Hemorrhoids are a common, generally insignificant swelling and distension of veins in the anorectal region. They become significant when they bleed or cause pain or itching. In the United States, at least 10 million people have hemorrhoids, and up to a third of these people seek treatment. Hemorrhoids are categorized as either internal or external. Internal hemorrhoids, produced by dilation and enlargement of the superior plexus, cannot be seen because they are above the anal sphincter, whereas external hemorrhoids, produced by dilation and enlargement of the inferior plexus, are below the anal sphincter and are apparent on inspection. Hemorrhoids develop when increased intra-abdominal pressure produces increased systemic and portal venous pressure, thus causing increased pressure in the anorectal veins. The arterioles in the anorectal area send blood directly to the swollen anorectal veins, further increasing the pressure. Recurrent and repeated increased pressure causes the distended veins to separate from the surrounding smooth muscle and leads to their prolapse (enlarged internal hemorrhoids that actually protrude through the anus).
Some factors that are associated with hemorrhoids are occupations that require prolonged sitting or standing; heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitis. Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids.
Nursing care plan assessment and physical examination
Establish a history of anal itching, blood on the toilet tissue after a bowel movement, and anorectal pain or discomfort. Ask if the patient has experienced any mucous discharge. Determine if the patient can feel the external hemorrhoids. Elicit a history of risk factors and dietary patterns. Inspect the patient’s anorectal area, noting external hemorrhoids. Internal hemorrhoids are discovered through digital rectal examination or anoscopy. Note any subcutaneous large, firm lumps in the anal area.
Nursing care plan primary nursing diagnosis: Pain (acute or chronic) related to rectal swelling and prolapse.
Nursing care plan intervention and treatment plan
Generally, hemorrhoids can be managed pharmacologically. Conservative treatments include application of cold packs to the anal region, sitz baths for 15 minutes twice a day, and local application of over-the-counter treatments such as witch hazel (Tucks) or dibucaine (Nupercainal) ointment. If conservative treatment does not alleviate symptoms in 3 to 5 days, more invasive management may be needed.
Invasive treatment may be indicated for thrombosis or severe symptoms. Sclerotherapy obliterates the vessels when the physician injects a sclerosing agent into the tissues around the hemorrhoids. With elastic band ligation, rubber bands are put on the hemorrhoids in an outpatient setting. The banded tissue sloughs. Successive visits may be necessary for many hemorrhoids. Although rubber band ligation has a high success rate, it may temporarily increase local pain and cause hemorrhage. In cryosurgery, the physician freezes the hemorrhoid with a probe to produce necrosis. Cryosurgery is used only for first- and second-degree hemorrhoids.
The most effective treatment is hemorrhoidectomy, the surgical removal of hemorrhoids, which is performed in an outpatient setting in 10% of patients. When the patient can resume oral feedings, administer a bulk medication such as psyllium. This medication is given about 1 hour after the evening meal to ensure a daily stool, which dilates the scar tissue and prevents anal stricture from developing. Postoperative care includes checking the dressing for excessive bleeding or drainage. The patient needs to void within the first 24 hours. If prescribed, spread petroleum jelly on the wound site and apply a wet dressing. Complications include urinary retention and hemorrhage. The newest surgical technique for treating hemorrhoids is stapled hemorrhoidectomy. The surgery does not actually remove hemorrhoids but rather the supporting tissue that causes hemorrhoids to prolapse downward.
Most patients can be treated on an outpatient basis. Teach patients and families about over-thecounter local applications for comfort. Explain the importance of promoting regular bowel habits. Emphasize the need for increasing dietary fiber and fluid through a balanced diet high in whole grains, raw vegetables, and fresh fruit. Moderate exercise such as walking can also help regulate bowel function. Postoperative actions include administering ice packs for pain control and positioning the patient for comfort. After the first 12-hour postoperative period, sitz baths three or four times a day may be instituted to prevent rectoanal spasms and reduce swelling. Explain that the first postoperative bowel movement is painful and may require suitable narcotic intervention for comfort.
Nursing care plan discharge and home health care guidelines
Teach the patient the importance of a high-fiber diet, increased fluid intake, mild exercise, and regular bowel movements. Be sure the patient schedules a follow-up visit to the physician. Teach the patient which analgesic applications for local pain may be used. If the patient has had surgery, teach her or him to recognize signs of urinary retention, such as bladder distension and
hemorrhage, and to contact the physician at their appearance.