University of BaguioGeneral Luna Road

Baguio City

AClinical Paper

On

Perianal Abscess

Presented to Mrs. Christine DiazClinical Instructor

In Partial FulfillmentOf the Requirements for

NCM103

By:

Czarina Kaye D.R. VillarosaNMB-III

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TABLE OF CONTENTS

TITLE PAGE…………………………………………………………………………………….

TABLE OF CONTENTS………………………………………………………………………..

I. INTRODUCTION.....................................................................................................................1

II. PATIENT’S PROFILE………………………………………………………………………2

A. BIBLIOGRAPHICAL DATA………………………………………………………..2

B. HISTORY……….………………………………………………………………….....2

B.1. PAST MEDICAL HISTORY………………………………………………..2

B.2. PRESENT MEDICAL HISTORY…………………………………………...2

III. THIRTEEN (13) AREAS OF ASSESSMENT

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I. Patient’s Profile

A. Biographical Data

Mr. X is male patient admitted at Baguio General Hospital Medical Center surgery

ward.He was born on June 12,2005 in First Gate, Ucab, Itogon, Benguet. He was a Filipino

citizen. He belongs in Roman Catholic church. Both his parents has no occupation that’s why he

stayed in his grandparents. He was a pupil

B. Patient History

1. History of Present Illness

10 days percutaneous transluminal angioplasty , the patient was apparently well until he

was hit by motorcycle. The patient was brought to the nearby hospital. Operation was done and

he was sent home after 5 days of hospital stay. Until 2 days percutaneous transluminal

angioplasty the patient was noted to have pus and certain smell coming out on the affected

area, no consultation was done until they decided to bring the child in our institution, hence was

subsequently admitted skin avulsion on left foot.

2. Past Medical History

Prior to admission,the patient was asked to have complete blood count and urinalysis. He

also undergo in skin test. It was found out that he has no allergies to food and drug.

3. Family History

The patient’s family has no history of hypertension, diabetes mellitus, coronary artery

disease.

4. Social and Environmental History

The patient was not a smoker. He did not also drink alcohol beverages.

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III. 13 AREAS OF ASSESSMENT

I. Psychological status

Mr. Gatchilian is a driver.bread winner of the family. In the hospital, his daughter is staying

with him. No significant others went to the hospital to visit him. Harmonious relationship and

open communication was observed within the family. The patient and his daugther also

communicate effectively with healthcare personnel such as physicians, staff nurses and student

nurses.

II. Mental and Emotional Status

Before hospitalization, the patient mentioned that he is having a good relationship with his

family and friends.

During hospitalization, Mr. Gatchalian is irritable at times at the student nurse who endorsed

to me. During our shift he had been kind and willing to cooperate with the nursing interventions

that I do.

Mr. Gatchalian is conscious. He is aware on his time of meals,and his time of sleep. He was

attentive and able to answer some question being asked.

III. Environmetal Status

According to the Mr. Gatchalian, he is living in a semi concrete house having two rooms, one

bathroom,a living room and kitchen. The house is well ventilated. There is no hazard mentioned,

the house is located along the highway.

Patients room has adequate lighting and warm terperature. Theere were 15 beds in the room

including his bed. The room is cleaned and mapped every shift,reducing the production of

microorganism aiming to decrease possibilities of acquiring further nosocomial infections leading

to other illnesses. Furthermore, the bed is approximately 6 meters away from the nurse’s station

for faster intervention in case of emergency.

IV. Sensory Status

Mr. Gatchalian verbalized that he has no illnesses or disturbances in her senses. He has pink

conjuctiva and has normal vision,he could hear our voice efficiently.There is no lesion or

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abnormal discharges in his ears and nose. He can also distinguish different taste.Mr. Gatchalian

was able to differenciate warm from cold.

V. Motor status

Prior to admission, Mr. Gatchalian was efficiently attending to his work.During

hospitalization, Mr. Gatchalian needs minimal help of his activities of daily living.he has limited

body movements. Moreover patient has easy fatigability on minimal activity.

VI. Nutritional Status

Prior to admission, Mr. Gatchalian verbalized that he has a normal eating pattern of three

times a day. On admission he was ordered diet as tolerated.

According to the patient he consumes foods which are nutritious.

VII. Elimination Status

Before hospitalization, the patient verbalized that she usually urinate 4 to 6 times a day and

having a clear to turbid urine and no discomfort during urination.

Mr. Gatchalian urinates one to two time every shift. He claimed no abnormalities in urination

such as dysuria.

VIII. Fluid and Electrolyte Balance

Mr. Gatchalian has daily habit of having one cup of noodles every morning.He also completes

five to eight glasses of water daily.

On admission, he had ordered nothing per orem the day of his operation.An IVF of PNSSIL x

31gtts per minute was given.

When he was assessed by the health care providers he has a good skin turgor. Supplemental

electrolytes were given.

IX. Circulatory Status

Mr. Gatchalian is not in cardio pulmonary distress. His cardiac rate ranges from 97 to 112 beats

per minute. He has a capillary refill of 2 to 3 seconds. Upon auscultation there were no murmur

sounds noted and there was regular rhythm.

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X. Respiratory Status

Before hospitalization, he was reported that he has no coughs and colds that causes nasal

congestion but proper intervention was given,he did not report any further respiratory

complication. Patient respiratory rate ranges fromm 24 to 28 cycles per minute.

XI. Temperature

The patient has normal body temperature ranging from 36.6 to 37.3 degrees Celsius.per

axilla.

XII. Integumentary Status

The patient has brown to light brown skin color.There are no presence of skin avulsion.

XIII. Comfort and Rest status

According toMr. Gatchalian, he sleeps 8 to 10 hours prior to admission. Mr. Gatchalian

awakes every time vital signs were taken.

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IV. Laboratory Findings and Interpretation

1. Clinical Pathology

Parameter Result Reference rangeWBC 6.4x10 /L 4.0 - 12Lymph# 1.6x10 /L 0.8 - 4Mid# 0.4x10 /L 0.1 - 0 .9Gran# 4.4x10 /L 2.0 – 7.0Lymph% 25.3% 20.0 – 40.0Mid% 6% 3.0 – 9.0Gran% 68.7% 50.0 - 70.0HGH 135glc 115.0 – 145.0RBC 4.47x10 /L 4.0 - 5.36HCT .419l L/L .330 - .436

MCV(H) 93.9 1L 76.0 – 90.0MCH 30.2 pg 25.0 - 31.0MCHC 322 g /L 320.0 – 360.0RDW CV 13.1% 11.5 - 14.5ROW SD 44.37L 35.0 - 56.0PLT 419x10 /L 140.0 - 440.0MPV (l) 6.8 IL 7.0 - 11.0PDW 15 15.0 - 17.0PCT (H) .284% .108 - .282

Remarks: Midcells may include less frequently occurring and rare correlating to monocytes, eosinophils, basophils, and other precursors of white blood cell.

2. Urinalysis Result Form

Physical ExaminationColor : light yellow Appearance: slightly turbid

Chemical ExaminationPh: 6.0 Specific gravity: 1.015 Sugar: negative Protein: negative

Microscopic Examination ResultPus cells 1-2 /hpfRed blood cell 0-1 /hpfYeast cell none/hpfBacteria none/hpfEpithelial cells rare/lpfMucus threads few/lfpAmorphous materials occasional/lfp

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V. ANATOMY AND PHYSIOLOGY

∙ Definition

A perianal abscess represents an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity. The severity and depth of the abscess are quite variable, and the abscess cavity is often associated with formation of a fistulous tract. For that reason, along with perianal abscess, perianal fistula also is discussed in this article.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Anal Abscess and Rectal Pain.

∙ Problem

An anorectal abscess originates from an infection arising in the cryptoglandular epithelium lining the anal canal. The internal anal sphincter is believed to serve normally as a barrier to infection passing from the gut lumen to the deep perirectal tissues. This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space. Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces. Extension of the infection can involve the intersphincteric space, ischiorectal space, or even the supralevator space. In some instances, the abscess remains contained within the intersphincteric space. The variety of anatomic sequelae of the primary infection is translated into va Types of Anorectal Abscesses

Patients with a perianal abscess typically complain of dull perianal discomfort and pruritus. Their perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation. Physical examination demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice.

Patients with an ischiorectal abscess often present with systemic fevers, chills, and severe perirectal pain and fullness consistent with the more advanced nature of this process. External signs are minimal and may include erythema, induration, or fluctuancy. On digital rectal examination (DRE), a fluctuant, indurated mass may be encountered. Optimal physical assessment of an ischiorectal abscess may require anesthesia to alleviate patient discomfort that would otherwise limit the extent of the examination.

Patients with an intersphincteric abscess present with rectal pain and exhibit localized tenderness on DRE. Physical examination may fail to identify an intersphincteric abscess. Although rare, supralevator abscesses present a similar diagnostic challenge. As a result, clinical suspicion of an intersphincteric or supralevator abscess may require confirmation through computed tomography (CT) scanning, magnetic resonance imaging (MRI), or anal ultrasonography. Use of the last modality is limited to confirming the presence of an intersphincteric abscess.

∙ Classification of anorectal abscess

Abscesses are classified based on their anatomic location. The most commonly described locations are perianal, ischiorectal, intersphincteric, and supralevator. The image below illustrates the different anatomic locations of anorectal abscesses.

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∙ Illustration of the major types of anorectal abscesses (submucosal not pictured).

Perianal abscesses represent the most common type of anorectal abscesses, accounting for approximately 60% of reported cases. These superficial collections of purulent material are located beneath the skin of the anal canal and do not transverse the external sphincter.

The next most common types of abscesses, in descending order of frequency, are ischiorectal, intersphincteric, and supralevator. An ischiorectal abscess forms when suppuration transverses the external sphincter into the ischiorectal space. Intersphincteric abscesses result from suppuration contained between the internal and external anal sphincters. A supralevator abscess results either from primary disease in the pelvis (eg, appendicitis, diverticular disease, gynecologic sepsis) or from suppuration extending cranially from an origin in the intersphincteric space, through the longitudinal muscle of the rectum and reaching above the levators.

Horseshoe abscesses, while rare, result from circumferential infiltration of pus within the intersphincteric planes.

∙ The Goodsall rule for perianal fistulas

The Goodsall rule states that the external opening of a fistulous tract located anterior to a transverse line drawn across the anal verge is associated with a straight radial tract of the fistula into the anal canal/rectum. Conversely, an external opening posterior to the transverse line follows a curved, fistulous tract to the posterior midline of the rectal lumen. This rule is important for planning surgical treatment of the fistula and is illustrated in the images below.

Diagram illustrating the Goodsall rule for anorectal fistulas. Fistulas that exit in the posterior half of the rectum generally follow a curved course toward the posterior midline, while those that exit in the anterior half of the rectum usually follow a radial course to the dentate line.

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Illustration of the Goodsall rule for anorectal fistulas. Note the curved nature of the posterior fistulas and the radial (straight) orientation of the anterior fistulas.

∙ Frequency

The peak incidence of anorectal abscesses is in the third and fourth decades of life. Men are affected more frequently than are women, with a male-to-female predominance of 2:1 to 3:1. Approximately 30% of patients with anorectal abscesses report a previous history of similar abscesses that either resolved spontaneously or required surgical intervention.

A higher incidence of abscess formation appears to correspond with the spring and summer seasons. While demographics point to a clear disparity in the occurrence of anal abscesses with respect to age and sex, no obvious pattern exists among various countries or regions of the world. Although suggested, a direct relationship between the formation of anorectal abscesses and bowel habits, frequent diarrhea, and poor personal hygiene remains unproved.

The occurrence of perianal abscesses in infants also is quite common. The exact mechanism is poorly understood but does not appear to be related to constipation. Fortunately, this condition is quite benign in infants, rarely requiring any operative intervention in these patients other than simple drainage.1

∙ Etiology

Perirectal abscesses and fistulas represent anorectal disorders arising predominately from the obstruction of anal crypts. Infection of the now static glandular secretions results in suppuration and abscess formation within the anal gland. Typically, the abscess forms initially in the intersphincteric space and then spreads along adjacent potential spaces.

∙ Indications

As a rule, the presence of an abscess is an indication for incision and drainage. Watchful waiting while administering antibiotics is inadequate.

∙ Contraindications

Clinical suspicion of anorectal abscess warrants aggressive identification and surgical drainage. Delayed surgical intervention results in chronic tissue destruction, fibrosis, and stricture formation and may impair anal continence. Delayed incision and drainage of an anorectal abscess is contraindicated.

.

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VI. Pathophysiology

As mentioned above, perirectal abscesses and fistulas represent anorectal disorders that arise predominately from the obstruction of anal crypts. Normal anatomy demonstrates anywhere from 4-10 anal glands drained by respective crypts at the level of the dentate line. Anal glands normally function to lubricate the anal canal. Obstruction of anal crypts results in stasis of glandular secretions and, when subsequently infected, suppuration and abscess formation within the anal gland results. The abscess typically forms in the intersphincteric space and can spread along various potential spaces.

Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species; however, no specific bacterium has been identified as a unique cause of abscesses.

Less common causes of anorectal abscess that must be considered in the differential diagnosis include tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis, lymphogranuloma venereum, Crohn's disease, trauma, leukemia, and lymphoma. These may result in the development of atypical fistula-in-ano or complicated fistulas that fail to respond to conventional surgical treatment.

∙ Presentation

The classic locations of anorectal abscesses listed in order of decreasing frequency are as follows: perianal 60%, ischiorectal 20%, intersphincteric 5%, supralevator 4%, and submucosal 1%. These major types are illustrated in the image below. Clinical presentation correlates with the anatomic location of the abscess.

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VI. Nursing Care Plan

Assessment Explanation of the problem Objective Nursing Intervention Rationale Evaluation

Subjective:

“Nahihirapan ako makatae dahil sa dressing sa puwet ko”

Objective:

>grimaces>guarding behavior >irritable at times>with intact dry dressing in the anal

Diagnosis:

Perianal Abscess Secondary to ruptured of fistula in the anus

Perianal Abscess Secondary to fistula ruptured in the anus.

Surgical Incision Site

 Altered Bowel Movement

Short term goal:

After 8 hours of nursing interventions, patient will verbalized feeling of comfort.

a) Patient can sleep well not feeling of ache in the stomach

b) Patient can pass out stool little by Little.

Long term goal:

After 3 days of nursing interventions the patient Bowel Movement will normalized by:

a) Patient will have normal elimination pattern.

b) Patient can eliminate without strains in the dressing.

Dx > Identify Factors that May cause/contribute constipation

Determined his motivation to begin an exercise program

Tx > Maintained and regulated above IVF as ordered.

Kept patient comfortable and warm

Position Patient in Side Lying Position

Tx > Encourage increased fliud

Assessing causative factors is an essential step in teaching and planning for improved bowel elimination.

Individuals who have been sucessful in an exercise program can assisst Mr. Gatchalian by providing incentives.

Correct infusion of IVF inside patient’s body.

Promotion of rest and sleep

Alleviate pain

Sufficient fluid intake is necessary

Short term goal

After 8 hours of nursing interventions goal met by:

a) Patient sleep during the whole shift.

b) Patient pass out stool.

Long term goal

After 3 days of nursing interventions goal partially met by:

a) Patient able to pass out stool without any strain in the dressing.

b) Patient is still constipated.

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intake unless contraindicated

Encouraged and Instructed in providing diet high in bulk/fiber and adequate fluids

for Bowel Absorption.

Easy Elimination

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VII. Drug Study

Drug Action Indication Contraindication Cautious use Adverse effects Nursing Responsibilities

Generic name: Oxacillin Sodium

Brand name:Bactocill

Classification:Antiinfective,antibiotic penicillin

Route: Intravenous

Dosage:250 mg every 8 hours

Semisynthetic, acid stable,penicillinase resistant isoxazolyl penicillin

Oxacillin is indicated in the treatment of infections caused by penicillinase producing staphylococci which have demonstrated susceptibility to the drug. Cultures and susceptibility tests should be performed initially to determine the causative organism and its susceptibility to the drug.

A history of a hypersensitivity (anaphylactic) reaction to any penicillin is a contraindication. Solutions containing dextrose may be contraindicated in patients with known allergy to corn or corn products

History of or suspected atopy or allergy,premature infants, neonates,lactation

Thrombophlebitis,superinfection,wheezing,sneezing,fever,anaphylaxis,nausea,vomiting,flatulence,rash,diarrhea

Assessments and drug effects

>Ask the patient prior to first dose about hypersensitivity reactions to penicillins,cephalosporins,and other allergies.>Withhold next drug dose and report the onset of hypersensitivity reactions and superinfections

Patient and family education

>Take oral medication around the clock

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Drug Action Indication Contraindication Cautious use Adverse effects Nuring Responsibilities

Generic name: Ketorolac

Brand name: Toradol

Classification: CNS agent, NSAID, analgesic,antipyretic

Route: IV

Dosage: 15 mg every 6 hours and PRN for pain

The primary mechanism of action responsible for ketorolac's anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor

he safety and effectiveness of single doses of keterolac have been established in pediatric patients between the ages of 2 and 16 years. ketorolac, as a single injectable dose, has been shown to be effective in the management of moderately severe acute pain that requires analgesia at the opioid level, usually in the postoperative setting.

Hypersensitivity to ketorolac, individuals with complet or partial syndrome of nasal polyps,angioedema,and bronchosplastic reaction to aspirin or other NSAIDS.

History of peptic ulcers,impaired renal or hepatic function,older adults, debilitated patients,pregnancy category B.Safety and effectiveness in children is stablished.

Drowsiness,dizzeness,headache,nausea,GI pain,hemorrhage,edema,sweating,pain at injection site

>Correct hypovolemia prior to administration of ketorolaac>Do not drive or engage in potentially hazardous activities until response is drug is known.>Do not use other NSAID while taking this drug.

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Drug Action Indication Contraindication Cautious use Adverse effects Nursing responsibilities

Generic name: Ascorbic Acid

Brand name: Ascorbicap

Classification: Vitamin

Route: Oral

Dosage:1 tablespoon once a day

Water soluble vitamin essential for synthesis and nMaintainace and collagen and intercellular ground substance of body tissue, cells,blood vessels, cartilage,bones,teeth,skin and tendons. Unlike most mammals,humans are unable to synthesize ascorbic acid in the body,therefore it must be consumed daily.

To acidify urine,to prevent and treat cancer, idiopathic methemoglobinemia. Widely use as an antioxidant in formulation in parenteral tetracycline and other drugs

Use of sodium ascorbate in patients on sodium restrition,use of calcium ascorbate in patients receiving digitalis

Excessive doses in patints with G6PD deficiency,hemocromatosis,sickle cell anemia,patients are prone to gout or renal canaculi.

Nausea,vomiting,heart burn,diarrhea,abdominal cramps,acute haemolytic anemia,mild sore at injection site,dizzeness,

Assessment

>Monitor for S and S of acute haemolytic anemia, sickle cell crisis.

Patient and family education

>Vitamin C increases the absoption of iron when taken at the same time as iron rich foods.Take large doses of vit. C in divided amount because the body uses only what is needed at a particular and excretes in urine.

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Drug Action Indication Contraindication Cautious use Adverse effects Nursing responsibilities

Generic name: Nalbuphine Hydrochloride

Brand name: Nubain

Classification: CNS agent agent, analgesic, narcotic agonist antagonist

Route: IV

Dosage: 3 mg every 4 hours and PRN

Synthetic narcotic analgesic with agonist and weak antagonins properties. Analgesic potency is about 3 or 4 time greater than that of pentazocine and approximately equal to that produce by equivalent doses or morphine. On a weak basis produces respiratoy depression about equl to that of morphine,however, in contrast to morphine doses lesser than 30 mg produce low futher respiratory depression . Antagonistic potency is approximately one forth that of naloxone and about 10 time greater than that of pentaxocine.

Symptomatic relief of moderate to severe pain. Also preoperative sedation analgesia and as a suipplement surgical anesthesia.

History of hypersensitivity to drug.

History of emotional instability or drug abuse, head injury, increase intracranial pressure, impaired respiration, impaired kidney or liver function.

Hypertension, hypotension, bradycardia,tachycardia, dizzeness,blured vision,burning sensation

>Assess respiratory status before drug administrationMonitor ambulatory

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