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02.04 Nursing Care and Pathophysiology for Hemorrhoids

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Pathophysiology: Inflammation of the veins in anus and rectum caused by straining or pressure, which allows for the veins to swell and be inflamed.

Overview

  1. Swollen and inflamed veins of the anus and lower rectum

Nursing Points

General

  1. Causes
    1. Portal hypertension
    2. Straining
    3. Irritation
    4. Pregnancy / Postpartum
  2. Types
    1. Internal
    2. External
    3. Prolapsed

Assessment

  1. Rectal pain
  2. Bright red bleeding with defecation
  3. Bulging skin/veins around anus

Therapeutic Management

  1. Sitz-bath
    1. Soak perineum in warm water for 15-20 minutes
    2. Can add baking soda or epsom salts
  2. Increase flow of stool to prevent constipation and straining
    1. High fiber diet
    2. ↑ Fluid intake
    3. Stool softeners
  3. Cold packs and analgesics
  4. Surgical Removal – Hemorrhoidectomy

Nursing Concepts

  1. Comfort
  2. Nutrition
  3. Elimination

Patient Education

  1. Do not strain during bowel movement
  2. Take stool softeners as needed (not daily/regularly)

Reference Links

Study Tools

Video Transcript

Okay guys, I know this is the lesson you’ve been waiting for – we’re gonna talk about hemorrhoids!

Now, let’s be honest – nursing school can be a pain in your ass, too, right? We try to keep it fun and interesting and lighthearted around here. In all honesty, hemorrhoids can be very embarrassing for patients, so if we can keep things lighter, they’ll be more comfortable. Things are only awkward if you make them awkward. So, if nursing school is a pain in your ass, take some analgesics and let’s talk hemorrhoids!

So what the heck are hemorrhoids anyway? They are swollen and inflamed veins in the anus and lower rectum. When the pressure builds in these veins, they can get engorged and tortuous, kind of like varicose veins in the legs. So they’ll bulge out and can be really painful. The two most common causes are portal hypertension, which is high pressure within the vessels in the gut and excessive straining. This could be when you’re constipated or after giving birth, I’d say that’s excessive straining all right. They can also get inflamed because of some sort of irritation – we all know what Tuesday’s Tacos can feel like coming back out, right? So any of those things can cause hemorrhoids to flare up. There are three main types based on location. Internal hemorrhoids are found within the rectal vault, external hemorrhoids are found around the anus, and prolapsed hemorrhoids happen when an internal hemorrhoid is big enough to be forced out and visible externally.
This top photo is an example of an external hemorrhoid and the bottom photo is a prolapsed hemorrhoid. You can see the beefy red tissue is an indication that this was internal and is now visible on the outside. As you can imagine, this is going to be very painful – a lot of times patients will want to stand or lay on their side because even sitting down is uncomfortable. They may also see bright red blood when the have a bowel movement. You may even see or hear this abbreviation – B.R.B.P.R. – it stands for Bright Red Blood Per Rectum – BRBPR is a quick way to explain what’s going on with your patient. We’ll see this with hemorrhoids as well as some other inflammatory bowel conditions and GI bleeds.

Our focus for hemorrhoids is to provide comfort measures and prevent them from getting worse – so we encourage a high fiber diet and increased fluid intake so that bowels move a little easier and the patient doesn’t have to strain so much. We can also give stool softeners. One thing we actually see a lot is that elderly patients become kind of obsessed with their bowel movements and will start taking stool softeners twice a day until they’ve got diarrhea – so just educate them that the number one goal is simply to not have to strain. We can also simply encourage them not to push so hard.

As far as comfort measures, we encourage patients to do sitz baths. Now this is something they talk about in nursing school, but honestly, no one ever explained it! I remember it because it’s like a little bath that you “sits” in. Essentially you want to soak JUST the perineum in warm water for 15-20 minutes. You can do this in a bathtub in shallow water, but they also have little sitz bath kits you can buy with a little basin. You fill it with warm water and … sits in it. You can add baking soda or epsom salts or just use plain warm water. We can also use cold packs or analgesics or creams or ointments that help to decrease the swelling. As these hemorrhoids get more severe or more recurrent, patients could also get a hemorrhoidectomy to have it removed.

It may seem obvious, but our priority nursing concepts for a patient with hemorrhoids are going to be comfort and elimination. We want to reduce the swelling and pain at the site and we also want to address their bowel movements so they aren’t so hard or irritating and the patient doesn’t have to strain or force it out.

So, let’s recap – hemorrhoids are engorged, swollen, inflamed veins in the anus and/or lower rectum. There are three types – external, internal, and prolapsed. We focus on comfort care with sitz baths, stool softeners, and working to get the patient straining less. If they are severe enough or recurrent, we’ll opt for a hemorrhoidectomy to remove them altogether.

That’s it for hemorrhoids. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!

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