INTRODUCTION A.

Number of cases/Statistics data of the Disease

Common in 3rd and 4th decade of life Male > female (2:1)

30% present with previous episodes. Increase incidence during summer and spring. Common in infants , poorly understood mechanism , fairly benign and majority settle with simple drainage.

B. Current trends about the case

Predictors Of Disease Behavior Change In Crohns Disease ScienceDaily (Aug. 10, 2009) Using the Vienna classification system, it has been shown in clinic-based cohorts that there can be a significant change in disease behavior over time, whereas disease location remains relatively stable. Clinical and environmental factors as well as medical therapy might be relevant in predicting disease behavior change in patients with CD. In previous studies, early age at diagnosis, disease location, perianal disease and, in some studies, smoking were associated with the presence of complicated disease and surgery.

The combined effect of markers of disease phenotype (e.g., age, gender, location, perianal diesease) and medical therapy (steroid use, early immunosupression) on the probability of disease behavior change were, however, not studied thus far in the published literature.

A research article to be published on July 28, 2009 in the World Journal of Gastroenterology addresses this question. Members of the Hungarian IBD Study Group led by Dr Peter Laszlo Lakatos from the Semmelweis University investigated 340 well-characterized, unrelated, consecutive CD patients (M/F: 155/185, duration: 9.4 7.5 years) with a complete clinical

follow-up. Medical records including disease phenotype according to the Montreal classification, extraintestinal manifestations, use of medications and surgical events were analyzed retrospectively. Patients were interviewed on their smoking habits at the time of diagnosis and during the regular follow-up visits. They found that perianal disease, current smoking, prior steroid use, early azathioprine or azathioprine/biological therapy are predictors of disease behavior change in CD patients. The new data with easily applicable clinical information as presented in the article may assist clinicians in practical decision-making or in choosing the treatment strategy for their CD patients.

C. Reasons for choosing such case study

The researcher chose perianal abscess as a subject for case study for the reason that the researcher would like to expand his limited knowledge regarding the disease. It also came to his attention the need to study this is due to the arising prevalence of the disease in our country. Also, the researcher themselves, as a student nurse intern is exposed to perianal abscess, so the need for them to study of the prevention, early diagnosis, treatment and restoration of health arises in order to protect themselves and then disseminate the knowledge to his patients and render nursing care.

D. Objectives of the study

Patient-centered objectives

Short term Goal: Conduct complete interview and information needed in the study. Provide therapeutic communication skills to the patient. Make plan of care in order to prevent other complications. Implement interventions and impart health teachings related to the problem. Evaluate for any response of the patient.

Long Term Goal: After 2 to 3 days of Nursing Intervention, the student nurse will be able to: Assess the health status and general condition of the patient. Conduct initial interview and gather information needed by the study. Explain the purse of the study. Establish rapport to the patient. Choose a case that will be appropriate to be subject in the case study.

After 6 to 8 hours of Nursing Intervention, the student nurse will be able to: Short Term Goal: Nurse-centered objectives Reinforce plan of care in dealing with the problem. Understand and appreciate good health condition. Experience present disease and need adequate knowledge regarding the problem. Know and understand the value of good health status. Client recognize and experiencing the problem.

After 2 to 3 days of Nursing Interventions the patient will be able to: Long Term Goal: Establish trust and cooperation in the student nurse. Verbalize concern regarding the health condition. Express appreciation in the study. Verbalize further information related the study. To know the purpose of the study.

II. NURSING ASSESSMENT

1. PERSONAL HISTORY

Patient X was born on January 20, 1985 at Concepcion, Tarlac and he is currently 26 years old. He is living at Concepcion, Tarlac together with his parents. His nationality is Filipino and a Roman Catholic. he was admitted in St. Raphael Foundation Medical Center last July 6 ,2011 and he has initial diagnosis of perianal abscess. Mr.Ube and Mrs. Cheese were married for 30 years . Patient X is the only son. The family has their own house in Concepcion, Tarlac made up of concrete wood with one bedroom, a living room and a bathroom with a septic tank without water carriage. Their source of water is from NAWASA, they also use this for drinking.

According to Patient X they dont usually go to mass but they pray and give thanks to God despite of their condition. Mr. Ube is a Tricycle Driver and Mrs. Cheese is a house wife. Mr. Ube is earning 200 pesos per day. Mr. Ubes family is the one who is helping the family in case of financial problems. According to Patient X, the familys environment is fair because of clean surroundings.
.

2. FAMILY HISTORY

aS Grandpa Choco

Grandpa Cocoa (Diabetes)

Mr. Ube

Mrs. Cheese (Diabetes)

Patient X (Perianal abscess)

3. HISTORY OF PAST ILLNESS

According to Mrs. Cheese, Patient X hadnt experience any disease or illness that required hospitalization before.

4. HISTORY OF PRESENT ILLNESS

7 days Prior to admission, swelling noted surrounding anal area, self medication with amoxicillin 1 day prior to admission.

5. PHYSICAL EXAMINATION (IPPA CEPHALOCAUDAL APPROACH) Vital signs = BP: 120/80 PR: 60 RR: 18 TEMP :36.9 HEENT : pink conjunctiva and anicteric HEART: AP; NR- RR with murmur. ABDOMEN: soft flat MABS. GENITOURINARY: (+) swelling perianal. EXTREMITIES: FEP. EVALUATION AND IMPRESSION: Perianal abscess.

III. ANATOMY AND PHYSIOLOGY

IV. PATIENT AND HIS ILLNESS A. Pathophysiology

GLANDULAR SECRETION STASIS

INFECTION AND SUPPURATION

ANAL CRYPST OBSTRUCTION

ABSCESS FORMATION

Once infection sets in intersphincteric space it can spread further. Duct of Anal gland penetrate internal sphincter into intersphincteric space.

 Internal anal sphincter a barrier to infection passing from gut to deep perirectal tissue. Infection starts in crypto glandular epithelium lining the anal canal.

B. Definition of the disease Often cavity is associated with fistulous tract. Infection of the soft tissue surrounding the anal canal, with formation of discrete abscess cavity.

C. Synthesis of the disease c.a Risk Factors

Any condition that causes a weakening of the immune system such as: o Diabetes o Organ transplant o AIDS Cancer Crohn's disease Ulcerative colitis Pregnancy

c.b Signs and symptoms

Anal pain o Worse during a bowel movement Skin lump near the anus Pus draining from the anus Skin redness around the anus Skin swelling around the anus Skin tenderness around the anus Rectal bleeding Constipation Fever Chills Stool incontinence

V. MEDICAL MANAGEMENT A. DIAGNOSTICS ANDLABORATORY PROCEDURES DIAGNOST IC AND LABORATO RY PROCEDU RES DATE ORDER ED / DATE RESULT S IN GENERAL DESCRIPTI ON INDICATI ON OR PURPOSE RESUL TS NORM AL VALUE S ANALYSIS AND INTERPRETATI ON

B. IVF, O2 THERAPY, NEBULIZATION, NGT, ETC. MEDICAL MANAGEMENT DATE ORDERED/ DATE STARTED/ DATE CHANGED GENERAL DESCRIPTION INDICATION/ PURPOSE CLIENTS RESPONSE

D. DRUGS GENERIC NAME (BRAND NAME) DATE ORDERED / DATE STARTED / DATE CHANGED / DATE DISCONTI NUED 7/6/11 7/7/11 ROUTE OF ADMIONISTR ATION DOSAGE AND FREQUENCY OF ADMINISTRA TION IV 200 mg/IV q8 GENERAL ACTION INDICATION CLIENTS RESPONS E WITH ACTUAL ADVERSE REACTIO NS.

Ciproflox acin (aror)

Ciprofloxa cin inhibits DNA enzyme in susceptibl e microorga nisms. It interferes with bacterial DNA replication . Ciprofloxa cin is also bactericid al.

Omepron (omepraz ole)

7/6/11 7/7/11

40mg/IV OD

Ciprofloxacin is also used in the treatment of infectious diarrhea, uncomplicated gonorrhea, empiric treatment of febrile neutropenia, and acute sinusitis. It can also be used for conjunctival keratitis, keratoconjunct ivitis, corneal ulcers, blepharitis, dacrocystitis, blepharoconju nctivitis, and acute meibomianitis. Shot-term treatment for erosive esophagitis and symptomatic gastroesophag eal reflux disease (GERD) poorly responsive to

> Nausea >Diarrhea >Dyspepsi a >Vomitin g >Constipat ion

Omeprazole is converted to active metabolites that irreversibly bind and inhibit H+K+-ATPase (an enzyme on the

>Headache >Diarrhea >Abdomi nal pain >Nausea >Dizziness >Vomiting >Constipat ion

surface of gastric parietal cells). It inhibits transport of hydrogen ions into the gastric lumen. Omeprazole increases the gastric pH and reduces gastric acid formation.

Ketomed (ketocon azole)

7/6/11 7/7/11

30mg/IV q6 X 4 doses

other treatment. Omeprazole is used for the long-term treatment of pathologic hypersecretor y conditions and active duodenal cancer. It is a maintenance healing of erosive esophagitis. Omeprazole can also be used in the treatment of H. pylori associated with duodenal ulcer and active benign gastric ulcers. It is also used in the prevention and treatment of NSAIDinduced ulcers.

>Nausea >dyspeps ia >GI pain >Anxiety >drowsin ess >dizzines s >headac he.

7/6/11 7/7/11 Nubain (nalbuphi ne HCl)

10mg/SIVP q6 X 4 doses

Short-term management of moderate to severe acute post-op pain.

Nalbuphine HCl has the effect of lowering the cardiac work load and can be

used immediatel y in myocardial infarction (use with caution where emesis is involved). Hemodyna mic studies in patients with severe arterioscler otic heart changes reveal that nalbuphine HCl has circulatory effects similar to those of morphine ie, a minimal decrease in oxygen consumptio n, cardiac index, left ventricular end diastolic pressure.

For the relief of moderate to severe pain. Nalbuphine HCl can also be used for preoperative analgesia, as a supplement to balanced anesthesia, surgical anesthesia, for obstetrical analgesia during labor and for the relief of pain following acute myocardial infarction. Postoperative somatic and visceral pain.

NURSING RESPONSIBILITIES: Prior: 1. check the doctors order 2. Explain the procedure to the patient the importance of the drug, it uses, and effects. 3. Determine hypersensitivity to the drug 4. Prepare the right medication at the right time and with the right dosage During: 1. Adhere to standard precautions 2. Administer at the right route

After: 1. Monitor for hypersensitivity and adverse reactions such as loose stool and diarrhea 2. Inspect IV injection site frequently for signs of phlebitis

E. DIET TYPE OF DIET DATE ORDERE D / DATE STARTE D / DATE CHANGE D/ 7/6/11 GENERAL DESCRIPTI ON INDICATIO N/ PURPOSE SPECIFIC FOOD TAKEN CLIENTS RESPON SE

High fiber

To prevent constipation/ trauma.

Fruits,vegeta bles,

SURGICAL MANAGEMENT F.1 DEFINITION OF THE OPERATION A Fistulotomy is the surgical opening of a fistulous tract. They can be performed by excision of the tract and surrounding tissue, simple division of the tract, or gradual division and assisted drainage of the tract by means of a seton a cord passed through the tract in a loop which is slowly tightened over a period of days or weeks. Fistulas can occur in various areas of the human body, and the location of the fistula influences the necessity of the procedure. Some, such as ano-vaginal and perianal fistulas are chronic conditions, and will never heal without surgical intervention.

F.2 PROCEDURE (PRE OP, INTRA OP, POST OP) Fistulotomy Preoperative Procedures

Most patients who undergo a fistulotomy can go home from the hospital the same day. If a patient must remain in the hospital, he or she is usually discharged the following day. As with any surgical procedure, certain preoperative tests are ordered. Blood and urine tests, a chest x-ray, and an EKG may be required. The need for additional tests depends on the patient's health and if general anesthesia is going to be utilized. These tests are normally done a few days prior to the surgery. Medications that "thin" the blood, including aspirin, are usually discontinued several days before scheduled surgery. On the day of surgery, other prescription drugs may also be held. The need for discontinuing medications must be discussed with the physician before the operation. If general anesthesia is going to be used, nothing can be eaten from midnight on the evening before surgery until after the procedure. This includes all food, water, chewing gum, and candy. This precaution decreases the possibility of vomiting during and after surgery.

Surgical procedure In this procedure, the surgeon opens the fistula tunnel. To accomplish this, a small portion of the anal sphincter usually is cut. Once the tunnel is open, it is then converted to a groove, which allows the fistula to heal from the inside out. Stitches are generally not needed and a dressing may be put in place. If the abscess is still present, the fistulotomy may be postponed until the abscess is drained and healed. A very shallow or small fistula can be treated in a doctor's office, using local anesthesia. Larger fistulas are operated on in the hospital, using spinal or general anesthesia. If the fistula is very deep and penetrates more than one sphincter, multiple procedures may be necessary. Post operative Unfortunately, most patients experience mild to moderate pain following these procedures, and the first few postoperative days can be quite uncomfortable. Medication is prescribed to help cope with the first few days. If the pain is mild, an over-the-counter remedy may be sufficient. All pain medication should be taken according to instructions.

VI. NURSING MANAGEMENT A. NCP Cues Nursing diagnosi s Acute pain r/t inflamma tion of the perirectal area. Scientif ic explan ation Plannin g Intervention Rationale Evaluat ion

S= masa kit ang pweta n ko O: the pt manife

Acu te pain is unplea sant sensor y and emotio

After 6 hours of nursing intervent ion the pt will report pain is relieved.

Vital signs were monito red q 4 until stable & dressin

Alterati

ons from normal

may be signs of infectio n. Moisten

After 6 hours of nursing interve ntion the pt

st: Recei ved pt lying on bed, awake , cohere nt with IVF of D5LR S 700 cc level at 30 gtts/mi n. VS taken as follows : T 36

BP120/80 RR24 PR- 49

nal experi ence arising from actual or potent ial tissue damag e or descri bed in terms of such damag e; sudde n or slow onset of any intensi ty from mild to severe with an anticip ated of predic table end and a durati on of

g was checke d.

High fiber diet was advise d.

ed dressin gs are favorabl e site for microor ganism to culture. To prevent constip ation, and trauma.

report pain is relieve d.

Encour age the patient to drink 3L of fluids a day. Give the patient analge sics.

To soften the stool.

For pain

less than 6 month s.

B. ACTUAL SOPIERS S MASAKIT UNG PWETAN KO O RECEIVED PT LYING ON BED, AWAKE , + TACHYPNEA , AFEBRILE WITH ON GOING IVF OF D5LRS APPROXIMAT ELY 700 CC LEVEL AT 30 GTTS/MIN M E T H O D

Eat nutritious food that high in fiber and drink a lot of water 3ml/day.

Soft diet, high fiber.

C. GORDONS ELEVEN FUNCTIONAL HEALTH PATTERNS

VII. DAILY PATIENTS RECORD/ EVALUATION DAYS NURSING PROBLE MS VITAL SIGNS LAB PROCED URES ADMISS ION PERIAN AL ABSCES S DAY 1 DAY 2 DAY 3 DAY 4 DISCHAR GE

IVF, O2, NGT, NEBULIZ ATION DRUGS DIET

D5LRS 1L/ 30GTTS /MIN HIGH FIBER, SOFT DIET

D5LRS 1L/ 30GTTS /MIN HIGH FIBER, SOFT DIET

D5LRS 1L/30GTT S/MIN HIGH FIBER, SOFT DIET

D5LRS 1L/30GTT S/MIN HIGH FIBER, SOFT DIET

D5LRS 1L/30GGT S/MIN HIGH FIBER, SOFT DIET

D5LRS 1L/30GTT S/MIN HIGH FIBER, SOFT DIET

VIII. DISCHARGE PLANNING A. GENERAL CONDITION OF THE CLIENT UPON DISCHARGE

IX . SUMMARY FINDING X. RECOMMENDATION AND CONCLUSION XI. LEARNING DERIVED XII. REFERENCES/ BIBLIOGRAPHY