NURSING PROCESS:THE PATIENT WITH AN ANORECTAL CONDITION
The nurse takes a health history to determine the presence and characteristics of itching, burning, or pain. Does it occur during bowel movements? How long does it last? Is any abdominal pain associated with it? Does any bleeding occur from the rectum? How much? How frequently? Is it bright red? Is there any other discharge, such as mucus or pus? Other questions relate to elim-ination patterns and laxative use, diet history (including fiber in-take), the amount of exercise, activity levels, and occupation (especially one that involves prolonged sitting or standing). As-sessment also includes inspection of the stool for blood or mucus and the perianal area for hemorrhoids, fissures, irritation, or pus.
Based on the assessment data, the major nursing diagnoses may include the following:
• Constipation related to ignoring the urge to defecate be-cause of pain during elimination
• Anxiety related to impending surgery and embarrassment
• Acute pain related to irritation, pressure, and sensitivity in the anorectal area from anorectal disease and sphincter spasms after surgery
• Urinary retention related to postoperative reflex spasm and fear of pain
• Risk for ineffective therapeutic regimen management
The major goals for the patient may include adequate elimination patterns, reduction of anxiety, pain relief, promotion of urinary elimination, managing the therapeutic regimen, and absence of complications.
The nurse encourages intake of at least 2 L of water daily to pro-vide adequate hydration and recommends high-fiber foods to pro-mote bulk in the stool and to make it easier to pass fecal matter through the rectum. Bulk laxatives such as Metamucil and stool softeners are administered as prescribed. The patient is advised to set aside a time for moving the bowels and to heed the urge to defe-cate as promptly as possible. It may be helpful to have the patient perform relaxation exercises before defecating to relax the abdom-inal and perineal muscles, which may be constricted or in spasm. Administering an analgesic before a bowel movement is beneficial.
Patients facing rectal surgery may be upset and irritable because of discomfort, pain, and embarrassment. The nurse identifies spe-cific psychosocial needs and individualizes the plan of care. The nurse maintains the patient’s privacy while providing care and by limiting visitors, if the patient desires. Soiled dressings are re-moved from the room promptly to prevent unpleasant odors; room deodorizers may be needed if dressings are foul smelling.
During the first 24 hours after rectal surgery, painful spasms of the sphincter and perineal muscles may occur. Control of pain is a prime consideration. The patient is encouraged to assume a comfortable position. Flotation pads under the buttocks when sitting help to decrease the pain, as may ice and analgesic oint-ments. Warm compresses may promote circulation and soothe irritated tissues. Sitz baths taken three or four times each day can relieve soreness and pain by relaxing sphincter spasm. Twenty-four hours after surgery, topical anesthetic agents may be beneficial in relieving local irritation and soreness. Medications may include topical anesthetics (ie, suppositories), astringents, antiseptics, tran-quilizers, and antiemetics. Patients are more compliant and less apprehensive if they are free of pain.
Wet dressings saturated with equal parts of cold water and witch hazel help relieve edema. When wet compresses are being used continuously, the petrolatum is applied around the anal area to prevent skin maceration. The patient is instructed to assume a prone position at intervals because this position promotes depen-dent drainage of edematous fluid.
Voiding may be a problem after surgery because of a reflex spasm of the sphincter at the outlet of the bladder and a certain amount of muscle guarding from apprehension and pain. The nurse tries all methods to encourage voluntary voiding (ie, increasing fluid intake, listening to running water, and dripping water over the urinary meatus) before resorting to catheterization. After rectal surgery, urinary output is closely monitored.
The operative site is examined frequently for rectal bleeding. The nurse assesses the patient for systemic indicators of excessive bleeding (ie, tachycardia, hypotension, restlessness, and thirst). After hemorrhoidectomy, hemorrhage may occur from the veins that were cut. If a tube has been inserted through the sphincter after surgery, evidence of bleeding may be visible on the dressings. If bleeding is obvious, direct pressure is applied to the area, and the physician is notified. It is important to avoid using moist heat because it encourages vessel dilation and bleeding
Most patients with anorectal conditions are not hospitalized. Those who have surgical procedures to correct the condition often are discharged directly from the outpatient surgical center. If they are hospitalized, it is for a short time, usually only 24 hours. Patient teaching is essential to facilitate recovery at home.
The nurse instructs the patient to keep the perianal area as clean as possible by gently cleansing with warm water and then drying with absorbent cotton wipes. The patient avoids rubbing the area with toilet tissue. Instructions are provided about how to take a sitz bath and how to test the temperature of the water. Sitz baths may be given in the bathtub or plastic sitz bath unit three or four times each day. Sitz baths should follow each bowel move-ment for 1 to 2 weeks after surgery. The nurse encourages the patient to respond quickly to the urge to defecate to prevent constipation. The diet is modified to increase fluids and fiber. Moderate exercise is encouraged, and the patient is taught about the prescribed diet, the significance of proper eating habits and exercise, and the laxatives that can be taken safely.
Expected patient outcomes may include the following:
• Attains a normal pattern of elimination
a) Sets aside a time for defecation, usually after a meal or at bedtime
b) Responds to the urge to defecate and takes the time to sit on the toilet and try to defecate
c) Uses relaxation exercises as needed
d) Increases fluid intake to 2 L per day
e) Adds high-fiber foods to diet
f) Reports passage of soft, formed stools
g) Reports decreased abdominal discomfort
• Is less anxious
• Has less pain
a) Modifies body position and activities to minimize pain and discomfort
b) Applies warmth or cold to anorectal area
c) Takes sitz baths four times each day
• Voids without difficulty
• Adheres to the therapeutic regimen
a) Keeps perianal area dry
b) Eats bulk-forming foods
c) Has a soft, formed stool on a regular basis
• Exhibits no evidence of complications
a) Has a clean incision
b) Has normal vital signs
c) Shows no signs of hemorrhage
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