• One piece system colostomy bag (R) What are the indications of forming a stoma? • Feeding (Percutaneous endoscopic gastrostomy) • Lavage ( Appendisectomy) • Decompression • Diversion – To protect (defunction) distal bowel anastomosis • Permanent drainage – after excision in rectal CA Types of colostomy • Temporary colostomy - also known as loop colostomy • Normal site – Transverse colon @ Sigmoid colon • End (Permanent) Colostomy • Normal site – distal end of the divided colon usually at the lateral edge of rewctus sheath, 6 cm above & medial to iliac crest. (Right iliac fossa) What is suitable site of forming a stoma? • Patient able to see the stoma while he is standing up • Away from scar and skin creases • Away from body prominence and waistline for clothes • Easily assesible to the patient • 5 cm from umbilicus • Not under a large fold of fat Complications of stoma • General • 1) Stoma diarrhoea-fluid & electrolyte imbalance • 2) Nutritional disorder • 3) Gallstone & Renal stone after ileostomy (Reduced bile salt absorption?) • 4)Psychosocial Specific Complications • 1) Ischaemic/gangrene • 2) Hemorrhage • 3) Prolapse • 4) Skin excoriation * • 5) Parastomal hernia • 6) Stenosis leading to constipation/obstruction How to prepare patient? • Psychosocial & physical preparation • Explaination of indication & complication • Marking the stoma site • Advices by clinical nurse specialist in stoma care • Bowel preparation for colostomy operation How to rehabilitate patient? • Inform the patient on function of colostomy bag • Reassure the pt that he can live a normal life with it • Eat soft non bulky diet • Change the bag when it is ¾ full • Daily stoma inspection • If complication arise seek, profesional help • Psychosocial and sexual support How to prevent skin excoriation? • Remove appliance gently to prevent stripping • Use skin barrier (water) to prevent the skin from contact with faeces • Change the bag before it is full Ileostomy vs Colostomy Ileostomy Colostomy
Site RIF LIF
Surface Spout Flush with skin
Contents Watery & Faeculent
erosive Permanent Post AP resection of stoma pancreatocolect rectum omy Temporary Low Hartmann’s stoma anastomosis procedure Nasogastric tube How to recognize? • Multiple opening at the gastric end • One proximal opening • 3 markings (50,60,70 cm) Indications • Diagnostic • 1) to aspirate blood in GI bleeding • 2) take sputum AFB in children • 3) aspirate duodenal content (Giardia lambdlia) • Therapeutic • 1) Decompression of stomach • 2) Feeding • 3) Rest the bowel Contraindications • Base of skull # • Oesophageal stricture • Comatose patient because of absence of gag reflex may cause aspiration ? Procedures Seat the pt and inspect for nasal deformitie • Warn pt about retching • Lubricate the tube • Pass horizontally backward through the nose into the nasopharynx • Ask patient to swallow • Confirm the position • Fix tube to adhesive tape 4 anatomical position of narrowing • Nose • Nasopharynx • Pharynx • Esophagus • Stomach (LES) How to confirm successful insertion? • Pumop air into syringe and auscultate for gastric splash • Put tube into water..No air coming out • Aspirate content and test with litmus paper • X ray Complications • Wrong position into trachea causing pneumonitis if feeding • Traumatize nasal cavity causing epistaxis • Goes into brain if # of basal skull or cribriform plate Sengstaken Blackmore Tube What are the purposes of the 4 channels?
• Inflation of the gastric balloon
• Inflation of the esophageal balloon • Aspiration of gastric content • Aspiration of esophageal content Indications • Upper GI hemorrhage from gastroesophageal varices Procedures • Remove dental plates & insert a mouth guard • Anaesthesize oropharynx by using 3-4 puffs of 50% lignocaine spray • Lubricate tube & pass through the mouth guard • Confirm has pass through the stomach by injecting air into the gastric lumen • Fill the gastric balloon by slowly injecting 200-300 ml of air • Gently withdraw the tube by pulling it against the LES • Check with X ray to confirm position • Inflate the esophageal balloon to 30-40 mmHg using a spygnomanometer,3 way tap & a 50 ml syringe • Seal & leave the tap in site • Apply 250g of traction to the tube by means of a pulley attached to the head of the bed Complications • Esophageal perforation (pressure necrosis) • Aspiration pneumonia • Airway obstruction Precautions • Before passing the tube, check both ballooons to ensure the absence of leak • Regular esophageal suction, to prevent aspiration pneumonia • Check pressure within the esophageal balloon every hour because some will leak slowly • Deflate the esophageal balloon 6 hours for 10 minutes to prevent pressure necrosis Urinary catheter Foley’s Catheter • Indication :- • Continuous bladder drainage • Monitoring urine output • To assist the nursing care of incontinent patient • Relieve obstruction Procedures (Male) • Hold the penis with sterile gauze,retract the foreskin and cleanse with aseptic technique • Insert 10 ml of 1% lignocaine into the urethra using a sterile noozle and apply lignocaine jelly at the tip of the catheter • Insert a 14 G or 16G FC into the gel filled urethra using forceps • Ask pt to inspire during the process • Confirm entry into the bladder & collect the urine • Inflate the balloon by instiling sterile water • Connect to urine bag Procedures (Female) • Position the patient supine with the heels together and the knees well apart • Under adequate lighthing, cleanse the vulva with aseptic technique • Hold the swab with dressing forceps. Use only once and swab from anterior to posterior • Insert 5 ml of 1% lignocaine gel into the urethra using a sterile noozle • Proceed as for male Ways to avoid infection • Use aseptic technique • Cleanse vulva from Anterior to posterior • Avoid leaving the catheter in situ for too long (2 weeks)? Non dwelling catheter vs Foley catheter • 1 opening at one end and another opening at the other end • For temporary use Contraindications • Ruptured urethra • Infection of urethra • Urethral stricture T tube Indications • For post CBD exploration to drain the bile while waiting for healing • To prevent biliary leakage if there is residual stone • For post operative T tube cholangiography • Maintain patency of biliary tract • Stone removal with forceps and Dormia basket Complications • Biliary peritonitis • CBD stricture • Fistula formation • Rupture of CBD during removakl What are the precautions in removal of the tube • Ensure that the tract is well formed and no distal obstruction of CBD by doing a T tube cholangiogram at 10 days post op • Trial of clamping for a short period. Look for pain, fever and jaundice if obstruction still persist What are the contraindications for removal • Fever, jaundice • Recurrence of pain after clamping the tube • Leakage of bile around the tube after clamping • Achlouric stool Suprapubic catheter Suprapubic catheter Indications • Urethral stricture or previous trauma (BPH) • Post operative urinary diversion eg bladder neck surgery • In acute retention to avoid urethral damage • Infection along the urinary tract eg prostatitis,epididymitis Contraindications • Contacted or decompressed bladder • Gross hematuria with clot (lumen inadequate to evacuate clot) • Previous intraabdominal surgery involving pelvis, small bowel may be encountered beneath the inferior portion of the incision Procedures • Pt is supine • Palpate/percuss bladder • Inject LA using spinal needle after wheal has been raised. Select a site 1 @ 2 finger breaths above the symphisispubis in the midline. Infiltrate widely • Localize bladder directing the spinal needle roughly 30 degree from the vertical in the midline aiming for tip of coccyx. Aspirate frequently to ascertain entry into the bladder • Incise skin, making a 2-3 mm stab incision Continued… • Insert needle unit into bladder. Attach the syringe onto the needle and carefully guide it toward the bladder as with spinal needle previously. There will be slight resistance as rectus fascia is penetrated and urine will be aspirated into the syringe as the bladder is entered. Advance the needle for another 2 cm to be sure this is well within the bladder • Insert the catheter through the needle after removing the syringe • Ascertain position in the bladder by aspirating • Secure catheter with silk suture • Attach catheter to urinary bag • Apply sterile dressing.Use Povidone Sutures Ideal sutures • All purpose • Sterile • Non capillary, non allerginic, non carcinogenic, non ferromagnetic • Easy to handle • Minimal tissue reaction • Capable of holding securely when knotted Monofilament • Made of single stranded material • Adv- Less resistance as they pass through tissue • Resist harboring organism which may cause suture line infection • Tie down easily • Used in vascular surgery • Contoh : Prolene, Dafilone, Ethilon Multifilament (Braided sutures) • Several filament twisted or braided together • Adv :- • Greater tensile strength, pliability & flexibility • Coated multifilament pass smoothly through tissue and enhance handling characteristics • Do not tend to slip in knot • Used in intestinal procedures • Contoh :- Vicryl & Silkam NaTURAL Absorbable sUTURES • Suture prepaid from collagen of healthy mammals or from synthetic polymers • Natural absorbable sutures – (catgut) – sheep intestine @ serosa of beef intestine • For soft tissue approximation • Digested by body enzymes • Cause moderate tissue reaction • Contoh :- Catgut Synthetic Absorbable Sutures • For soft tissue approximation • Hydrolysed and less tissue reaction compared to natural absorbable suture • Eg Vicyl (Polyglactin 910) • Monocryl (Polyecaprone 25) Non absorbable sutures • Not digested by body enzymes or hydrolized in body tissue • Application :- • Tissue approximation includes CVS,ophthalmic,CNS • Exterior skin closure • Patient with history of reaction to absorbable sutures like tissue hypertrophy or keloidal tendency • Contoh :- • Silk • Nylon – Ethilon • Polyesther fibre – Mersilene • Polyprophylene - Prolene Colour/Material/Usage • Blue – Prolene ( for skin closure) • Black – Silk (Tendon/muscle) • Straw coloured – Catgut (Episiotomy closure) • Purple - Vicryl (Rectus sheath closure) Others