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 and
symptoms 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 ako” 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 to
admission, 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

Activity Before hospitalization During hospitalization Analysis

Nutrition
Diet
Elimination
Urination
Bowel movement
Rest and sleep
Number of hours sleep
Naps
Substance use
Smoking
alcohol
others
Sexual Activity

VI. PHYSICAL ASSESSMENT

Body part Technique used Findings Interpretation and

analysis
Mental
Asking question Responsive to all the Cooperative, able to follow
questions being asked. instruction,
understandable. Clear
 tone and inflection

Anthropometric measurements
Height
Weight
Vital signs
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Head
Hair
Eyes
Vision
Ears and hearing
Nose and sinuses
Mouth teeth and tongue
Face
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 strength
Joint 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 N/A 2.50-6.43 mmol/L
nitrogen
Creatinine:
Male N/A 79.6-132.6 mmol/L
Blood uric N/A
acid 0.201-0.413 mmol/L
Male 0.142-0.336 mmol/L
Total 4.97 mmol/L 3.63-6.12 mmol/L
cholesterol
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, 3.74 mmol/L 3.5-5.8 mmol/L
K
Chloride, Cl N/A 97-108 mmol/L
HBAIC N/A 4.1%-6.2%

 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 Result Normal Values

n
BS 4.99 mmol/L Normal 3.59-5.95
Glucose mmol/L
BS 96.6 umol/L Normal 62.1-133.3
Creatinin umol/L
e
BS Uric 368.0 umol/L Normal 210.0-420
Acid umol/L
BS SGOT 44.03 u/L Normal Less than 47.33
u/L
BS SGPT 24.95 u/l Above the 10.00-17.33 u/L
normal level

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 Few
Epithelial Cells
Renal Epithelial N/A
Cells
Amorphous N/A
Urates/Phosphate
s
Mucous Threads Few
Bacteria Few Negative or Rare

 The color, the transparency, the pus cells have abnormal results than the other
examination.
  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 Result Adult

Count
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’s
immune response.
 The results for the hemoglobin, hematocrit, and WBC have a normal finding.
 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.

 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 broken
down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are
produced 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. This
muscle 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 is
called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small
intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small
intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other
digestive 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. In
the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food.
Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the
large intestine help in the digestion process. The first part of the large intestine is called the cecum (the
appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels
across the abdomen in the transverse colon, goes back down the other side of the body in the descending
colon, 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 the
diaphragm 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 the
small 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 makes
bile (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 mechanical
digestion 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
 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 – modifiable Modifiable

Age: Hygiene
Gender Practices

Infection of rectal
Area

Forming abscess lets

Out the pus
 Remain as infecting foci &
supprates

Discharge pus in fluid

through
The outlet/tract

Formation of fistula or
Abnormal path way

Untreated fistula or
clogged outlet of fistula

Promote internal/external
openings
With recurrent anal abscess
&
Formation of tract or tunnel

Untreated fistula

X. DRUG STUDY
Generic/Brand Classification & Contraindication Dosage and Side effect Nursing responsibility
name Indication route

Mefenamic NSAIDS / Contraindicated with 500 mg per Head ache,  Give with food or
Acid/ Dolfenal hypersensitivity to tablet orally dizziness, milk to decrease
 Relief of
mefenamic acid, rash, GI upset
moderate pain
aspirin allergy and as sweating, dry  Arrange for
when therapy
treatment of mucous, GI periodic
will not exceed
perioperative pain upset, renal ophthalmic
1 week
with coronary artery impairment, examinations
 Treatment of
bypass graft. bronchospasm during long term
primary
therapy
dysmenorrhea
 Take drug with
food: take only
prescribed
dosage: do not
take the drug or
longer than 1
week
 Discontinue drug
and consult your
 health care
provider if rash,
diarrhea or
digestive
problems occurs
 Report sore
throat, fever,
rash, itching,
weight gain,
swelling in ankles
or finger, changes
in vision, severe
diarrhea, right
upper abdominal
pain

Paracetamol / Analgesic (non- Contraindicated with 500 mg per Headache,  Do not exceed the
Biogesic opiod) allergy in tablet orally chest pain, recommended
acetaminophen. dyspnea, dosage.
Anti-pyretic /
hepatic  Reduce dosage
 Temporary toxicity, renal with hepatic
reduction failure, impairment
fever, cyanosis,  Discontinue drug
temporary rash, fever if hypersensitivity
relief of minor reactions occurs
aches and  Give drug with
pains caused food if GI upset
by common occurs
cold and  Take the drug
influenza, only for
headache, sore complains
throat, indication; it is
toothache not an anti-
( patients age inflammatory
2 years and agent
older) back  Chew the
ache, chewable tablets
menstrual before
cramps, minor swallowing;
arthritis pain dissolve
and muscle dispersible
aches tablets in mouth
(patients older before
than 12 years swallowing.
 old
 Unlabelled use
; Prophylaxis
in children
and patients
at risk for
seizures who
are receiving
DPT
vaccination to
reduce
incidence of
fever and pain.
Ketorolac Anti- pyretic Aspirin allergy, 3ml via IV Nausea and  Protect drug vials
tromethamine / concurrent uses of vomiting, from light
Nonopiod Analgesic
Acular LS, NSAIDS; active peptic dizziness GI  Administering
NSAIDS / ulcer disease, recent pain, Renal every 6 hours to
GI bleed or impairment, maintain serum
 Short- term
perforation, bleeding, levels and control
management
hypersensitivity to dyspnea, pain
of pain (up to
ketorolac as hempotysis,  Every effort will
5 days)
prophylactic pheriperal be made to
 Ophthalmic
 relief of ocular analgesic before edema, local administer the
itching due to major surgery. burning drug on time to
seasonal control pain,
conjunctivitis dizziness,
and relief of drowsiness, can
postoperative occur
inflammation  Burning and
after cataracts stinging on
surgery. application
 Report sore
throat, fever,
rash, itching,
weight gain,
swelling in ankles
or finger, change
of vision
Nalbuphine Opiod agonist- Contraindicated with 10 ml via Iv Sedation,  Reassure patient
hydrochloride / antagonist hypersensitivity to clamminess, about addiction
Nubain analgesic / nalbuphine sulfites sweating, liability, most
pruritus, dry patient who
 Relief of
mouth, receive
moderate to
hypotension,
severe pain
  Preoperative urinary
analgesic, as a urgency,
supplement to respiratory
surgical depression,
anesthesia dyspnea

Hemostan Anticoagulant 1g via IV GI disorder,  Not advisable to

Biomedis / every 4 hours nausea and use for prolonged
Hemostatics
Tranexemic acid for 3 days vomiting, periods in
 For general headache, patients
surgeries Post impaired predisposed to
operative renal,hypotens thrombosis.
medication ion  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.

 Mefenamic acid (analgesic)- to relief pain, 500 mg

 Take immediately after meal.
 Cloxacillin (antibiotic)
 500 mg, 1 cap 4x a day
 Take on empty stomach- 1 hour before meal/ 2 hours after meal.
 Do not quit taking your medicines.
 Laxatives- to prevent straining.

E xercise- to maintain the proper circulation of the blood and a good condition.

 Ambulation
 Moderate exercise
 Avoid doing strenuous activity.
 Rest if necessary.

T reatment-will do a physical examination and medical history.

 Take the continous medicine by doctor’s order- ( mefenamic, cloxacillin).

 Follow-up check-up to monitor easily if there is further complications/ infections.
 Treating anal fistula as soon as possible gently may relieve your symptoms and help to resume the
activities.

H ealth Teaching- to be aware and know his responsibilities.

 Advise the patient to keep perineal care as dlean ad possible cy gently cleansing with warm water
and drying with absorbent cotton wipes.
  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

 Comfortable clothing.
 Avoid stress; stress may low healing.
 Relax in a way of deep breathing exercise.
O pd- keep all appointments.

 Make a list of questions may you have for the next hospital visit.
 Do not stop taking medicines without first talking to your caregiver.
D iet

 Low fat/low cholesterol ( margay, peanuts, oil, vegetable).

 Avoid; butter, lard, sweets.
 High-fiber and protein, carbohydrates- for energy.
 Increase fluid intake to relieve constipation.
 Eating healthy foods may help you have more energy and heal faster.

S piritual/Support- to lessen depression/anxiety.

 Emotional support
 Prayer

XIV. INDEX
XV. CURRICULUM VITAE