ms case pres
TRANSCRIPT
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Our Lady of Fatima University
College of Nursing
Regalado, Quezon City
Anal Fistula
A Case Presentation presented
To the faculty of the
College of Nursing
By:
Molo, Ralph Kenneth
Morales, Jade Claire
Naag, Libertine
Natividad, Minerva Jane
Oivete, Veronica Anne
Pastrana, John Derick
Rebagoda, Mary Ann
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Recoy, Geovy
Sanglay, Dexter
Sulio, Mark Paul
Talampas, Michael
Tan, Rodolfo Jr
GROUP 23
Ms. Rachel Anne Sarmiento, RN, MAN(C )
March 2011
Table of Contents
I. INTRODUCTION
II. GENERAL OBJECTIVE
III. PATIENT·S PROFILE
IV. PATIENT·S HISTORY
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a. Past health history
b. Present health history
c. Family health history
V. ACTIVITIES OF DAILY LIVING
VI. PHYSICAL ASSESSMENT
VII. LABORATORY FINDINGS
VIII. ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED
IX. PATHOPHYSIOLOGY
X. DRUG STUDY
XI. NURSING CARE PLAN
XII. COURSE IN THE WARD
XIII. DISCHARGE PLAN
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I. INTRODUCTION
Anal fistula is a small tunnel that forms under the skin and connects to a previously infected anal
gland to the skin on the buttocks outside the anus. It is usually a result of an infection that may have
developed from trauma, fissures and regional enteritis. It is a tiny channel or tract that develops in the
presence of inflammation and infection. It is associated with an abscess as a result of the infection. If
the opening of the fistula seals over before the fistula is cured, an abscess will develop behind it and
this will lead to an opening may be or may not be of another tunnel. The patient will then feel the
irritation of skin around the anus, drainage of pus that relieves the pain, fever, and feeling poorly in
general.
In our patient·s case, he just had a recurring abscess that led to a fistula. Two months prior to his
check up, he felt a small mass just at the margin line of his anus. After a couple of days, the mass had
just ruptured with the release of pus and some blood. And after a couple of days without applying any
medications, the wound become dry without him knowing that the fistula is worsening. It created a
fistula, forming a tunnel at the time of his check up last December 24, 2011. The doctor then advised
him to undergo fistulectomy.
Fistulectomy or the excision of the fistulous tract is the recommended procedure for surgery. The
lower bowel is evacuated thoroughly with several prescribed enema. It usually involves opening up the
fistula tunnel. Often this will require cutting a small portion of the anal sphincter, the muscle that
helps to control bowel movements. Joining the external and internal openings of the tunnel and then
allowing it to heal from the inside out.
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Our patients have just undergone fistulectomy last January 9, 2011. One day prior to surgery, he
signed a consent regarding the surgical procedure. Preoperative procedures were done like NPO post
midnight, laboratory tests and pre operative medications. All laboratory tests were on normal results,
therefore the patient is already subjected to undergo fistulectomy.
II. OBJECTIVES
This study was done with the following objectives:
GENERAL OBJECTIVE:
To have in depth understanding of the disease process and nursing management on Anal Fistula.
SPECIFIC OBJECTIVES:
1. To identify possible risk factors that may have contributed to the development of Anal Fistula.
2. To fully understand the etiology, predisposing factor, pathophysiology, diagnosis, sign andsymptoms of Anal Fistula.
3. To identify measures that could minimize the risk of occurrence of the Anal Fistula.
4. To elucidate and discuss the anatomy and physiology of the organs involve in the disease process of Anal Fistula.
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5.
Perform a comprehensive assessment on a patient with Anal Fistula.
6. To have in depth analysis of disease process of Anal Fistula.
7. To have plan and implement nursing interventions to patient having Anal Fistula.
III. PATIENT PROFILE
General Information
Name: Mr. F.D.B.
Age: 36 years old
Gender: Male
Date of Birth: November 2, 1974
Place of Birth: Cebu
Religion: Roman Catholic
Admission Date: January 9, 2011 Time: 1500H
Discharge Date: January 18, 2011 Time: 1600H
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Chief Complain: ´Sumasakit ang tumbong ko lapag umuupo akoµ as verbalized by the
patient.
Reason for Visit: The patient visited because he noticed that there were two unidentified mass in his
anus.
Source of Information: Patient
Admission Diagnosis: Anal Fistula
Admitting physician: Dr. Sandoval
IV. PATIENT·S HISTORY
Present History:
2 months prior to admission, patient noted two pea sized mass at the anus, associated with pain
sitting. No other assessed signs and symptoms. No consult done and no meds taken. 1 month prior toadmission, still sitting with mass at the anus, patient also noted a yellowish discharge with blood.
Patient then sought consult at his private doctor and he was scheduled for fistulectomy. Patient was
admitted to the institution.
Past medical history:
The patient has no history of being hospitalized due to any diseases. He did not have a history of
hypertension, DM and cancer. He also has no allergies to any foods and drugs. He is taking vitamin
supplements like Strestabs and Potencee for protection against nay illness. He does not have the
complete immunization.
Family History:
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Both on parent·s side have no history of hypertension, diabetes mellitus, cancer and asthma.
V. ACTIVITIES OF DAILY LIVING
VI. PHYSICAL ASSESSMENT
Body part Technique used Findings Interpretation and
analysis
Mental
Asking question Responsive to all thequestions being asked.
Cooperative, able to followinstruction,understandable. Clear
Activity Before hospitalization During hospitalization Analysis
Nutrition
Diet
EliminationUrination
Bowel movement
Rest and sleepNumber of hours sleepNaps
Substance useSmoking
alcoholothers
Sexual Activity
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tone and inflection
Anthropometric measurements
Height
Weight
Vital signs
TemperaturePulse Rate
Respiratory Rate
Blood Pressure
Head
HairEyes
Vision
Ears and hearing
Nose and sinuses
Mouth teeth and tongueFace
Neck
Muscles
Lymph nodes
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Trachea
Thyroid
Chest and Back
Skin
Thorax and Lungs
Breast and axillae
Abdomen
Genitals
Upper extremities
Hands
Muscle strength
Joint range of motion
Lower extremities
Hands
Muscle strengthJoint range of motion
Gait and Balance
VII. LABORATORY FINDINGS
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A. ECG
Done on: January 4, 2011 QRS: Axis
Rhythm: Linus PR: 0.16 secs
Rate Atrial: 65 bpm QRS: 0.06 secs
Rate ventricular position: QT: 0.28 secs
ECG interpretation: Normal sinus rhythm
B. Chest X-ray
Done on: January 4, 2011
Results:
Clear lung fields.
Heart is not enlarged.
Hemidiaphragm and sulci are intact.
Dextroscoliosis of the thoracic spine.
C. Clinical Chemistry
Done on: January 9, 2011
Result Normal Values
Fasting 3.34-6.12 mmol/L
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blood sugar N/A
Blood urea
nitrogen
N/A 2.50-6.43 mmol/L
Creatinine:
Male N/A 79.6-132.6 mmol/L
Blood uric
acid
Male
N/A
0.201-0.413 mmol/L
0.142-0.336 mmol/L
Total
cholesterol
4.97 mmol/L 3.63-6.12 mmol/L
Triglycerides 0.76 mmol/L 0.41-1.86 mmol/L
HDL 1.12 mmol/L 1.04-1.56 mmol/L
LDL 3.50 mmol/L 2.40-3.80 mmol/L
SGOT N/A 0.40 u/dl
SGPT N/A 0-38 u/dl
Sodium, Na 145.5 mmol/L 135-148 mmol/L
Potassium,
K
3.74 mmol/L 3.5-5.8 mmol/L
Chloride, Cl N/A 97-108 mmol/L
HBAIC N/A 4.1%-6.2%
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y All of the results were normal in this laboratory tests and this shows that the patient is a
candidate for the surgical procedure. Other tests are not applicable.
Serum Test
Test Concentratio
n
Result Normal Values
BS
Glucose
4.99 mmol/L Normal 3.59-5.95
mmol/L
BS
Creatinin
e
96.6 umol/L Normal 62.1-133.3
umol/L
BS Uric
Acid
368.0 umol/L Normal 210.0-420
umol/L
BS SGOT 44.03 u/L Normal Less than 47.33
u/L
BS SGPT 24.95 u/l Above the
normal level
10.00-17.33 u/L
As far as we see in the serum test, Glucose, Creatinine, Uric Acid, SGOT have normal results.
Above the normal level of the SGPT may be an indication of a liver problem.
D. Macroscopic Examination
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Results Normal values
Color Dark yellow Straw amber
Transparency Slightly turbid Clear
Reaction Acidic Acidic or alkaline
Specific Gravity 1.015 1.005-1.025
Sugar Negative Negative
Protein Negative Negative
RBC 0-1/hpf 0-1 /hpf
Pus Cells 6-8/hpf 0-2 /hpf
Squamous
Epithelial Cells
Few
Renal Epithelial
Cells
N/A
Amorphous
Urates/Phosphate
s
N/A
Mucous Threads Few
Bacteria Few Negative or Rare
y The color, the transparency, the pus cells have abnormal results than the other
examination.
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y The result of the Bacterial in the patient examination was few so the bacterial in urine
sediment reflect genital urinary tract infection or contaminated of external genital.
E. Complete Blood Count
Result Normal Values
Hemoglobin
Male: 148.0 g/L 140-180 g/L
Hematocrit
Male: 0.44 g/L 0.42-0.54 g/L
WBC
Male: 6.5 g/L 5.0-10.0x10 g/L
Differential
Count
Result Adult
Segmenters 0.60 50-65%
Lymphocytes 0.31 25-40%
Monocytes N/A 3-9%
Eosinophils 0.09% 1-3%
Stab N/A 2-5%
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Basophiles 0-1% 0-1%
Complete blood count- blood count that includes separates count for red and white blood cells.
Hemoglobin- in the red blood cells of the normal human adult that consists of two alpha chains
and the two beta chains.
Hematocrit- determines the percentage of RBC in the plasma.
White Blood Cells- also produced, transport, and distribute antibodies as part of the body·simmune response.
y The results for the hemoglobin, hematocrit, and WBC have a normal finding.
y In other differential count like Eosinophils this is the only have abnormal findings, than
other differential count results.
F. Hematology
Examination Normal Values Results
PT 10.4-12.6 sec 11.6 sec
% Activity 70-130% 103%
JNR N/A 0-89
Control N/A 11.4 sec
PTT 28-36 sec 22.7 sec
Control N/A 26.9 sec
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Hematology- that deals with the blood and blood performing organs.
y At the hematology examination the PT, % Activity have a normal result than the PTT examination
which have a abnormal result, so the PTT has a decreased level than the other examination of our
patient.
VIII. ANATOMY AND PHYSIOLOGY
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Figure 1 The anatomy of digestive system
The Digestive Process:The start of the process - the mouth: The digestive process begins in the mouth. Food is partly brokendown by the process of chewing and by the chemical action of salivary enzymes (these enzymes areproduced by the salivary glands and break down starches into smaller molecules).
On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the
esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic,wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. Thismuscle movement gives us the ability to eat or drink even when we're upside-down.
In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids iscalled chyme.
In the small intestine - After being in the stomach, food enters the duodenum, the first part of the smallintestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the smallintestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and otherdigestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.
In the large intestine - After passing through the small intestine, food passes into the large intestine. Inthe large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food.
Many microbes (bacteria like B acteroides , Lactobacillus acidophilus , Escherichia coli , and Klebsiella ) in thelarge intestine help in the digestion process. The first part of the large intestine is called the cecum (theappendix is connected to the cecum). Food then travels upward in the ascending colon. The food travelsacross the abdomen in the transverse colon, goes back down the other side of the body in the descendingcolon, and then through the sigmoid colon.
The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus.
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Parts of the digestive system:
abdomen - the part of the body that contains the digestive organs. In human beings, this is between thediaphragm and the pelvis
alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach,
intestines, and anus.
anus - the opening at the end of the digestive system from which feces (waste) exits the body.
appendix - a small sac located on the cecum.
ascending colon - the part of the large intestine that run upwards; it is located after the cecum.
bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into thesmall intestine.
cecum - the first part of the large intestine; the appendix is connected to the cecum.
chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the
small intestine for further digestion.
descending colon - the part of the large intestine that run downwards after the transverse colon and
before the sigmoid colon.
digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes
food and gets rid of waste.
duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.
epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to
the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens
so that air can go in and out of the windpipe.
esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements(called peristalsis) to force food from the throat into the stomach.
gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive
chemical which is produced in the liver) into the small intestine.
gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes
food and gets rid of waste.
ileum - the last part of the small intestine before the large intestine begins.
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intestines - the part of the alimentary canal located between the stomach and the anus.
jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.
liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makesbile (which breaks down fats) and some blood proteins.
mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes
in the mouth are the beginning of the digestive process (breaking down the food).
pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from
the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine.
peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the
stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while
upside-down.
rectum - the lower part of the large intestine, where feces are stored before they are excreted.
salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break
down carbohydrates (starch) into smaller molecules.
sigmoid colon - the part of the large intestine between the descending colon and the rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanicaldigestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and
enzymes.
transverse colon - the part of the large intestine that runs horizontally across the abdomen.
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Figure 2. External anatomy of the anus Figure 3. Internal anatomy of the anus
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Figure 4. Anatomy of anal fistula
IX. PATHOPHYSIOLOGY
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Infection of rectalArea
Forming abscess letsOut the pus
Usually, every abscess opens one day or the other and lets out the pus. Sometimes it needs
surgical intervention to drain, especially when it is deep. In any case, if it doesn·t heal up properly or
if it is not properly drained after letting out the pus then it will usually remain as infecting foci and
suppurates. Also this will constantly or intermittently discharge pus or fluid through the
outlet/tract. In due course, this tract gets lined with granulation tissue which resists healing (joining
the other surface). Fistula·s length and openings (internal and external) usually vary in size and
number according to the location of the abscess and care taken over it. Usually, the fistula tract will
be a curved one. Untreated fistula or clogged outlet of fistula (due to infection or draining debris
obstruction) will usually promote multiple internal/external openings with recurrent anal abscess
and re-formation of tract or tunnel.
Non ² modifiable ModifiableAge: HygieneGender Practices
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Remain as infecting foci &su rates
Untreated fistula
X. DRUG STUDY
Discharge pus in fluidthrough
The outlet/tract
Formation of fistula orAbnormal path way
Promote internal/externalopenings
With recurrent anal abscess&
Formation of tract or tunnel
Untreated fistula orclogged outlet of fistula
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Generic/Brand
name
Classification &
Indication
Contraindication Dosage and
route
Side effect Nursing responsibility
Mefenamic
Acid/ Dolfenal
NSAIDS /
y Relief of
moderate pain
when therapy
will not exceed
1 week
y Treatment of
primary
dysmenorrhea
Contraindicated with
hypersensitivity to
mefenamic acid,
aspirin allergy and as
treatment of
perioperative pain
with coronary artery
bypass graft.
500 mg per
tablet orally
Head ache,
dizziness,
rash,
sweating, dry
mucous, GI
upset, renal
impairment,
bronchospasm
y Give with food or
milk to decrease
GI upset
y Arrange for
periodic
ophthalmic
examinations
during long term
therapy
y Take drug with
food: take only
prescribed
dosage: do not
take the drug or
longer than 1
week
y Discontinue drug
and consult your
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health care
provider if rash,
diarrhea or
digestive
problems occurs
y Report sore
throat, fever,
rash, itching,
weight gain,
swelling in ankles
or finger, changes
in vision, severe
diarrhea, right
upper abdominal
pain
Paracetamol /
Biogesic
Analgesic (non-
opiod)
Anti-pyretic /
y Temporary
Contraindicated with
allergy in
acetaminophen.
500 mg per
tablet orally
Headache,
chest pain,
dyspnea,
hepatic
toxicity, renal
y Do not exceed therecommended
dosage.
y Reduce dosage
with hepatic
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reduction
fever,
temporary
relief of minor
aches and
pains caused
by common
cold and
influenza,
headache, sore
throat,
toothache (
patients age 2
years and
older) back
ache,
menstrual
cramps, minor
arthritis pain
and muscle
aches
(patients older
failure,
cyanosis,
rash, fever
impairment
y Discontinue drug
if hypersensitivity
reactions occurs
y Give drug with
food if GI upset
occurs
y Take the drug
only for
complains
indication; it is
not an anti-
inflammatory
agent
y Chew the
chewable tablets
before
swallowing;
dissolve
dispersible
tablets in mouth
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than 12 years
old
y Unlabelled use
; Prophylaxis
in children
and patients
at risk for
seizures who
are receiving
DPT
vaccination to
reduce
incidence of
fever and pain.
before
swallowing.
Ketorolac
tromethamine /
Acular L S,
Anti- pyretic
Nonopiod Analgesic
NSAIDS /
y Short- term
management
of pain (up to
Aspirin allergy,
concurrent uses of
NSAIDS; active peptic
ulcer disease, recent
GI bleed or
perforation,
hypersensitivity to
ketorolac as
3ml via IV Nausea and
vomiting,
dizziness GI
pain, Renal
impairment,
bleeding,
dyspnea,
hempotysis,
y Protect drug vials
from light
y Administering
every 6 hours to
maintain serum
levels and control
pain
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5 days)
y Ophthalmic
relief of ocular
itching due to
seasonal
conjunctivitis
and relief of
postoperative
inflammation
after cataracts
surgery.
prophylactic
analgesic before
major surgery.
pheriperal
edema, local
burning
y Every effort will
be made to
administer the
drug on time to
control pain,
dizziness,
drowsiness, can
occur
y Burning and
stinging on
application
y
Report sore
throat, fever,
rash, itching,
weight gain,
swelling in ankles
or finger, change
of vision
Nalbuphine
hydrochloride /
Nubain
Opiod agonist-
antagonist analgesic
/
Contraindicated with
hypersensitivity to
nalbuphine sulfites
10 ml via Iv Sedation,
clamminess,
sweating,
y Reassure patient
about addiction
liability, most
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y Relief of
moderate to
severe pain
y Preoperative
analgesic, as a
supplement to
surgical
anesthesia
pruritus, dry
mouth,
hypotension,
urinary
urgency,
respiratory
depression,
dyspnea
patient who
receive
Hemostan
Biomedis /
Tranexemic acid
Anticoagulant
Hemostatics
y For general
surgeries Post
operative
medication
1g via IV
every 4 hours
for 3 days
GI disorder,
nausea and
vomiting,
headache,
impaired
renal,hypotens
ion
y Not advisable to
use for prolonged
periods in
patientspredisposed to
thrombosis.
y Not
recommended for
prophylaxis
during pregnancy
& before delivery
XI. NURSING CARE PLAN
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XII. COURSE IN THE WARD
XIII. DISCHARGE PLAN
M
edication - continue medication as ordered by the doctor.
y Mefenamic acid (analgesic)- to relief pain, 500 mg
y Take immediately after meal.
y Cloxacillin (antibiotic)
y 500 mg, 1 cap 4x a day
y Take on empty stomach- 1 hour before meal/ 2 hours after meal.
y Do not quit taking your medicines.
y Laxatives- to prevent straining.
E xercise- to maintain the proper circulation of the blood and a good condition.
y Ambulation
y Moderate exercise
y Avoid doing strenuous activity.
y Rest if necessary.
T reatment-will do a physical examination and medical history.
y Take the continous medicine by doctor·s order- ( mefenamic, cloxacillin).
y Follow-up check-up to monitor easily if there is further complications/ infections.
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y Treating anal fistula as soon as possible gently may relieve your symptoms and help to resume theactivities.
H ealth Teaching- to be aware and know his responsibilities.
y Advise the patient to keep perineal care as dlean ad possible cy gently cleansing with warm waterand drying with absorbent cotton wipes.
y Instruct how to perform sitz bath.-may be given in the bath tub or plastic sitz bath
- 3-4x each day
-should follow each bowel movement 1-2 weeks after surgery
y Comfortable clothing.
y Avoid stress; stress may low healing.
y Relax in a way of deep breathing exercise.
O pd- keep all appointments.
y Make a list of questions may you have for the next hospital visit.
y Do not stop taking medicines without first talking to your caregiver.D iet
y Low fat/low cholesterol ( margay, peanuts, oil, vegetable).
y Avoid; butter, lard, sweets.
y High-fiber and protein, carbohydrates- for energy.y Increase fluid intake to relieve constipation.
y Eating healthy foods may help you have more energy and heal faster.
S piritual/Support- to lessen depression/anxiety.
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y Emotional support
y Prayer
XIV. INDEX
XV. CURRICULUM VITAE