body and

Patient was able to accept one’s physical body
2.
keeping it healthy and keeping it healthy

Adjusting to retirement and reduced

Patient was able to adjust to retirement and
3.
income reduced income

4. Adjusting to death of spouse His spouse was still alive

Establishing an explicit affiliation with

Patient was able to achieve an explicit
5.
one’s age group affiliation with one’s age group

Meeting social and civic

Patient had met social and civic
6.
responsibilities responsibilities

15
 DISEASE PROFILE
Perianal Fistula
A perianal fistula is a small tunnel that develops between the end of the bowel and the skin
near the opening of the anus region.
It’s usually caused by an infection near the anus, which results in a collection of pus
(abscess) in the nearby tissue.

Anatomy
A thorough understanding of the pelvic floor and sphincter anatomy is a prerequisite for
clearly understanding the classification system for fistulous disease.
The external sphincter muscle is a striated muscle under voluntary control by three components:
submucosal, superficial, and deep muscle.
Its deep segment is continuous with the puborectalis and forms the anorectal ring, which is
palpable upon digital examination.
The internal sphincter muscle is a smooth muscle under autonomic control and is an extension
of the circular muscle of the rectum.

Epidemiology
The incidence of anal fistula developing from an anal abscess ranges from 26% to
38%. One study showed that the prevalence of it is 8.6 cases per 100,000 population. In
men, the prevalence is 12.3 cases per 100,000 population, and in women, it is 5.6 cases per
100,000 population. The male-to-female ratio is 1.8:1. The mean patient age is 38.3 years.

Causes
Rectal foreign bodies
16
Crohn disease
Anal fissures
Carcinoma
Radiation therapy
Tuberculosis

Pathophysiology

17
The fistula in anal and perianal region develops from infection of the anal crypts gland.

The initial infection occurs in the ducts of the anal glands and the spread of infection
results in the formation of abscess.

The crytoglandular theory states that obstruction of the anal gland duct results in an
infection.

The presence of these glands deep in relation to the anal canal and sphincter, the infection
follows the path of least resistance resulting in abscess formation at the termination of the
gland.

If the abscess is ruptured, a fistula is formed.

Clinical Manifestation
In book In patient
Anal Pain Pain was manifested, especially while
sitting
Inflammation Inflammation was present
Rectal bleeding Rectal bleeding was absent
Discharge from fistula Watery discharge was present
Dyschezia Dyschezia was present

Diagnostic Investigations
According to the book In the patient
History taking done
Physical examination done
MRI fistulography done
Lab investigations done

18
MRI fistulography findings
Small irregular fluid collection in the soft tissue posterior to the coccyx, eccentrically to
the right of the midline with given dimensions is possibly a perianal fistula.

Lab investigations of the patient

Result Method
Grouping- Rh typing O-positive Agluttination

Parasitological Report
Report for urine examination
Physical Examination
Color light yellow
Transparency clear
Reaction acidic
Chemical Examination
Albumin nil
Sugar nil
Microscopic Examination
Pus cells nil
RBCs nil
Casts nil
Crystals nil
Epithelial cells nil

Hematological Report
Test Result Unit
CBC
Total Count
W.B.C 7640 /cumm
R.B.C 4.83 /cumm
Platelets 3,05,000 /cumm
Differential Count
Neutrophils 53 %
Lymphocytes 39 %
Monocytes 06 %
Eosinophils 02 %
Basophils 00 %
Haemoglobin 13.2 gm%
PCV 43 %
MCHC 31 %
MCH 27 pg

19
 MCV 88 fl
Prothrombin tine
Test 12.5 sec
Control 14.0 sec
INR 0.89 sec

Biochemistry report
Blood Glucose ( R ) 88 mg/dL
Serum Urea 22 mg/dL
Serum Creatinine 1.0 mg/dL
Sodium 139.02 mEq/l
Potassium 4.36 mEq/l
Serum Bilirubin Total 0.6 mg/dL
Serum Bilirubin Direct 0.2 mg/dL
SGPT 25 IU/L
Alk. Phosphatase 63 U(K.A)
SGOT 29 IU/L

Immunological report
HIV I & II Antibodies Negative
HBSAG negative
Anti HCV Antibody (IgM) Negative

Treatment
Fistulotomy
A fistulotomy is the surgical opening of a fistulous tract.
A probe is passed into the tract through the external and internal openings. The overlying skin,
subcutaneous tissue, and internal sphincter muscle are divided with a knife or electrocautery,
and the entire fibrous tract is thereby opened.
At low levels in the anus, the internal sphincter and subcutaneous external sphincter can be
divided at right angles to the underlying fibers without continence being affected. Curettage is
performed to remove granulation tissue in the tract base.
Opening the wound out on the perianal skin for 1-2 cm adjacent to the external opening with
local excision of skin promotes internal healing before external closure.
Complete fistulectomy creates larger wounds that take longer to heal and offers no recurrence
advantage over fistulotomy.

Nursing Management
Assess the patient’s physical condition and evaluate emotional responses and cognitive
status.
Assess the nutritional status of the patient.
Monitor the vital signs of patient and assess the respiratory status.

For post-operative assessment,

20
Assess wound or drainage site for the manifestation of infection.
Assess the pain level.
Interventions
Record vital signs and assess the patient’s nutritional and neurological status.
Administer pain medications as prescribed.
Provide high fibre and high protein diet to avoid constipation and promote wound healing.

Prognosis
In anal fistulas of cryptoglandular origin healing rates for simple fistulas approach 80%.

DRUG PROFILE

Drugs used in patient

Name of Drug Dose Route Direction

Tablet Dulcolax 1 tab Per oral HS
Ezevac Enema 30ml Per rectal HS
Injection Ceftriaxone 200mg Intravenous BD
Injection metronidazole 50mg Intravenous TDS
Injection paracetamol 1gm Intravenous QID
Injection Pethidie 25ml Intravenous SOS
Injection Phenargan 12.5ml Intravenous SOS
Injection Pantopraozole 40mg Intravenous BD

A. Tab Dulcolax
Generic name: Bisacodyl
Trade name: Correctol, Dulcolax, Bisac-Evac
Class: Stimulant laxatives
Mechanism of action: Available as suppositories and enteric-coated tablets, bisacodyl is a
potent stimulant of the colon. It acts directly on nerve fibers in the mucosa of the colon.
Indication:
 Constipation
 Bowel preparation
 Pharmacologic provocation
Adverse reactions:
 Risk of dependency on user

21
  Rectal bleeding
 Upset stomach
 Vomiting
Nursing considerations:
 Assess the patients for abdominal distension and cramping
 Monitor the patient’s fluid and electrolyte levels, as this drug can lead to
hypokalemia
 Instruct the patient to drink 1500-2000 mL/day of fluid
 Bisacodyl should not be taken for more than 7 days unless directed by doctor
B. Ezivac Enema
Trade name: Ezivac enema
Class: Laxatives
Mechanism of action:
Sodium and chloride, major electrolytes of the fluid compartment outside of cells (i.e.,
extracellular), work together to control extracellular volume and blood pressure.
Disturbances in sodium concentrations in the extracellular fluid are associated with
disorders of water balance.
Indication:
 Constipation
 Dehydration
 Metabolic acidosis
 Wound irrigation therapy
Adverse reactions:
 Anal irritation
 Burning sensation
 Stomach cramps
 Diarrhea
 Nausea

Nursing considerations:
 Provide anticipatory guidance to the patient on what to expect from the procedure
 The patient should empty their bladder before the procedure
 Ascertain the patient’s care plan for the type of enema and the amount of solution
22
  Administer the solution slowly
 Provide privacy to the patient by closing the bed curtains or door and keep the
patient covered as much as possible
C. Injecton Ceftriaxone
Generic name: Ceftriaxone
Trade name: Rocephin
Class: Cephalosporin Antibiotics - 3rd Generation
Mechanism of action: The penicillins interfere with the last step of bacterial cell wall
synthesis (transpeptidation or cross-linkage), resulting in exposure of the osmotically less
stable membrane. Cell lysis can then occur, either through osmotic pressure or through the
activation of autolysins.
Indication:
• Surgical Prophylaxis
• Gram negative infection
• Biliary Tract Infection
• Endocarditis
• Staphylococcal Infection
• Peritonitis
Adverse reactions:
 Hypersensitivity
 Diarrhea
 Nephritis
 Neurotoxicity
 Hematologic toxicities
Nursing considerations:
• Make sure that patient do not have cephalosporin and penicillin allergy.
• Patients are suggested in taking a lot of water with this medicine.
• Use cautiously in patients with renal impairment, where does adjustment is
necessary.
• Advice patient to inform doctor if allergy occurs.
• Regarding suspension it should be shaken well before taking it.
• Evaluate bowel activity and stool consistency carefully and urine output.
• Evaluate I/V site for phlebitis, check mouth for white patches on mucous
membranes, tongue.
23
 • Assess blood studies: AST ALT, CBC, bilirubin, LDH, alkaline phosphate monthly
if patient is on long term therapy.
D. Inj. Metronidazole
Generic name: Metronidazole
Trade name: Metron, Flagyl
Class: Nitroimidazole antimicrobials
Mechanism of action:
 Metronidazole diffuses into the organism, inhibits protein synthesis by interacting
with DNA, and causes a loss of helical DNA structure and strand breakage.
Therefore, it causes cell death in susceptible organisms

Indication:
 Amebiasis
 Bacterial vaginosis
 Pelvic inflammatory disease
 Trichomoniasis infection
 Giardiasis
 Intra-abdominal infections
 Helicobacter pylori eradication
Adverse reactions:
 Nausea
 Vomiting
 Epigastric stress
 Abdominal cramps
 Unpleasant metallic taste, oral moniliasis
Nursing considerations:
 Continue to observe patients for onset of neurologic symptoms and consider
discontinuing metronidazole when or if new neurologic symptoms appear
 During and after prolonged therapy or repeated courses, complete blood count
(CBC) with differential requires monitoring
 Elderly patients and previously diagnosed patients with severe hepatic impairment
and or end stage renal disease should be monitored closely
E. Inj. Paracetamol
Generic name: Paracetamol, Acetaminophen

24
 Trade name: Codomol, Cetamol, Niko
Class: Anti pyretic, non-opioid analgesic
Mechanism of action: The antipyretic effect of paracetamol is mediated by the inhibition
of prostaglandin E2 synthesis in thermoregulatory center of the hypothalamus.

Indication:
 Fever
• Mild to moderate pain (from headache, menstrual periods, toothache,
 backache, osteoarthritis or cold/flue aches)
• Contraindications
• Hypersensitivity
• Severe hepatic impairment or active liver disease
Adverse reactions:
 Nausea, vomiting
 Stomach pain
 Loss of appetite
 Dark urine, clay colored urine
 Jaundice
Nursing considerations:
• Monitor the signs and symptoms of hepatotoxicity
• Report the rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in
voiding patterns.
• Give the tab with food if GI upset occurs.
• Instruct the patient to avoid alcohol.
• Asses for fecal occult blood or nephritis
F. Inj. Pethidine
Generic name: Meperidine
Trade name: Demerol
Class: Synthetic opioid agonists
Mechanism of action: It acts at κ receptors in lamina I and II of the dorsal horn of the
spinal cord and decreases the release of substance P, which modulates pain perception in
the spinal cord.
Indication:
 Diarrhea
25
  Cough
 Acute pulmonary edema
 Pain in trauma, cancer or other severe pain
Adverse reactions:
 Severe respiratory depression
 Elevation of intracranial pressure
 Physical dependence
 Delirium
Nursing considerations:
 Assess the patient’s pain level and vital signs before administration of pethidine
 Monitor the patient’s respiratory rate, as pethidine can cause respiratory depression
 Assess the patient’s level of consciousness as pethidine can cause drowsiness
 Assess the patient’s hypersensitivity to opioids
G. Inj. Phenergan
Generic name: Promethazine
Trade name: Phenergan
Class: Antihistamines (1st Generation)
Mechanism of action:
 Histamine is a chemical messenger that increases vascular permeability, leading to
fluid moving from capillaries into surrounding tissues. This causes swelling and
dilation of vessels.
 Antihistamines act as antagonists at the H-1 receptors and stop this effect. This
results in a reduction in allergy symptoms and any related symptoms.
 First-generation antihistamines easily cross the blood-brain barrier into the central
nervous system and antagonize H-1 receptors.
Indication:
 Allergic and inflammatory conditions
 Nausea
 Vomiting
 Motion sickness
Adverse reactions:
 Fatigue
 Dizziness
 Lack of coordination
26
  Tremors
 Dryness of nasal passage
 Retention of urine
 Blurred vision
 Paradoxical hyperactivity in young children
Nursing considerations:
 Warn patients about possible photosensitivity and instructing on ways to avoid it
 Instruct patient to take first dose 30-60 minutes before traveling
 Carefully monitor the adverse effects of antihistamines in elderly patients
 Exercise caution in case of children with respiratory dysfunction
 Antihistamines such as promethazine should not be used during breastfeeding as it
may lead to seizure in infants.
H. Inj. Pantoprazole
Generic name: Pantoprazole
Trade name: Pantop, Panzole, Pantoacid
Class: Proton Pump Inhibitors (PPIs)
• Therapeutic class: antiulcer class
• Pharmacologic class: proton pump inhibitors
Mechanism of action:
• It acts by irreversible inhibition of the H/K ATPase, the terminal step in the acid
 secretory pathway in gastric parietal cells
• Inhibits both basal and stimulated gastric acid secretion
• Inactive at neutral pH
• Have overtaken H2 blocker
Indication:
• Peptic ulcer with or without bleeding
• GERD (Gastro-Esophageal Reflux Disease
• Erosive esophagitis
• Zollinger-Ellison Syndrome
• Stress ulcer
• Aspiration pneumonia
• H. Pylori regimen
Adverse reactions:

27
 • Well tolerated-Relatively safe
• Nausea
• Diarrhea
• Headache
• Abdominal pain
• Muscle and joint pain
• Prolonged use: atrophic gastritis
Nursing considerations:
• Advise patient to take pantoprazole exactly as prescribed.
• Advise patient to follow the dosage instruction
• Advise patient not to crush, chew or break the tablet.
• Instruct patient to notify healthcare provider about any allergies
• Instruct patient to notify the physician of any side effects.

28
 NURSING CARE PLAN
Health Problems
Loss of appetite
Disturbed sleep pattern
Anxious and stressed
Pain

Actual Prioritized Nursing Diagnosis

 Acute pain related to surgical procedure as evidenced by facial

expression of pain
 Deficient knowledge regarding disease condition related to inadequate
knowledge as evidenced by patient’s verbalization.

Potential Nursing Diagnosis

 Risk for infection as evidenced by inadequate knowledge to avoid exposure
to pathogens.

29
 Date Assessment Nursing Nursing Planning Interventions Rationale Evaluation
Diagnosis Goals

2080/08/12 Subjective Acute Patients  Assess level  Patient’s  Provides The goal was
data pain pain will of pain of level of pain baseline completely
Patient related to be patient was informatio met as
verbalized, “I surgical reduced  Maintain assessed n about evidenced by
feel pain at procedure within comfortable which was level and patient’s
the surgery as three position of at 7/10 on site of verbalization
site.” evidence hours of patient the pain pain and pain
by facial nursing  Administer scale  Lateral scale 4/10.
Objective expressio interventianalgesic as  Patient was position
data, n of pain on per kept in left ealps to
Frowning physician’s lateral prevent
face, order position pressure
Unwillingness  Reassess  Inj. on surgery
to eat level of pain Pethidine site
anything in patient and Inj.  Pethidine
Phenergan exerts its
was analgesic
administere effect by
d as per acting as
physician’s agonist as
order µ-opioid
 Patient’s receptor.
level of pain Phenergan
was has
reassessed antihistam
ine action
that treats
allergic
reactions.

30
 Date Assessment Nursing Nursing Planning Interventions Rationale Evaluation
Diagnosis Goals
2080/08/13 Subjective Deficient Patient  Assess level  Patient’s  Provides The goal was
data: knowledge will have of knowledge level of baseline completely
Patient regarding knowledg of patient knowledge information met as
verbalized, “I disease e about about the about disease about evidenced by
don’t know condition the disease. was patient’s patient’s
much about related to disease  Provide health assessed, no level of verbalization
my disease inadequate treatment teaching about any knowledge. of knowledge
and surgery knowledge procedure perianal knowledge  Health about the
procedure.” as within fistula and about disease teaching disease and
evidenced three fistology. observed. makes treatment
Objective by patient’s hours.  Counsel about  Health patient procedure.
data: verbalizatio surgical teaching aware
Illiteracy n. procedure. about about the
 Reassess level perianal disease and
of knowledge fistula was provides
of patient provided and required
about disease general information
condition and information  Counselling
surgical on fistology about
procedure. was given. surgical
 Counselling procedure
about reduces the
surgical level of
procedure stress of
was done. patent
 Patient was regarding
oriented surgery.
about the  Reassessme
surgery nt helps to
 Patient’s make
level of further
knowledge intervention
on disease s
and accordingly
conditions .
and surgical
procedure
was
reassessed.

31
 Date Assessment Nursing Nursing Planning Interventions Rationale Evaluation
Diagnosis Goals

2080/08/12 Objective data Risk for Patient’s  Assess the  Condition  Provides The goal was
Surgical infection surgical condition of of wound baseline completely
fistotomy at as wound surgical was informatio met as
perianal evidenced will heal wound and assessed, no n about the evidenced by
region by without see signs of signs of condition no signs of
surgery at any infection. infection of the infection.
perianal infection observed. wound
region  Teach patient Patient was  Maintenan
way of taught about ce of
maintaining importance perianal
perianal of dressing hygiene,
hygiene and prevents
washing infection.
perianal  Dressing
area helps to
thoroughly keep the
after surgical
defalcation. wound
 Perform
dressing of  Dressing of clean and
surgical surgical prevents
wound as wound was infection.
ordered by performed  Reassessin
physician as per g the
physician’s surgical
order wound and
 Reassess
 Surgical monitoring
surgical
wound’s the signs
wound and
condition of
monitor signs
was infection
of infection.
reassessed helps to
and signs of make
infection further
was interventio
monitored, ns
no signs accordingl
present. y

32
Daily progress note
Day General condition Investigations Treatment
2080/ fair None Medication as Tab.
8/10 Dulcolax and ezevac
enema
2080/ Weak due to None Fistulotomy done, post-
8/11 surgery operative medications
administered
2080/ recovering None Observation and under
8/12 evaluation and
continuation of post-
operative medications
200/8/ fair None Dressing and discharge
13

STRESS MANAGEMENT
Stress management consists of a wide spectrum of techniques and psychotherapies aimed
at controlling a person's level of stress, especially chronic stress, usually for the purpose of
improving everyday functioning. The techniques of stress management applied to this case
are:
 The patient was provided orientation about the ward.
 Detail explanation about the disease condition and surgical procedure was done to
the patient and the family member.
 Patient was informed about diet and medications prior to surgery.
 Patient was suggested to apply diversional therapy as deep breathing and talk
therapy to manage stress.

HEALTH TEACHING

Heath teaching and discharge teaching are crucial components of patient care in
healthcare settings aiming to provide patients with information and education to
help them understand their medical conditions, treatment options, and self-care
responsibilities. So, health and discharge teaching were given to both patient and
care givers on following topics:

Information on diagnosis: Explained the patient's medical condition in clear and

understandable language. Used some of the visual aids, diagrams and videos to
illustrate the condition.

33
Diet and Nutrition: Offered guidance on dietary restrictions, recommended foods,
any necessary modifications to the patient's diet based on his condition. The patient
was advised to take high energy and protein rich diet, maintain a balanced diet and
increase calorie intake. Furthermore, the patient was suggested to increase fluid
intake and its importance.
Rest and recovery: Emphasized the need for adequate rest and sleep to support the
body's recovery process to the patient and provided him with informal health
teachings regarding the importance of enough sleep and rest for quick recovery.
Hygiene: The patient was provided with knowledge of importance regarding the
maintenance of good personal hygiene to prevent infection and complications. He
was encouraged regular handwashing, nail trimming and keeping the body clean.
Medication management: Provided detailed instructions on how to take
prescribed medications, including dosages, timing, and any special considerations.
Emphasized the importance of completing the full course of treatment.
Infection prevention: The patient was educated on the causes of perianal fistula,
typically through perianal abscess. He was advised on measures to prevent perianal
abscess such as avoiding constipation, staying hydrated and avoiding straining
during bowel movements.
Follow-up care: Scheduled the follow-up appointments with the healthcare
provider to monitor progress and to adjust treatment if needed. He was provided
contact information in case of emergencies or questions.
Activities and exercise: Activities which involved stress were restricted and he
was advised to do light exercise and walking that his body can tolerate for quick
recovery.

OUTCOME
Patient’s operative procedure was successful and patient was discharged.

SUMMARY
I got an opportunity to conduct a case study in depth during my clinical posting as
per the demand of Bsc. Nursing second year curriculum. For my case study I chose
Mr. Dilli Rawat with Perianal fistula. During this case study, I collected relevant
health history that were important from the patient and his family. He came to Bir
Hospital in Surgical OPD on 2080/06/23 with the complaint of watery discharge
from anal region and was planned for fistulotomy on 2080/8/11. He was admitted
on 2080/08/10 in male surgical ward. I began my case study by assessing the
patient’s physical, emotional and social needs which involved taking medical
histories, conducting physical examinations and assessing vital signs. I maintained
accurate and detailed patient records including assessments, care plans and
progress notes. As this is my first time preparing a case study in undergraduate
level, there might be various limitations that I shall work on, in coming days. My
previously set objectives were achieved. I gained a lot of knowledge about Perianal
fistula and detailed insights into it. Furthermore, I learned to apply the theoretical
knowledge into practical area and also an experience to solve various types of
problems in hospital settings. Hence, this case study came out to be a knowledge
gaining and a lifetime experience for me.

34
 LEARNING FROM THE STUDY
The case study I have just conducted has provided me with valuable insights and
lessons that can be applied to various aspects of my work or research. Through a
thorough examination of the subject matter, data analysis, and critical thinking,
several key takeaways have emerged:
 Through this case study, I gained valuable insights into the dynamics of the
disease.
 I learned about pathophysiology, management and surgical management of the
disease.
 I gained the ultimate confidence while caring and managing the patient with the
disease.
 I got the opportunity to learn about the personal background of the patient, his
family and the environment he grew with including his socio-cultural, educational,
religious and economic status.
 I learned a lot about nursing care and the approach to be made for the nursing
diagnosis which helped me to gain my knowledge about nursing process and
nursing careplan.

REFERENCES
• National library of medicine, USA (www.nlm.nih.gov)
• www.Healthline.com
• NANDA-I
• Bailey & Love’s Short Practice of Surgery (24th edition)
• Lippincott Illustrated Reviews: Pharmacology 7Th edition

35