Week 12: Chp 58: Hemorrhoids

Question 1

What is a hemorrhoid?

Answer 1

swollen or dilated veins in the anorectal area

-they are varicose veins of the rectum

Question 2

What are hemorrhoids caused by?

Answer 2

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

Question 3

Internal Hemorrhoid

Answer 3

lying above the dentate line

-cannot be seen on visual inspection

Question 4

External Hemorrhoid

Answer 4

lying below the dentate line

Question 5

What can happen to a hemorrhoid?

Answer 5

can become prolapsed or protrude through the anal canal

-may become thrombosed or clotted

Question 6

Strangulated hemorrhoid

Answer 6

is trapped by the anal sphincter, compromising blood flow to the vein in the hemorrhoid

Question 7

Grading System for Internal Hemorrhoids

Answer 7

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

Question 8

Clinical Manifestations of Internal hemorrhoids

Answer 8

bleeding is almost always painless and is observed as bleeding during bowel movement

Question 9

Clinical Manifestations of External Hemorrhoids

Answer 9

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

Question 10

How are external hemorrhoids diagnosed?

Answer 10

visual inspection

Question 11

How are internal hemorrhoids diagnosed?

Answer 11

digital examination, anoscopy (procedure involving a small, tubular instrument inserted into the anal canal for inspection), and sigmoidoscopy

Question 12

Treatment of hemorrhoids

Answer 12

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

Question 13

What happens if conservative therapy does not alleviate symptoms within 3 to 5 days?

Answer 13

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

Question 14

Medications used for Treatment of Hemorrhoids

Answer 14

• Local Anesthetics
• Protectants/ Emollients
• Astringents
• Corticosteroids

Question 15

Local Anesthetics

Answer 15

provide temporary relief from burning, itching, and pain

-Benzocaine, dibucaine, lidocaine

Question 16

Protectants/ Emollients

Answer 16

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

Question 17

Astringents

Answer 17

promote skin dryness, which helps relieve itching, irritation, and inflammation
-calamine, zinc oxide, witch hazel

Question 18

Corticosteroids

Answer 18

reduce inflammation

-hydrocortisone

Question 19

Surgical Management

Answer 19

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

Question 20

Rubber-band Ligation

Answer 20

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

Question 21

Bipolar, infrared, and laser coagulation

Answer 21

uses bipolar current or infrared or laser light, which causes coagulation and necrosis of the hemorrhoid, leaving fibrosis in the submucosal layer

Question 22

Sclerotherapy

Answer 22

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

Question 23

Cryosurgery

Answer 23

used liquid nitrogen to freeze the hemorrhoid

-procedure usually associated with intense pain and is not first method of choice

Question 24

Hemorrhoidectomy

Answer 24

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

Question 25

Complications following surgery for hemorrhoids

Answer 25

infection, pain, urinary retention, fecal impaction, damage to the sphincter, bleeding, and abscess formation, which involves a localized collection of pus

Question 26

Complications: Fecal impaction and why does it occur?

Answer 26

as a result of inadequate pain management, with the person being afraid to have a bowel movement or as a result of opiate usage

Question 27

Complications: urinary retention

Answer 27

occurs because of rectal spasms and pain

Question 28

Nursing Management: Assessment and Analysis

Answer 28

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

Question 29

Nursing Diagnoses

Answer 29

- 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

Question 30

Nursing Assessments

Answer 30

- vital signs - visual inspection of rectal area - frequency and character of bowel movements - bowel habits postoperatively compared with preoperative pattern - pain - intake and output

Question 31

Assessments: Vital Signs

Answer 31

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

Question 32

Assessment: Visual inspection of rectal area

Answer 32

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

Question 33

Assessment: Frequency and character of bowel movements

Answer 33

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

Question 34

Assessment: bowel habits postoperatively compared with preoperative pattern

Answer 34

if the patient becomes constipated after surgery, this can lead to increased pain with each subsequent bowel movement

Question 35

Assessment: Pain

Answer 35

pain results secondary to the surgical procedure, and associated inflammation -adequate pain management allows the patient to resume normal activities sooner

Question 36

Assessment: Intake and Output

Answer 36

urinary retention may occur because of rectal spasms and pain

Question 37

Nursing Actions

Answer 37

- administer pain medications - provide cold packs and sitz baths - administer laxatives - apply local moist heat

Question 38

Nursing Actions: Administer Pain Medications

Answer 38

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

Question 39

Nursing Actions: Provide cold packs and sitz baths

Answer 39

these interventions are used to reduce swelling and pain

Question 40

Nursing Actions: administer laxatives

Answer 40

``` 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 ```

Question 41

Nursing Actions: apply local moist heat

Answer 41

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

Question 42

Teaching

Answer 42

- 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

Question 43

Teaching: Care of surgical site

Answer 43

area should be washed gently and patted dry to keep the surgical area free from contaminants that may cause infection

Question 44

Teaching: measures to prevent constipation

Answer 44

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

Question 45

Teaching: Avoid stimulant laxatives

Answer 45

they are irritating and habit-forming

Question 46

Teaching: non-pharmacological methods of reducing pain

Answer 46

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