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Hemorrhoids Nursing Guide

Content created/revised by Kim Matthews, RN

Overview: Hemorrhoids

This content is intended as a Quick Reference for hemorrhoids and will cover an overview as well as nursing considerations utilizing the nursing process.

Etiology and Epidemiology

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.

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 (Mott et al., 2018).

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.

Associations with hemorrhoids include (Mott et al., 2018):

  • Straining during bowel movements due to constipation
  • Pregnancy
  • Anal intercourse
  • Low fiber diet
  • Obesity
  • Chronic diarrhea
  • Pelvic floor dysfunction
  • 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.


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

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

Nursing Considerations & Care Plan


The individual with hemorrhoids should be assessed for:

  • Pain
  • Constipation
  • Bleeding
  • Anal itching

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

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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.

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.


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