Week 12: Chp 58: Hemorrhoids Flashcards
What is a hemorrhoid?
swollen or dilated veins in the anorectal area
-they are varicose veins of the rectum
What are hemorrhoids caused by?
caused or precipitated by straining during defecation, prolonged constipation, heavy lifting, prolonged standing and sitting, portal hypertension (as in cirrhosis), increased intra-abdominal pressure, pregnancy, obesity, and heart failure
-most frequently reported by women
Internal Hemorrhoid
lying above the dentate line
-cannot be seen on visual inspection
External Hemorrhoid
lying below the dentate line
What can happen to a hemorrhoid?
can become prolapsed or protrude through the anal canal
-may become thrombosed or clotted
Strangulated hemorrhoid
is trapped by the anal sphincter, compromising blood flow to the vein in the hemorrhoid
Grading System for Internal Hemorrhoids
used according to severity of prolapse and serves as a guide for treatment
- Grade I: the hemorrhoids do not prolapse
- Grade II: the hemorrhoids prolapse on defecation but reduce spontaneously
- Grade III: the hemorrhoids prolapse on defecation and must be reduced manually
- Grade IV: the hemorrhoids are prolapsed and cannot be reduced manually
Clinical Manifestations of Internal hemorrhoids
bleeding is almost always painless and is observed as bleeding during bowel movement
Clinical Manifestations of External Hemorrhoids
itching, irritation, and pain of the rectal area
- pain and pruritus of the rectal area
- bleeding may occur and is usually seen on toilet paper but may also be streaked in the stool
How are external hemorrhoids diagnosed?
visual inspection
How are internal hemorrhoids diagnosed?
digital examination, anoscopy (procedure involving a small, tubular instrument inserted into the anal canal for inspection), and sigmoidoscopy
Treatment of hemorrhoids
usually conservative and involves relief of symptoms and associated pain
-cold packs and sitz baths (warm water baths covering the hips and buttocks) three or four times a day to reduce some swelling and decrease pain
What happens if conservative therapy does not alleviate symptoms within 3 to 5 days?
patient needs to be referred to a primary care provider
- patient is encouraged to consume adequate fluid and fiber intake to decrease constipation associated with hemorrhoids
- stool softeners also recommended
- topical nitroglycerin (0.4%) may be used to decrease pain caused by thrombosed hemorrhoids as well as topical nifedipine
- over-the-counter preparations available in creams and suppositories
Medications used for Treatment of Hemorrhoids
- Local Anesthetics
- Protectants/ Emollients
- Astringents
- Corticosteroids
Local Anesthetics
provide temporary relief from burning, itching, and pain
-Benzocaine, dibucaine, lidocaine
Protectants/ Emollients
form physical barrier on the skin to prevent irritation of the perianal region
-cocoa butter, lanolin, white petroleum, zinc oxide, mineral oil, cod liver oil, or shark liver oil
Astringents
promote skin dryness, which helps relieve itching, irritation, and inflammation
-calamine, zinc oxide, witch hazel
Corticosteroids
reduce inflammation
-hydrocortisone
Surgical Management
not required unless the hemorrhoid is thrombosed
-patients with grade III or IV may require definitive treatment with surgery
>rubber-band ligation
>bipolar, infrared, and laser coagulation
>sclerotherapy
>cryosurgery
>hemorrhoidectomy
Rubber-band Ligation
most widely used technique
- hemorrhoid is identified using an anoscope
- a rubber band is placed around the base of the hemorrhoid, which constricts circulation, causing the hemorrhoid to slough off in 2 to 4 days
Bipolar, infrared, and laser coagulation
uses bipolar current or infrared or laser light, which causes coagulation and necrosis of the hemorrhoid, leaving fibrosis in the submucosal layer
Sclerotherapy
involves injecting a sclerosing agent (an agent that causes formation of scar tissue) directly into the hemorrhoid, which causes an inflammatory reaction leading to the vessel drying up and disintegrating
Cryosurgery
used liquid nitrogen to freeze the hemorrhoid
-procedure usually associated with intense pain and is not first method of choice
Hemorrhoidectomy
excision of the vein
- the area may be left open to heal by secondary intention, or may be closed with sutures
- closing the area with sutures is less painful for the patient but has a higher risk of infection
Complications following surgery for hemorrhoids
infection, pain, urinary retention, fecal impaction, damage to the sphincter, bleeding, and abscess formation, which involves a localized collection of pus
Complications: Fecal impaction and why does it occur?
as a result of inadequate pain management, with the person being afraid to have a bowel movement or as a result of opiate usage
Complications: urinary retention
occurs because of rectal spasms and pain
Nursing Management: Assessment and Analysis
clinical manifestations of hemorrhoids include rectal pain, and itching that may be accompanied by bleeding
-the management is based on severity of clinical manifestations, location, and response to conservative therapy
Nursing Diagnoses
- acute pain r/t inflammation in the rectal area
- knowledge deficit r/t the care of hemorrhoids and/or postoperative care
- risk for altered bowel elimination: constipation r/t fear of pain with bowel movements
Nursing Assessments
- vital signs
- visual inspection of rectal area
- frequency and character of bowel movements
- bowel habits postoperatively compared with preoperative pattern
- pain
- intake and output
Assessments: Vital Signs
a fever may be indicative of an infection and should be reported to the healthcare provider
-an increased heart rate and/ or respirations may be indicative of pain
Assessment: Visual inspection of rectal area
the rectal area may appear reddened secondary to itching
- postoperatively, it may appear swollen from manipulation during surgery
- there should not be significant drainage or bleeding
Assessment: Frequency and character of bowel movements
the patient often tries to avoid having a bowel movement due to painful defecation, particularly after surgery because of the increased pain associated with bowel movements
-this can lead to constipation and should be avoided because this will further increase pain and perhaps bleeding of the surgical site
Assessment: bowel habits postoperatively compared with preoperative pattern
if the patient becomes constipated after surgery, this can lead to increased pain with each subsequent bowel movement
Assessment: Pain
pain results secondary to the surgical procedure, and associated inflammation
-adequate pain management allows the patient to resume normal activities sooner
Assessment: Intake and Output
urinary retention may occur because of rectal spasms and pain
Nursing Actions
- administer pain medications
- provide cold packs and sitz baths
- administer laxatives
- apply local moist heat
Nursing Actions: Administer Pain Medications
the first bowel movement after surgery may be painful, and the patient needs to take an analgesic prior; fainting has occurred during bowel movements early after surgery because of the intensity of the pain along with vagal stimulation
>Local anesthetics: provide temporary relief from burning, itching, and pain
>Astringents: promote skin dryness, which helps relieve itching, irritation, and inflammation
>Corticosteroids: reduce inflammation
>Protectants/ Emollients: form a physical barrier on the skin to prevent irritation of the perianal region
Nursing Actions: Provide cold packs and sitz baths
these interventions are used to reduce swelling and pain
Nursing Actions: administer laxatives
bulk laxatives (hydrophilic psyllium) require the use of increased fluids, or they can result in constipation -if the patient has not had a bowel movement within 3 days after surgery, a mild laxative may be ordered
Nursing Actions: apply local moist heat
local moist heat can be used to provide comfort but should be avoided in the immediate postoperative period because of an increased risk of bleeding
Teaching
- care of surgical site
- measures to prevent constipation
- avoid straining to have a bowel movement and avoid sitting for long periods of time
- avoid stimulant laxatives
- nonpharmacological methods of reducing pain
- contact healthcare provider if unable to urinate
Teaching: Care of surgical site
area should be washed gently and patted dry to keep the surgical area free from contaminants that may cause infection
Teaching: measures to prevent constipation
include good sources of fiber; include whole grain and raw vegetables and fruits
- regular bowel habits are important for the patient in the postoperative period for avoiding constipation
- increasing fluids and fiber in their diet helps prevent constipation
- over-the-counter stool softeners such as docusate sodium may also be used
- the use of narcotic analgesics may increase the chances of developing constipation
Teaching: Avoid stimulant laxatives
they are irritating and habit-forming
Teaching: non-pharmacological methods of reducing pain
cold packs and sitz baths alleviate some pain associated with hemorrhoids
-the use of sitz baths can be used for cleansing as well as having a soothing effect, and they can be used three of four times a day
