CASE PRESENTATION

ON
FAECAL FISTULA

SUBMITTED TO: SUBMITTED BY:

Mrs. Jhunilata Pradhan Ram Ninad Pattnaik

Asst. Professor Msc. Nursing , 2 nd year

Sum Nursing college, BBSR

SUBMITTED ON:
 IDENTIFICATION DATA

Client’s name : Mr. Manas Rana

Age : 20 years
Sex : male
IP No : 6372993185
Date of admission : 22/11/2023
Ward : Ward 7
Bed no. : 23
Education : 10th
Occupation : Business
Marital status : Unmarried
Religion : Hinduism
Address : At/po- Sundargarh, Orissa
Provisional diagnosis : Faecal fistula with abdominal trauma

I. Presenting Chief Complaints:

The patient complaints for –
 Abdominal pain since 2 weeks (Abdominal pain was aggravated from 7 days)
 Feculent discharge from the surgical site since 2 weeks

II. History of Present Illness

Mr. Manas Rana came to Emergency department , SUM Hospital due to severe abdominal pain on
date (22/11/2023) after checkup in E.D , my patient was send to Ward- 7 at 10:45pm.
III. Past medical history
Mr. Manas Rana was taken to a local hospital of Cuttack due to a road traffic accident on October
month of 2023.
IV. Past surgical History
Mr. Manas Rana was having an Exploratory Laparotomy surgery on 4.11.23.
V. Family History
Mr. Manas Rana family have no significant history of any other communicable disseses.
 VI. Family characteristics-
Mr. Ranjit Bisoi lives in nuclear family.

S. Name of the Relationship Age Educationa Occupation Health Status Age &
No. family members with the (yr.) / l Status mode of
Patient Sex death
1 Mr. Rabindra Father 51yr/M Graduation Business Healthy -
Rana
2 Mr. Lalendra Brother 24 yr/M Engineerin Student Healthy -
Rana g

III. Socioeconomic history:

 My patient is the Son of head of the family.
 He belongs to a middleclass family.
 He is a businessman.
 Electricity and water facilities are available in house.
 Drainage facility is proper.
 Income per month: The monthly income is approx. 50,000/-.
 Expenditure : approx.: 30,000 /- rupees
 Recreational facilities : Present
 Medical facilities : Available
IV. Personal History
 Habits & hobbies: His habits is drink lots of water throughout the day.
His hobbies is spending time in Travelling .
 Elimination pattern:
 Bladder elimination :- Self voiding
 Bowel elimination :- He passed stool since admission
 Sleeping pattern: Sleeping pattern is good 8hrs per day
 Nutritional history :
Vegetarian / non-vegetarian: Non-vegetarian
Likes / dislikes: He likes all kinds of vegetables &fish.
Any change in the dietary pattern: Avoidance of irritant foods, fried, fast food and balance diet
is advice.
V. Vital Signs:
S.NO Vital Sign Normal Value Patient’s Value
 1. Temperature 98.6 F 96.8 F

2. Pulse 60 – 80 Beats/M 74 Beats/M

3. Respiration 14 – 20 Breath/M 22 Breath/M

4. Blood Pressure 120/80 mmHg 110/80 mmHg

VI. Visual Analogue Scale: The pain score of my patient is (4 – 5) and the pain is radiating from
lower abdomen.

PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
 LEVEL OF CONSCIOUSNESS : Conscious and response to all my questions
 ORIENTATION : Oriented to time and person and oriented to place
 SKIN COLOUR : Brown
 MOOD : Alert
 ACTIVITY : Active but doctor order to take bed rest
 BODY BUILD : Thin
 NOURISHMENT : Not much nourished
 SPEECH : slow voice
2. ANTHROPOMETRIC MEASUREMENT
 WEIGHT : 59 kg
 HEIGHT : 159 cm
 BODY MASS INDEX : 63.4kg/m2
3. HEAD TO FOOT EXAMINATION
I. HEAD
 SHAPE : Normocephalic
 SCALP : Clean
 HAIR : My patient having black hair and distributed all over the scalp.
 FACE : My patient doesn’t have any puffiness or swelling in face.
  SUBJECTIVE SYMPTOMS : No complaints
II. EYES
 EYE BROWS : Hair are equally distributed and both eyes brows are symmetric
 EYE LASHES : Eye lashes are clean and equally distributed
 EYE LIDS : Normal
 PUPILLARY REFLEX: Reacting to light
 PUPIL SIZE : Round
 SCLERA : White
 CONJUNCTIVA : Normal
 CORNEAL REFLEX : Present
 VISSION : Normal
 EYE MOVEMENT : Conjugate eye movement
 USE OF GLASSES/CONTACT LENSES : My patient is not using any type of
glasses/ contact lens.
 SUBJECTIVE SYMPTOMS : No complaints
III. EARS
 USE OF HEARING AIDS : No
 EAR CANAL : Both the canals are clean
 TYMPANIC MEMBRANE : Normal
 HEARING : Weber test is done and my patient can hear in both the ears
 SUBJECTIVE SYMPTOMS : No complaint
IV. NOSE
 EXTERNAL NOSE : Normal in shape and symmetry in size
 NASAL SEPTUM : Central
 NASAL POLYPS : Absent
 NASAL MUCOSA : There is no swelling, bleeding or any discharge
 FRONTAL & MAXILLARY SINUSES: Normal
 SMELL SENTATION : Present
 SUBJECTIVE SYMPTOMS : No complaint
V. MOUTH & THROAT
 LIPS : No redness and swelling and lip is symmetry
 TEETH : Clean
 GUMS : No bleeding is present
 TONGUE : Clean, moist all around tongue without any redness
 UVULA : No tenderness or redness
 TASTE : Normal taste present
 BAD ODOUR : Present
 TONSIL : Enlargement is not present
 VOICE : slow voice
 SUBJECTIVE SYMPTOMS : No complaint
VI. NECK
 NECK : No mass is present
  RANGE OF MOTION : Possible
 THYROID GLAND : Not enlarged
 JUGULAR VEIN : Not distended
 TRACHEA : Midline
 SUBJECTIVE SYMPTOMS : No complaints
VII. THORAX AND LUNGS
 THORAX : Symmetrical
 THORAX EXPAINSION : Normal & Equal
 BREATH SOUND : 22 breath/min
 COUGH : Absent
 SPUTUM : Absent
 SUBJECTIVE SYMPTOM : No complaints
VIII. HEART
 HEART SOUND : S1 & S2 sound is present but S3 & S4 is absent
 APICAL PULSE : Absent
 PERIPHERIAL PULSE : 82 beat/min
 PACEMAKER : Absent
 OXEYGEN SUPPORT : Absent
 SUBJECTIVE SYMPTOMS : Room air
IX. GASTROINTESTINAL SYSTEM
 MOUTH : Clean
 TEETH : Clean
 TONGUE : Clean
 ORAL ULCER : Absent
 ABDOMEN : Surgical wound present
 PERISTALSIS : Present
 NUTITIONAL ROUTE : Oral feeding
 BOWEL OPENED : Present
 APPETITE : Normal
 PERCUSSION : Presence of Air
 INGUINAL LYMPH NODE : No nodes are present
 LIVER : Normal in size
 SPLEEN : Normal in size
 KIDENY : Normal in size
 BOWEL SOUND : Present
 PERIANAL SKIN INTEGRITY : Intact
 SUBJECTIVE SYMPTOMS : Abdominal pain present science 7 days and
Feculent discharge from the surgical site since 2 weeks

X. GENITOURINARY SYSTEM
 URINATION : Self Voiding
 URINE : No sediments are present
  GENITALIA : No discharge or edema is present
 SUBJECTIVE SYMPTOMS : No complain
XI. INTEGUMENTARY SYSTEM
 SKIN : Intact
 COLOUR : Brown
 TEXTURE : Normal
 TURGOR : Normal
 HYDRATION : Not hydrated
 TEMPERATURE : 96.3F
 DISCOLOURATION : Absent
 CYANOSIS : Absent
 PERIPHERIES : Warm
 ICTERUS : Absent
 LESIONS/MASSES : No lesions/ masses are present
 SUBJECTIVE SYMPTOMS : Dry skin
XII. MUSCULOSKELETAL SYSTEM
 POSTURAL CURVES : Normal
 MUSCLE TONE : Normal
 UPPER EXTRIMITIES
 SYMMETRY : Upper extremities are symmetrical
 MUSCLE STENGTH : Weakness
 RANGE OF MOTION : Possible
 BICEPS REFLEX : Normal
 TRICEPS REFLEX : Normal
 OEDEMA : Absent
 JOINTS : NO complaint
 DEFORMITY : Absent
 LOWER EXTERMITIES
 SYMMETRY : Lower extremities are symmetrical
 MUSCLE STRENGTH : weakness
 RANGE OF MOTION : Possible
 OEDEMA : Absent
 JOINTS : No Tenderness
 DEFORMITY : Absent
 GAIT : Normal
 VARICOSE VEINS : Absent
 DEPENDENCY LEVEL : Independent
 SUBJECTIVE SYMPTOMS : Pain in lower abdomen

FAECAL FISTULA
INTRODUCTION

A Fistula is an abnormal connection between two body parts , such as an organ or blood vessel and
another structure. Fistulas are usually the result of an injury or surgery. Infection or inflammation can also
cause a fistula to form.

DEFINITION

An faecal fistula or enterocutaneous fistula ( ECF) is an abnormal communication between the small or
large bowel and the skin. An ECF can arise from the duodenum, jejunum, ileum, colon or rectum.

ETIOLOGY-

SL.NO ACCORDING TO BOOK ACCORDING TO PATIENT

RISK FACTORS
Abdominal trauma Abdominal trauma
Intra-abdominal sepsis Surgery on G.I Tract
Crohn diseases Intra- abdominal sepsis
Inadvertent small bowel injury
 Surgery on G.I Tract

PATHOPHYSIOLOGY

CLINICAL MANIFESTATION OF Faecal Fistula

SL.NO ACCORDING TO BOOK ACCORDING TO PATIENT

1. Severe Pain in the lower abdomen. Abdominal
swelling, distension or bloating Pain in the middle or right
upper abdomen.
2. Vomiting
3. Malnutrition. Malnutrition
4. Low grade fever and chills Feculent discharge from
5. Feculent discharge from the surgical site surgical site
6.
7.
8.
9.

DIAGNOSTIC EVALUATION (ACCORDING TO BOOK)

 Physical examination
 History collection
 Abdominal ultrasound
 CT Scan
 Blood test

ACCORDING TO PATIENT

 History was collected and known that my patient having a abdominal trauma 2 months ago .
 Physical examination-on palpation abdomen is slightly enlarged and pain present.
 Endoscopy :Upper GI Endoscopy- Duodenal scar; Duodenal submucosal Lession.
 Abdominal ultrasound-Normal in shape and size multiple calculi and fistula size 15cm, POD 4/5 .

SL.N INVESTIGATION PATIENT’S VALUE NORMAL INTERPRETATION

O VALUE
1. Complete blood
count
Blood studies
Haemoglobin 10.2gm/dl 13-17 Decreased.
Total Red blood 3.95ul 5.5-5.9 Decreased
cell count 33% 36- 52 Decreased
PCV 83.5fl 81-97 Normal
MCV 25.8pg 26.0-34.0 Decreased
 MCH 1.5-4.5 Normal
Platelets 1.75 lakhs 4.4-11.3 Increased
Total WBC 13.26 mil/ul 40-80% Normal
different count 80% 24-40% Decreased
Neutrophil 14.7% 0-3% Normal
Lymphocytes 0.1% 4-8% Normal
Eosinophil 0.55 1-2% Decreased
Monocytes 0.3% 0-20 Increased
Basophils 60mm/1hr Increased
ESR
120-140mg/
Routine dl Normal
2. Investigation 101mg/dl <7 Fair control
RBS 6.7% 13-45mg/dl Increased
Hba1c 60mg/dl 0.5-1.5 Normal
Blood urea 1.04mg/dl 135-145 Decreased
S.creatinine 132mg/l 3.5-5 Normal
S.sodium 3.6meq/l Normal
S.potassium 95-115 Decreased
96meq/l
S.Chloride 12.4sec
PT control 1.00
INR 7.35-7.45 Normal
3. ABG 7.433 35-45mmhg Normal
PH 35.7 70-100mmhg Normal
PCO2 72.2 22-26mmol/l Low
PO2 21.9
HCO3
Yellow
4. Urine test Clear
Colour 2-3hpf Normal
Appearance 2-3hpf 4.8-7.5 Normal
Pus cell 5.5 1.003-1.060 Normal
PH 1.020 2-20 increased
Specific gravity Negative <10
Sugar 1+50mg/dl M-2-5,f-8-10 Increased
Protein 2-3hpf 0-2 Increased
Epith cell 4-5hpf 0.3-1.0
RBC 0.55mg/dl
5. LFT 0.1-0.4
Bilirubin(T) 0.20 5-40 Normal
BIilirubin(D) 12.40 IU/L 40-129 Increased
888.00lU/L 6.8-8.3 Normal
SGPT 6.3gm/dl Increased
Alkaline 3.3-5.2
phosphate 3.3gm/dl 2.5-3.6 Decreased
Protein 3.0gm/dl Normal
Albumin
Globulin

6 Lipid profile
Total cholesterol 190mg/dl 150-200 Normal
HDL 40-60 Normal
 LDL 44mg/dl 70-130 Normal
VLDL 123mg/dl 20-40 normal
Triglycerides 24mg/dl 50-150 normal
121mg/dl

BLOOD GROUPING - O positive

Rh typing- Positive

COMPLICATION-

SL NO ACCORDING TO BOOK ACCORDING TO PATIENT

1 Malnutrition
2 Dehydration Leakage from abdomen
3 Skin infections dehydration
4 Diarrhoea
5 Leakage from an opening of abdomen

MANAGEMENT
ACCORDING TO BOOK ACCORDING TO PATIENT
Non pharmacological measure-  Complete bed rest.
 Promote bed rest.  Ensure hydration
 Ensure liquid diet.

Pharmacological management-
 Antiemetics(To prevent or supress Tab. ondansetron (8mg) SOS
vomiting) Tab. Pantoprazole (40mg) OD
 Proton pump inhibitor(Supresses gastric
secretion)
 Gallstone Dissolving Drugs(Dissolve in bile
with the help of bile salts)-Ursodeoxycholic Tab. Tapentadol Extended release (Tapal-ER)
Acid and Chenodeoxycholic Acid 50mg sos
 Analgesic(To reduce pain)
 NSAID(Relieve pain,inflammation and
fever)- Diclofenac
Tab. Taxim-o (200mg) BD
 Anticholinergic-Hyoscine
 Antibiotic(Cephalosporins)
Third generation-Cefixime

Surgical management- Explaratory laparotomy

1. Explaratory laparotomy

NUTRITIONAL PLAN-
Continue with liquid diet.

APPLICATON OF VERGINIA HENDERSON’S NEED THEORY IN NURSING PROCESS-

Henderson was born on 30th November, 1897 in Kansas City, Missouri and dies on 17th march 1996.

She called as “the Nightingale of modern nursing”, “Modern -day mother of nursing”

She earned her Diploma in nursing .from the army school of nursing in 1921, Bsc .in 1932, M.A in 1934.

She worked as a teaching nursing in 1923, member of faculty. And research associate.

She was honored at the annual meeting of the nursing and allied health section on the medical library
association.

She created basic nursing curriculum for nursing in 1937

She developed the theory in 1950 -1970.

She proposed 14 components of basic nursing care.

 Pain reduce
 Eat and drink adequately.
 Eliminate body waste
 Move and maintain desirable posture
 sleep and maintain desirable posture
 sleep and rest
 select suitable clothes-dress and undress
 Maintain body temperature within normal range
 Keep body clean and well groomed and protect from injury.
 Avoid dangers in the environment and avoid injuries others
 Communicating with others in expressing feeling
 worship according to one’s faith
 work in such a way that there is a sense of accomplishment
 Play and participate in various forms of recreation, learn, discover, or satisfy the curiosity that
leads to normal development.

Nursing care plan :( By q application of nursing theory)

ASSESSMENT

 patient had abdomen pain , assess the location, severity(0-10 scale) and character of pain.
 Eat inadequate diet ,he was thirsty demanded more orally fluids
 Elimination Patient was self void ,no bowel movement, since two days
 Moving: Able to move self in bed with support.
 Dressing and undressing appropriately: he was dressed independently.
 Avoiding dangers and injury to others: he was conscious and orientated and able to follow the
instruction regarding safety.
 Communication: he was able to express self clearly. Hear and saw clearly.
 NURSING DIAGNOSIS:-

 Acute pain related to impaired skin integrity related to surgical procedure.

 Imbalanced Nutrition less than body requirements related to Loss of appetite as
evidenced by weakness.
 Anxiety related to change in health status as evidenced by irritability.
 Deficient knowledge related to disease condition as evidenced by asking frequent
question.

ASSESSME NURSING GOAL PLANNING IMPLEMENTATI RATIONALE EVALUATI

NT DIAGNOSIS ON ON
Based on
Virginia
Henderson’s
Theory
Subjective Impaired skin Patient will Assess the -monitored To identify Patient pain
data: integrity related display cause ,locat location, type and was
Patient says to surgical timely ion and duration, severity of relieved .
that feel pain procedure . healing of severity of intensity of pain, pain. he feel
in abdomen (Expl.laporotom wound pain by using 0 to 10 comfort.
and feculent y). without scale in pain
discharge complicatio scale.
from ns. -To obtain
surgical site Monitor -Monitored baseline
in the vital signs blood pressure, data.
abdomen pulse and
Provide respiration.
comfortable - To feel
Objective position -Provide comfort.
data: comfortable
Tenderness position by lying
and rigid on left lateral
abdomen
position.
right upper
quadrant and
Kept the
facial area clean -Administered To relieve
expression and dry. Analgesic as per pain
VAS-4-5 doctor’s advice-
Diclofenac.

Imbalanced Patient Assess the Checked To collect

Subjective nutrition less nutritional nutritional nutritional status the baseline Patient’s
data: than body status will status and data nutritional
Patient says requirement be improved needs of the status was
that feel related to loss of patient improved
weakness, appetite as To identify as
indigestion evidenced by Assess the Checked BMI evidenced
and nausea. weakness weight and BMI-63.4kg/m2 by increase
BMI To prevent weight
Objective Advice for Advice for indigestion
data: healthy diet healthy diet like
Abdominal high-fiber food
pain score and avoid fat
increased, diet
Weight
decreased Rest for 6-7
BMI- Encourage hours To easily
underweight patient for digestion
bed rest Administered IV
fluid like
NS,DNS and RL
Administer as per doctor’s To improve
ed IV fliud order hydration
As per
doctor’s
order

Subjective Anxiety related Patient Asses the Assessed To know Patient

data: to change in anxiety will patient behavioural the baseline anxiety was
Patient health status as be reduced anxiety response. data reduced
having stress evidenced by level some exent.
and worried insomnia and
about irritability Encourage Encouraged to
disease to take rest take 6-7 hours To reduce
stress
Objective Provide Provided
data: divertional divertional
Anxiety and therapy therapy like To feel
insomnia listening music, relax
reading book etc
Provide
psychologic Provided
al support psychological To maintain
support good
Interperson
al
relationship
Subjective Deficient Patient will Assess the Assess the To educate Patient was
data: knowledge be gain patient patient know the patient gain
Patient says related to knowledged language odia language in their own knowledge
that lack of disease regarding and include language on disease
knowledge condition as the disease family and at their condition
regarding evidenced by condition members or own level and home
disease asking frequent significant of care
question others in understandi managemen
Objective teaching. ng t
data :
Asking Advice Advice to eat
frequent regarding high fiber food To know
question food and avoid fat the good
food nutrition
Educate the
disease Educate the
condition disease
condition its To gain
causes, sign and knowledge
symptoms, regarding
complication the disease
and treatment condition

HEALTH EDUCATION-

DIET-

- Advice do not skip meals.

- Instruct for take 1.2 to 1.5 lit water per day.
- Advice to eat high- fibre diet.
- Avoid high spicy and fatty food.
- Teach maintain about input and out put chart.
- vital signs and weight regularly.

Management of disease condition

- Teach the patient and family members about cause ,effects,treatment,prognosis and complication
of faecal fistula.
- Teach the patient to recognize and report complication like pain , weakness, nausea and vomiting.
- Advice to avoid strees and strain.
- Advice the family members for provide home care to the patient.
- Teach relaxation techniques i.e like watching TV ,reading news paper,meditation.
- Do regular exercise to maintain healthy weight.
- Teach the family members about support the patient psychologically and physically.

Medication

- Teach the patient and family member about time and frequency of taking medication.
- Teach the family members for skip of drug may induce serious complication.
 - Teach about side effects of medication.
- Advice to complete the course of medication.

Follow up-

- Instruct the patient to review for re-checkup as a prescribed.

- Advise that if any side effects occur then report to the physician.
- Advice for regular CBC ,TSH,T3 and T4.

CONCLUSION

A Fistula is an abnormal connection between two body parts , such as an organ or blood vessel and
another structure. Fistulas are usually the result of an injury or surgery. Infection or inflammation can also
cause a fistula to form.

Early detection of symptoms and prompt management is necessary to prevent the further complications
and prevent the patient from life threatening condition.

BIBLIOGRAPHY

 Brunner & Suddharth’s. Textbook of Medical Surgical Nursing; 11th edi; New Delhi: Reed
elseiver .- (p) LTD Page no-
 Tripathy KD.Essential of medical pharmacology; Seventh Edition; Jaypee Brothers medical
publishers (p) LTD. Page no-661-671
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