Basic procedures in healthcare 1 (SOL / VCA81)TOPICS: 14a) GIT emptying14b) Faecal sampling for testing14c) Types of faecal testing14d) Gastric lavage14e) Digital removal of stool14f) Enema14g) Stoma care

14a) GIT emptying

basic information

faecal and its monitoring

terms

drugs affecting defecation

14a) GIT emptying

Defecation = colonic emptying,

- vomiting, gastric lavage,

- frequency of emptying individual.

• Faecal composition:

• undigested food, water, flaked epithelial cells, mucus.

• Factors influencing defecation:

• age, diet, amount of fluids in a food, activity and life, privacy when emptying…

14a) GIT emptying

Faecal:

• daily amount 100 – 300 g,

• we monitor:- frequency,- colour,- form / shape,- odour,- pathological admixtures.

14a) GIT emptying

We monitor:

• Frequency

• individual.

• Form / shape (see Bristol stool scale)

• consistent, pen / sausage shape, hard lumps.

• Odour

• due to fermentation and rotting undigested food residues,

• stool - rotting smell,

• some diarrhoea - sour smell,

• when melaena - sweet.

14a) GIT emptying

• Faecal colour:

Faecal colour Kind of ingested food

light brown normal mixed food

yellow preponderance of milk products

dark greenchlorophyll-rich vegetables

(spinach, lettuce)

dark brown to blackmore red meat, chocolate,

blueberries, cocoa, preparations Fe

14a) GIT emptying

Pathological faecal colour:

Pathological faecal colour Reason

ACHOLIC(silver)

disorder of bile flow into the intestine, does not contain bile pigment

MELEANA(black, tarry, digested blood)

bleeding from the upper section of the digestive tract

(bleeding from the stomach)

ENTERORRHAGIA(thin blended with fresh blood)

bleeding from the lower portion of the digestive tract (large intestine)

14a) GIT emptying

Pathological admixtures in faecal:

Pathological admixtures Possible reasons

phlegm, pus, blood colitis

watery with mucus and undigestedfood residues

inflammation of the intestinesof various origins

worm parts in the faecal intestinal parasites: tapeworms, roundworms

14a) GIT emptying

Terms:

• pyrosis - heartburn,

• regurgitation - return ingested food back into the oesophagus and mouth,

• haematemesis - vomiting blood or bloody vomiting, a symptomof bleeding in the upper gastrointestinal tract,

• haemoptysis - coughing or spitting blood out of the airways,

• miserere – vomiting of intestinal contents when ileus,

• tenesmus – painful urge to stool,

• borborygmus - sound of the abdomen during movementsof gas and fluid in the intestines („collywobbles“),

• ileus - stop the passage of chyme through the intestine,

14a) GIT emptying

Terms:

• constipation - difficult, less frequent and less abundant defecation,

• diarrhoea - more frequent emptying loose faecal,

• skybala - each thickened parts of hardened faecal in the gut,

• paradoxical diarrhoea – liquid faecal, which wraps around skybala,

• melaena - black, tarry faecal containing digested blood,

• enterorrhagia – light red undigested blood, indicating bleeding from the gut,

• acholic faecal – silver-gray discoloration faecal in case of flow disorder of bile.

14a) GIT emptying

Drugs affecting defecation:

• laxatives –emptying support, drugs based on cellulose(e. g.: Lactuloza, Gutalac, Dufalac and others),

• antidiarrhoics – slow emptying (e. g.: Endiaron, Reasec, Imodium and others).

laxatives antidiarrhoics

14b) Faecal sampling for testing

faecal sampling principles

the most common mistakes when faecal sampling

faecal sampling containers

14b) Faecal sampling for testing

Principles when faecal sampling for testing:

• we sample the material according to the lab,

• we sample into a pre-labeled containers,

• we fill dispatch for each sample,

• we follow the principles of health and safety and use disposable gloves,

• we pay attention to the contamination of the container from the outside,

• we follow the requirements for transport,

• we record examination results,

• we take a sample in amounts the size of a hazelnut for qualitative purposes at shaped faecal - preferably from inside the faecal, we take a sample of 15 - 30 ml at loose faecal.

14b) Faecal sampling for testing

Principles when faecal sampling for testing:

• for high quality testing, we collect the faecal in a pre-weighed container usually after for 24 hours – we send to the lab 50 - 100g.

faecal sampling to the tube

14b) Faecal sampling for testing

The most common mistakes when faecal sampling:

• wrong procedure when sampling,

• not following the prescribed diet (distortion of results),

• sampling from the surface of the faecal,

• improper storage of sampled material,

• late delivery of the sampleat the laboratory,

• incorrect sample identificationor incorrectly filled dispatch.

*

14b) Faecal sampling for testing

Faecal sampling containers:

• wide-neck tube with a shovel,

• plastic container for single use,

• tube with glass rectal tube.

14c) Types of faecal examination

• physical examination

• biochemical examination

• microbiological examination

• parasitological examination

14c) Types of faecal examination

Physical examination - see 14a)

Assessing with the look and nose/smell:

• amount,

• pH,

• colour,

• consistency,

• odour,

• admixtures,

• frequency.

bedpan

14c) Types of faecal testing

Biochemical examination

Microscopic examination:

• faecal examinations for residues.

Quantitative examination:

• total fat in the faecal.

Qualitative examination:

• examination of faecal for occult blood – after diet,

• examination of faecal for occult blood – without diet.

home test for occult blood in the faecal

14c) Types of faecal testing

Microbiological examination

• faecal sampling for bacteriological examination,

• rectal swab.

Parasitological examination

• faecal sampling for parasites,

• perianal swab.

sampling containers

14d) Gastric lavage

term explanation

procedure and principles

14d) Gastric lavage

• the procedure is most commonly performed at poisoning (alcohol, mushrooms…),

• TIME is important → the sooner after ingestion, the better,

• importance: removingof substance (or mostof its content) beforeit is absorbed intothe blood and causespoisoning,

• in case of poisoningwith unknownsubstance sample.

gastric lavage

14d) Gastric lavage

Procedure:

• the patient is in a stable position on the side (or sitting whena nurse is holding a small kid on her lap),

• we introduce to the patient strong enough catheter with central hole,

• we introduce the catheter such that we moisture the end part with hydrosoluble lubricant (when emergency then use water),

• we take it between the thumb and forefinger of right hand likea pen and slowly introduce into the stomach,

• after introduction into the stomach, gastric contents usually flow out of the catheter. If not, apply a small amount of air to the catheter (control it with stethoscope),

14d) Gastric lavage

Procedure:

• the patient responds with sudden cough when introducing the catheter into the respiratory tract → pull out the catheter IMMEDIATELY,

• we perform the lavage application with NaCl 0,9%: (200 to 300 ml in adult), we aspire the content subsequently back,

• it is not appropriate to exceed the recommended volumes,

• we send the first lavage batch to the toxicology,

• we continue with the lavage until we do not aspire the pure liquid,

• we pull the catheter out and we check the patient.

14e) Digital removal of stool

procedure indication

performance procedure

Indication- patient can not empty even after enema.

Procedure:

• the patient is placed on its side, bedpan is near,

• we take a glove, we spread a Vaseline on the forefinger,

• we gently insert the forefinger into the rectum → we pull out the faecal,

• it can cause the emptying reflex.

14e) Digital removal of stool

14f) Enema

term explanation

types of enema

forms of administration

cleansing enema (tools, preparation of the patient, position of the patient, procedure)

laxatives enema

therapeutic enema

diagnostic enema

videos

14f) Enema

- administration of the fluid into the colon through the rectum.

•Types:- cleansing – intestine lavage,- laxatives – faecal softening and induction of defecation,- therapeutic – treatment intestine mucosa,- diagnostic – application of contrast medium for examination of intestine.

14f) Enema

Forms of administration:

• cleansing – large amount of fluid (1 – 1,5 l),

• micro enema – a small amount of drug substance 0,5l(e. g.: Yal),

• droplet – as infusion. Janett syringe

14f) Enema

Cleansing enema:

• cleansing of intestines before surgery, child delivery, constipation, before treatment and dg. enema, before large intestine examination.

• Tools:

• liquid - 1 – 1,5 l water at people bodies temperature (in children NaCl 0,9% – amount by age, determined by the physician).

14f) Enema

Tools:

• liquid - 1 – 1,5 l water at people bodies temperature

• rack,

• irrigator with tube,

• gloves,

• toilet paper, swab,

• bedpan,

• vomit bowl,

• scoop, grease or lubricant gel,

• rectal tube.

rectal tubes

irrigator

tools

14f) Enema

Preparation of the patient before the procedure:

• careful and thorough examination,

• ensure cooperation and privacy,

• the patient breathes deeply,

• the patient must inform us about the problems,

• let the enema to flow slowly,

• inform the patient to walk around the toilet for 10-20 min,

• monitor the results,

• record the procedure in the medical documentation.

14f) Enema

Position of patient:

- on side,

- improvisation of gynaecological position,

- knee-chest position.

on side

gynaecological

knee-chest

14f) Enema

Procedure:

• we inform the patient about the procedure +adjust the position,

• preparation tools (rack, irrigator, water temperature… ),

• we connect the irrigator tube with the rectal tube,

• we let to flush it all with water to vomit bowl→ there must not be any air in the tube,

• we spread Vaseline on the end of the rectal tube,

• we gently introduce in the rectum (6 - 8 cm),

• gas can occur,

• we let the liquid flow slowly out,

• we talk to the patient during the procedure!!!

14f) Enema

Procedure:

• we urge the patient to breathe easily, turn down the water pressure (or we stop it) always, when the urge to defecate is unbearable,

• we stop the flow of water before the irrigator drains all the water,

• we pull out the tube with one hand, and wipe with the swab with second hand,

• the patient should not go to the toilet immediately, but he / she should wait a while so the enema can be effective,

• the patient is moving around the toilet or we can sit him / her on bedpan,

• we clean the tools.

14f) Enema

Laxatives enema:

- performed when constipation.

• Tools:

• see cleansing enema,

• smaller amount of laxative agent,- e. g. glycerine suppositories, Yal,- form: micro enema.

Glycerine suppositories

14f) Enema

Therapeutic enema:

• indication is e. g. treatment of inflammation of large intestine → ATB application,

• form: micro enema, droplet enema.

Before administering a therapeutic enemaALWAYS apply a cleansing enema!!!

14f) Enema

Diagnostic enema:

• indication: part of RTG of contrast examination of large intestine,

• before application of dg. enema, we perform cleansing enema first,

• used contrast agent – e. g.: barium meal,

• CAUTION! - It is important to monitor whether the patient after the enema will go to empty the intestines.

Passage of barium meal during ingestion

physiology X Zenker's diverticulum

Source: https://en.wikipedia.org/wiki/Upper_gastrointestinal_seriesDownload: 28. 7. 2015

14f) Enema

Video – droplet enema:

• https://www.youtube.com/watch?v=LZUqiMm1718

Video – cleansing enema:

• https://www.youtube.com/watch?v=WB-jde_wisE

Video – laxatives enema:

• https://www.youtube.com/watch?v=DURh0dbG7YA

14g) Stoma care

term explanation

types of stoma

colostomy (term, indication)

aids / tools for patients with a stoma (basic, additional)

appropriate diet for patients with a stoma

14g) Stoma care

Stoma

• temporary or permanent outlet intestines (or ureter) through the abdominal cavity,

• It can be divided based on time (temporary / permanent)or insertion site.

14g) Stoma care

Types of stoma:

• tracheostomy,

• oesophagostomy,

• gastrostomy,

• ileostomy,

• colostomy,

• epicystotomy,

• urostomy,

• laparotomy…

urostomy

ileostomy

14g) Stoma care

Colostomy:

• the most common types of stoma:

• sigmoideostomy,

• transversostomy,

• coecostomy.

14g) Stoma care

Colonostomy:

- stoma is a small circular hole of red colour (2 – 5 cm),

- mostly located in the left lower abdomen,

- surface is constantly wet and shiny,

- gas and faecal come from the stoma spontaneously → bags for capturing the secretions,

- it is not sensitive to pain,

- CAREFULLNESS is necessary when taking care of stoma → mucosa is easily hurt and begins to bleed.

14g) Stoma care

Indications for creating a colostomy:

• inflammatory large intestine,

• tumour surgery,

• pouches of the intestine, which are quickly inflamed,

• intestinal perforation,

• ileus,

• intestinal bleeding,

• insufficient function of sphincter muscle,

• disorderly development of the embryo intestine,

• damage because of irradiation of other organs in the small pelvis.

14g) Stoma care

Aids / tools for patients with a stoma:

- basic: bags and pads,

• One-piece system :

• bags firmly connected with the pad,

• the bag is fallen off and a new oneis attached every time it is changed.

14g) Stoma care

Aids / tools for patients with a stoma:

• Two-piece system:

• it contains the bag and the pad,

• connection with flange ring,

• pad remains on the body for several

days (colostomates change the bags, or shake them out,

ileostomates and urostomates release them).

14g) Stoma care

Additional aids / tools:

• protective films and pastes,

• patches removers,

• cleaning solutions,

• dusting powders,

• odour absorbers,

• absorbent gelling,

• various insertion or seal rings.

protecting pastefor patients

with a stoma

14g) Stoma care

Additional aids / tools :

• recently → top level,

• concerns about odours are completely useless (colostomy bags contain activated charcoal filter against odour), and flanges between pad and bagare faultless,

• pads contain naturalgelatine with healing effects.

14g) Stoma care

stomic tools / aid

14g) Stoma care

Appropriate diet for patients with a stoma:

• mixed, varied and tasty with plenty of fruit and vegetables,

• in addition, some requirements and adherence to certain dietary rules,

• shortly after surgery residue-free diet, cooked - to be more digestible,

• eat more frequently and in small portions,

• drink at least 2 litters of non-sweetened beverages a day (diuresis should be at least 1 l),

• ileostomy -  requires additional salt substitute, the same colonostomy - Ii there is a considerable amount of loose faecal,

• plenty of fibber, which is important for proper passage of faecal through the intestine, for patients with ileostomy, fibber has almost no meaning, or even bothers.

Revision

Explain the terms (melaena, ileus, tenesmus… ).

Describe the process of cleansing / droplet enema.

What kinds of stoma do we distinguish?

Please provide indications for the stoma implementation.

Please provide indications for gastric lavage.

List the types of faecal examination.

Describe what do we observe on physical testing of faecal.

Explain the difference between the terms: diarrhoea X paradoxical diarrhoea, melaena X enterorrhagia …

What are laxatives / antidiarrhoics? Give an example.

Describe what dietary measures are important for patientswith a stoma.

Reference:

MIKŠOVÁ, Zdeňka, Marie FROŇKOVÁ, Renáta HERNOVÁ a Marie ZAJÍČKOVÁ, Kapitoly z ošetřovatelské péče II. Aktualiz. a dopl. vyd. Praha: Grada, 2006, 172s. ISBN 80-247-1443-4

VELKÝ LÉKAŘSKÝ SLOVNÍK [online]. 2015 [cit. 2015-04-05]. Dostupné z: www.lekarske.slovniky.cz

EDUKACE KLIENTA SE STOMIÍ [online]. 2015 [cit. 2015-05-19]. Dostupné z: http://ose.zshk.cz/vyuka/edukace.aspx?id=18

KLYSTÝR [online]. 2015 [cit. 2015-05-19]. Dostupné z: http://www.modrykonik.cz/klystyr/

OŠETŘOVATELSKÉ POSTUPY - Vylučování stolice [online]. 2015 [cit. 2015-05-19]. Dostupné z: http://www.eamos.cz/amos/kos/modules/low/kurz_text.php?id_kap=9&kod_kurzu=kos_392

O ŽIVOTĚ SE STOMIÍ [online]. 2015 [cit. 2015-05-19]. Dostupné z: www.stomici.cz

PICTURES * (if it is not stated differently): pinterest.com, google.com (key words: „ok“, „not ok“, „stomach“ … )