Nursing Care Plan | NCP Anorectal Abscess and Fistula

An anorectal abscess, sometimes called a perirectal abscess, is the formation of pus in the soft tissue that surrounds the anal canal or lower rectum. Perianal abscess is the most common form, affecting four out of five patients; ischiorectal (abscess in the ischiorectal fossa in the fatty tissue on either side of the rectum) and submucosal or high intermuscular abscesses account for most of the remaining cases of anorectal abscess. A rare form of anorectal abscess is called pelvirectal abscess, which extends deeply into pelvic regions from the rectum. In approximately half of the cases, fistulas develop without any way to predict them. Anorectal abscesses can lead to anal fistulas, also known as fistula in ano. An anal fistula is the development of an abnormal tract or opening between the anal canal and the skin outside the anus. It should not be confused with an anal fissure, which is an elongated ulcer located just inside the anal orifice, caused by the traumatic passage of large, hard stools.

Perirectal abscesses are usually caused by an infection in an anal gland or the surrounding lymphoid tissue. Lesions that can lead to anorectal abscesses and fistulas can be caused by infections of the anal fissure; infections through the anal gland; ruptured anal hematoma; prolapsed thrombosed internal hemorrhoids; and septic lesions in the pelvis, such as acute salpingitis, acute appendicitis, and diverticulitis. Ulcerative colitis and Crohn’s disease are systemic illnesses that can cause abscesses, and people who are immunosuppresssed are more susceptible to abscesses. Patients who are at high risk are diabetics, those who engage in receptive anal sex, and those with inflammatory bowel disease and immunosuppression. Other causes include constipation, chronic diarrhea, syphilis, tuberculosis, radiation exposure, and HIV infection.

Nursing care plan assessment and physical examination
Ask the patient to describe the kind of pain and the precise location. Determine if the pain is exacerbated by sitting or coughing. Ask if the patient has experienced rectal itching or pain with sitting, coughing, or defecating. Elicit a history of signs of infection such as fever, chills, nausea, vomiting, malaise, or myalgia. Ask the patient if she or he has experienced constipation, which is a common symptom because of the patient’s attempts to avoid pain by preventing defecation.

Inspect the patient’s anal region. Note any red or oval swelling close to the anus. Digital examination may reveal a tender induration that bulges into the anal canal in the case of ischiorectal abscess, or a smooth swelling of the upper part of the anal canal or lower rectum in the case of submucous or high intermuscular abscess. Digital examination may reveal a tender mass high in the pelvis, even extending into one of the ischiorectal fossae if the patient has a pelvirectal abscess. Examination of a perianal abscess generally reveals no abnormalities. Examination may not be possible without anesthesia. Note any pruritic drainage or perianal irritation, which are signs of a fistula. On inspection, the external opening of the fistula is usually visible as a red elevation of granulation tissue with purulent or serosanguinous drainage on compression. Palpate the tract, noting that there is a hardened cordlike structure. Note that superficial perianal abscesses are not uncommon in infants and toddlers who are still in diapers. The abscess appears as a swollen, red, tender mass at the edge of the anus. Infants are often fussy, but may have no other symptoms.

Patients with perirectal abscesses and fistulas may delay seeking treatment because of embarrassment relating to the location, the odor, or the sight of the lesion. Provide privacy and foster dignity when interacting with these patients. Inform the patient of every step of the procedure. Provide comfort during the examination.

Nursing care plan primary nursing diagnosis: Pain (acute) related to inflammation of the perirectal area.

Nursing care plan intervention and treatment plan
The abscess is incised and drained surgically. For patients with fistulas, fistulotomies are performed to destroy the internal opening (infective source) and establish adequate drainage. The wound is then allowed to heal by secondary intention. Frequently, this procedure requires incision of sphincter fibers. Fistulectomy may be necessary, which involves the excision of the entire fistulous tract.

Encourage the patient to urinate, but avoid catheterization and the use of suppositories. Postoperatively, a bulk laxative or stool softener is often prescribed on the day of the surgery. Intramuscular injections of analgesics are given to control pain. Assess the perirectal area hourly for bleeding for the first 12 to 24 hours postoperatively. When open fistula wounds are left, as in a fistulotomy, the anal canal may be packed lightly with oxidized cellulose. Encourage the patient to drink clear liquids after any nausea has passed. Once clear liquids have been taken without nausea or vomiting, remove the intravenous fluids, and encourage the patient to begin to drink a full liquid diet the day after surgery. From there, the patient can progress to a regular diet by the third day after surgery. The most common complications are incontinence (if sphincter fibers were incised during surgery) and hemorrhage.

Immediately following the procedure and before the patient enters the postanesthesia care unit, place a dry, sterile dressing on the surgical site. Provide sitz baths twice a day for comfort and cleanliness, and place a plastic inflatable doughnut on a chair or bed to ease the pain of sitting. As soon as the patient tolerates activity, encourage ambulation to limit postoperative complications.

Teach the patient how to keep the perianal area clean; teach the female patient to wipe the perineal area from front-to-back after a bowel movement in order to prevent genitourinary infection. Teach the patient about the need for a high-fiber diet that helps prevent hard stools and constipation. Explain how constipation can lead to straining that increases pressure at the incision site. Unless the patient is on fluid restriction, encourage him or her to drink at least 3 L of fluid a day.

Nursing care plan discharge and home health care guidelines
Teach female patients to wipe from front to back to avoid the contamination of the vagina or urethra with drainage from the perirectal area. Teach the patient to avoid using bar soap directly on the anus because it can cause irritation to the anal tissue. Teach patients to dilute the soap with water on a washcloth to cleanse the area. Explain the need to remain on a diet that will not cause physical trauma or irritation to the perirectal area. A diet high in fiber and fluids will help soften the stools, and bulk laxatives can help prevent straining. Emphasize to the patient the need to avoid spicy foods and hot peppers to decrease irritation to the perirectal area upon defecation. Teach the patient the purpose, dosage, schedule, precautions and potential side effects, interactions, and adverse reactions of all prescribed medications. Encourage the patient to complete the entire prescription of antibiotics that are prescribed.