Different Therapeutic Diets
• Used for pts with atherosclerosis and heart disease
Diet is the sum of the food consumed by a person or other
organism.
Diet Therapy is concerned with recovery from illness and
prevention of disease.
What is Therapeutic Diet:
• Planned diet
• Modification of normal diet
• Prescribed by doctor and planned by dietician
• Used to supplement the medical or surgical treatment
• Removing or adding foods
• Change nutrients, caloric content and/or texture
• Increase or decrease the energy values
• Increase or decrease bulk in the diet e.g., high or low
fiber diets
Purposes of Therapeutic Diets:
• Regulate amounts of food
• Assist body organs to maintain normal function
• Aid in digestion
• To improve specific health conditions
• Increase or decrease body weight
• Modify the intervals of feedings
Significance:
• Useful in managing disease
• Promote greater resistance to specific conditions
• Prevention or supplemental treatment
• Indication:
• Kidney failure
• Lower serum cholesterol
• Control elevated blood sugar levels
• Treat celiac disease – a disease where the small
intestine can’t absorb nutrients
• For example: gluten-free diets
Types of Therapeutic Diets:
• Regular diet
• Liquid diet
• Soft diet
• Diabetic diet
• Calorie controlled diet
• Low cholesterol diet
Regular Diet:
• Balanced diet usually used for ambulatory patients
• At times it has a slightly reduced caloric content
• Foods such as rich desserts, cream sauces, salad
dressings and fried foods may be decreased or
omitted.
Liquid Diet:
• Nutritionally inadequate and should only be used for
short periods of time:
• Uses:
• After surgery or heart attack
• Pts with acute infections or digestive problems
• To replace fluid lost by vomiting or diarrhea
• Before some Xrays of digestive tract
Clear Liquid Diet:
• Water, apple or grape juice, fat-free broths, plain
gelatin, popsicles, ginger ale, tea, coffee
• Low Cholesterol Diet:
• Restrict foods containing cholesterol
Low Protein Diet:
• Limit foods high in saturated fats such as beef, libers,
pork, lamb, egg yolk, cream cheeses, shellfish, whole
milk and coconut and palm oil products.
Low Residue Diet:
• Used for patients with digestive and rectal disease
such as colitis or diarrhea
• Eliminates or limits foods high in bulk or fiber such as
raw fruits and veggies, whole grains and cereals, nuts,
seeds, beans and peas, coconut and fried foods.
Diabetic Diet:
• Goods are grouped according to type, nutrients and
calories.
• Pts are allowed a certain number of items from each Therapeutic Diet for Malnutrition:
exchange list according to individual needs.
Calorie Controlled Diet:
Low Calorie Diet:
• Used for patients who are overweight
• Avoid or limit high calories foods such as:
• Butter, cream, whole milk, cream soups or gravies,
sweet soft drinks, alcoholic beverages, salad
dressings, fatty meats, candy and rich desserts
High Calorie Diet:
• Used for patients who are underweight, or who have
anorexia nervosa, hyperthyroidism, or cancer
• Extra protein and carbs are included
• Avoid high-bulk foods such as green salads,
watermelon and fibrous fruits
• Avoid high-fat foods such as fried foods, rich pastries,
and cheese cake because they digest slowly and spoil Conclusion:
appetite.
Low Cholesterol Diet:
• Restricts foods containing cholesterol
• Used for pts with atherosclerosis and heart disease
• Limit foods high in saturated fats such as beef, liver,
pork, lamb, egg yolk, cream cheese, natural cheeses,
shellfish, whole milk and coconut and palm oil
products.
Fat Restricted or Low-Fat Diet:
• Used for pts with gallbladder and liver disease,
obesity, and certain heart diseases
• Avoid cream, whole milk, cheese, fats, fatty meats,
rich desserts, chocolates, fried foods, salad dressings,
nuts and coconut.
Sodium Restricted Diet (Low Sodium or Low Salt Diet):
• Used for pts with cardiovascular diseases such as
hypertension or congestive heart disease, kidney
disease and edema
• Avoid or limit addition of salt to any foods, smoked
meats or fish, processed foods, pickles, sauerkraut,
olives and processed cheeses.
High Protein Diet:
• Used for children and adolescents who need
additional growth, pregnant or lactating women,
before and/or after surgery, pts suffering from burns,
fevers or infections
• Regular diet with added protein rich foods such as
meats, fish, milk, cheese and eggs.
• Used for pts with certain kidney diseases and for
certain allergic conditions
• Regular diet with limited or decreased protein rich
foods
Bland Diet:
• Consists of easily digested foods that do not irritate
the digestive tract
• Used for pts with ulcers and other digestive diseases
• Avoid coarse foods, fried foods, highly seasoned
foods, pastries, raw fruits and veggies, alcohol,
carbonated beverages, nuts, coffee, tea, smoked and
salted meats and fish.
• High energy and high protein
• Energy and nutrient dense foods
• Pick foods from the menu which can be fortified
• Used of supplements
• Recipe fortification
• Examine what a resident like to eat and encourage
those types of foods.
Dietary Guidelines:
• Also eat a variety of food
• Maintain ideal weight
• Avoid excess fat (total and unsaturated) and
cholesterol
• Eat foods with adequate dietary fiber
• Avoid excess sugar
• Avoid excess salt
• Therapeutic diets to be used when necessary
• Ensure that residents with malnutrition are eating
foods which taste good and full of flavor
• Menu design should aim for diet integration so that
everyone eats the same type of foods
• Portion control is an essential tool in menu planning
• Standard recipes help with the delivery of nutritional
care
Gastric and Intestinal Decompression
• Intended for pts with gastric distension receiving
aggressive ventilatory resuscitative measures prior to
intubation
• Nasogastric tube may be used to perform gastric
decompression for the patient with known or
suspected gastric distension.
Gastric Decompression is the removing of the contents of
the stomach through the use of a nasogastric tube. This
may be performed if a person has ingested some sort of
toxins, such as in cases of too much alcohol, or in cases of
bowel obstruction where the person needs to be put on
bowel rest.
Gastric Distension
• Is the enlargement of the stomach, and can be due to
a number of causes
• Physiologic (normal) gastric distension occurs when
eating.
Tuon kay bobo ta! #Top10saNPLEcuttie<3
 • Distension of the upper stomach stimulates the
secretion of stomach acid, while distension of the
lower stomach stimulates gastrin secretion.
Other causes include:
• Binge eating associated with bulimia nervosa
• Tumors causing obstruction
• Diabetic neuropathy
• Scarring due to pyloric gastritis
• Delayed gastric emptying
• To identify the cause of gastric distension, an upper
endoscopy or barium upper GI imaging should be
done
Nasogastric Tube
• A nasogastric tube is a flexible tube of rubber or
plastic that is passed through the nose, down through
the esophagus, and into the stomach. It can be used
to either removes substances from or add them to the
stomach. An NG tube is only meant to be use on a
temporary basis and is not for long-term use.
• Is a special tube that carries food and medicine to the
stomach through the nose. It can be used for all
feedings or for giving a person extra calories.
Types of Nasogastric Tubes:
LEVIN TUBE:
• Single lumen, hole near tip
• Prevents accumulation of intestinal liquids and gas
during and following surgery. Prevents nausea,
vomiting and distension due to reduced peristaltic
action.
SUMP: (SALEM)
• Double lumen, radiopaque
• 1st lumen: suction of gastric contents
• 2nd lumen: blue extension (pig tail) open to room air
to maintain a continuous flow of atmospheric air into
the stomach.
• Controls the amount of suction pressure placed on
• Stomach walls. Prevents injury, ulcers
Continue Types of Nasogastric Tubes:
MOSS TUBE
• Tri-lumen
• 1st lumen: Balloon anchors it in the stomach
• 2nd lumen: Feeding tube
• 3rd lumen: Aspiration and lavage
SENGSTAKEN-BLAKEMORE
• Triple Lumen
• 1st lumen: Inflates the balloon in the stomach to press
against the esophagogastric junction.
• 2nd lumen: Inflates the balloon in the esophagus to
press directly against varices.
• 3rd lumen: Used for aspiration and lavage
MINNESOTA TUBE:
• 4 Lumen
NUTRIFLEX TUBE
• Feeding tube: usually radiopaque
• Mercury weighted
• Coated with lubricant
• Activated with gastric secretions to keep tube supple
and not injure stomach lining.
• During the past twenty years, the beneficial effects of How to perform gastrointestinal decompression
gastrointestinal decompression have been recognized
and accepted as an important part of surgical therapy.
• Experience has shown that it is much easier to
prevent distention of the gastrointestinal tract by
suction applied to indwelling tube than to relieve a
distention already present.
• Various types of tubes have been developed in an
attempt to obtain more effective and quicker
decompression of the small bowel. Ideally,
gastrointestinal decompression of the small bowel.
Ideally, gastrointestinal decompression should be
obtained by maintaining an effective suction
simultaneously in both the stomach and small bowel.
An acceptable practical solution to this problem is not
available at present.
• Gastrointestinal decompression has been found to be
particularly useful in two clinical entities:
▪ Intestinal obstruction
▪ Paralytic ileus. As a definitive means of treating
patients with simple small bowel obstruction
without operation, it has an important but
somewhat limited role. In general, these
limitations depend upon the difficulty in
distinguishing with certainty between simple and
strangulation obstructions and the time and care
necessary for the use of the method.
• As an essential part of the surgical treatment of all
cases of obstruction, decompression should be
routinely.
• In obstructions of the colon, decompression by means
of great extent, prevent a distention already present
from becoming greater. Decompression of a
distention already present must be secured by
operative means.
• The greatest benefit of gastrointestinal
decompression have come from the effective control
od the distension and vomiting associated with
paralytic ileus. This method of treatment is most
effective when used in prophylactic fashion.
Considerable differences of opinion exist as to its
exact role in postoperative care. In general, it is
indicated in the treatment of all patients undergoing
major abdominal surgical procedures and particularly
in those patients having operations upon the
gastrointestinal tract or in the treatment of any
patient in whom more than a minimal degree of ileus
can expected to follow operation.
• This form of therapy should be an essential part of
treatment of any patient with peritonitis. Associated
with control of distention and vomiting,
decompression protects the patient against the
bronchial aspiration of the gastric contents,
encourages the adequate and rapid healing of
intestinal suture lines, minimizes the incidence of
abdominal wound dehiscence and evisceration and
decreases the incidence of postoperative adhesive
obstruction.
• Associated with control of distention and vomiting
decompression protects the patient against the
bronchial aspiration of gastric contents, encourages
the adequate and rapid healing of intestinal suture
lines, minimizes the incidence of abdominal wound
dehiscence and evisceration, and decreases the
incidence postoperative adhesive obstruction.
• Place the patient in high fowlers’ position and instruct
them to swallow on command. Insert the tube into an
unobstructed nostril and slowly advance until at the
predetermined length. Check tube placement before
evacuation by air insufflation into the stomach with a
large syringe.
Which tube is used for gastrointestinal decompression?
• Cantor Tube
• This is a 10-foot long, single-lumen tube used for
intestinal decompression. The cantor tube has a
mercury-weighted rubber tab attached to its
perforated tip to help carry the tube through the
stomach and intestine.
What is the suction setting for gastric decompression?
• When using a one lumen gastric tube to decompress
the gastrointestinal tract, a regulator that has an
intermittent suction setting, with preset on-and-off
cycles must be used. Set the initial level of suction
within the “low range” (0-80mmHg), starting between
40-60mmHg. The suction level should not exceed
80mmHg.
Gastrostomy Feeding and J-tube Feeding
What is jejunostomy tube?
• A jejunostomy tube or J-tube is a soft plastic feeding
tube that is placed through the skin of the abdomen
into the jejunum (middle section of the small
intestine) bypassing the stomach entirely.
• The jejunostomy tube may be placed laparoscopically
(through a microscope inserted through the belly
button) or surgically. Jejunostomy tube like the
gastrotomy tube (G-tube), may be an actual tube or a
button. Only liquids may pass through the
jejunostomy tube.
The jejunostomy tube is put in place by one of these
methods:
• 1. Surgical – the tube is secured to the skin by
stitching the tube’s external fixation disc to it.
Occasionally, it may be secured by an internal fixation
disc.
• 2. Via a percutaneous endoscopic gastrotomy (PEG)
tube (a feeding tube placed into the stomach) – much
thinner jejunostomy extension tube is passed through
the PEG tube into the jejunum. Careful placement of
the jejunostomy tube is verified by X-ray. The
percutaneous endoscopic gastrotomy (PEG) tube is
retained in the stomach by a disc to ensure it does not
fall out. However, the jejunostomy extension tube is
only secured by an adaptor at the end of the PEG
tube.
• Radiologically – the tube is placed under X-ray control,
and is usually secured by stitching external fixation
disc to the skin.
Cleaning the skin around the jejunostomy tube
• To clean the skin, you will need to change the
bandages once a day or more if the area becomes wet
or dirty.
• The skin area should be always kept clean and dry.
You will need:
• Warm soapy water and a washcloth
• Dry, clean towel
• Plastic bag
• Ointment or hydrogen peroxide (if your doctor
recommends)
• Q-tips
Tuon kay bobo ta! #Top10saNPLEcuttie<3
Follow these guidelines every day for good health and skin To unblock tube: 5. Prepared measured To ensure correct amount
care: • Use warm boiled water to flush tube amount of of calories.
• Wash your hands well for a few minutes with soap • Try using soda water or bicarbonate of soda/water medication in
and water. solution to flush appropriate
• Remove any dressing or bandages on the skin. Place • Massage the tube along its length between the thumb container.
them in the plastic bag and throw the bag away. 6. Elevated the These positions enhance
and forefinger and try flushing periodically
patient’s bed to a the gravitational flow of
• Check the skin for redness, odor, pain, puss or • Wrap a hot flannel around the tube; ensure you
high-fowlers’ solution and prevent
swelling. Make sure the stitches are in place. protect your skin position. aspiration of fluid into
• Use the clean towel or Q-tip to the skin around the • If your are unable to unblock the tube then you will the lungs
jejunostomy tube 1 to 3 times a day with mild soap need to go to hospital 7. Placed protective Prevent to get wet
and water. Try to remove any drainage or crusting on • Purpose: sheet under tubing
the skin and tube. Be gentle. Dry the skin well with a • To provide hydration, nutrition or medication via 8. Removed cap or plug
clean towel. surgical opening into the stomach or jejunum when from the feeding
• If there is draining, place a small piece of gauze under oral route is contraindicated. tube.
the disc around the tube. • Considerations: 9. Aspirated stomach
• Do not rotate the tube. This may cause it to become 1. Special formulas or blender-prepared nutrients may contents with
blocked. be administered at room temperature and should syringe
be discarded if not used within a 24-hour period. 10. \Noted the amount Avoids overfilling the
Replacing the dressings around the jejunostomy tube of residual stomach
2. Possible side effects to consider are distensions,
withdrawn and
You will need: vomiting, diarrhea and constipation. Therefore,
injected gastric fluid
• Gauze pads, dressings, or bandages frequency of feeding, amount of formula, back into tube (Do
• Tape concentration of formula and content of formula not administer if
• Your nurse will show you how the place the new may need to be adjusted. Consultation with residual is greater
bandage or gauze around the tube and tape it physician or registered dietician may be indicated. than 100mL or twice
securely to the abdomen. 3. During continuous feedings, assess frequently for the hourly rate of
• Usually, spilt gauze strips are slipped over the tube abdominal distension. feeding)
and taped down on all four sides. Tape the tube down 4. Medications may be administered through the 11. Connected enteral Provides access to the
as well. feeding tube. Liquid preparations are preferred. bag tubing, pumped formula
• Do not use creams, powders, or sprays near the site Enterocoated tablets cannot be used. Flush tubing tubing to the
with water before and after to ensure full jejunostomy
unless the nurse says it is OK.
instillation of complete dose of medication. Each 12. With the infusion
medication should be given separately and flushed controller, purged
Jejunostomy tube maintenance:
the tubing of air and
The following applies to all jejunostomy tubes with 20 to 30 mL water between each medication.
attached it to the
regardless of how they are placed. 5. Gastrotomy tubed (G-tubes) that have a balloon tip
feeding tube
• As jejunostomy tube are usually fine bore tubes, it is should be changed as ordered by the physician; 13. Opened the
essential to ensure a thorough flushing regimen is in other types of G-tubes (e.g., mushroom, molecot) regulator clamp of
place. COOLED BOILED WATER is required and a new are changed in an outpatient setting. Jejunostomy the enteral tube to
syringe used daily. To flush the jejunostomy tube, tubes are only changed by physician. allow formula to
follow the instructions your nurse gave you. You will 6. If patient needs more water intake than is allowed flow through
use the syringe to slowly push warm water into the with the enteral feeding, physician orders need to 14. Adjusted to the
side opening of the J-port. be obtained to determine the amount of extra doctor’s
• All medications needs to be reviewed as bypassing the water frequency needs to be given to the patient recommended flow
stomach can affect the absorption of some drugs and daily. rate and according
• Equipment: to the patient’s
dosage may need to be altered. The correct
tolerance
preparation of medications, as far as possible is • 60 mL syringe
15. Flushed tube with Water cleanses the
essential, i.e., liquid/soluble/dispersible. • Graduated container
50-60 mL of water lumen of the tube and
• Glass of water after each feeding to prevents future blockage.
Over granulation of Stoma Site • Prepared formula ensure patency
• This is excessive growth of ‘tissue’ around the stoma • Clamp 16. Pinched tubing and Clamping or capping
site. This can be caused by incorrect position of the • Gloves remove enteral bag, feeding tube prevents
external fixation disc and/or infection. If external • Protective sheet controller tubing any reflux of the feeding
fixation disc is not stitched to the skin, ensure it is in • Enteral feeding bag and tubing and then clamped or
correct position. Keeping the stoma site clean and dry • Enteral feeding pump (optional) capped feeding
can help minimize this problem. Some physicians may tube.
Procedure Rationale
use silver nitrate to cauterize the tissue. Steroid 17. Left patient in semi- These position facilitates
1. Gathered all To save time and energy.
creams may also be used, but long-term used dose fowler’s position for digestion and movement
equipment to be
not predispose to candida infections (fungal). A snug at least 30 minutes of feeding from the
used for the
stomach along the
fitting tube that does not leak and avoiding trauma to procedure.
alimentary tract, and
the site will help avoid this common and recurrent 2. Explained the To established rapport
prevent potential
problem. Call nutrition nurse/doctor if infection is procedure to the and gain cooperation.
aspiration of the feeding
suspected. patient.
into the lungs
3. Provided privacy J-tube feedings are
18. Discarded soiled
Tube blockage embarrassing to some
supplies in
individual.
• This could possibly be due to inadequate flushing of appropriate
4. Performed hand To reduce transfer of
tube, or delay in flushing tube after feed has finished. containers
hygiene and wore microorganisms.
Blockage could also be caused by medication 19. Washed hands
gloves
formulation, or the way it is administered.

Tuon kay bobo ta! #Top10saNPLEcuttie<3

 20. Documented in Plan to replace the Prevents complication • Is an enema that cleans out the colon or rectum that
patient’s record: appliance immediately if relieves constipation, or threats diseases, such as
a. Verification of the client has localized inflammatory bowel diseases. (Chron’s disease and
proper tube symptoms ulcerative colitis)
placement. Schedule an appliance Coincides with a time Cleansing enema
b. Amount of aspirated change for an when the gastrocolic • Is a subtype of therapeutic enema. You may need a
stomach content asymptomatic client reflex is less active and
cleansing enema to clean out bowel before a medical
c. Feeding solution and before a meal and before prevents repeating
amount procedure, such as colonoscopy.
a bath or shower hygiene
d. Medications Detoxification or Detox enema
Plan to empty the pouch Prevents soiling
administered just before the appliance • This is not a medical term or practice, but many
e. Amount of water will be changed people perform enemas with the idea that the
administered Pull the privacy curtain Demonstrates respects ingredients will help clear the body inflammation.
f. Patient’s response to for the client’s dignity • There are many different ‘recipes’ for a detox enema.
procedure. Place a client in a supine Facilitate access to the Some detox enema advocates claim certain enema
g. Instructions given to or dorsal recumbent stoma ingredients offer health benefits beyond the colon,
patient/caregiver position such as eliminating toxins from the body and
Wash your hands or Reduces the transmission increasing “good” bacteria.
perform an alcohol-based of microorganism; Diagnostic enema
PERFORMING COLOSTOMY CARE hand rub; don gloves complies with standard • Is an enema that helps diagnose certain conditions of
precaution
the colon or rectum, including abdominal pain,
COLOSTOMY CARE Unfasten the pouch and
bleeding symptoms, and ulcerative colitis. A barium
• Clean skin is an important part of your colostomy care discard it in a lined
enema is a diagnostic enema. Barium shows up well
receptacle or waterproof
with new stomas a small amount of blood may be on xrays and allows your doctor to see the colon in
container. Facilitates
noted on the cloth. detail.
access to the faceplate
• This is normal due to the stoma having a rich blood Equipment:
Gently peel the faceplate Prevents skin trauma
supply. from the skin A. disposable linen-saver pad
• When cleansing the stoma, use oil/moisturizer free Wash the peristomal area Cleans the mucus and B. Bath blanket
soap and a soft cloth. with water or mild soapy stool from the skin. C. Bedpan or commode
• Rinse the soap off the skin and pat dry. This will assist water using a soft wash Promote potential for D. Clean gloves
in obtaining a good seal between the skin and water. cloth or gauze square. Pat adhesion. When the E. Water-soluble lubricant, if tubing not pre-lubricated
• Always look at the skin when cleansing it. The skin the peristomal skin dry faceplate applied. F. Paper towel
should be without redness or irritation. The skin with gauze. Large Volume Enema
around the stoma should be level/smooth. Attach a new pouch to Avoid pushing the pouch • solution container with tubing of correct size and
• Dips and creases in the skin can develop after surgery, the ring of the faceplate. into place after the tubing clamp
faceplate has been
resulting in difficult appliance wear time. • correct solution, amount and temperature
applied.
Small Volume Enema
Fold and clamp the Seals the pouch so
How often should I change the appliance?
bottom of the pouch leaking will not occur • Prepackaged container of enema solution with
• Normally an ostomy appliance will be changed every Peel the backling from Prepared the appliance lubricated tip.
3-5 days. the adhesive on the for application.
• Showering and bathing can be done with your pouch faceplate. The following are commonly used enema solutions
on. If you are due to change you appliance, you may Have the client stand or Keeps the skin taunt 1. Tap water
remove it to shower. lie flat avoid wrinkle • 500-1000mL
• Always select a time when your stoma is least active, Position the opening over Prevents air gaps and skin • Distends intestine
before meals or first thing in the morning. the stoma and press into wrinkle • Increases peristalsis
Steps Rationale place from the center • Soften stools
outward
wash hands Reduce the transmission • 15mins time effect
of microorganism and Perform hand hygiene
Adverse side effects:
complies with standard after removing gloves.
• Fluid and electrolyte imbalance
precaution. Removes transient
microorganisms • Water intoxication
Inspect the faceplate, Determine the necessity
Documentation: 2. Normal saline
pouch and peristomal for changing the
skin. appliance and provides Assessment data • 500-1000mL
data about the condition Peristomal care • Distends intestines
of the stoma and Application of new • Increases peristalsis
surrounding skin appliance. • Soften stools
Determine how much the Provides an opportunity • 15mins time effect
client understands about for health teaching: Adverse effect:
stomal care and changing prepares the client for Performing Cleansing Enema • Fluid and electrolyte imbalance
an ostomy appliance assuming self-care 3. Soap solution
Wash hands and perform Removes transient What is an enema? • 500-1000mL concentrate at 305/1000mL
hand hygiene measures microorganisms • An enema is the insertion of liquid into the rectum or • Distends intestines
after removing gloves
colon by the way of the anus. A physician may • Irritates intestinal mucosa
Obtain replacement Facilitates organization
recommend an enema for therapeutic or diagnostic • Soften stools
equipment, supplies for and efficient time
purpose. Constipation is one of the most common • 10-15mins time to effect
removing the adhesive management
(e.g., the manufacturer’s reasons for an enema. Adverse side effects:
recommended solvent if • Rectal mucosa irritation or damage
appropriate) and Types of enemas: 4. Hypertonic solution
products for the skin Therapeutic enema
• 70-130mL
Tuon kay bobo ta! #Top10saNPLEcuttie<3
 • Distends intestines
• Irritated intestinal mucosa
• 5-10mins time to effect
5. Oil solutions (mineral, olive or cotton seed oil)
• 15-200mL
• Lubricate stools and intestinal mucosa
• 30mins time to effect
Procedure:
1. Introduce yourself and verify the client’s identity.
Explain to the client what are you going to do, why is
it necessary, and how the client can cooperate.
Indicate that the client might experience a feeling of
fullness, while the solution is being administered.
2. Perform hand hygiene and observe other appropriate
infection control procedures
3. Provide privacy
4. Assist the adult client to a left lateral position, with
the right leg as acutely flexed as possible and the
linen-saver pad under the buttocks
5. Lubricate about 5cm (2inches) of the rectal tube
6. Run some solution through the connecting tube of a
large-volume enema set and the rectal tube, to expel
any air in the tubing; then close the clamp.
7. Insert the enema tube:
✓ For clients in the left lateral position; lift the
upper buttock
✓ Insert the tube smoothly and slowly into the
rectum, directing it towards the umbilicus
✓ Insert the tube 7-10m (3-4inches)
✓ If resistance is encountered at the internal
sphincter, ask the client to take a deep breath,
then run a small amount of solution through the
tube.
✓ Never forces tube or solution entry. If instilling a
small amount of solution to flow freely, withdraw
the tube. Check for any stool that might have
blocked the tube during insertion. If present,
flush it and retry the procedure. You may also
perform a digital rectal examination, to
determine if there is an impaction or other
mechanical blockage. If resistance persists; end
the procedure and report the resistance to the
primary care provider and nurse in charge.
8. Slowly administer the enema solution
✓ Raise the solution container, and open the clamp
ato allow fluid flow or compress a pliable
container by hand.
✓ During most low enemas, hold or hang the
solution container no more than 30cm(12inches)
above the rectum. During a high enema, hang the
solution container approximately 45cm
(18inches) above the rectum.
✓ Administer the fluid slowly. If the client
complaints of fullness or pain, lower the
container or use the clamp to stop the flow for
30secs, then restart the flow at a slower rate.
✓ If you are using a plastic commercial container,
roll it up as the fluid is instilled.
✓ After all the solution has been instilled, or when
the client cannot hold anymore and feels the
desire to defecate, close the clamp, and remove
the rectal tube from the anus.
✓ Place the rectal tube in a disposable towels as you
withdraw it.
9. Encourage the client to retain the enema.
✓ Ask the client to remain lying down
✓ Request the client to retain the solution for the
appropriate amount of time (e.g., 5-10mins for
cleansing enema, or at least 30mins for a
retention enema)
10. Assist the client to defecate
✓ Assist the client to a sitting position on the
bedpan, commode or toilet.
✓ Ask the client who is using the toilet not to flush
it. The nurse needs to observe the feces.
✓ If the specimen of feces is required, ask the client
to use a bedpan or commode.
11. Document the procedure
a. Type and volume if appropriate enema was given
b. The type of solution; length of time was retained;
the amount, color and consistency of the returns;
and the relief of flatus and abdominal distention
in the client record.
Post Op Care:
Cholecystectomy
1. Open Cholecystectomy
• Surgical removal if gallbladder through a single, large
cut of incision on the abdomen.
• Incision usually at right upper paramedian or upper
midline of the abdomen.
Indication for Open Cholecystectomy
1. severe inflammation of the bile duct or gallbladder
2. inflammation of the abdominal lining (Peritonitis).
3. portal hypertension (high pressure in blood vessels
in the liver)
4. uncontrolled bleeding
2. Laparoscopic Cholecystectomy
• A surgical removal of gallbladder with few small
incisions on the abdomen using a laparoscope, a think
tube with camera, ports or “trocars”, and special
laparoscopic instruments.
Procedure on Lap Cholecystectomy:
• A. Standard sites of four ports used in Laparoscopic
cholecystectomy.
1. The lateral port is used to retract the gallbladder.
2. The subcostal port is used to retract the
gallbladder.
3. The superior midline port is used to insert the
laparoscope later in the procedure while the
gallbladder is being withdrawn from the umbilical
cord.
4. The umbilical port is most often used to insert the
laparoscope for the most of the procedure and then is
used to withdraw the gallbladder after the
laparoscope is moved to the superior midline port.
• B. Preparing the gallbladder for removal by ligating it
from the attachments (e.g., cystic duct, artery,
vein)
1. The gallbladder is retracted through the lateral
port.
• A laparoscope is inserted through the umbilical port
to visualize the gallbladder.
• C. Removal of the gallbladder.
• Laparoscope through the superior midline port.
• Removal of the gallbladder through the umbilical port.
Advantages for Lap Cholecystectomy
• 1. It is a treatment of choice for symptomatic
gallbladder disease.
• 2. Suitable for most clients because of minimal trauma
to the abdominal wall.
• 3. Shorter hospitalization (within 24hrs after lap
cholecystectomy, the patient may go home and may
return to work after a few days.)
Disadvantage: if the stone are known to exist in the
common bile duct.
Pre-operative Care
1. Maintain patient on NPO at midnight
2. Skin preparation (ex. Showering with antibacterial
soap)
3. Occasionally an enema to reduce colon mass and
incontinence contaminating the operative field.
4. Administering of an antibiotic as ordered by the
physician.
Post-op Care
1. Respiratory status is carefully monitored because of
the potential for development of atelectasis and
pneumonia.
2. Monitor drainage from all biliary tubes and
drainage from the incision site, amount, character and
color
3. Assess cardiovascular status and manifestation of
hemorrhage or shock. (it is rare to develop but can
occur if an inflamed gallbladder has adhered to the
liver.
4. Analgesia for pain management. It is important and
should be given on a regular basis to promote comfort
and rest as well as to enhance the individual’s ability
to cough and deep breathe.
5. Maintain hydration and fluid balance Intravenous
fluids until the client is no longer NPO status and can
receive fluids orally.
Performing Hot Sitz Bath
• A sitz bath is a type of therapy done by sitting in
warm, shallow water. It can help soothe pain,
itching and other symptoms in the anal and
genital areas. It can also keep these are clean if
you cant take a bath or shower. Sitz is from the
German word sitzen, which means to sit.
Original term
• The term sitz bath is derived from the German
word “Sitzbad”, meaning a bath (Bad) in which
one sits (sitzen).
Objectives:
• To relieve muscle spasm
• To soften exudates
• To hasten the suppuration process
• To hasten healing
• To reduce congestion and provide comfort in the
perineal area
Purposes:
• To relieve pain, congestion and inflammation in
case of:
• Hemmoroids
• Tenesmus
• Rectal surgery
• Anal fissure
• After proctoscopic or cycloscopic exams
• Sciatica
• Uterine and rectal colic
Indications:
• Hemmoroids
• Anal fissure/surgery
• Episiotomy
Tuon kay bobo ta! #Top10saNPLEcuttie<3
 • Utering cramps Place the hot water bag To maintain flow of blood
• Important considerations: under the feet of the to the feet
• Warm water should not be used if considerable client
congestion is already present Add hot water slowly and Do not direct the flow of
• The patient should be observed closely for signs keep temperature of the water on patient and
water in the tub at 110F- place you hand between
of weakness and faintness
120F or as tolerated by client’s body and the
• After the patient is in the tub or the chair, check the client stream of water being
to see whether or not there is pressure against poured.
the patient’s thigh or legs Leave the patient in tub Check the client
• Support the patient’s back in the lumbar region for 10-20 minutes as frequently or give hand
Contraindication: ordered bell to call as needed
• Menstruating or pregnant woman Remove the client from
Equipment the tub after removing
1. Sitz tub or chair with 1/3 full of water (105-110F) the ice cap and hot water
2. (2) bath towels bag. Dry client
3. Bath thermometer completely
4. Ice cap with cover Assist the client back to
5. Hot water bag with cover bed and keep him warm
and comfortable
6. Chair
Tidy the room
7. Bath mat (or thick towel)
Record the treatment
8. Safety pins
and the client’s response
9. Draw sheet
10. Rubber ring
11. Bath blanket
12. Cotton bandage
13. Can or hot water or pail
14. Large pitcher with hot water (150F)

Steps Rationale
Check the physician’s A dependent function
order needs doctor’s order
Assemble all the To save time and effort
equipment in the client’s
bedside
Introduce yourself. To gain client’s
Identify the client and cooperation
explain the procedure
and reason why it is
necessary
Let the client void first Warm water might relax
before the procedure the urethral sphincter
and make the client void
in the solution
Place a chair covered
with blanket
Drape the client’s trunk
with bath towel and pin
opening of the towel
Undress the client by Covering client’s body
covering the entire body with bath blanket
with bath blanket. Place prevents chilling
crosswise with the
opening at the back
pin ends of the blanket
together at the back of
the blanket
Assist the client to sit in a This will be used as a
chair and note the pulse basis of comparison
and color of face during the procedure
Half fill the tube or chair
with water (110F)
Assists the client to sit in
the tub or chair opening
the blanket at the back to
envelope the client and
tub
Adjust ice cap to client’s The ice cap prevents the
head. rushing of blood to head
resulting in congestion
and headache
Tuon kay bobo ta! #Top10saNPLEcuttie<3