External

Hemorrhoids

INTRODUCTION

Hemorrhoids are vascular

structure that helps in
controlling stool in the anal
canal. They became
pathological when theres
inflammation also known as
piles which are often painful,
swelling and irritating.
Almoranas is another word
for hemorrhoids that comes
from the tagalong dialect
spoken by many people here
in the Philippines.

It was first attested in English

1398, the word hemmorrhoid
derives from the old French
"emorroides", from Latin
"hmorrhoida -ae", in turn
from the Greek
(haimorrhois), which means
"liable to discharge blood",
from (haima) "blood,
(rhoos) "stream, flow,
current", and from (rheo) "to
flow, to stream".
Hemorrhoids are the
varicosities of the veins of
the hemorhoidal plexus.

Hemorrhoids are classified

into internal and external.
Our patient had external
hemorrhoid. External
hemorrhoid can be seen
easily under the skin at the
opening of anal cavity. This
type of hemorrhoid is
extremely painful. If the vein
ruptures it will became
thrombosed hemorrhoid.
While internal hemorrhoid
are not usually painful until
they bleed when they
became swollen.

In many cases, the cause for

hemorrhoids is unknown. The
following lifestyle choices
and conditions can increase
the risk for developing
hemorrhoids:
Alcoholism
Anal intercourse
Chronic diarrhea or
constipation
Diet high in fat and low in
fiber (high fiber foods
include whole grain
foods, fresh fruits, and
vegetables)

Obesity
Jobs that require sitting
or standing for long
periods
Lack of physical activity
Loss of pelvic floor
muscle tone due to age,
pregnancy, childbirth, or
surgery
Severe heart disease or
liver disease

Hemorrhoidectomy is a
surgical procedure that is
performed to remove
hemorrhoids. As the
surgical site is very
sensitive area,
hemorrhoid surgery
causes a lot of pain. It is
a simple operation.
Surgery is completely
effective in about 95% of
cases. However,
additional surgery may
be required if the
hemorrhoids recur.

Our client undergone a new

form of technology for
hemorrhoidectomy which is
Harmonic Scalpel. Ituses
ultrasonic technology, the
unique energy form that
allows both cutting and
coagulation of hemorrhoidal
tissue at the precise point of
application, resulting in
minimal lateral thermal
tissue damage. Because
theHarmonic Scalpel uses
ultrasound, there is less
smoke than is generated by
both lasers and

10

This is a case of client D.D., a 23 year-old male who was

diagnosed with external hemorrhoids. The client was received
in the operating room in The Doctors Hospital., Incorporated
per stretcher last July 18, 2016 at 7:00 AM.

OBJECTIVES
Within 2 days of preparing and devising a case
study regarding External Hemorrhoids, we will be
able to:

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12

COGNITIVE
Review Medical-Surgical Nursing concepts
specifically Hemorrhoids comprehensively.
Identify the predisposing and precipitating
factors that lead to the clients present health
condition.
Formulate a concrete and systematic
pathophysiology of the Hemorrhoids.
Develop a specific, measurable, attainable,
realistic and time-bounded nursing care plan.
Formulate appropriate discharge plan

13

PSYCHOMOTOR
Gather all pertinent data comprehensively.
Conduct a thorough physical assessment
using cephalocaudal approach.
Assess the clients level of understanding
regarding present health condition.
Conduct health teaching effectively.
Implement effective and reliable nursing
interventions.

14

AFFECTIVE
Display the virtues of a globally competitive
Augustinian student nurse at all times.
Establish trust, open communication and
teamwork within the members of the group
throughout the study.
Respect clients rights, beliefs, norms and
values at all times.
Exhibit enthusiasm and patience in rendering
effective nursing care.
Maintain confidentiality regarding the clients

PATIENTS
INFORMATION

16

Clients Name: D.D

Age: 23 years old
Height: 177 cm ( 5 ft and 8 inches)
Weight: 187 lbs (85 kg)
Sex: Male
Civil Status: Single
Religion: Catholic
Nationality: Filipino
Birth Date: April 3, 1993
Birthplace: Bacolod City
Current Address: Prk. Kainain 1 Brgy. Pta
taytay Bacolod City

17

Educational Attainment: Graduated BS

Computer Science at CHMSC
Present Occupation: Call Center agent at
Teleperformance
Date and Time of Admission: July 17, 2016
4:56 pm
Accompanied by: Clients mother
Attending physician: Dr. C.
Medical Diagnosis: Bleeding external
hemorrhoids
Drug and Food Allergy: Sea foods
Sources of Information: Patient, Patients chart

18

Health Status upon Admission

Manner of admission: Ambulatory
Level of consciousness: Not noted/assessed
Mood upon admission: Not noted/assessed
Vital Signs upon admission:
Temperature: 36.2 C
HR: 98 bpm
RR: 20 cpm
BP: 130/80 mmHg

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HISTORY OF PRESENT
ILLNESS
According to the patient, he experienced pain in his
anal area after defecating 1 year ago. He noticed that
every time he defecates there is always a present of
blood in his stool. He also noticed that there is a
painful lump near his anus that becomes itchy every
after he defecates. He didnt take any medications
and didnt seek for any consultation at that time. Last
Saturday, July 16, 2016, he experienced constipation
and force himself to defecate. He defecated watery
stool and according to him, the pain near his anus
worsened after. According to the patient, 1 day before
he was admitted, he noticed that the symptoms are on

20

PAST MEDICAL
HISTORY
According to the client, he was hospitalized at the
age of 14 due to urinary tract infection and he was
given medications in the hospital. He was admitted
for 1 day and was discharged after.

21

PAST SURGICAL
HISTORY
The patient didnt undergo any surgery
before.

22

PSYCHOSOCIAL
HISTORY
According to the client, he doesnt engage in
any vices, because he believes that it will only
harm his health. He spends most of his time
with his girlfriend, family and work. He has a
good relationship with his family and opens up
with them whenever he has problems.

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OCCUPATIONAL
HISTORY
The client is currently working as a call
center agent at Teleperformance for 3 years.
His shift starts at 7 am to 4pm (SaturdayWednesday) with a two 15 minute-break and
1 hour lunch time.

24

FAMILY HISTORY
According to the client, both of his parents
has hypertension. He stated that there are no
other diseases that run in the family like DM
or Cancer. He also mentioned that there was
no history of hemorrhoids in their family.

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PREDISPOSING AND PRECIPITATING FACTORS

Males are more prone to develop hemorrhoids than
females. The client is fond of eating spicy foods
and he doesnt eat fruits and vegetables because
he prefers eating meats. The client is a call center
agent and has a shift of 9 hours with two 15
minutes break in between and 1 hour lunch time.

GENERAL SURVEY

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Gordons
Functional
Assessment
Tool

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Health perception-Health management

The client is aware of the possible
consequences he might encounter if he
considers to practice unhealthy lifestyle and
include unhealthy foods in his daily diet. He is
not fond of eating fruits and vegetables.
According to him, he loves eating meats and
spicy foods. He verbalized that he doesnt care
about what would happen regarding his health
as long as he is satisfied of what he eats.
According to the client, he usually self-

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Nutritional- Metabolic Pattern

The client is not fond of eating vegetables and
fruits. He prefers eating spicy foods. He mostly
eats bicol express and he is also fond of eating
junkfoods that are spicy such as oishi. He could
consume 2-3 cups of rice per day. He also drinks
soda and coffee. According to him, he usually
consumes 1-2 cups of coffee per shift in his
work. However, he drinks plenty of water
approximately 2-3 liters everyday.

Elimination Pattern
30

He urinates 5-6 times a day approximately

240 mL each voiding episode and defecates
2x a day usually in the morning and evening.
Activity- Exercise Pattern
The client is a call center agent. He usually
spends his 9 hour-shift sitting at his desk with
two 15mins break in between. According to him,
he doesnt engage in any sports activities and
exercises. He prefers to stay at home after his

31

Sleep- Rest Pattern

He usually sleeps around 8-9 PM and wakes up
at 5 AM since he has a shift of 7AM - 4PM.
Cognitive- Perceptual Pattern
There were no signs of any hearing problems as
we talked spontaneously. There was a good
exchange of ideas in the conversation. He
actively responds to different questions asked
to him during the assessment and answers

32

Self- Perception- Self- Control Pattern

The patient has self-control and he knows what
hes doing. He verbalized that there were times
that he could shout towards his mother
unintentionally when he becomes irritated but
regrets and apologize right after. Hes an open
type of person and he seeks advise from his
parents and girlfriend whenever he has
problems.

33

Role Relationship Pattern

Client D.D. is the only child and is currently
staying with his parents. He has a good
relationship with his parents. Also, he provides
financial support to their family.
He has a girlfriend and they are currently in
their 7th year of being in a relationship.

34

Sexual- Reproductive Pattern

The patient doesnt engage in any sexual
activities because according to him, he has
great respect for his girlfriend.
Coping Stress- Tolerance Pattern
According to the client, he manages to
overcome stress through watching movies and
sleeping.

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Value Belief Pattern

The client is a Roman Catholic. According to
him, he attends church meeting when he have
enough time. He reads bible and prays
everyday. He doesnt believe in quack doctor or
any form of traditional healing.

36

Growth and Development Pattern

The client is in the Intimacy vs. Isolation
stage of Erik Eriksons Theory of Psychosocial
Stages. According to the information we
obtained, the client fits into the description in
the normal findings. The client found the love
and companionship in his girlfriend and friends.
They built and developed a good relationship
between each other that made him more
satisfied with his life as a young adult.

CEPHALOCAUD
AL APPROACH

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SYSTEMS
APPROACH

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Doctors Orders

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Time
July 17,2016
7:40 pm

Doctors Order
Diet:
NPO Post midnight

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Medication:
Metoclopromide (Plasil) 10g IVTT

IV Fluids:
PNSS @ 120 cc/hr
Laboratory Test:
SGPT(Serum Glutamic-Pyruvic
Transamirase),

Protime(Prothrombin Time test)

Significance
-To reduce the chances of
elimination during the surgery.

-To facilitate small bowel

intubation
-To reduce nausea and vomiting

-To incorporate other IVTT

medications
-To check for the medical
treatments that may affect the
liver
-To measure how long it takes the
blood to clot

July 18,2016

Medication:

6 am

Faktu suppositories
1 suppositories per rectum

- To stop itching, bleeding,

burning accompanying
hemorrhoids

8:10 am

Cefoxitin (Alfoxin)
1 gm IVTT Q8H

-For infection in genitourinary and

soft tissue

8:15 am

Celecoxib (Celenex)
400mg / 1 cap P.O. once a day
for 4 days

-For acute pain

Paracetamol (Naplex)
600mg IVTT Q6H x 24 hrs

-For pain

Norgesic forte
1 tablet P.O. TID x 3 days

-To relieve pain and discomfort

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42

IV Fluids:
D5LR @ 120 cc/hr

For maintenance of body fluids

and nutrition and for rehydration

Procedure:
Monitor vital signs every 15
minutes until stable,
Continue post op care

To monitor the patients health

status

43

July 19, 2016

Faktu ointment @ operation

site every after bowel
movement

-To stop itching, bleeding,

burning accompanying
hemorrhoids

Hot sitz bath for 20 minutes

- For pain relief and cleanses

the perineum

Laboratory
Results

44

45

Date
July 17,2016
7:24 pm

Examination
WBC Count

Result
12.1

Reference
Significance
5.00-10.00 x 10^ Increase in
9/L
number of WBC
indicates an
infection

Monocytes

2.00-6%

A high
monocyte count
might be a sign of
a chronic infection

Eosinophil

15

1.00-4%

Rise in the
number of
eosinophil
indicates infection

PATHOPHYSIOL
OGY

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PROBLEM LIST

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NURSING CARE
PLAN

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GENERAL OBJECTIVE

To recognize the physiologic responses of the body to

disease conditionspathologic, physiologic, and
compensatory

50

SUBJECTIVE CUES
Gasakit pa ang akon buli.
as verbalized by
the client

51

OBJECTIVE CUES
Pain scale of 7/10 noted
Anxiety noted
Vital signs are as follows:
Temperature: 36.8C
Pulse Rate: 65 bpm
Respiratory rate: 18 cpm
Blood Pressure: 140/100

OTHERS

52

Date

Examination

Result

Reference

July 17,2016
7:24 pm

WBC Count

12.1

5.00-10.00 x 10^
9/L

Monocytes

2.00-6%

Eosinophil

15

1.00-4%

Lymphocytes

23

25.00-40.00%

NURSING DIAGNOSIS

RATIONALE

Alteration in comfort:
53
Pain related to post
operation wound
secondary to External
Hemorrhoids

Hemorrhoids are vascular structure that

helps in controlling stool in the anal canal.
They became pathological when theres
inflammation also known as piles which are
often painful, swelling and irritating.
Almoranas is another word for hemorrhoids
that comes from the tagalong dialect spoken
by many people here in the Philippines.
External hemorrhoid can be seen easily
under the skin at the opening of anal cavity.
This type of hemorrhoid is extremely painful.
Hemorrhoidectomy is a surgical procedure
that is performed to remove hemorrhoids. As
the surgical site is very sensitive area,
hemorrhoid surgery causes a lot of pain.

SPECIFIC OBJECTIVES
After 16 hours of rendering
effective nursing care the client
will be able to:

Demonstrate use of
relaxation skills and other
methods to promote
comfort and alleviate pain
Reduce pain level

NURSING INTERVENTIONS
Independent:
54
Investigate pain reports, noting location, duration,
intensity (0-10 scale), and characteristics (dull, sharp,
constant).

RATIONALE

Changes in location or intensity are not uncommon but

may reflect developing complications.

Assess vital signs for changes from baselines

Vital signs are usually increased as result of autonomic

response to pain

Provide restful, quiet environment

Reduces stimuli that may increase pain

Instruct patient or SO in deep breathing, relaxation

techniques, guided imagery, massage and other
non-pharmacologic aids.

Helps patient to focus less on pain, and may improve

efficacy of analgesics by decreasing muscle tension.

NURSING INTERVENTIONS

RATIONALE

Collaborative:
55

Administered analgesic as indicated.

To aid in relief of pain

Celecoxib (Celebrex)
400mg / 1 cap P.O.

Celecoxib works by reducing hormones that cause

inflammation and pain in the body

Warm water helps soothe and relax the anal sphincter,

which helps lessen any pressure, while also reducing
any itching sensations..

Performed hot sitz bath as ordered.

EVALUATION

After
7 hours of rendering effective nursing interventions, the patient was able to:
56
Demonstrate use of relaxation skills, other methods to promote comfort such as deep
breathing exercise
Verbalized pain scale of 5/10
Goal is fully met.

DISCHARGE
PLAN

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EVALUATION

58

59

In our 2 days of exposure at The Doctors Hospital,

Incorporated, we have encountered different clients every
day. Patients coming from different places, both men and
women in different ages and with different complains. We
chose this for our case presentation because it is our first
time to assist in this particular case which is Hemorrhoids.
As student nurses, we are expected to learn not only inside
the classroom but in our experiences in the clinical area as
well. Learning doesnt end in the four corners of our
classroom. We chose this case for us to extend and improve
our knowledge and understanding with regards to the
causes, effects, complications, signs and symptoms, and
nursing implications for haemorrhoids.

60

As student nurses and as a group, we have experience

so much stress throughout our nursing life. But this wasnt a
hindrance to be an inspiration to the different people we
encounter everyday in our exposures. We believe that we
are grouped together for a reason and that is to come out
from our different shells and speak out our minds and
hearts to be considered as responsible student nurses. We
have also learned that sometimes, one brain is not enough
to suffice the needs of the group. We are leaders in our own
different ways. If we continue to help each other and to
work as one group, for sure we will be able to accomplish
our objectives throughout our different exposures.

THANK YOU!

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