Chapter I

Introduction

An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an
opening beside the anus. Fistulas usually result from an infection. They may develop from
trauma, fissures, or regional enteritis. Pus or stool may leak constantly from the cutaneous
opening. Untreated fistulas may cause systemic infection with related symptoms.

Surgery is always recommended, because few fistulas heal spontaneously. A fistulectomy

(ie, excision of the fistulous tract) is recommended surgical procedure. The lower bowel is
evacuated thoroughly with several prescribed enemas. The fistula is dissected out or laid open by
an incision from its rectal opening to its outlet. The wound is packed with gauze.

Purpose and Objectives

This case study aims to present the nursing care of a patient with fistula-in-ano
undergoing a fistulectomy procedure. Specifically, this study seeks to achieve the following
objectives:

To the researchers, gain knowledge about the case of a patient with fistula-in-ano undergoing a
fistulectomy procedure which includes a systematic study of the patient’s past and present
history of illness and the nursing care directed to the wellness of the patient. Be able to learn
about the illness of the patient, its etiology and specific treatments needed to improve the health
status of the patient.

To the patient, improvement in the patient’s current condition and receive the appropriate
nursing care that will hasten his recovery and to prevent any hazards that will only worsen the
condition of the patient.

Scope and Limitations

The case is all about a patient with fistula-in-an oundergoing a fistulectomy procedure.

The researchers decided to pursue the studying of this case because anorectal disorders
are common, and the majority of the population will experience one at some time during their
lives.
 The gathering of the information about the case study was conducted for two days.
November24, 2010, the day when our patient was admitted in the hospital and the interview was
done at the same time. November 27, 2010, the day when the physical assessment as conducted.
The client was admitted at the surgical ward in San Juan Medical Center. The area was equipped
with modern facilities and adequate resources sufficient enough for the needs of its patients.
Since the hospital is owned by the government, every patient should provide their own supplies
during their hospital stay.
The data presented in this case study was gathered for 4 days during a rotation of Related
Learning Experience. All of the patient’s information was gathered pre-operatively.
Most of the data were collected through assessment and interview. Moreover, the
patient’s chart which includes all of the necessary information about the progress of the patient’s
condition has provided the researchers the data needed to further prove the case of the patient.
Other data such as the diagnostic procedure results were not yet available since the
patient was newly admitted dated November 24, 2010, the last day of our first week’s rotation.
Because the case came only in the last day of the first week of our duty, the group had a
very limited time assessing the actual condition of the client. Since it was only for one day the
group was able to assess the patient, the group had to maximize the time and make use of the
opportunity while the patient is still in the hospital.

Nursing Theoretical Framework

Since our client is admittedly a bisexual, Sigmund Freud’s Psychosexual theory can be
applied in his case. Any problem that occurred during the Phallic stage can affect the identity of
a person.

The Phallic stage, in Sigmund Freud's theory of psychosexual development, is the third
stage of child development, occurring between the ages of 3 and 6. The source of pleasure at this
stage is the genitals. This is also the stage, Freud believed, in which boys find themselves being
sexually attracted to their mother. The term "Oedipus complex" derives from the Greek legend of
Oedipus.The Oedipus complex stands for the idea that a son becomes jealous and afraid of his
father. He may take on the father's traits, and strive to be like him in order to receive the mother's
attention. The equivalent in girls, called the Electra complex, was termed subsequently, not by
Freud himself who disagreed with the theory that girls went through the same process. Here girls
are thought to be in competition with their mother for their father's attention.

Freud thought the phallic stage brought conflicting feelings of guilt over their secret
sexual desires and their fear of punishment for these feelings, dealt with by repressing these
feelings and identifying with the same-sex parent instead, known as "identification with the
aggressor". The Oedipal conflict is resolved if the child grows into a sexually normal adult,
otherwise the child will experience sexual deviances such as promiscuity, extreme sexual
inhibition or sexual confusion. The development of the superego can help resolve the conflict by
integrating moral and social values and expectations about their roles as a male or female.
 Chapter II Assessment

A. Nursing Health History

1. Biographic Data

Mr. R.D. age 31, was born on March 31, 1978, single and a resident of San Juan.
He works as a beer house waiter.

2. Chief Complaints

The patient was admitted at ER due to the complaints of difficulty in defecation

caused by the pain located at the anorectal region. The pain, as described by the patient,
was knife-like which lasts for about 30 minutes after defecation.

3. Medical Diagnosis

Fistula-in-ano

4. Past Medical History

Mr. R.D, had hemorrhoids before which led to an infection as evidenced by

presence of pus. There was swelling and pain felt while defecating. The client will be
undergoing Fistulectomy for the second time already. The first fistulectomy was done last
December 2008, and he was confined for 8 days; he was placed on a high fiber diet.

When it comes to his lifestyle, he eats typical Filipino diets, which are high in
cholesterol and low in fiber. He does skip meal sometimes, and has reported fond of
eating foods which are high in salt and sugar. He is an occasional drinker. He also added
that he has no known allergies.

As far as he can remember, he has complete immunizations.

5. Present History

Two years prior to admission, Mr. R.D., had fistula-in-ano characterized by

swelling and pain felt in every defecation. Fistulectomy was the procedure done which
was advised by his physician. He was placed on a high fiber diet and was confined for 8
 days. There were diagnostic tests done including the X-ray, Ultrasound and CBC. All of
the results of the patient’s diagnostic tests were normal. Except for the fact that the
patient has Fistula-in-ano.

November 17, 2010, 3 weeks prior to admission, Mr. R.D. was again feeling pain
in every defecation which was characterized by a sharp, knife-like pain. There was also a
presence of pus in his stool. It was for about 30 minutes that the pain lasts. He has taken
Varamoid, an analgesic to ease the pain while defecating but according to the patient, It
has no effect since the pain is still felt whenever the patient is going to defecate. The pain
persists that the patient can no longer do his daily activities; hence, the patient was then
admitted to the hospital.

6. Socioeconomic History

The client was born a Catholic. He works as a waiter on a beerhouse. He earns

P12, 000 a month. Mr. R.D lives in an apartment in San Juan, which he rents and pays for
P 3500 a month. It has 1 bathroom and 1 kitchen for the whole family. He rarely goes to
work out on a gym. According to him, praying is what he does whenever he has
problems.

When it comes to his lifestyle, he eats typical Filipino diets, which are high in
cholesterol and low in fiber. He does skip meal sometimes, and has reported fond of
eating foods which are high in salt and sugar. He is an occasional drinker. He also added
that he has no known allergies.
7. Family Health History

MOTHE
FATHER
R

patie
1st nt
child

MALE FEMALE

KIDNEY FAILURE

HEMORRHOIDS

FISTULA IN
ANU

As illustrated above, the mother of the patient died because of kidney failure. The elder
sister of the patient has hemorrhoids. While our patient has fistula in anu for the second time
because of the presence of anorectal abscess. Other than that no more illness noted in the family
history because the patient cannot no longer remember..

B. Review of Systems

1. Subjective Data

a. Person’s Gordon Approach

Before Hospitalization During Hospitalization

Health Perception – Health The client usually seeks for The client believe that after
Management medical help only when he surgery his condition will be
feels sick. He takes OTC better
drugs without prescription
Analysis & Interpretation: Health is a state of complete physical, mental and social well being
and not merely an absence of disease or infirmity. The client seeks for medical support just when
there is alteration in his health and if he cannot tolerate the present health condition.

Reference: Basic Nutrition & Diet Therapy, revised edition by Caudal

Before Hospitalization During Hospitalization

Nutritional – Metabolic The client eats a typical The client was in high fiber
Pattern Filipino food. He is eating diet prior to surgery.
foods that are high in sodium
and sugar. He drinks 6 – 7
glasses of water everyday
Analysis & Interpretation: Nutrition is the study of food and how the body makes use of it. It is
not only concerned with the quantity, quality of the food one eats but the process by which one
receives and utilizes the food in the body for growth and renewal as well as maintenance of
different body functions. The basic function of nutrition is to maintain life by allowing one to
grow and be in a state of optimum health.

Reference: Basic Nutrition & Diet Therapy, revised edition by Caudal

Before Hospitalization During Hospitalization

Elimination The client usually has his BM The client has difficulty in
2 – 3 times per week. He eliminating feces due to the
 always feels pain while pain he feel and swelling
defecating. He experienced it every time he defecates. The
3 weeks prior to admission. doctor ordered for fleet enema
He described his anus. He said procedure prior to surgery.
it is swelling and there is
presence of pus a little blood
when he defecates.
Analysis & Interpretation: Colonic constipation is the infrequent and difficult passage of
hardened stool. In severe cases the hardened stool may consolidate into an impaction. This bolus
of stool serves as a nidus for bacterial over growth and produces an obstruction that further slows
colonic transit time and the passage of further fecal contents.

Reference: Fundamentals of Nursing by Cozier & Erbs 7th Edition pg. 1099

Before Hospitalization During Hospitalization

Activity – Exercise Pattern The client goes to gym The client was under active
whenever he has time. He ROM
works as a waiter and usually
stands for long hours in his
whole shift.
Analysis & Interpretation: Mobility is the ability to move freely, easily, technically,
rhythmically and purposely in the environment and is an essential part of living. Physical activity
is bodily movement produced by skeletal muscle contraction that increases energy expenditures.
Exercise is a type of physical activity defined as a planned, structured and repetitive bodily
movement performed to improve or maintain one or one components of physical fitness.

Reference: Fundamentals of Nursing by Cozier and Erbs, 8th Edition Vol. 2 pg. 1106 – 1107

Before Hospitalization During Hospitalization

Sleep – Rest Pattern He sleeps for 6 – 7 hours a day The client sleeps for about 3 –
4 hours only in a day due to
the pain he feels and due to
uncomfortable position.
Analysis & Interpretation: Most healthy adults need 7 – 9 hours of sleep at night. Difficulty in
sleeping due to pain and stress or may lend to weakness and fatigue.
Reference: Fundamentals of Nursing by Kozier and Erbs, 7th Edition pg.1260

Before Hospitalization During Hospitalization

Cognitive – Perceptual Pattern The client is alert and calm.
He only feels anxiety
whenever he feels any
discomfort or deviation on his
health status. He has remote &
intact memory. He is oriented
to time, place and person.
Responds appropriately to
verbal and physical stimuli.
Analysis & Interpretation: In elders and middle age groups changes in cognitive abilities are
more often a difference in speed than in ability.
He is active and coherent. He
has a positive attitude towards
his upcoming surgery he
doesn’t feel any anxiety nor
fear. His memory is intact and
has response verbal and
physical appropriate.

Reference: Fundamentals of Nursing by Kozier & erbs 7th Edition pg. 1327

Before Hospitalization During Hospitalization

Self – Perception – Self He sees his self as a healthy His major goal is to prolonged
Concept Pattern and successful man for having life and maintains a healthy
a good job. life after surgery.
Analysis & Interpretation: Self concept is one’s mental image of one’s self. A positive self –
concept is essential to a person’s mental and physical health. Individuals with a positive self –
concepts are better able to develop and maintain interpersonal relationship and resist psychologic
and physical illness.

Reference: Fundamentals of Nursing by kozier & Erbs 7th Edition pg. 1379

Before Hospitalization During Hospitalization

Role – Relationship Pattern He has a close relationship He still able to express love to
with his family his family
Analysis & Interpretation: A role is a set of expectations about how the person occupying one
position behaves.

Reference: Fundamentals of Nursing by Kozier & Erbs 7th Edition pg. 1379
 Before Hospitalization During Hospitalization
Sexuality Reproductive He engages 2 – 3 times in a The client has no problem
sexual intercourse every week. with his sexuality and as well
He uses condom. He engage as for his sexual life. He
sexual intercourse in both man doesn’t anticipate any
and woman. deviations from his sexual life
even after surgery
Analysis & Interpretation: Sexuality a major part of being human. It is the aspect of the self
that deals with reproduction, pursuit of sexual pleasure, love and personal fulfillment. Gender
identity, gender role, & sexual orientation are all components of sexuality.

Reference: Fundamentals of Nursing by Kozier Erbs 7th Edition pg. 1444

Before Hospitalization During Hospitalization

Coping – Stress – Tolerance When under stress the patient The client did not exhibit any
seeks help from either his signs of stress but whenever
friends or family. He drinks he is stressed out, he says he
alcohol to escape from his passes it off by sleeping,
problem eating and praying. He also
seeks emotional support from
his family and friends.
Analysis & Interpretation: Coping may be described as dealing with change – successfully or
unsuccessfully. A coping strategy (coping mechanism) is a natural or learned way of
responsibility to a changing environment.

Reference: Fundamentals of Nursing by Kozier & Erbs 7th Edition pg. 435

Before Hospitalization During Hospitalization

Value – Belief Pattern He is a catholic. He prays The client is prays more often
whenever he has problem. for the success of his
operation.
Analysis & Interpretation: Values goals or beliefs (including spirituality) that guide choices or
decisions. Perceived conflicts in values, beliefs or expectations that are health related.

Reference: Fundamentals of Nursing by Kozier & Erbs 7thy Edition pg. 171
 b. Physical Assessment

Body Technique Normal Actual Interpretation Analysis

Appearance findings Findings
VITAL SIGNS
Temperature 36.5-37.5 C 36.5 0C
Respiratory 16-20 cpm 19 cpm
Pulse Rate 60-80 bpm 85bpm
GENERAL SURVEY
Length 5’7”
Weight 75.5kg
SYSTEM OF APPEARANCE
Skin Inspection No edema Presence of A Body odor is
and unpleasant B mainly
palpation body odor N caused when
O the bacteria,
R growing on
M skin
A decomposes
L the sweat.
One can treat
body odor by
using suitable
deodorant and
maintaining
personal
hygiene.
Head Inspection Normocephalic; The patient’s N
and hairs evenly head size is O
palpation distributed; the proportion to R
face the size of his M
is symmetrical body and with A
a L
normocephalic
shape. The
hairs are
evenly
distributed.
There is no
presence of
dandruff. The
face is
symmetrical
and with
negative facial
musculature.
Eyes Inspection Symmetrical or The patient’s N
and evenly placed eyes are O
palpation and symmetrical. R
inline with each Eyebrows and M
other. Non eyelashes are A
protruding and evenly L
equal palpebral distributed.
fissure. The cornea
and lens are
clear. Pupils
sizes are equal
Ears Inspection Has same skin The ears of N
color with his the patient are O
face; symmetrical, R
symmetrical, soft, and M
firm; pliable and at A
the level of L
the cantus of
the eye. There
is no presence
of discharges
on the ear
canal. Able to
hear sounds
on both ears.
Nose Inspection located Patient’s nose N
and symmetrically is smooth, O
palpation on the midline nasolobial R
of the fold is M
face that is symmetrical, A
without septum is L
swelling, located in the
bleeding, midline, no
lesions, or presence of
masses. No nasal
discharge or discharge
flaring and seen. Patent
uniform nostrils.
color
Mouth Inspection The lips should The lips are N The mouth
be pink, soft pinkish in O and lips are
moist, smooth color and R normally
texture with no moist, no M pink,
evidence of presence of A symmetrical,
cracks or L smooth and
lesions or
lesions. moist.
inflammation.
 Not crack and Tongue is Normal
symmetrical. found at the healthy teeth
midline and are white and
can move shiny.
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.
Neck Inspection the muscles of Patient’s neck N The neck
and the neck are moves freely. O muscles,
palpation symmetrical Trachea is R lymph nodes
with the head at located in the M of the head
a midline. A and neck
central position. Cervical L carotid
The patient is lymph nodes arteries are
able are non – located within
to move head palpable. the neck. the
through a full There is no neck should
range presence of move freely
of motion masses. without
without discomfort
complaint of
discomfort or
noticeable
limitation.
Chest Inspection No retractions; Patient’s chest N
is cylindrical O
with regular R
breathing M
pattern. Lung A
expansion is L
symmetrical
No retractions.
Abdomen Inspection Surface is Patient’s N Abdomen
 and uniform in abdomen O skin is subject
palpation color and in appears R to the same
pigmentation; globular and M color
No striae / without A variation of
stretch marks presence of L the rest of the
are scars/lesions body. Round
present; No with a abdomen
rashes or presence of protrudes in a
lesions are tenderness convex
present; upon sphere from
Normally range palpation horizontal
from flat to plane.
rounded.
Genitalia No lesions; Not assessed, Examination
(Male) the patient of genitalia is
refused to. embarrassing
for the client.
Cultural
background
may add
further to
apprehension.
Anus/Rectum Absence of Not assessed, Examination
fistula or the patient of genitalia is
hemorrhoids refused to. embarrassing
for the client.
Cultural
background
may add
further to
apprehension.
Extremities Inspection Symmetric; Presence of A Nail care for
and dirt in the B teens, both
palpation finger nails. N girls and boys
O is important
R for many
M reasons. Not
A only does it
L say a lot
about your
attention to
personal
grooming, but
proper care
can prevent
painful
 problems, and
the
appearance,
condition and
colorization
of your
natural nails
can indicate
possible
underlying
health
problems
NEUROLOGICAL
GCS 15 15 N Glasgow
O Coma Scale
R measures
M consciousness
A by an
L objective
numerical
scale:
Eye Opening:
4
Verbal
Response: 5
Motor
Response: 6

2. Objective Data

a. Mini – Mental Status Examination

I. General Appearance

II. Level of Consciousness

The patient is conscious and coherent. He is cooperative and uses simple words in
communicating.
C. Comprehensive Definition and Description of Terms

1. Anatomy – Physiology

ANAL CANAL- The anal canal begins a few centimeters proximal to the classic
and well visualized dentate line and it ends at the anal verge. The anal canal is about 5 cm
in length. Histologically, the proximal end of the anal canal is the point at which the
columnar epithelium of the rectum becomes a transitional epithelium.

The external anal sphincter is skeletal muscle and thus under voluntary control.
There is a distinct anatomic plane between the internal and external anal sphincter
occupied by longitudinal connective tissue fibers continuous with the outer longitudinal
muscle wall of the rectum. The puborectalis muscle is felt to represent the deep
component of the external anal sphincter and appears to be the most significant muscle
for maintaining fecal continence.

2. Pathophysiology
 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.

Fistula-in-ano is nearly always caused by a previous anorectal abscess. Main

cause of this is an injury at external anal area due to scratching, shaving and infected hair
roots etc. After injury, infection occurs and an abscess is formed. Usually that abscess
drains spontaneously making an opening which may be a Fistula in ano. After
spontaneous drainage or surgical occasionally a tract is left behind, causing recurrent
symptoms.

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.
Patient Based
Unresolved Phallic stage that led to gender
confusion resulting to sexual promiscuity and
same sex activity thus causing trauma to anal
canal

Tearing of the anal Presence of a fistula, Presence of abscess and

tissues inflammation, and pain discomfort

Medical Diagnosis: Fistula-In-Ano requiring

Fistulectomy

Fecal incontinence

Toxemia

Fistula-In-Ano has a chance of going back again

Infection

Hemorrhoids
 Chapter III Planning

A. List of Priorities Nursing Diagnosis according to priority

1. Acute pain related to actual tissue damage

2. Constipation related to ignoring the urge to defecate because of pain during

defecation

3. Impaired skin integrity related to damage of fistula

B. Nursing Care Plan

Cues Nursing Analysis Goal Nursing Rationale Evaluation

Diagnosi Intervention
s
Subjective: Acute Pain After an Obtain To rule out After an hour
“Masakit pain Stimuli hour of client’s worsening of nursing
kapag ako related nursing assessment of interventions
ay to actual interventio of pain to underlying the patient
dumudumi. tissue Nociceptor ns the include condtion was able to
” As damage patient location, and verbalize
verbalized will have characteristic developmen relief from
by the A delta a reduced s, onset, t of pain
client. fiber severity of duration, & condition.
pain. precipitating
Objective: and
- observed Spinal aggravating
evidence of Gangia factors. Note
pain and
- Facial investigate
mask, sleep Dorsal changes from
disturbance Horn (Pain previous
- Irritability SignalMod reports.
- Pain scale ified)
of 7 Use pain To
scale determine
Lateral appropriate the severity
Spninothal for of pain.
mic tract age/cognition
(SpinalCor (e.g, pain
d) assessment
scale for
elderly.
Pain
(Brain) Accept Pain is a
client’s subjective
description experience
of pain. and cannot
Acknowledg be felt by
e the pain others.
and convey
acceptance of
client’s
response to
pain.
Observe non- Serves as an
verbal cues indicator
or pain when client
behaviors is unable to
such as facial verbalize
expressions and may/not
especially to be
persons who congruent
cannot with verbal
communicate reports.
verbally.

Determine To know
frequency of how long
bowel the problem
movement. has been.

Determine Varies with

client’s individuals
acceptable and
level of pain. situation.

Respond Reduces
immediately anxiety and
to complaint patient and
of pain. demonstrate
s concern
that helps in
 fostering a
trusting
relationship.

Eliminate Patients
additional may
stressors or experience
sources of an
discomfort as exaggeratio
much as n in pain if
possible. other stimuli
are further
stressing
them.

Administer Analgesics
analgesics as reduce pain
ordered. in clients
and doctors
must be
notified if
regimen is
unable to
meet pain
control.

Provide Promote
comfort non
measures pharmacolo
(touch, gical
repositioning managemen
 , quiet t of pain.
environment)

Encourage To prevent
adequate fatigue.
rest.

Increase fiber Food those

intake. are rich in
fiber makes
movement
of food and
elimination
easier.

Drink 8-10 Aids in

glasses of peristalsis,
water serves as
everday. lubricant of
the
intestines

Cues Nursing Analysis Goal Nursing Rationale Evaluation

Diagnosi Intervention
s
Subjective: Constipa Passage of After 8 Encourage To provide The patient
tion hard and hours of intake of at adequate was able to
“Nahihirap related formed nursing least 2L of hydration have an
an ako to stool interventio water daily adequate
dahil ignoring n, the elimination
masakit the urge patient is Recommend To promote pattern.
pag to Fistula-in- expected high-fiber bulk in the
dumudumi” defecate ano to foods stool and to
As because promote make it
verbalized of pain Trauma to adequate easier to
by the during the eliminatio pass fecal
client defecati anorectal n patterns. matter
on muscles through the
Objective: rectum

Fistula-in- Pain felt Administer To decrease

ano when the analgesic pain felt by
stool is before a client
Presence of pushed bowel
pus in the against the movement
stool anorectal
muscles Have the To relax the
(+) flatus with fistula patient abdominal
perform and perineal
Abdominal relaxation muscles,
Tenderness exercises which may
Constipatio before ne
n related to defacating constricted
ignoring or in spasm
the urge to
defecate Advise
because of patient to set
pain during aside a time
defecation for bowel
movement s
and to heed
the urge to
 defecate as
promptly as
possible.

CUES NURSIN ANALY GOAL NURSING RATIONA EVALUATI

G SIS INTERVENT LE ON
DIAGNO ION
SIS

OBJECTIV Impaired After 4 Review To identify After 4

ES: tissue hours of history of the hours of
integrity nursing possible cause causative nursing
Damage in related to interventio factors intervention
the fistula damage in n the prior to the patient
Present of the fistula patient will impaired verbalized
pus in the verbalize tissue understandin
anus understand integrity g of
ing of condition
condition and
and Note for poor This may determined
determine health be the causative
the practices contributed factors prior
causative to another to the
factors factor condition
prior to the related to
condition the
condition
Assess This might
adequacy of be one of
blood supply the factor
and related to
innervations the
of the affected condition
tissue

Obtain history
of the For further
condition compariso
n of the
data

Assess Some areas

environmental of the
location of country of
home/work in duty seem
the past and to be
present as susceptible
well as recent to certain
travel disease
entities

Record size, It provides

color, smell, comparativ
location, e baseline
temperature, data for
consistency of further
wound or inspection
lesions if
possible

Encourage
verbalization This may
of feelings help to
regarding determine
present the factors
condition regarding
the
condition
 Chapter IV Implementation

A. Medical Management

1. Drug Study

Drug Trade Name: Aeruginox

Generic Name: Cefuroxime axetil
Dose, Frequency, Route 750mg IV
Classification Antibiotic Cephalosporin
Action Inhibit prostaglandin synthesis
Indication Parenteral lower respiratory infection cause by
s.pneumoniae, s.aureus. Dermatologic infection
caused by s.pyogens UIT caused by E.coli
Contraindication Contraindicated with allergy to
cephalosporinzor or penicillin. Use cautiously
with renal failure
Adverse Reaction Decrease in hemoglobin and hematocrit
Nursing Responsibilities Swallow tablets whole and do not crush, the
tablets may be taken without regard for fluid.
Protect tablets from excessive moisture.

Drug Generic name : Etoricoxib

brand name : Arcoxia
Classification
Nonsteroidal Anti-Inflammatory Drugs
 (NSAIDs)
Dose, Route, Frequency 120 mg
Action ARCOXIA provided rapid and powerful relief
of excruciating pain
ARCOXIA delivered anti-inflammatory power
Indication Relief of acute & chronic pain.
Contraindication History of hypersensitivity to etoricoxib or to
any of the excipients of Arcoxia; active peptic
ulceration or active GI bleeding; patients who
have experienced bronchospasm, acute rhinitis,
nasal polyps, angioneurotic edema, urticaria or
allergic-type reactions after taking
acetylsalicylic acid or NSAIDs including
cyclooxygenase-2 (COX-2) inhibitors; severe
hepatic dysfunction (serum albumin <25 g/L or
Child-Pugh score ≥10); estimated renal
creatinine clearance <30 mL/min; children and
adolescents <16 years; inflammatory bowel
disease; congestive heart failure (NYHA II-
IV); patients with hypertension whose blood
pressure has not been adequately controlled;
established ischemic heart disease, peripheral
arterial disease and/or cerebrovascular disease.
Adverse Reaction The following drug-related adverse
experiences were reported in clinical studies in
patients with OA, RA or chronic low back pain
treated for up to 12 weeks. These occurred in
≥1% of patients treated with Arcoxia and at an
incidence greater than placebo:
Asthenia/fatigue, dizziness, lower extremity
edema, hypertension, dyspepsia, heartburn,
nausea, headache, increased ALT and AST.
:Psychiatric Disorders: Anxiety, insomnia,
 confusion, hallucinations.
Nervous System Disorders: Dysgeusia,
somnolence.
Cardiac Disorders: Congestive heart failure,
palpitations, angina.
Vascular Disorders: Hypertensive crisis.
Respiratory, Thoracic and Mediastinal
Disorders: Bronchospasm.
Gastrointestinal Disorders: Abdominal pain,
oral ulcers, peptic ulcers including perforation
and bleeding (mainly in the elderly), vomiting,
diarrhea.
Hepatobiliary Disorders: Hepatitis, jaundice.
Skin and Subcutaneous Tissue Disorders:
Angioedema, pruritus, erythema, rash, Stevens-
Johnson syndrome, toxic epidermal necrolysis,
urticaria.
Nursing Responsibilities Teach pt. That the drug must be continued for
prescribed time to be effective
Advise pt. To rehydrate prior to theraphy; take
with a full glass of water to enhance absorption
Caution pt. To report bleeding, bruising,
fatigue, malaise; report GI symptoms: Black
tarry stools, cramping

Drug Trade Name: Ponstel

Generic Name: Mefenamic Acid
Dose, Frequency, Route 500mg TID P.O.
Classification Anti – inflammatory
Action Antipyretic activities related to inhibition of
prostaglandin synthesis exact mechanism of
action are not known
Indication Relief of moderate pain when therapy will not
 exceed one week
Contraindication Contraindicated with hypersensitivity to
mefenamic acid, aspirin allergy and as
treatment as perioperative pain with coronary
artery bypass grafting
Adverse reaction CNS: headache, dizziness, insomnia, fatigue
tiredness, ophthalmic effect
DERMATOLOGIC: rash, pruritus, sweating,
dry mucous membranes, stomatitis
GI: nausea, dyspepsia, GI pain, diarrhea,
vomiting, constipation, flatulence
GU: dysuria, renal impairment
HEMATOLOGIC: bleeding, platelet inhibition
with higher doses
RESPIRATORY: dyspnea, bronchospasm
Nursing Responsibilities Take drug with food; take only the prescribed
dosage do not take the drug longer than one
week

Drug Trade name: Senokot-S

Generic name: Senna
Classification LAXATIVE, STIMULANT (By mouth)
Dose, Route, Frequency 1tab OD
Action Causes local irritation in colon, which
promotes peristalsis and bowel evacuation.
Softens feces by increasing water and
electrolytes in large intestine.
Indication Acute constipation; preparation for bowel
examination
Contraindication Hypersensitivity to drug or its components
GI bleeding or obstruction
Suspected appendicitis or undiagnosed
abdominal pain
Acute surgical abdomen
Fecal impaction
Inflammatory bowel disease (such as Crohn's
disease)
Adverse Reaction GI: nausea, vomiting, diarrhea, abdominal
 cramps, nutrient malabsorption, yellow or
yellowish-green feces, loss of normal bowel
function (with excessive use), dark
pigmentation of rectal mucosa (with long-term
use), protein-losing enteropathy
GU: reddish-pink discoloration of alkaline
urine, yellowish-brown discoloration of acidic
urine
Metabolic: electrolyte imbalances (such as
hypokalemia)
Other: laxative dependence (with long-term or
excessive use)
Nursing Responsibilities  To prepare patient for bowel examination,
give 12 to 14 hours before procedure,
followed by a clear liquid diet.
 Take each dose with a full glass of cold
water or juice and drink plenty of fluids
while taking this medication.
 You should not use a laxative within 2
hours before or after taking other
medicines.
 You should not use a laxative containing
bisacodyl, such as Dulcolax, within 1 hour
before or after drinking milk or taking an
antacid

Drug Generic name: Tranexamic acid

Trade name: Transcam
Classification Antifibrinolytic
Dose, Route, Frequency 500mg/IV
Action It inhibits the activation
of plasminogen to plasmin, a molecule
responsible for the degradation of fibrin. Fibrin
is the basic framework for the formation of a
blood clot in hemostasis.
Indication Short- term
management of hemorrhage
Contraindication Severe renal failure, active intravascular
clotting
thromboembolic disease, color vision
disorders, subara chnoid
bleeding.
Adverse Reaction Common
Nausea
Vomiting
 Diarrhea (Diarrhea)
Uncommon
Blood Pressure Below Normal (Hypotension)
Blood: Increased Chance of DVT (Blood Clot
in the Deep Veins)
Deep Vein Thrombosis
Pulmonary Embolism
Rare
Eye: Color Perception Change
(Dyschromatopsia)
Nursing Responsibilities

2. Treatment

O2 therapy- the purpose of administering O2 in the post-operative client is to maintain

pulmonary ventilation, thus preventing hypoxia (reduced O2 in the blood) and hypercapnia is
reduced (hypoventilation).

D5LR- 5% dextrose in lactated ringers is used to clients who are dehydrated. Intravenous
fluids are administered to replace fluid losses for 4-5 days.

Hot Sitz Bath- used to treat hemorrhoids and anal fistulas. It is a bath in which the H2O
or saline solution soaks both the hips and buttocks of the bather who sits up.

3. Diet

High Fiber Diet- constipation is common after surgery it can range from a minor irritation
to a serious complication. High Fiber Diet helps to prevent constipation and prevent serious
complication in the post operation site.

4. Activity/Exercise

Active ROM- patients are encouraged to be out of bed as soon as possible as it reduces
the incidence of post operative complications. Ambulation increases ventilation and reduces
stasis of bronchial secretions in the lungs.

B. Surgical Management
 D5LR- resembles the normal composition of blood serum and plasma, potassium level
below body's daily requirement.

Replacement therapy particularly in ECF deficit accompanies by acidosis the goal of

management is to maintain the pulmonary ventilation to prevent further complication like
hypoxia (reduce O2 in the blood) and hypercapnia (excess CO2 in the blood), administering
oxygen will help prevent this complications. To prevent the fluid and electrolyte imbalance,
D5Lr must administer. It also resembles the normal composition of blood serum and plasma.
Constipation is one of the highest causes of hemorrhoids. Having a high fiber diet mix formed
stool, soft and it can pass through the anal passage easily and without strain and force.

C. Patient’s Daily Progress Notes

Day Procedure Diet Activity Drugs Treatmen Surgery Nursing

t Problem
Day 1 Fleet DAT Active
Nov. Enema increase ROM
24, Fiber
2010 Skin test
Day 2 Skin test NPO at Mefenamic IVF, O2 Fistulectomy Pain
Nov. 12 MN Acid 500 inhalation
25, mg/tab via nasal
2010 Change of DAT at cannula @
dressing 2pm 2LPM

Day 3 DAT Aeruginox IVF

Nov. increase 250mg/tab
26, fiber TID
2010
Zenikot 1
tab OD
Day 4 Full diet
Nov. at 6PM
27,
2010 DAT at
2PM

Chapter V Evaluation

Medication

 The patient was advised to take home medications such as Cefuroxime 500g tablet 2x a day
for 7 day and Arcoxia 120mg 1 tab as necessary to relieve pain.

Exercise

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

Treatment

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

Health Teachings

 Eat a high fiber diet after two days

 Use the bathroom once a day. A warm bath may help your symptoms.

 Shower standing up and bathe the area with water to soothe and keep it clean.

 Do not sit in the bathtub

 Using stool softeners and adhering to good hygiene, such as sitz baths after every bowel
movement, decreases discomfort and helps for recovery.

Out Patient Department

 MR D. was advised to have a follow up check up in the surgery department with his surgeon
every Wednesday from 2-4 in the afternoon.

Diet

 The patient was in DAT (DIET AS TOLERATED) and also encourage to eat a high fiber
diet and a high protein rich foods. 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.