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Hemorrhoids the Bottom Line
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Hemorrhoids the Bottom Line
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Hemorrhoids, The Bottom Line
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 2- Approximate time required: 120 min.
Educational Goal:
To educate Adult Foster Care providers about hemorrhoids.
Educational Objectives:
Define hemorrhoids.
Present the signs and symptoms of hemorrhoids.
Instruct about the non-serious nature of occurrences
Provide caregiving and follow-up instructions
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Hemorrhoids, The Bottom Line
For a caregiver not too many events can cause more concern than finding blood coming from the bottom of one of your residents. What’s causing the blood to flow? Is it a minor scratch, a bad infection, or is it a symptom of something really serious like cancer? This has happened to me several times in my caregiving career. We sent the patients to the doctor and waited anxiously for the diagnosis. Most of the time, the diagnosis came back as a case of hemorrhoids. I remember the first time I had to deal with a case of hemorrhoids. I thought, “What’s a hemorrhoid and how am I supposed to take care of that? You can’t exactly put a Band-Aid on their bottom, can you?”
Definition
Hemorrhoids are swollen veins around the anus and lower rectum. They look like lumps of discolored purplish flesh giving rise to their other name, piles. There are two places where hemorrhoids form. The first is just under the skin around the anus. These are called external hemorrhoids. External hemorrhoids are usually asymptomatic and don’t cause any problems. The second place they are found is inside the rectum. These are called internal hemorrhoids. Internal hemorrhoids have several grades based on the severity of the symptoms experienced by the patient.
Both kinds of hemorrhoids are typically not serious. Often they resolve spontaneously within about a week. Sometimes when the swelling goes down, a skin tag (excessive skin) is left behind.
Signs and Symptoms
A physical description is not much use to an in-home caregiver. You’re not likely going to inspect your client’s bottom - that’s just plain weird. You can, though, be on the lookout for the outward signs of hemorrhoid trouble.
Causes and Risks
Everyone has the potential to get hemorrhoids because of how humans are built. Since up to 75 percent of humans may experience them in their lifetime, it has been speculated that this is just the price we must pay for being upright beings. We are subject to the pull of gravity that puts pressure in the anal region. The reason engorgement and swelling sometimes occurs in the rectal veins is not clearly understood. What is understood is that there is an increase in pressure in the lower rectum. Increases in pressure are caused by:
Skin and tissue tone weaknesses can also lead to engorgement. Age is definitely a risk factor and so is anal surgery. Other risk factors include events that force a lot of sitting like wheelchair- bound patients or paralysis victims. Of course, any lifestyle choices that lead to any of the above could be considered risk factors for hemorrhoids. For example, a low-fiber diet that leads to constipation or chronic use of diarrhea medicine as seen in anorexia and bulimia sufferers put these residents at greater risk.
Seriousness
Any time blood comes from the bottom, it’s a cause for concern among caregivers. Too many serious problems can cause rectal bleeding. It would be wise when blood or pain appears to send patients to the doctor just as a matter of course. If the diagnosis comes back as hemorrhoids, then caregivers can relax a bit. Most occurrences are not serious and considered minor problems by health professionals. According to one expert, Dr. Howard K Berg of the University of Maryland St. Joseph Medical Center, “treatment for hemorrhoids is only undertaken if they are truly symptomatic. The mere presence of hemorrhoids is not an indication for any therapeutic intervention.”
What’s a caregiver to do then?
Don’t be surprised if the doctor does little or nothing at all. The doctor knows that most cases will go away by themselves within a week. Caregiving mainly deals with patient comfort issues. This is where you as a patient advocate might have to kick up a bit of a fuss. If your patient is uncomfortable and needs attention and the doctor has done nothing, remind the doctor that you can’t treat the patient without doctor’s orders. That includes minor over-the-counter comfort therapy for hemorrhoids. It may be minor to a doctor but they still have to do something about it. If the doctor can’t be bothered with such trivial occurrences, get his nurse or even a home health nurse to follow up and get you the necessary orders.
When does it become serious?
Complications that can turn a minor irritation into a more serious concern are very rare, but you should know about them anyway. Events that require further medical intervention are:
Other Caregiver Factors
There are some important anatomic facts that caregivers should know about. Where the hemorrhoids occur should matter to caregivers. External anal tissues have a lot more nerve endings than internal tissues. Pain and discomfort problems are more likely to occur. Internal hemorrhoids may be less painful but prolapsing outside the anal sphincter has its own problems to contend with. If internal hemorrhoids are associated with pain, then the seriousness factor has jumped significantly.
Dealing with the Diagnosis Process
There is a justifiable amount of embarrassment and fear when hemorrhoid symptoms first appear in patients both on the resident and caregiver’s part. No one want’s to talk about or inspect a bottom. Embarrassment leads to inaction, which leads to prolonged suffering on the part of your residents. Uncomfortable residents are bad for business and make caregiving harder. Experienced caregivers can help reduce embarrassment and fear by educating residents about what might be going on and what might happen when they go to the doctor’s office. If you suspect the resident has hemorrhoids, I suggest the following:
Caregivers could also include in the patient’s file any questions that they want the doctor to answer. The Mayo Clinic website suggests the following questions:
Source http://www.mayoclinic.org/diseases-conditions/hemorrhoids/basics/preparing-for-your-appointment/con-20029852 questions modified to fit article
Treatments
Most hemorrhoid occurrences are not serious health concerns and will resolves themselves in a week or so. Treatments ordered by the doctor will most likely be of a preventative nature or symptom relief. If in the rare case more aggressive treatment is required, there are simple surgical procedures that can be utilized, many done on an outpatient basis. If these procedures are done, recuperative therapies will need to be performed. So that you can more fully follow any doctor’s orders, let’s go over all the possible treatments that could be ordered.
Prevention
The best treatment is to not get hemorrhoids in the first place. But if they do occur, there will always be the chance that they will pop out again in the future so prevention should be taken seriously. Fortunately most prevention therapy is what you are doing already as part of your regular caregiving duties.
Symptom Relief
You can count on the doctor first giving orders that have more do to with getting rid of patient discomfort than eliminating the hemorrhoids. As I stated earlier, the hemorrhoids will most likely disappear by themselves in a week or so. If they don’t, then it’s time to contact the doctor again. The doctor has many choices of medication to choose from. A lot of them are over-the-counter products that can be self- administered. Letting the resident apply medication to their own bottoms is a lot less embarrassing, but you still have to get doctor’s orders to cover your own bottom. You also have to make a judgement call of whether the resident has the mental capacity to apply the medication appropriately, as in the case of the developmentally disabled. If this is the case, it would be wise to get a nurse delegation, again to cover your own tush.
Medications
There are 123 medications approved for hemorrhoids. Most are combination products. Each doctor will have their own favorite variety but usually are open to requests. They are sold in various forms, including creams, ointments, suppositories, and chemical wipes. I’ll explain all of them as group by major ingredient, what they do, and what to watch for as a caregiver. It will be up to you to read the ingredient list of the product that you use to determine what actions will be required by you.
Local anesthetics - benzocaine, benzyl alcohol, dibucaine, lidocaine, and pramoxine. These are all short-acting numbing agents. Since they wear off fairly quickly, frequent re-application might be needed. Some patients are allergic to the “caines” (drugs names ending with caine). If a red rash appears or increased irritation is felt, then avoid all the caines in the future. Notify the doctor and dentist of the allergy because the caines are used a lot by them. Wash hands after use because often people forget then rub their eyes or nose and have to deal the numbness that follows. This might sound kind of stupid, caregivers wear gloves to apply medicines after all, but residents do not. Residents applying it themselves will have to be reminded every time or even be supervised in their hand washing. If there are any open sores, the med will sting before the numbness kicks in. A very rare but life-threatening occurrence happens when too much lidocaine is absorbed through the skin and gets into the blood stream. Basically the heart muscle is numbed and the person can die. To avoid this, do not attempt to apply large amounts in an attempt to reduce the number of re-applications needed. Internal hemorrhoids don’t have very many nerve endings to numb so these drugs will mostly not be prescribed. If there is pain associated with internal hemorrhoids, that’s a red flag and should be brought to the attention of the doctor.
Vasoconstrictors - ephedrine, epinephrine, and phenylephrine. These medications shrink blood vessels. They also make them less leaky. It is easy to understand why the medication could be useful in reducing a swollen hemorrhoid. Unfortunately, the drug that is absorbed into the blood stream can constrict blood vessels throughout the body. Those residents with uncontrolled diabetes or hypertension, cardiovascular disease, hyperthyroidism, enlarged prostate, and glaucoma should avoid the use of preparations that contain vasoconstrictors. Residents taking monoamine oxidase inhibitors, tricyclic antidepressants, or high blood pressure drugs should avoid the use of topical vasoconstrictors because they can cause adverse drug events. If the doctor orders you to use them anyway, monitor the resident more closely for signs of trouble. In most cases, short-term use will cause no real problems.
Protectants - zinc oxide, shark liver oil, cocoa butter, topical starch, and lanolin. Think of these agents as barriers, just like diaper rash creams. They prevent nasty things from coming in contact with the protected area. They also keep the area from drying out and provide lubrication against abrasions and pain. They are well tolerated and don’t cause many caregiver concern in their use. Petroleum jelly could be used for this purpose as well. It could be applied after every bowel movement.
Analgesics/anesthetics/antipruritic - menthol, juniper tar and camphor. These are called counterirritants. They work by giving the body something else to focus on beside the pain from the hemorrhoid. I wouldn’t recommend using them by themselves and in my opinion have limited use in hemorrhoid treatments.
Astringents- calamine, zinc oxide, and witch hazel. These chemicals tend to shrink or constrict body tissues by coagulating the proteins on the cell’s surface. This provides temporary protection of irritated rectal areas and relieves the irritation and burning that hemorrhoids can cause. Calamine and zinc oxide have astringent activity (in addition to being protectants) and may be applied internally or externally. Witch hazel is applied only externally. Witch hazel pads are very convenient to use after every bowel movement. First wipe, and then use the medicated pads.
Corticosteroids - hydrocortisone 1%. Hydrocortisone is a weak member of the steroid anti-inflammatory class of drugs. It mimics the body’s own system for reducing inflammation. It can also help reduce itching (pruritus). It may be a mild form, but it is still a steroid and precautions must be taken when used. Keep hydrocortisone out of the eyes and other sensitive areas by proper hand washing after application. Do not apply it for more than two weeks without doctor approval. Prolonged use can thin the skin. If the skin is compromised already as in the case of the infirmed and the elderly, nasty skin tears may occur.
Caregiving Considerations 
Treating the hemorrhoid condition depends on the severity of the symptoms not the extent of the hemorrhoids. If they are not painful or bleeding, then don’t worry too much about them. If they prolapse, put on a glove and push them back in. If there is discomfort, get the resident to the doctor or get the home health nurse out so that you can get doctor’s orders for therapy. There are a few other things you can do beyond preventative efforts and medication. Some of these suggestions might be considered therapy, so if you’re worried about it, get prn doctor’s orders.
Curative Therapies
Regardless of your good caregiving effort, sometimes hemorrhoids stubbornly won’t go away or cause more serious concerns. It is important for you to know what advanced therapeutic options are available so that you can help your residents deal with this embarrassing condition. Treatments are determined by the doctor based on the severity of symptoms. All but the most severe can be handled by minimally invasive procedures. They often can be done right at the doctor’s office or other outpatient setting and the patient can come home right after the procedure.
Pain Due to a Blood Clot
If there is a blood clot in an external hemorrhoid, the doctor can do a simple incision to remove the clot. The pain often is relieved right away. Proper wound care will be required until the incision heals.
Chronic Conditions
For persistent bleeding or chronically painful occurrences, there are a number of simple procedures the doctor can choose from.
Large Hemorrhoids
Surgery may be required for larger hemorrhoids or failures in other therapies. This is considered simple surgery and is performed in an outpatient setting or an overnight hospital stay.
Conclusion
There you have it - the subject of hemorrhoids from to top to bottom, and I really do mean the bottom this time. The bottom line for the resident is though the pain and bleeding can be troubling, if it’s caused by hemorrhoids it really is no big deal. The bottom line for caregivers is get the resident checked out by the doctor and helps your resident deal with an embarrassing subject and symptom-relieving therapies. If more advanced therapies are required, they are also simple in nature. Now I have said bottom way too much in one paragraph so I will simply finish by writing the end. (I bet writing the end made you think of something else.)
As always, good luck in your caregiving efforts.
Mark Parkinson RPh.
References:
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What are Water Pills?
Author: Mark Parkinson RPh: President AFC-CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To provide a better understand of what water pills are.
Educational Objectives:
Define water pills and diuretics.
List the uses of diuretics.
Instruct how diuretics work in the body
Tell what caregivers need to know about diuretic medication.
Procedure:
Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
What are Water Pills?
Just about everyone in the care business has heard of water pills. But if you look at your residents’ medication list, you will not find anything labeled as a water pill. First, one doctor tells the patient this medication is a water pill. Then a nurse mentions that the medication is a diuretic. Then your pharmacist will counsel you that the medication is one of several different classes of medications referred to as water pills. What’s going on? One of the more common medications that care providers have to deal with are so-called water pills. What are water pills? What do they do? How do they work? Most importantly, what do caregivers have to know about them?
Definition
To help clarify the situation, let’s start off with a definition and medical terminology. The term “water pills” is everyday slang for the medical term diuretic. A diuretic is anything that causes an increase of the production of urine. To the common man, it may 
sound better to say, “I have to take my water pills” rather than “I have to take my urine pills.” Ugh, that does sound unpleasant. It would be more accurate to say, “I have to take my ‘get rid of my extra water by increasing my urine output’ pills.” That’s way too long so most people just say water pills. When communicating with other medical personnel, it is more professional for caregivers to use the correct term of “diuretic.” That’s how I will refer to it for the rest of the article. After all, you are a medical professional.
Uses
Diuretics have been around for a long time. They were first discovered when it was noticed that certain sulfa antibiotics made patients go the bathroom more. Before that time, it was difficult to remove unneeded water from the body. So specialized medications were developed to take advantage of this side effect. Many decades later, there is a proliferation of diuretics in multiple drug classes. Most of them now have cheap generics, which make them all the more favorable to use as first-line therapy for many illness and conditions.
Diuretics are used in the treatment of heart failure, liver cirrhosis, hypertension (high blood pressure), influenza, water poisoning (too much water), certain kidney diseases, and tissue swelling (ankle swelling or other edemas). They are also used to help excrete unwanted substances by increasing urine output, like in aspirin overdose cases.
They are often misused by patients to lose water weight and mask illegal drug use. That information is particularly useful for mental health homes. They have to watch for diuretic misuse in their anorexic and bulimic residents and those who try to hide the self-treatment of mental illnesses with mood-altering drugs.
How They Work
It might seem a bit of a stretch for adult foster caregivers to learn how medications work. I assure you, it’s not. For you, it’s not about making therapeutic decisions; it’s about monitoring for effect. It’s part of your job to observe and report anything out of the ordinary.
I would like for you to consider the following questions about water pills and your residents: “How do you know what is unusual if you don’t know what the medication does? Is that mid-day nap just daytime drowsiness or a side effect of the medication? Is that demand for additional glasses of water mean the diuretic is working too well? Is that new diuretic going to make your resident wobbly on their feet and possibly fall and hurt themselves? The answer to all of these questions is maybe yes. Wouldn’t your job be easier if you knew that beforehand and could watch for those diuretic medication effects?
First things first, to monitor for effect, you have to know which medication is a diuretic. The drug lists and medication information you receive probably will not readily notify you that a medication has a diuretic effect, so I will.
Common Diuretic Medications
Many of these medications are combined with other drugs, especially blood pressure and heart meds. It is also common to combine different classes of diuretics into one pill.
Caffeine is also a diuretic. Over-the- counter water pills are most likely just caffeine pills. Too much glucose in the blood can also make you pee more because water follows sugar.
Water also follows salt, which is how most of these medications work. To understand how, let’s briefly discuss the science of osmosis. If you pour water on a slug, all the water will be pulled out and it will turn into a gooey mess. If you put salt on meat, the water will be pulled out and the meat will get salt cured. Water always flows to where there is salt. If you want to pull water past a membrane, put a bunch of salt on one side and the water will flow through the membrane toward the salt. We call that process osmosis. Let’s now talk about how the body uses osmosis to get rid of water. It all happens in your kidneys.
Kidney Anatomy and Physiology
The kidneys are two bean-shaped organs, about the size of your fist. They are located just below the rib cage on either side of the spine, toward the outside of your back. All of your blood flows into and out of the kidneys several times a day. When the waste-filled blood comes in to the organ, it flows into millions of filtering units called nephrons. Each nephron starts with a globe-like sieve called a glomerulus. It screens out the bigger blood elements like the red blood cells and proteins. The rest of the waste-filled liquid flows into loop-shaped tubules. By the end of the tubules, all that remains is the waste that flows into the bladder through the ureters. The cleaned fluid is then put back into the blood stream.
You might have heard that your kidneys act like a filter to remove waste products from the body. It’s a bit more complicated than that. A filter prevents material from flowing through it. We want to get rid of the waste, not retain it. So the kidney is designed to let most of the liquid elements of our blood flow into tubules. As the liquid flows through the tubules, the kidneys pull back in what our bodies need. What’s leftover collects in the bladder and we void it as urine. Here’s the interesting part. The kidneys do not pump the water back in. They pull back the salts. Water naturally follows the salts by osmosis, and we are able to reabsorb the water and the salts we need to retain. Yes, that is very cool and more importantly that explains a few things about high blood pressure control, salt intake, and diuretic medication effects.
Effects of Diuretics
A major way your body is set up to control blood pressure is by controlling how much salt is taken back in at the kidney’s nephrons. If the body needs to lower the pressure of the blood, one way it reduces it is by reducing how much salt is taken back in the kidneys. More salt in the urine means more water flows into the bladder.
Modern medicine has learned to take advantage of that mechanism. Doctors are able to reduce fluid retention, lower blood pressure, and reduce the burden on internal organs, especially the heart. The easiest way to do this is by reducing our salt intake. The less salt in the blood stream, the less fluid is retained in the blood. That is why the doctor will recommend a sodium-restricted diet as first-line therapy for many illnesses. If that is not enough, then the doctor can prescribe diuretic medications to kick the effect up a notch or two.
What the Caregiver Has to Know
Adult foster care providers are everybody’s helper. You are in the business of serving everyone. You serve the patient by ensuring a lifestyle that is as healthy and normal as possible. You serve the doctor by monitoring their patient and notifying them when something seems wrong. It all starts with knowing your residents and knowing what the doctor is trying to do for them. As you know, though, that is easier said than done. Adult foster care providers are at the far end of the medical pecking order. Far too often, no one bothers to tell you what’s going on medically with your resident. It’s up to you to find out. It’s part of your job to ask the questions and keep asking until you know. Let me provide you with some answers.
Effects
When you see a diuretic medication on a resident’s med list, the doctor is trying to remove bodily fluids. The doctor hopes that by doing so, a desired effect will be produced, most likely lowering blood pressure, reducing edema, and making it easier for a weakened organ to function.
What you as a care provider have to monitor for is:
Side Effects
Diuretic medications can have other effects on the body that the doctor never intended. Most are just annoyances that you just has to endure. Some are temporary and will go away by themselves as the body gets used to the medication. Some are very serious that you the caregiver must watch for.
I recommend that you read the side effect info that comes with any new prescription. Watch for the listed side effects for a couple of months. After that, just watch for the unusual occurrences in the resident’s life.
Generally speaking watch for:
A Few Special Notes
A gout attack can be caused by dehydration and electrolyte imbalances. They are very painful, so any occurrence should be called in to the doctor. Attacks usually occur in the big toe. If they continue to happen, it would be prudent to ask the doctor if the diuretics are contributing to the problem.
Many diuretic medications work on or are affected by the body’s prostaglandins. They are chemicals produced by the body to regulate many bodily functions. NSAIDs also work on the prostaglandins. An increase in NSAID use may cause more diuretic side effects. Generally, the occasional use will not cause any issues, but if the MAR’s prn chart shows a lot of NSAID use, then go back to monitoring closely for diuretic side effects.
It has been shown that diuretic medication use can cause diabetic problems. If you take care of a diabetic, monitor closely blood sugars when using diuretics.
As a general rule of thumb, diuretics are taken in the morning so as not to disturb sleeping patterns by having to go to the bathroom.
Some diuretics bleed off potassium, others are called potassium sparing. I would talk to the doctor about any salt substitutes that you use in cooking. Some of them are potassium chloride. There is the potential for messing up the resident's electrolytes.
Conclusion
Water pills, who knew that they would be that complicated? At least now you understand them better and are more prepared to monitor for effects. Just keep track of the blood pressure, take the edema measurement, and monitor for thirst, drowsiness, grouchiness, confusion, and muscle cramps and things will be fine.
As always, good luck in your caregiving.
Mark Parkinson RPh
References:
Diuretic. Wikipedia the Free Encyclopedia. 13 April 2017,https://en.wikipedia.org/wiki/Diuretic
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