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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



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



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



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.



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.



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



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:



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



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



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



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



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%



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


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



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.



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


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%



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



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



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.



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.



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.



Figure 2. External anatomy of the anus Figure 3. Internal anatomy of the anus



Figure 4. Anatomy of anal fistula

IX. PATHOPHYSIOLOGY



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



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



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



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


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



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



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



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

/


hypersensitivity to

nalbuphine sulfites

10 ml via Iv Sedation,

clamminess,

sweating,

y Reassure patient

about addiction

liability, most



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



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.



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.



y Emotional support

y Prayer

XIV. INDEX

XV. CURRICULUM VITAE

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