Basic procedures in healthcare 1
(SOL / VCA81)
TOPICS:
14a) GIT emptying
14b) Faecal sampling for testing
14c) Types of faecal testing
14d) Gastric lavage
14e) Digital removal of stool
14f) Enema
14g) 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
light brown
yellow
Kind of ingested food
normal mixed food
preponderance of milk products
dark green
chlorophyll-rich vegetables
(spinach, lettuce)
dark brown to black
more 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 undigested
food residues
inflammation of the intestines
of 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 symptom
of 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 movements
of 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 sample
at the laboratory,
• incorrect sample identification
or 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
home test for occult blood in the faecal
 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.
14c) Types of faecal testing
Microbiological examination
• faecal sampling for bacteriological examination,
• rectal swab.
sampling containers
Parasitological examination
• faecal sampling for parasites,
• perianal swab.
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: removing
of substance (or most
of its content) before
it is absorbed into
the blood and causes
poisoning,
• in case of poisoning
with unknown
substance  sample.
gastric lavage
14d) Gastric lavage
Procedure:
• the patient is in a stable position on the side (or sitting when
a 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 like
a 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
14e) Digital removal of stool
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.
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.
on side
14f) Enema
Position of patient:
- on side,
- improvisation of gynaecological position,
- knee-chest position.
knee-chest
gynaecological
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.
Glycerine suppositories
• Tools:
• see cleansing enema,
• smaller amount of laxative agent,
- e. g. glycerine suppositories, Yal,
- form: micro enema.
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 enema
ALWAYS 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
Source: https://en.wikipedia.org/wiki/Upper_gastrointestinal_series
Download: 28. 7. 2015
physiology
X
Zenker's diverticulum
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:
ileostomy
urostomy
• tracheostomy,
• oesophagostomy,
• gastrostomy,
• ileostomy,
• colostomy,
• epicystotomy,
• urostomy,
• laparotomy…
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 one
is 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 paste
for 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 bag
are faultless,
• pads contain natural
gelatine 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 patients
with 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“ … )