Case Study: Fistulectomy

Group 6: Bulatao, Lesley Charmaine C. Cabudoc, Maricar G. Comilang, Janielle Lyn M. Constante, Quolette M. Dela Cruz, Rhealyn N. Ebuenga, Allyssa O. Espanueva, Gaylen C. Fabon, Yvette Stephanie Nichol B. Franco, Ma. Eliza Joy L. Fuentes, Raquel F.

Introduction

An anal fistula is an abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skin. Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.

Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats. Anal fistulas do not generally harm and they often do not hurt, but they can be irritating because of the pus-drain (and, it is not unknown for formed stools to be passed through the fistula); additionally, recurrent abscesses may lead to significant short term morbidity from pain, and create nudes for systemic spread of infection. A fistula is a tiny channel or tract that develops in the presence of inflammation and infection. It may or may not be associated with an abscess, but like abscesses, certain illnesses such as Crohns disease can cause fistulas to develop.

The channel usually runs from the rectum to an opening in the skin around the anus. However, sometimes the fistula opening develops elsewhere. For example, in women with Crohns disease or obstetric injuries, the fistula could open into the vagina or bladder. Since fistulas are infected channels, there is usually some drainage. Often a draining fistula is not painful, but it can irritate the skin around it. An abscess and fistula often occur together. If the opening of the fistula seals over before the fistula is cured, an abscess may develop behind it.

An anal fistula is almost always the result of a previous abscess. Just inside the anus are small glands. When these glands get clogged, they may become infected and an abscess can develop. A fistula is a small tunnel that forms under the skin and connects a previously infected anal gland to the skin on the buttocks outside the anus. After an abscess has been drained; a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop. Symptoms related to the fistula include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.

Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication exists, and is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulas often develop four to six weeks after an abscess is drained, sometimes even months or years later.

Fistula surgery usually involves opening up the fistula tunnel. Often this will require cutting a small portion of the anal sphincter, the muscle that helps to control bowel movements. Joining the external and internal openings of the tunnel and con-verging it to a groove will then allow it to heal from the inside out. Most of the time, fistula surgery can be performed on an outpatient basis. Treatment of a deep or extensive fistula may require a short hospital stay. Discomfort after fistula surgery can be mild to moderate for the first week and can be controlled with pain pills.

The amount of time lost from work or school is usually minimal. Treatment of an abscess or fistula is followed by a period of time at home, when soaking the affected area in warm water (sitz bath) is recommended three or four times a day. Stool softeners or a bulk fiber laxative may also be recommended. It may be necessary to wear a gauze pad or mini-pad to prevent the drainage from soiling clothes. Bowel movements will not affect healing.

CASE ABSTRACT

This is the case of Patient X, a 34 year old male who was admitted last September 3, 2009, under the service of Dr. R. Lopez of Valuecare. He came to the hospital with a chief complaint of hematochezia and painful bowel elimination. Three weeks prior to admission, Patient X experienced hematochezia. He noted painful defecation, however describes having constipation or diarrhea. He decided to seek consult and was admitted to undergo proctosigmoidoscopy.

He was initially diagnosed with an anal fistula and was to be forwarded to the OR for proctosigmoidoscopy and fistulectomy on September 4, 2009 at 7 a.m. Meanwhile, Patient X was hooked to a liter of D5LR which was to run for 8 hours. He was also advised to be on NPO and for urine collection. His attending physician ordered CBC, urinalysis and x-ray. The following morning, at 6:35 a.m., Patient X was wheeled to the OR table, inducted with spinal anesthesia and was placed on lithotomy for proctosigmoidoscopy. At 7:35, Dr. Lopez confirmed the anal fistula. At 8:00 a.m., Dr. Lopez and Dr. Publico started the fistulectomy, the procedure was well tolerated and Patient X was brought to the Recovery Room for further management.

At the Recovery Room, Patient X was inserted with a Foley Catheter for urine collection and was transferred to room. He was hooked to a liter of D5NM + Ketorolac 60 mg to run for 6 hours and was placed on diet as tolerated. A few hours later, the foley catheter was removed and he was able to void freely. The sack on the surgical site was removed later on. On September 5, 2009 at 5:40 a.m. the IVF was discontinued upon request and on September 6, 2009, Patient X was discharged ambulatory.

Physical Assessment

GENERAL DATA
1. General Information Name: D.Y. Age: 34 y/o Gender: Male

Chief complaint: Hematochezia Admitting diagnosis: Proctosigmoidoscopy Fistulectomy

2.

Vital Signs Temperature: 36.4 Pulse Rate: 62 Respiratory rate: 16 Blood Pressure: 100/70

3. General Survey 3.1 Anthropometric Measurement

Height: 55 Weight: 72kg

3.2 General Appearance

The patient shows sign of distress, conscious and coherent. He is oriented to the place, person, and time. He is well-developed, looks according to his age. Well- nourished and calm.

4. Skin

5. Head

The patients skin is brown, smooth and fair, without any abnormalities found. He has good skin turgor and is warm to touch. The patients head size is proportion to the size of his body and with a normocephalic shape. The hairs are evenly distributed. There is no presence of dandruff or scar. The face is symmetrical and with negative facial musculture. The patients eyes are symmetrical. Eyebrows and eyelashes are evenly distributed. Pale conjunctiva. Anicteric sclera. The cornea and lens are clear. Pupil sizes are equal. The visual acquity is good (20/20).

6. Ears

7. Nose

The ears of the patient are symmetrical, soft and pliable, and at the level of the outer cantus of the eye. There is no presence of discharges on the ear canal. Able to hear sounds on both ears. Patients nose is smooth, nasolobial fold is symmetrical, septum is located in the midline, no presence of nasal discharge seen. Patent nostrils. The lips are pinkish in color and moist, no presence of cracks or lesions. Tongue is found at the midline and can move freely. Complete teeth without presence of cavity. Gums and buccal mucosa are pinkish in color, smooth and moist. Uvula is on the midline. There is no presence of inflammation of tonsils.

8. Mouth and Pharynx

9. Neck
Patients neck moves freely. Trachea is located in the midline. Cervical lymph nodes are nonpalpable. There is no presence of masses.

10. Chest and Lungs

Patients chest is cylindrical with regular breathing pattern. Lung expansion is symmetrical and no retractions.

11. Heart
The precordium is flat. Apical pulse is located at the fifth intercostal space left mid-clavicular line. Heart rhythm is regular.

12. Abdomen
Patients abdomen appears globular and without presence of scars/lesions, with a presence of tenderness upon palpation. Not assessed, the patient refused to. Not assessed, the patient refused to. Nail and nail beds are pinkish with no sign of inflammation. Decreased ROM upon surgery. Spine is on the midline. Coordinated gait.

13. Genitals

14. Anus and rectum 15. Back and Extremities

Anatomy & Physiology:

Digestive Functions

Th e D Sy ige s t st em iv e

Digestive functions
Ingestion occurs when foods enter the digestive tract through mouth. Mechanical processing is the physical manipulation of solid foods, first by the tongue and the teeth and then by swirling and mixing motions of the digestive tract. Digestion refers to the chemical breakdown of food into small organic fragments that can be absorbed by the digestive epithelium. Secretion aids digestion through the release of water, acids, enzymes and buffers by the digestive tract and accessory organs.

 Absorption is the movement of small organic molecules, electrolytes, vitamins, and water across the digestive tract. Excretion is the elimination of waste products from the body. Within the digestive tract, these waste products are compacted and discharge through the process of defecation

o l o t s i H

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Four Major Layers of Digestive Tract

1. Mucosa
Inner lining. An example of a mucous membrane. Consist of an epithelial surface moistened by glandular layer of loose connective tissue, the lamina propria. Increase the surface area available for absorption

 Permit expansion after a large meal. Forms fingerlike projections, called villi. Outer portion of the mucosa contains a narrow band of smooth muscle and elastic fibers Muscularis mucosae, move the mucosal folds and villi.

2. Submucosa Second layer of loose connective tissue that surrounds the muscularis mucosae. Contains large blood vessels and lymphatics as well as network of nerve fibers, sensory neurons and parasympathetic motor neurons. This neural tissue submucosal plexus helps control and coordinate the contractions of smooth muscle layer and also helps regulate the secretion of the digestive glands.

3. Muscularis externa Collection of smooth muscle cells arranged in an inner circular layer and an outer longitudinal layer. Contractions of these layers in various combinations agitate or propel materials along the digestive tract. These are autonomic reflex movements controlled primarily by a network of nerve, the myenteric plexus, sandwiched between the inner and outer smooth muscle layers.

 Parasympathetic stimulation increases muscular tone and activity, and sympathetic stimulation promotes muscular inhibition and relaxation.

4. Serosa A serous membrane Covers the muscularis externa along most portions of the digestive tract inside the peritoneal cavity The parietal and visceral peritoneum that lines the inner surfaces of the body wall. The parietal and visceral peritoneum are connected by double sheets of serous membrane called mesenteries, loose connective tissue sandwiched between epithelia provides an access route for the passage of blood vessels, nerves and lymphatics servicing the digestive tract.

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f o s t l n a e i r m e e at v o M M

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Peristalsis and Segmentation

Peristalsis
Waves of muscular contractions that move along the length of the digestive tract. During a peristaltic movement, the circular muscles first contract behind the digestive contents. Then longitudinal muscles contract, shortening adjacent segments. A wave of contraction in the circular muscles then forces the materials in the desired direction.

Segmentation
Movements that churn and fragment digestive materials. This action results in a thorough mixing of the contents with intestinal secretions. Because they do not follow a set pattern, segmentation movements do not propel materials in a particular direction.

The Stomach
Located within the left upper quadrant of the abdominopelvic cavity. Receives food from the esophagus. The stomach has four primary functions the temporary storage of ingested food, the mechanical breakdown or resistant materials, the beginning of digestion by breaking chemical bonds through the action of enzymes and acids, and the production of intrinsic factor, a compound necessary for absorption of vitamin B12.

 The agitation of ingested materials with gastric juices secreted by the glands of the stomach produces a viscous, soupy mixture called chyme. The principal anatomical landmark of the stomach is a muscular organ with the shape of an expanded J. The esophagus connects to the stomach at the cardia. The bulge of the stomach superior to the cardia is the fundus of the stomach. The large area between the fundus and the curve of the J is the gastric body.

 Pylorus the curve of the J connects the stomach with the small intestine. A muscular pyloric sphincter regulates the flow of the chyme between the stomach and the small intestine. The stomach resembles a muscular tube with narrow and constricted lumen. When full, it can expand to contain 1-1.5 liters. This degree of expansion is possible because the stomach wall contains a number of prominent ridges and folds called rugae.

 The visceral peritoneum covering the outer surface of the stomach is continuous with a pair of mesenteries. The greater omentum extends below that hangovers and protects abdominal viscera. The much smaller lesser omentum extends from the lesser curvature to the liver. Stomach is lined by an epithelium dominated by mucous cells. These secreted mucus produced helps protect the lining from the acids, enzymes, and abrasive materials it contains.

 Gastric pits shallow depressions and open onto the gastric surface. Each gastric pit communicates with the gastric glands that extends deep into the underlying lamina propria. These glands are dominated by two types of secretory cells: parietal cells and chief cells. Together these cells secrete about 1500 ml of gastric juice each day. Chief cells secrete pepsinogen, an inactive form of the enzyme pepsin.

Regulation of Gastric Activity

The cephalic phase the sight, smell, taste or thought of food initiates at the cephalic phase of gastric secretion directed by the CNS, prepares the stomach to received food. Under the control of vagus nerve, parasympathetic fibers innervate parietal cells, chief cells, and mucous cells of the stomach. The gastric phase begins with the arrival of food in the stomach. Stimulation of stretch receptors in the stomach wall and chemoreceptors in the mucosa triggers the release of a hormone, gastrin, into the circulatory system.

3. The intestinal phase begins when chyme starts to enter the small intestine. The purpose of this phase is to control rate of gastric emptying and ensure that the secretory, digestive, and absorptive functions of the small intestine can proceed efficiently.

Digestion in the stomach

The stomach performs preliminary digestion of proteins by pepsin and, for a variable period, permits the digestion of carbohydrates by salivary amylase. This enzyme remains active until pH throughout the material in the stomach falls below 4.5, usually within 1-2 hours after a meal. As the stomach contents become more fluid and the pH approaches 2.0, pepsin activity increases and protein disassembly begins.

 Protein digestion is not completed in the stomach, but there is usually enough time for pepsin to breakdown complex proteins into smaller peptide and polypeptide chains before the chyme enters the small intestine.

The Small Intestine

About 6 meters (20 ft) long and has a diameter ranging from 4 cm at the stomach to about 2.5 cm at the junction with the large intestine. It has three subdivisions: the duodenum, the jejunum, and the ileum. The duodenum is the 25 cm (1 ft) closest to the stomach. This portion receives chyme from the stomach and exocrine secretions from the pancreas and liver. The jejunum, which is supported by a sheet of mesentery, is about 2.5 meters (8 ft) in length. The bulk of chemical digestion and nutrient absorption occurs in the jejunum.

 The jejunum leads us to the third segment, the ileum. The ileum ends at the sphincter, the ileocecal valve, which controls the flow of chyme from the ileum into the cecum of the large intestine. Plicae intestinal lining bears a series of transverse folds. Villi lining of the intestine is also thrown into series of fingerlike projections. Small intestine were a simple tube with smooth walls, it have a total absorptive area around 3300 square centimeters, or roughly 3.6 square feet. Lacteal refers to the pale, cloudy appearance of the lymph in these channels.

Intestinal Movements
Two examples are the gastroenteric reflex and the gastroileal reflex. Gastroenteric reflex initiated by distention, which immediately accelerates glandular secretion and peristaltic activity in all segments. Gastroileal reflex is a response to circulating levels of hormone gastrin. Intestinal juice moistens the intestinal contents, assists in buffering acids, and dissolves both digestive enzymes provided by the pancreas and the products of digestion.

Intestinal hormones

Secretin is released when the pH falls in the duodenum, occurs when acid chyme arrives from the stomach. The effect is to increase the secretion of water and buffers by the pancreas and liver Cholecystokenin is secreted when chyme arrive in the duodenum, especially when it contains lipids and partially digested proteins, targets the pancreas and liver, accelerates the production and secretion of all types of digestive enzymes. Gastric inhibitory peptide is released when fats and glucose enter the small intestine. This peptide hormone inhibits gastric activity and causes the release of insulin from pancreatic islets.

The Large Intestine

The horseshoe-shaped large intestine begins at the end of the ileum and ends at the anus. Lies below the stomach and liver. The principal functions of large intestine include reabsorption of water and compaction of feces, the absorption of important vitamins liberated by bilateral action, and the storing of fecal material prior to defecation. The large intestine often called the large bowel.

 It has an average length of approximately 1.5 meters (5 ft) and a width of 7.5 cm (3 in). It is divided into three major regions: the pouch like cecum, the first portion of the large intestine; the colon, the largest portion of the large intestine; and the rectum the last 15 cm (6 in) of the large intestine and the end of the digestive tract. Large intestine absorbs a variety of other substances from the chyme Vitamins (2) bilirubin products bile salts toxins Movement from the transverse colon through the rest of the large intestine results from the powerful peristaltic contractions, called mass movement.

The Cecum
Material arriving from the ileum first enters an expanded chamber called cecum. Ileocecal valve a muscular sphincter guards the connection between the ileum and the cecum. It usually has the shape of a rounded sac and the slender veniform appendix attaches to the cecum along its posteromedial surface. Appendix is almost 9 cm( 3.5 in)

The Colon
The most striking external feature of the colon is the pouches, or hustrae, that permit considerable distension and elongation. Longitudinal bands of muscle, the Taenia coli, are visible on the outer surface of colon just beneath the serosa. The ascending colon begins at the ileocecal valve. It ascends along the right side of the peritoneal cavity until it reaches the inferior margin of the liver. Transverse colon, colon turns horizontally, continues toward the left side, passing below the stomach and following the curve of the body wall.

 Descending colon turns inferiorly. The descending colon continues along the left side until it curves and recurves as the sigmoid colon.

The Rectum
Forms the end of the digestive tract. Anorectal canal last portion of the rectum contains small longitudinal folds joined by the transverse folds that mark the boundary between columnar epithelium of the rectum and a stratified squamous epithelium similar to that found in the oral cavity. Anus the opening of the anorectal canal, the epidermis becomes keratinized and identical to that on the surface of the skin.

 The circular muscle layer of the muscularis externa in this region forms the internal anal sphincter. The external anal sphincter guards the exit of the anorectal canal. Consist of muscle fibers, is under voluntary control.

Pathology and Physiology

History of Constipation

H20 Intake

Activity: Power Lifting

HARDENING OF THE STOOL

DIFFICULTY IN EXPULSION OF STOOL

VALSALVA MANEUVER

INTRA-ABDOMEN PRESSURE

COMPRESSION OF LOWER DIGESTIVE TRACT

 PRESSURE IN RECTUM

PASSAGE OF HARDENED STOOL

CAUSES FRICTION TO LINING

PREDISPOSITION TO ANAL GLAND INFECTION IN THE INTERSPHINTERIC PLANE

FORMS ABSCESS IN THE PERI-ANAL AREA

FORM A CHRONIC TRACT ( FISTULA-IN-ANO)

 INFLAMMATORY RESPONSE DUE TO INFECTION

WBC

NEUTROPHILS

RELEASE OF CHEM. MEDIATORS

HISTAMINE & PROSTAGLANDIN SEROTONIN

PAIN FEVER

Clinical presentation
History (in order of prevalence) Perianal discharge-intermittent or constant Perianal pain-worse during defecation, may be constant Swelling /lump in the perianal area Bleeding in the perianal area Diarrhea Discoloration of skin surrounding the fistula External opening in the perianal discharging Fever

Past medical history

Important points in the history that may suggest a complex fistula include the following:
Inflammatory bowel disease

Diverticulitis History of trauma Previous radiation therapy for prostate or rectal cancer Tuberculosis Immune suppression-Steroid therapy, HIV infection

Review of symptoms -Abdominal pain -Weight loss -Change in bowel habits Physical examination Physical examination findings remain the mainstay of diagnosis

Classification of fistula in-ano

Parks classification system (all are in relation to the sphincters) The Parks classification system defines 4 types of fistula-in-ano that result from cryptoglandular infections.

1.Intersphincteric-commonest-70% Common course - Via internal sphincter to the intersphincteric space and then to the perineum. They result from perianal abscesses 2. Transsphincteric -25% Common course - Low via internal and external sphincters into the ischiorectal fossa and then to the perineum. Originate from ischiorectal abscesses 3.Suprasphincteric -5% Common course - Via intersphincteric space superiorly to above puborectalis muscle into ischiorectal fossa and then to perineum. Result from supralevator abscesses

4. Extrasphincteric-1% Bypass the anal canal and sphincter mechanism, passing through the ischiorectal fossa and levator ani muscle, and open high in the rectum

Current procedural terminology codes classification

1.Subcutaneous 2.Submuscular (intersphincteric, low transsphincteric) 3.Complex, recurrent (high transsphincteric, suprasphincteric and extrasphincteric, multiple tracts, recurrent)

Laboratory

Examination done
Urinalysis Color Transparency Reaction (pH) Pus cells

Date
Sept. 3, 2009

Result

Normal Values
Yellow Clear 4.8-7.8 0-8

Significance

Yellow Turbid 6.0 10-15

Normal
Turbid is a manifestation of pus in the urine.

Normal
Indicates UTI anywhere from the kidneys to the urethra. Hematuria potentially a sign of a bladder infection. Bacteria in urine sediment reflect genito urinary tract infection or contamination of external genitalia.

RBC

8-12

0-5

Amorp. Urates Bacteria

Few Few Negative or rare

Examination done Mucus threads

Date

Result Moderate

Normal Values

Significance Is a normal finding in the urine. Presence of squamous cells may mean that the sample is not as pure as it it needs to be.

Squamous

Few

Spec. grav. Sugar Protein

1.020 Negative Trace

1.015-1.025 Negative Negative

Normal Normal Proteinuria suggest renal failure.

Complete Blood Count Hemoglobin Hematocrit RBC count WBC count Platelet count

Sept. 3, 2009 143 0.43 4.76 5.9 Adequate 140-170gm/L 0.41-0.51 4.60-5..20 4.50-11.00 200.00-400.00 Normal Normal Normal Normal Normal

Examination done Differential count Segmenters Lymphocytes Eosinophils X-RAY

Date

Result

Normal Values

Significance

0.60 0.35 0.05 Sept. 3, 2009 Findings:

0.55-0.65 0.25-0.35 0.02-0.05

Normal Normal Normal

The lungs are clear and well expanded. There is no evidence of acute pulmonary infiltration non consolidation. The heart is normal. There is no engorgement of the pulmonary vascularities. The ribs, soft tissue outlines and the diaphragm are likewise unremarkable. Impression: Normal chest findings.

Drug Study

Name of Drug Plasil

Classification Antacids, anti-emetic agents, antiulcerants

Dosage/ frequency 1 amp x 1 dose

Route TIV

Mechanism of action Dopamine antagonist that acts by increasing receptor sensitivity and response of upper GIT tissues to acerthylcoline.

Indication Disturbanc es of GI motility

Nursing responsibilities Give at least 30 mins.. Before meals and at bedtime. Assess mental status during treatment. Instruct pt. to avoid hazardous activities for at least 2 hours. Advice pt to avoid alcohol and other depressant that enhance sedating properties of this drug.

Name of Drug Ranitidin e

Classification Antacids, anti- emetic, antiulcerants

Dosage/ frequency 1 amp x 1 dose

Route TIV

Mechanism of action Completely inhibits action of histamine on the H2 at receptor site of parietal cells. Decreasing gastric acid secretions.

Indication selected cases of persistent dyspepsia, stress ulceration, & in patients at risk of acid aspiration during anesth

Nursing responsibilities Assess pt. for abdominal pain. Note for presence of blood in emesis, stool or gastric aspirate. May be added to total parenteral nutrition solution.

Name of Drug Co amoxiclav

Classification Antibiotic

Dosage/ frequency 625 mg/ tab q 8hrs x 6 doses

Route PO

Mechanism of action An antibiotic that is a combination of a penicillin (amoxicillin) and a substance called clavulanic acid. It kills bacteria, by interfering with their ability to form cell walls. The bacteria therefore break up and die.

Indication skin & soft tissue infections, UTI, pre & postsurgical procedure s, bone & joint

Nursing responsibilities
Instruct

patient to immediately report signs or symptoms of hypersensitivity reaction, such as rash, fever, or chills.
Monitor

patient carefully for signs and symptoms of hypersensitivity reaction.

Monitor

patients vital signs before, during and after medication.

Name of Drug Flanax forte

Classification non-steroidal antiinflammatory and ant rheumatic products

Dosage/ frequency 550 mg/ tab q 8 hrs x 3 doses

Route PO

Mechanism of action Reversibly inhibits cyclooxygenas e-1 and 2 (COX-1 and 2) enzymes, which result in decreased formation of prostaglandin precursors; has antipyretic, analgesic, and antiinflammatory properties

Indication Relief of mild to moderatel y severe pain & fever w/ or w/o accompany ing inflammati on eg musculosk eletal trauma, post-op pain & postdental extraction .

Nursing responsibilities Advice the pt. to take this medication exactly as directed; do not increase dose without consulting physician. Do not crush tablets Instruct client to take with food or milk to reduce GI distress.

Name of Drug

Classification

Dosage/ frequency

Route

Mechanism of action

Indication

Nursing responsibilities Tell pt. that she may experience drowsiness, dizziness, lightheadednes s, or headache also, nausea, vomiting, or heartburn Instruct pt. to report DOB, chest pain, skin rash and itching.

Name of Drug Fibrosine sachets

Classification Laxatives and purgatives

Dosage/ frequency 1 sachet in 1 glass of water TID x 2 days

Route PO

Mechanism of action Is a stimulant laxative. It acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement.

Indication Fiber supplemen t to maintain regularity of bowel movement.

Nursing responsibilities
Instruct

patient to report if she/ he develop nausea, vomiting, or stomach pain. Instruct patient to stop laxative and inform nurse or physician if she/ he experienced Rectal bleeding or failure to have a bowel movement within 12 hours after use of a laxative, may be a sign of a serious condition.

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PRE-OP

Assessment
Subjective: Masakit kapag ako ay dumudumi, as verbalized by the patient pain in rectal region Objective: a pain rating of 7 on a scale of 010 Irritable Confused change in pulse rate increase and decrease in respiratory rate

Diagnosis
Acute pain related to actual tissue damage

Planning
After 1 hour of nursing intervention, the client will experience lesser pain.

Nursing Interventions
Performed a comprehensive determined whether the client is experiencing pain the tine of initial interview. assessed pain in a client using a self report 0-10 numerical pain rating scale assessed and document the intensity of pain and discomfort.

Evaluation
Goal has been partially met. The client experienced lesser pain.

Assessment

Diagnosis

Planning

Nursing Interventions
asked the client to describe appetite, bowel elimination and ability to rest and sleep. obtained a prescription to administer by the doctor.

Evaluation

Assessment Subjective: Nahihirapan ako dumumi as verbalized by the patient Objective: Bright red blood with stool (+) flatus Abdominal tenderness

Diagnosis Constipation related to discomfort during defecation

Planning After 1 hour of nursing intervention the client will relief from discomfort of constipation

Nursing Interventions Assessed usual pattern of defecation including time of day, amount and frequency of stool Assessed history of bowel habits Palpated for abdominal distention, percuss for dullness and auscultate for bowel sounds

Evaluation Goal has been partially met. The client has experienced lesser pain from the discomfort of constipation.

Assessment

Diagnosis

Planning

Nursing Interventions Encouraged the client to heed defecation warning signs Checked for impaction of feces in bowel Provide privacy for defecation Administer stool softeners ordered by the doctor

Evaluation

POSTOP

Assessment Subjective: Objective: Open wound

Diagnosis High risk for infection r/t inadequate primary defense as manifested by broken skin

Planning After 2 hours of nursing intervention the patient will gain knowledge in infection control as evidenced by discussing the wound care.

Nursing Interventions Independent Establish Rapport Teach patient to wash hands often, especially before toileting, Before and after meals.

Evaluation After 2 hours of Nursing intervention the patient will be able to gain knowledge in infection control as evidenced by his discussion in wound care. Therefore, the goal was met

Assessment

Diagnosis

Planning

Nursing Interventions
Discuss to

Evaluation

patient the following signs of infection: redness, swelling, increased pain, or purulent drainage on the site and fever Demonstrate and allow return demonstration of wound care

N O E I G T R A A U L H C A S V I E D N D A L N P A

MEDICATION
Take Home Med. Fibrosine Sachet
1 sachet in 1 glass of water 3 times a day.

EXERCISE
Avoid heavy lifting, straining and strenuous exercise for two weeks at a minimum (i.e., weightlifting, jogging, swimming, etc.)

TREATMENT
Fistulectomy - in a fistulectomy, the surgeon makes an incision in the fistula tract, opening it up and merging it with the anal canal. This allows the tissues to heal from the inside out.For very small fistulas, a fistulotomy may be performed in a doctors office, using only local anesthesia. Larger fistulas, however, require surgery under spinal or general anesthesia, and are typically performed in a hospital or surgery center. Patients typically experience mild or moderate discomfort or pain following this procedure, with a recovery time of one to four weeks.

HEALTH TEACHING
Maintain a liquid diet for two days after the procedure (i.e., soup, Jell-O, etc.) Eat a high fiber diet after two days Use the bathroom once a day. A warm bath may help your symptoms. Take over-the-counter pain medicine as needed Shower standing up and bathe the area with water to soothe and keep it clean. Do not sit in the bathtub

 Do not use topical steroids or topical agents such as Preparation H Expect some drainage for two to four weeks after the procedure as the Surgisis AFP plug is incorporated and the fistula tract is closed. Using stool softeners and adhering to good hygiene, such as sitz baths after every bowel movement, decreases discomfort and helps for recovery.

OPD
For anal fissures, the WASH regimen is indicated. For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Botulinum toxin injection has been shown to be an effective alternative to surgery for the treatment of uncomplicated idiopathic anal fissure. Topical application of clove oil cream has demonstrated significant benefit in patients with chronic anal fissure. The application of topical 0.5% nifedipine ointment has been used as a chemical sphincterotomy agent. It has been shown to offer a significant healing rate for acute anal fissure and may prevent it from becoming a chronic fissure.

DIET
A high-fiber diet causes a large, soft, bulky stool that passes through the bowel easily and quickly. Because of this action, some digestive tract disorders may be avoided, halted, or even reversed simply by following a high-fiber diet. A softer, larger stool helps prevent constipation and straining. This can help avoid or relieve hemorrhoids. More bulk means less pressure in the colon, which is important in the treatment of irritable bowel syndrome and diverticulosis (defects in the weakened walls of the colon). In addition, fiber appears to be important in treating diabetes, elevated cholesterol, colon polyps, and cancer of the colon.