Nursing Management of Anorectal disease

• Reassure the patient.
• Relieving constipation.
• Reducing anxiety.
• Relieving pain.
• Promoting urinary elimination.
• Monitoring and managing complications.
• Promoting home and community based care teaching patients
• Self care

Relieving Constipations:

• Encourages intakes of at least 2 liters of water daily to provide adequate hydration.
• Encourage high fiber foods to promote bulk in the stool and to make ti easier to pass fecal matter through the rectum.
• Bulk laxative such as meta mucilage and stool softeners are administered.
• The patient is advised to set aside a time for moving the bowel and to need the urge to defecate as promptly as possible.
• Relaxation exercise before defecating to relax the abdominal and perineal muscles which may be constricted or in spasm.
• Analgesic before a bowel movement is beneficial.

Reducing Anxiety:

• Reassure the patient.
• Patients privacy should be maintained.
• Soiled dressings are removed from the room promptly to prevent unpleasant odors; room deodorizer may be needed if dressings are foul smelling.
• Identify the social needs, psychological needs and care according to them.

Relieving Pain:

• Patients are encouraged to assume a comfortable position.
• Floating pad is put under the buttocks when sitting which help to decrease the pain, as may ice and analgesics ointments.
• Warm compress is given which promote circulation can relieve soreness and pain by relaxing sphincter spasm.
• 24 hrs after surgery, topical anesthetic agents is used which may be very beneficial in relieving local irritations and soreness.
• Topical Anesthetics (i.e. suppositories) astringents, antiseptics, tranquilizers and anti emetics are used as prescribed.
• To relieve o edema - wet dressing saturated with equal parts of cold water and witch hazel is used (when wet compress are used continuously, the petrolatum is applied around the anal area to prevent skin execration.
• Patient is instructed to assume a prone position at intervals because this position promotes dependent drainage of o edematous fluid.

Anorectal Abscess

Definition:
It an abscess (a large packet of infection) adjacent to the anus. It is often known as anal abscess, renal abscess, peri-rectal abscess and perianal abscess. The condition in variably becomes extremly painful and usually worsens over the course of just a few days. Pain may be limited and sporadic at last but invariably worsen to a constant pain which can become very severe when body position is changed (i.e. standing up rolling over and so forts).

Anorectal Abscess is caused by obstruction of an anal gland resulting in retrograde infection.

Cause:

• caused by high density of infection
• common bacteria
• staphylococcus
• methicillin resistant staphylococcus aureus

|| Note:: Bacteria which collect in one place or another for any variety of reason. Anal abscesses which out Rx, are likely to spread and affect other parts of body, particularly the groin and rectal lumen. All abscesses can progress to serous generalized infections requiring lengthy hospitalization if not treated.||

Clinical Features:

• swelling, redness, tenderness (if superficial)
• pain --> initial limited and sporadic, later-severe pain, excoriating pain during bowel movement.
• fever
• night time chills.
• bleeding
• diarrhea, mucopurulent discharge, foul smelling pus
• crampy abdominal pain
• visual inspection - haemorrhoids on touch

Diagnosis

• History taking
• Physical examination
• P/R examination --> Abscess feel
• Sigmoidoscopy --> identify portions of anorectal
• Rectal swab for c/s text - identify the pathogens

Management

• Medical Management
• Surgical Management
• Nursing Management

Medical Management:

• sitz bath
• analgesic
• antibiotics

|| Note: Anal abscess unfortunately, cannot be treated by a simple course of antibiotics or other medications. Even small abscess will need the attention of a surgeon immediately.||

Surgery:

• Deep incision and drainage performed (to the root of the abscess)
• Allow the abscess to drain its exudate.
• Exudate sent for microbiological analysis to determine the type of infection.
• Incision not closed, as the damaged tissue must heat from the inside towards the skin over a period of time. The wound may be packed with gauze and allowed to heat by granulation.
  

Definitive Rx (several options are there, they are)

• doing nothing
• conversion to a cutting Seton
  
• lay-open of fishila -in - ano
• fibrin flue infection
• fishila plug
• endorectal advancement flap.
• anal fistula plug

Doing nothing
A drainage section can be left in place long term to prevent problems. Safest option although it does not definitely cure the fistula.

Conversion to a cutting Seton
This involves a similar process to a draining seton but the suture is tied tightly. This gradually cuts through the muscle and skin involved, leaving behind a small area of scarring. This cures the fistula but leaves behind a scar and cause problems with incontinence. This option is not suitable for complex fistulae, or those that cross the entire anal sphincter.

Lay open of fistula - in - ano;
This option involves an operation to cut the fistula open and let it heal naturally. This cause the fistula but leaves behind a scar, and cause problems with incontinence. This option is not suitable for complex fistulae or those that cross the entire anal sphincter.

Fibrin glue infection:
Fibrin glue infection is a method explored in recent years with variable success. It involves injecting the fistula with a biodegradable give which should in theory, close the fistula from the inside out and let out heal naturally. It avoids the risk of incontinence and creates minimal stress for the patient.

Fistula Plug:
Fistula plug is an "advanced" version of the fibrin glue method. It involves "plugging" the fistula with a plug made of porcine small intestine sub mucosa (sterile biodegradable) fixing the plug from inside of the anus with suture, and again letting the fistula heal "naturally" from the inside out. According to some sources, the success rate with this method is an high as 80%.

Endorectal advancement flap:
Endorectal advancement flap is the procedure in which the internal opening of fistula is identified and flat of mucosal tissue is cut around the opening.

Anal Fistula

Anal Fistula is a tiny, tubular, fibrous that extends into the anal canal from an opening located beside the anus or it is an abnormal connection between the epithelialized surface of the anal canal and perianal skin.

Or,

It is an opening at or near the anus usually into the rectum above the internal sphincter.

Causes:

• Infection.
• Develop from traumas fissures or regional enteritis.

Note: Originate from the anal glands which are located between tow layers of the anal sphincter and which drains into the anal canal. It the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this is the fistula.

Clinical Features:

• Pus or stool my leak constantly from the cutaneous opening.
• Passage of flatus, faeces from the vagina and bladder.
• Pain
• Discharge either bloody.
• Puritis-ani itching
• Systemic symptoms if abscess become infected.

Diagnosis:

• EUA (Examination under Anesthesia)
• Examination can be an anascopy findings
• Opening of the fistula into the skin may be seen.
• Area may be painful on examination.
• Redness
• Area of induarion may be felt-thickening due to chronic infection.
• A discharge may be seen.

Management:

1. Surgical Management
2. Nursing Management

Surgical Management:
Several stages to treating an anal fistulas,

• Treating Active infection before surgery. Antibiotic can be used with other infections, but the best way of healing infection is to prevent the build up of pus in the fistula which lead to abscess formation can be done with a seton a length of refuse material loop through the fistula which keeps it open and allows pus to drain out.

Anal Fissure

Anal Fissure is a longitudinal or ulceration in the lining of the anal canal or is a crack like sore in the anal region. The tear usually extends from the anal opening and located posteriorly in the mid-line.

Causes:
Most anal fissures are caused by stretching of the anal mucosa beyond its capability various causes are,

• Trauma of passing a large firm stool.
• Tightening of the anal canal because of stress and anxiety.
• Severe and chronic constipation
• Severe and chronic diarrhea.
• Crohn's disease and ulcerative colitis.
• Tight sphincter muscle.
• Anal Intercourse.
• Child birth.
• Trauma
• Overuse of laxatives.

Clinical Features:

• Pain during and even hours after defecation.
• Burning, possibly painful itching.
• Visible tear in the anus.
• Constipation.
• Bleeding; Blood on the stool or on toilet paper.
• A tearing sensation during daofication.

Management:

1. Medical management
2. Surgical management

Conservative / Medical Management:
For many years up until 1995, customary Rx includes:

• warm baths
• sitz baths
• Topical anesthetics
• Stool bulking agents
• Mechanical anal stretching
• Emollient suppositories
• Increase in water intake.
• A suppository combining an anesthetic with a corticosteroid helps to relieve the discomfort. Anal diation under anesthesia may be required.

Surgical Management:
Lateral internal sphincterotomy with excision of the fissure, the success rate is 90%-95%.
Potential complication after surgery.

• infection
• anal leakage.

Prevention:
In infants under 1 year, frequent diapper change can prevent anal fissure. For adults, the following can prevent fissure:

• Treating constipation by eating food rich in dietary fibres, avoiding caeffin, drinking a lot of water and taking stool softener.
• Treating diarrhea promptly.
• Lubricating the anal canal with water based tube (petroleum jelly is not recommended because it can harbor harmful bacteria).
• Avoiding straining or prolonged sitting on the toilet.
• Using a moist, wipe instead of perfumed and harsh toilet paper.
• Keeping the anus dry and hygiene.
• When using anal parm (cream) don't use the dispenser which can injure the area. Instead use a finger to insert a pea size amount of cream.
• Carmex lip ointment also helps and is much expensive then analpam.