Nursing Guide to Hemorrhoids: Nursing Diagnosis, Interventions, & Care Plans

Hemorrhoids Etiology and Epidemiology 

Definition

Hemorrhoids are swollen veins in the lower rectum or around the anus. There are two types of hemorrhoids: External and internal. External hemorrhoids form under the skin around the anus. Internal hemorrhoids form in the lining of the anus and lower rectum.

Etiology

Hemorrhoids develop when there are problems with the venous drainage of the anus. This causes the venous plexus and connecting tissue to dilate. The size, presence of thrombosis, and location of the hemorrhoids determine the amount of pain experienced (Bleday & Breen, 2023).

Internal hemorrhoids are classified as grade 1 through 4 depending on the amount of prolapse (GI Alliance, 2020). 

• Grade 1: No prolapse
• Grade 2: Prolapse occurs when under pressure such as during a bowel movement but returns spontaneously
• Grade 3: Prolapse must be manually pushed back in
• Grade 4: Prolapse that cannot be pushed back in 

The prevalence of hemorrhoids is unknown because most individuals are asymptomatic or do not seek medical care. Although the exact cause of hemorrhoids is not well understood, hemorrhoids are associated with conditions that increase pressure on the hemorrhoidal venous plexus. 

Conditions associated with hemorrhoids include (Texas Hemorrhoid Institute, 2024):

• Straining during bowel movements due to constipation
• Pregnancy
• Digestive disorders and a low fiber diet
• Obesity
• Chronic diarrhea
• Pelvic floor dysfunction
• Genetic predisposition
• Cirrhosis with ascites 

Thrombosed hemorrhoids occur when a blood clot develops inside the internal or external hemorrhoid. The area may turn a blue color. Quick treatment of a thrombosed hemorrhoid is necessary to prevent damage to surrounding tissue as a result of lost blood supply. 

A physical evaluation is an important aspect of a diagnosis of hemorrhoids. Anoscopy may be performed to visualize internal hemorrhoids.

Hemorrhoids Diagnosis 

Individuals with grade 1 internal hemorrhoids may not have any symptoms. The symptoms for both internal and external hemorrhoids are the same and may include: 

• Intense itching
• Burning
• Pain
• Redness
• Swelling
• Bright red bleeding 

Thrombosed hemorrhoids have the same symptoms, but the symptoms are often more severe. 

A physical evaluation is an important aspect of a diagnosis of hemorrhoids. Anoscopy may be performed to visualize internal hemorrhoids. 

Many people may assume they have hemorrhoids when there may be other causes for their symptoms such as: 

• Inflammatory bowel disease
• Proctalgia fugax
• Rectal prolapse
• Skin tags
• Proctitis
• Polyps
• Fissure
• Fistula
• Colorectal cancer

Hemorrhoids Nursing Management 

For temporary relief of symptoms due to hemorrhoids, there are multiple over-the-counter and home remedies. 

Most remedies contain a combination of ingredients such as: 

• Witch hazel
• Zinc oxide
• Corticosteroids
• Topical anesthetics
• Decongestants
• NSAIDs for pain 

Other conservative treatments include: 

• Fiber supplements
• High fiber diet
• Warm sitz bath
• Increased water intake
• Stool softeners
• Prescription anesthetics 

Thrombosed external hemorrhoids should have surgical removal of the thrombus within the first 2 to 3 days. This can typically be done in the physician’s office. Other treatments for grades 1 to 3 can also be performed in an office setting. These treatments include infrared photocoagulation and rubber band ligation. Both of these treatments cause necrosis of the hemorrhoid (Mott et al., 2018). 

Surgical hemorrhoidectomy is the most effective treatment for recurrent grade 3 or 4 hemorrhoids. Although a hemorrhoidectomy results in more pain, longer recovery time, and more blood loss than outpatient procedures, it has a lower rate of reoccurrence. 

Other surgical options include: 

• Stapled hemorrhoidopexy
• Hemorrhoidal artery ligation 

Common Signs and Symptoms

A person with grade 1 internal hemorrhoids may not have any symptoms. The symptoms for both internal and external hemorrhoids are the same and may include:

• Intense itching
• Burning
• Pain
• Redness
• Swelling
• Bright red bleeding

Thrombosed hemorrhoids have the same symptoms, but the symptoms are often more severe.

Red Flags

While most hemorrhoid complications are manageable, a few can become life-threatening if left untreated or if they progress significantly. Observe for:

• Profuse bleeding that may result in hypovolemic shock
• Symptoms of sepsis, including fever, rapid respirations, and elevated heart rate
• Foul-smelling drainage
• Blue or black discoloration of rectal tissue

Potential Complications

Hemorrhoids can lead to several potential complications, especially if left untreated or improperly managed. Here are the most common complications:

• Thrombosis
• Strangulation caused by a hemorrhoid’s blood supply being cut off
• Chronic blood loss resulting in iron-deficiency anemia
• Infection of hemorrhoid or associated abscess

Treatments 

Pharmacological

Most treatment focuses on symptom relief. For the temporary relief of symptoms due to hemorrhoids, there are multiple prescriptions, over-the-counter, and home remedies.

Most remedies contain a combination of ingredients, such as:

• Witch hazel
• Zinc oxide
• Corticosteroids
• Topical anesthetics
• Decongestants
• NSAIDs for pain

Other conservative treatments include:

• Fiber supplements for constipation
• Probiotics
• Stool softeners
• Prescription anesthetics

Non-Pharmacological

Non-pharmacological interventions include:

• High-fiber diet
• Warm sitz bath
• Increased water intake

Surgical

Thrombosed external hemorrhoids should have surgical removal of the thrombus within the first 2 to 3 days. This can typically be done in the provider’s office. Treatments for other grades of hemorrhoids can also be performed in an office setting. These treatments include infrared photocoagulation and rubber band ligation. Both of these treatments cause necrosis of the hemorrhoid. Inject sclerotherapy can also be performed in an office, which causes scarring of the hemorrhoidal tissue, resulting in fixation (Hawkins et al., 2024). 

Surgical hemorrhoidectomy is the most effective treatment for recurrent grade 3 or 4 hemorrhoids. Although a hemorrhoidectomy results in more pain, longer recovery time, and more blood loss than outpatient procedures, it has a lower rate of recurrence.

Other surgical options include:

• Stapled hemorrhoidopexy
• Hemorrhoidal artery ligation

Hemorrhoids Nursing Care Plan 

Assessment & Interventions

Interventions include:

• Administer topical medications as ordered.
• Administer analgesics as ordered.
• Assess bowel habits, including frequency and characteristics.
• Assess bowel signs.
• Encourage high fiber diet.
• Encourage and monitor fluid intake.
• Assess bleeding related to hemorrhoids, including the amount.
• Monitor labs as ordered.

Hemorrhoids Nursing Diagnosis/Risk For 

• Constipation related to low residue diet, hemorrhoidal pain, or medication as evidence by abdominal pain, passage of hard stool
• Pain related to hemorrhoidal pain, constipation, surgery as evidence by verbalization of pain 

Hemorrhoids Nursing Interventions 

• Assess for presence of hemorrhoids
• Assess for pain related to hemorrhoids
• Administer topical medication as ordered
• Assess bleeding related to hemorrhoids including the amount
• Monitor labs as ordered
• Encourage high fiber diet
• Encourage and monitor fluid intake
• Administer stool softeners or laxatives as ordered
• Assess bowel habits including frequency and characteristics
• Assess bowel sounds
• Assess vital signs
• Administer analgesics as ordered
• Provide warm sitz baths 

Expected Outcomes 

• Verbalizes or demonstrates a decrease in hemorrhoidal pain
• Shows no signs of anemia related to bleeding
• Regains normal bowel function
• Demonstrates effective coping 

Individual/Caregiver Education 

• Condition, treatment, and expected outcome
• Causes of hemorrhoids and ways to avoid hemorrhoids in the future
• Ways to combat constipation including:
  • High fiber diet
  • Increase fluid intake
  • Exercise as tolerated
  • Topical medications use
  • Analgesic dosing
• Recommended follow-up with healthcare provider
• Notify healthcare provider or seek immediate medical care for: increased pain, large amounts of bleeding, inability to pass stool 

Psychosocial Support

Hemorrhoids, though a common and non-life-threatening condition, can significantly impact a person's psychosocial well-being. The embarrassment, discomfort, and limitations imposed by hemorrhoidal symptoms can lead to various challenges, including emotional distress, social withdrawal, and even workplace issues.

Strategies to address psychosocial challenges include:

• Reassure the person that hemorrhoids are common and treatable.
• Provide emotional support and refer to a mental health professional if needed.
• Suggest lifestyle accommodations, including seating cushions and alternating standing and sitting.
• Acknowledge how hemorrhoids may affect intimate relationships.
• Provide practical advice for managing symptoms to maintain sexual health, such as using lubrication, discussing boundaries with partners, and timing intimate activities during symptom-free periods.

Home Management

Self-care interventions include:

• Combat constipation by including a high fiber diet, increased fluid intake, and exercise.
• Avoid heavy lifting and prolonged standing, which can exacerbate venous pressure.
• Use topical medication.
• Administer analgesic dosing.
• Notify the healthcare provider or seek immediate medical care for severe pain, large amounts of bleeding, or inability to pass stool.

Content Release Date  

4/1/2022 

Content Expiration 

12/31/2028

Content Contributor 

Content created/revised by Kim Matthews, RN 

Kimberly Matthews, RN obtained a nursing degree from Western Kentucky University in 1998.  Ms. Matthews possesses over 20 years of nursing experience with over 17 of those in the Skilled Nursing industry.  Ms. Matthews has extensive experience in MDS, restorative nursing programs, and nursing management.  Ms. Matthews is currently a Post Acute Care Content writer and subject matter expert for MDS. 

Disclosures 

Kim Matthews, RN has no relevant financial or non-financial relationship(s) with ineligible companies to disclose. 

Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC. 

All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental. 

References 

• GI Alliance. (2020). 4 types of hemorrhoids & how they are treated. https://gialliance.com/gastroenterology-blog/4-types-of-hemorrhoids-how-they-are-treated
• Mott, T., Latimer, K., & Edwards, C. (2018). Hemorrhoids: Diagnosis and treatment options. American Family Physician, 97(3), 172-179. https://www.aafp.org/pubs/afp/issues/2018/0201/p172.html