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TUBE FEEDING

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Gastrointestinal Intubation

Is the insertion of a rubber or plastic tube into the stomach. It is inserted through the mouth, the nose or abdominal wall.

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FEEDING TUBES

A feeding tube is used to help deliver nutrients to a patient's body when they can not take food in through the mouth.

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TYPES OF FEEDING TUBES
1. Nasogastric Tube SHORT TUBES  A common short term use feeding tube  Nasogastric Tube is placed into the nostrils of the patient and run through the nose down the esophagus into the stomach.  Used to remove fluid and gas from the upper GI tract or to obtain a specimen of gastric contents for lab studies.  Short term (3 to 4 weeks)
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SHORT TUBES Levin Tube- is a one-lumen nasogastric tube. Usually made of plastic with several drainage holes near the gastric end of the tube. There are graduated markings on the lumen so that you can see how far you have inserted the tube into the patient. 14 to 18 Fr ( 125 cm or 50 in long) Can be connected to low intermitten suction (30 to 40 mmHg) This nasogastric tube is useful in instilling material into the stomach or suctioning material out of the stomach.
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Gastric Pump or Salem-Sump Tube A radiopaque, clear plastic double lumen NG tube. Used to decompress the stomach and keeps it empty. 120 cm (48in) long It has a drainage lumen and a smaller secondary tube that is open to the atmosphere hat serves a vent. The major advantage of this two-lumen tube is that it can be used for continuous suction. The continuous airflow reduces the frequency of stomach contents being drawn up into the whole of the lumen which is in the patient's stomach because it protects gastric suture lines and it maintains the force of suction at the drainaige opening.

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Sengstaken – Blakemore tube Tripple lumen tube Used to apply pressure to stop bleeding from esophageal varices. The two lumen are used to inflate the gastric and esophageal balloon.

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MEDIUM TUBES
Nasoenteric Feeding tubes. Duodenum: 160 cm long Jejunum: 175 cm

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G-Tube  It is also sometimes called PEG-Tube, Mushroom, or Malecot tube.  The G-Tube is connected directly to the patient's stomach through an incision made in the abdominal wall structure. This kind of feeding tube is designed for long term tube feeding and its placement is generally on the left hand side of the abdominal cavity slightly below the ribs.

Gastric leakage can occur with this tube placement. The corrosive nature of the gastric juices found in the stomach can irritate the skin around the incision if there is leakage. Proper cleaning and gauze covering are done to minimize this irritation. rosechellebaggaosiupan 6/20/2012

2. J-Tube  Known as a Jejunostomy tube or a PEJ tube  Place surgically by making a small incision in the abdominal wall.  J-tube is connected directly to the patient's small intestine and nutrients completely bypass the stomach .

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Long Tubes
Nasoenteric Decompression Tube It is introduced through the nose and passed through the esophagus and stomach into the intestinal tract. Used to aspirate intestinal contents so that gas and fluid do not distend the intestine Used to relieve obstruction of the small intestine and may used prophylactically .

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Miller-Abbott Tube This tube is also a two-lumen nasogastric tube. 300 cm long 12, 14, 16, 18 Fr One lumen is used to introduce mercury, water, or saline into the balloon at the end of the tube for weighting of the tube. The other lumen is used for aspiration.
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The Cantor Tube.
This nasogastric tube has one lumen and a bag on the end. 300cm long and has 16 Fr lumen Mercury is inserted into the bag, and the mercury helps move the tube along the intestinal tract. Before the tube is inserted into the patient, mercury is injected directly into the bag with needle and syringe. The needle makes an opening large enough for the mercury to go through but not large enough for the mercury to leak out. When the tube is inserted into the patient, the bag holding the mercury becomes long. The Cantor tube is very effective when used for intestinal decompression (relief of stretching of the intestine through suctioning out intestinal contents)
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Harris Tube


 

Used for suction and irrigation Single lumen 180cm long 14 Fr

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Method of Nutrient Delivery into Tube

The Bolus/Syringe method uses a syringe needle to deliver the nutrient formula into the outside opening of the feeding tube. The nurse or doctor measures the amount of formula needed for the patient and pours it into a syringe. The syringe tip is placed inside the feeding tube opening and as the syringe top is depressed, the fluid flows into the tube using gravity.
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The Gravity Drip method, as the name suggests, also uses gravity to deliver nutrients through the feeding tube. This method is similar to the method used to deliver I.V. doses of medications. A formula bag is connected via tubes to the feeding tube and hung on an I.V. rack that is above the patient. Ice pouches may be attached to the drip bag to keep the formula cool and a roller clamp placed on the bag's tube controls the flow of the formula. Bags are usually changed every 24 hours to reduce the risk of bacteria in the formula and to ensure fresh formula is being used.
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The Pump Feeding method is a method of formula delivery that is controlled by a device powered by battery or electricity. The amount of formula to be delivered is determined by the doctor and adjusted accordingly on the device's interface controls. This method is used for J-Tube feeding tube connections to move the food through the tube (which sometimes falls below the patient's center of gravity) and ensures that is makes it into the small intestines. rosechellebaggaosiupan 6/20/2012

NASOGASTRIC TUBE INSERTION

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Rosechelle B. Siupan,RN,MAN

INDICATIONS:

 

 

Drain and Decompress the stomach by aspiration of gastric contents (fluid, air, blood). Introduce fluids and medication Assist in the clinical diagnosis through analysis of substances found in gastric contents. Obtain a specimen of the gastric contents In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration
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CONTRAINDICATIONS:
 

Patients with sustained head trauma, maxillofacial injury, or anterior fossa skull fracture. Inserting a NG tube blindly through the nose has potential of passing through the criboform plate, thus causing intracranial penetration of the brain. Patients with a history of esophageal stricture, esophageal varices, alkali ingestion at risk for esophageal penetration. Comatose patients have the potential of vomiting during a NG insertion procedure, thus require protection of the airway prior to placing a NG tube.
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Complications:

The main complications of NG tube insertion include aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting

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Excessive manipulation or movement by the patient during placement including coughing or gagging may potentiate cervical injury. Nasal irritation, sinusitis, epistaxis, rhinorrhea, skin erosion or esophagotracheal fistula secondary to NG placement. Aspiration pneumonia secondary to vomiting and aspiration. Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal intubation.
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EQUIPMENT REQUIRED:
    


 


  

Non-allergenic tape Protective pad or towel Gloves Basin Safety pin Cup of water with straw Stethoscope 60 cc Irrigating syringe Water soluble lubricant NG tube (plastic or rubber) of appropriate size Suction rosechellebaggaosiupan 6/20/2012 pH indicator strips

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Positioning:

Position the patient as follows:
 If

the patient is awake and alert-in a sitting position or in high-Fowler’s. the patient is obtunded or unconscious-head down, preferably in a left side lying position.

 If

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Length of NG tube to be inserted:

Determine the length of the NG tube to be passed by measuring the length from : ADULT
 Bridge

of nose to earlobe  earlobe to xiphoid process INFANT/CHILD Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel.
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Procedure:
   

Don non-sterile gloves Identify the patient. Explain the procedure to the patient Place a protective pad/towel on the patient’s chest as well as provide the patient with a basin to minimize contact with aspirated gastric contents. Inspect both of the patient’s nostrils for patency. Have the patient blow nose if able. Lubricate the first 6 inches of the NG tube liberally with a water soluble lubricant. Choose the largest patent nostril and begin to pass the NG tube through the nostril to the nasopharynx; direct the tube through the nostril aiming down and back. Pass tube via either nares posteriorly, past the pharynx into the esophagus and then the stomach.
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Once in the pharynx instruct the patient to swallow (you may offer ice chips/water) either mimicking the action or by sipping on small amounts of water advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.

If awake and alert have the patient place chin to chest to facilitate easier passage of the tube. Introduce the tube until the selected mark (indicated by the tape) is reached. rosechellebaggaosiupan 6/20/2012

If resistance is met, rotate tube slowly with downward advancement toward.Do not force. Withdraw tube immediately if changes occur in patient's respiratory status, if tube coils in mouth, if the patient begins to cough or turns cyanotic. Advance tube until mark is reached

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Verify NG tube placement in the stomach by:  Aspirating gastric contents with the irrigation syringe and test the pH.  While listening over the epigastrum with a stethoscope quickly instill a 10-30cc air bolus with the irrigation syringe. Air entering the stomach will produce a “whooshing” sound.  Ask the patient to hum or talk. Coughing, cyanosis or choking may indicate that the NG tube has passed through the larynx.  Place the open end of the NG tube in a cup of water. Persistent bubbling may indicate that the NG tube has passed through the larynx.

x-ray
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If unable to positively confirm that the NG tube has been placed is in the stomach the tube must be removed immediately and re-attempted. Once confirmed for placement, secure the NG tube by placing one end of tape on from the bridge to the tip of the nose and the other end wrapped around the tube itself. If possible the nose should be clean.

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To deter the NG tube from dangling and possible dislodgment:  Curve and tape the tube to the patient’s cheek to prevent unnecessary tugging on the nostrils. Attach the tube to the patient’s gown. (Do not tape to the patient’s forehead as this will put pressure on the nares.  Wrap a small piece of tape around the tube near the connection creating a tab.  Loop a rubber band in a slip knot near the connection and pin to the patient’s gown.
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Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

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ADMINISTERING ENTERAL FEEDINGS VIA NASOGASTRIC TUBE

FACULTY GUIDELINES
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NURSING ACTIONS

RATIONALE

ASSESSMENT 1. Assess client’s need for Identify clients who enternal tube feedings. need tube feeding before they become nutritionally depleted.

2. Assess for signs and symptoms of malnutrition.

Certain

conditions, such as gastrointestinal diseases, cancer, severe infections, head injury, trauma, and metabolic diseases, make clients candidates for enteral nutrition.
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3. Assess client for food Prevents client from allergies. developing localized or system allergic responses.
4. Auscultate for bowel sound before feeding.
Absent

bowel sounds may indicate decreased ability of GI tract to digest or absorb nutrients.
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5. Obtain baseline weight and laboratory values. Assess client for fluid volume excess or deficit, electrolyte abnormalities such as hyperglycemia. 6. Verify for physician’s order for formula, rate, route, frequency.

Enteral

feedings are to restore or maintain a client’s nutritional status. Provides objective data to measure effectiveness of feedings.
Ensures

correct formula will be administered in appropriate volume.
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PLANNING
1. Expected outcomes… A. Nutrition status is improved, as evidenced by Increasing weight, improving laboratory values, and improved intake and output. B. Client has no signs of respiratory distress (e.g., increased respiratory rate, coughing, poor color), discomfort.
Indicates

the client’s nutritional needs are being met.

Entry

of feeding tube into airways or aspirator of feeding causes respiratory distress.

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2. Explain procedure to client. 3. Perform hand hygiene.
4. Prepare feeding container to administer formula continuously: A. Check expiration date on formula and integrity of container.

Well-informed

client is more cooperative and ease. Reduces transmission of microorganisms.

For

client’s safety.

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Ensures

GI tolerance of

B. Have tube feeding at room temperature.

C. Connect tubing to container as needed or prepare ready-tohand container.

formula. Prevents leakage of tube feeding. Cold formula may cause gastric cramping and discomfort because the liquid is not warmed by the mouth and esophagus. Tubing must be free of contamination to prevent bacterial growth.

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D. Shake formula container well, and fill container tubing with formula. Open stopcock tubing, and fill tubing with formula to remove air. Hang on IV pole. 5.For intermittent feeding have asepto syringe ready and be sure formula is at room temperature. 6.Place client in highfowlers position or elevate head of bed at least 30 degrees.

Filling

the tubing with formula prevents axcess air from entering gastrointestinal tract once infusion begins.

Cold

formula causes gastric cramping.

Elevated

head helps prevent aspiration.
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IMPLEMENTATION
1. Apply gloves. 2. Determine tube placement. Consider the aspirate’s appearance.
Reduces

transmission of microorganisms. On occasion, color alone may differentiate gastric from intestinal placement. Because most intestinal aspirates are stained by bile to a distinct yellow color, and most gastric aspirates are not.

3. Check for gastric residual.
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A. Connect asepto syringe to end of feeding tube, press rubber valve to aspirate gastric contents.

Residual

volume indicates if gastric emptying is delayed. Delayed gastric emptying may be reflected by 100ml or more remaining in the client’s stomach.

B. Return aspirated Return of aspirate prevents contents to stomach fluid and electrolyte unless the volume imbalance. exceeds 100ml. 4. Flush tubing with 30ml water 5.Intiate feeding:
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Ensures

tube is clear and

patent.

A. Pinch proximal end of feeding Prevents air from tube. entering client’s stomach. B. Connect the asepto syringe Asepto syringe with rubber valve at the end of receives formula for the feeding tube. installation. C. Fill asepto syringe with measured amount of formula. Height of asepto Release tube and elevate asepto syringe receives asepto syringe to no more than formula for 18inchcs above insertion site installation. and allow it to empty gradually by gravity. Refill until prescribed amount has been delivered to client.
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6. Advance rate of concentration of tube feeding gradually. 7. Following intermittent infusion or at the end of continuous infusion, flush nasoenteral tubing with 30ml of water, using irrigating syringe. Repeat every 4 to 6 hours around the clock. 8. When the tube feeding is not administered, cap or clamp the proximal end of the feeding tube.

Prevents

diarrhea and gastric intolerance to formula. Provides client with source of water to help maintain fluid and electrolyte imbalance. Clears tubing of formula.
Prevents

from entering stomach between feedings.
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9. Rinse bag and tubing with warm water whenever feedings are interrupted. 10. Change bag and tubing every 24hours. EVALUATION 1. Measure amount of aspirate (residual) every 8 to 12hours. 2. Monitor finger-stick blood glucose every 6hours until maximum administration rate is reached and maintained for

Rinsing

bag and tubing with warm water clears old tube feedings and reduces bacterial growth. Reduces incidences of bacterial growth.
Evaluates

tolerance of tube feeding.
Alerts

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nurse to clients tolerance of glucose. May require physician to revise type of formula
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3. Monitor intake and output every 8hours.

Intake

and output are indications of fluid balance or fluid volume excess or deficit.
Weight

4. Weigh client daily until maximum administration rate is reached and maintained for 24hours, then weigh client three times per week.

gain is indicator of improved nutritional status; however, sudden gain of more than 2lb in 24hours usually indicates fluid retention.

5. Observe return of Improving laboratory normal laboratory values. values indicate an improved nutrittional status.
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6. Observe client’s respiratory status.

Change

in respiratory status can indicate aspiration of tube feeding.
Reduces

7. Observe client’s level of comfort.

gastric emptying can lead to abdominal discomfort.
Confirms

8. Auscultate bowel sound.

normal peristalsis is present.

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 Prepared By: Austeria N. Capino, RN, MAN

Nursing Faculty
 Noted by; Ms. Noli Pagdanganan

Level III Academic Coordinator
 Concurred By: Ester Climaco, RN, MAN
 Approved by; Dean Roberto C. Sombillo, RN,

RM, MAN

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ELVIRA S. MEDINA RN, MAN.

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 1.

Describe Indications and contraindications for Percutaneous Endoscopic Gastrostomy (PEG) Feeding.
Gastrostomy

 Define  Feed

a Patient via Gastrostomy

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1.

2.

Gastrostomy = is an artificial opening through which a feeding tube is passed. The tube is usually inserted endoscopically and is therefore known as percutaneous Endoscopic Gastrostomy. (PEG). Jejunostomy = the surgical formation of an opening through the abdominal wall into the jejunum. The opening made by Jejunostomy.
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Indication for PEG include long term feeding as for a nasogastric tube, or for conditions requiring enteral feeding for more than two weeks, and an ability to tolerate NG tubes (Reilly 1998; Arrowsmith 1996).

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PEG tubes are contraindicated for the same conditions as NG tubes except for basal skull fractures and prolonged feeding. The British Society of Gastroenterology (1996) and Arrowsmith (1996). Also note that additional contra indicated are:
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. Patient unfit for endoscopy . Current chest infection . Ascitis . Portal hypertension (with gastric varices) . Active gastric ulcer . Total gastrectomy . Uncorrected coagulopathy (blood clotting dysfunction)
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. More comfortable than NGT tube . Cosmetically more acceptable for some patients. . Reduced risk of tube displacement . Reduce risk of tube blockage . Does not need regular replacement.
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Mr. Hamilton is unable to maintain an adequate nutritional status orally, as he is unable to swallow due to post surgery for cancer of the oesophagus. Nursing Diagnosis: Nutrition, altered: less than body requirement
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Mr. Hamilton will receive a balanced nutritional intake, totaling a calorific intake of x calories in 24 hours via his PEG.

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1. Correct

solution 2. Graduated container, to hold the feeding 3. Large bulb syringe 4. Graduated container with 60 ml of water, to flush the tubing 5. Graduated container, to measure residual formula 6. 4x4 gauze
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amount of feeding

To administer a PEG feed, the same guidelines provided for NG tube feeding. However, it is not necessary to check for correct positioning of a tube.

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1. 2. 3. 4. 5. 6. 7.

Assemble equipment and supplies Explain to the client what you are going to do. Wash hand Provide client Privacy Wear sterile Gloves Check the residual. Hold the barrel of the syringe 7-15 cm(3-6 in) above the ostomy opening
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7. Slowly pour the solution into the syringe, and allow it to flow through the tube by gravity. 8. Just before the all the formula has run through and the syringe is empty, add 30ml of water. 9. If the tube is sutured in place, hold it upright and remove the syringe, and them clamp the tube to prevent leakage. Or cover end with 4x4 gauze.
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10. After the feeding ask the client to remain in the sitting position or slightly elevated right lateral position for at least 30 minutes. 11. Ensure client comfort and safety. 12. Document all assessments and interventions.
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Has Mr. Hamilton received a balance diet and the required number of calories? This will be measure through accurate recording of the daily nutritional intake. If the goal has not been reached, the plan of care will need to be revised accordingly.
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Jose Byron Dadulla Evardone Arellano University College of Nursing

6/20/2012

A colostomy is an opening that is made in the colon with surgery.
After the opening is made, the colon is brought to the surface of the abdomen to allow stools to leave your body. The opening at the surface of the abdomen is called a stoma. The stool leaves the colon through the stoma and drains into a flat, changeable, watertight bag or pouch. The pouch is attached to the skin with an adhesive (substance that seals the pouch to the skin).
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 Indications  Cancer,

for use:

 Diverticular

disease  Crohn's disease  Trauma or injury.
A temporary colostomy may be needed to allow the colon to rest and heal for a period of time. A temporary colostomy may be in place for weeks, months, or years. The temporary colostomy will eventually be closed and bowel movements will return to normal. A permanent colostomy is usually needed when a part of the

colon must be removed or cannot be used again.

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 The

colon is part of the digestive system. The digestive system consists of the parts of the body that are involved in the digestion (breakdown) of food. Food moves from your stomach to the small intestine where food is digested and nutrients are absorbed. The food then goes to the colon (part of the large intestine). The colon absorbs water from digested food and turns the digested food into stool.
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 Colostomy

types are related to the place on the colon where the surgery is done. The location of the surgery depends on your health condition and the reason you need to have a colostomy.

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 This

colostomy has a stoma (opening) that is located on the right side of the abdomen. The output (stool) that drains from this stoma is in liquid form.

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 This

colostomy has a stoma that is located in the upper abdomen towards the middle or right side. The output that drains from this stoma may be loose or soft.
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 This

colostomy has a stoma that is located on the lower left side of the abdomen. The output that drains from this stoma is firm.
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 Pouch:

There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special covering that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release gas slowly and help to decrease gas odor.

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 This

type of pouch allows you to open the bottom of the pouch to drain the output. The open end is usually closed with a clamp. The open-ended pouch is usually used by people with ascending or transverse colostomies. The output from these colostomies is looser and is unpredictable

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 This

type of pouch is removed and thrown away when the pouch is filled. Close-ended pouches are usually used by people with a descending or sigmoid colostomy. The output from these types of colostomies is firm and does not need to be drained .

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A

one-piece pouch contains the pouch and adhesive skin barrier together as one unit. The adhesive skin barrier is the part of the pouch system that is placed around the stoma and attached to skin. When the pouch is removed and replaced with a new one, the new pouch must be reattached to the skin.

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 The

two-piece pouch has two parts: an adhesive flange and pouch. The adhesive flange stays in place while the pouch is removed and new pouch is attached to the flange. The pouch does not need to be reattached to the skin each time. The twopiece system can be helpful for patients with sensitive skin.

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 The

way in which you should change your colostomy pouch depends on the type of pouch you use. Your caregiver will give you specific instructions on how to change your colostomy pouch.

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Clean the skin around the stoma with warm water. You may also use soap but do not use soaps that have oil or perfumes. Pat your skin dry. Use a pouch that has an opening that is one-eighth of an inch larger than the stoma. Use skin protection products if you have irritated skin around the stoma. The skin can be treated with these products to protect your skin and create a dry surface.

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 Center

the pouch over the stoma and press it firmly into place on clean, dry skin. It may be helpful to hold your hand over the newly applied pouch for 30 seconds. The warmth of your hand can help to mold the adhesive skin barrier into place. the old pouch in another plastic bag to be thrown away if the pouch is disposable. If you use a reusable pouch, talk to your caregiver about how to clean the reusable pouch.

 Place

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Empty the pouch when it is one-third to one-half full. Do not wait until the pouch is completely full because this could put pressure on the seal, causing a leak. The pouch may also detach, causing all of the pouch contents to spill.
Place toilet paper into the toilet to reduce splash back and noise. Take the end of the pouch and hold it up. Remove the clamp (if the pouch has a clamp system).

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 People

with descending or sigmoid colostomies may be able to irrigate their colostomies on a regular basis. Irrigating the stoma means putting a fluid into the stoma to empty the bowel. This may also be called an enema. Irrigation allows a person to have timed bowel movements. Irrigation can allow a person to be free from stool output for about 24 to 48 hours. Once stool output is regular, a stoma cap can be used between irrigations instead of using a drainable pouch. The stoma cap will absorb mucus and deodorize and vent gas.
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 Stoma

retraction: Retraction happens when the height of the stoma goes down to the skin level or below the skin level. Retraction may happen soon after surgery because the colon does not become active soon enough. Retraction may also happen because of weight gain. The pouching system must be changed to match the change in stoma shape.

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 Peristomal

hernias occur when part of the bowel (colon) bulges into the area around the stoma. Hernias are most obvious during times when there is pressure on the abdomen. For example, the hernia may be more obvious when sitting, coughing, or straining. Hernias may make it difficult to create a proper pouch seal or to irrigate. The hernia may be managed with a hernia belt. Changes may also need to be made to the pouching system to create a proper seal. Surgery may also be done in some people
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A

prolapse means the bowel becomes longer and protrudes out of the stoma and above the abdomen surface. The stomal prolapse may be caused by increased abdominal pressure. Surgery may be done to fix the prolapse in some people.

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A

stenosis is a narrowing or tightening of the stoma at or below the skin level. The stenosis may be mild or severe. A mild stenosis can cause noise as stool and gas is passed. Severe stenosis can cause obstruction (blockage) of stool. If the stoma is mild, a caregiver may enlarge it by stretching it with his finger. If the stenosis is severe, surgery is usually needed.

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 People

with colostomies can eat a regular diet. Choose healthy foods from all the food groups. To avoid constipation, eat foods such as oatmeal, whole-grain breads and cereals, fruits and vegetables. There may be some foods that you cannot tolerate very well. If a food gives you cramps or diarrhea, do not include that food in your diet. Try the food again in a few weeks. Eat small portions first and then gradually increase your portion sizes.

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Avoid foods that cause gas and odor.  Vegetables such as broccoli, cabbage, and cauliflower,Beans, eggs, and fish.  You can also reduce gas by eating slowly and not using straws to drink liquids.

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Fresh parsley  Yogurt  Buttermilk.

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 Drink

at least 8 to 10 (eight ounce) cups of water each day.
liquids for most people to drink are water, juices, and milk.

 Healthy

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 an

abdominal opening is created  the intestines are brought out through the skin  the intestine is sutured to the skin  the stoma is complete

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Ostomies

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 Ostomy
 Gastrostomy  Jejunostomy  Ileostomy  Colostomy

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 Ostomy-opening

for GI,urinary or respiratory tract onto the skin  Gastrostomy- opening through abd.wall into the stomach  Jejunostomy- abd.wall into the jejunum  Ileostomy-opens into the ileum  Colostomy-opens into the colon

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Ostomy wafer, gloves, scissors, pen or pencil, and sponges are used when pouching a stoma.

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Ostomy skin barriers, also called wafers

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Ostomy drainage bag

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Cleanse the stoma and surrounding skin with warm tap water.

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Remove the paper backing from the wafer.There are many pouching systems available.This pouch is a one-piece system and has a skin barrier already attached.Others are twopiece systems where the skin barrier is attached first and the pouch is attached to the skin barrier.

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Place the wafer and pouch with the stoma centered in the cutout opening of the wafer.

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Check to make sure the stoma fits the hole so a minimum of the surrounding skin is exposed to contact with stool.

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Place gauze over the stoma to absorb stool while the wafer and pouch are being prepared

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 The

stoma should appear red , similar in mucosal lining of the inner cheek.  Very pale or darker colored stoma with bluish or purplish hue indicate impaired blood circulation to the area.

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2

to 3 weeks . Failure to recede may indicate a problem , for example blockage.

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 Slight

bleeding initially when the stoma is touched is normal but other bleeding should be reported.

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 Any

redness and irritation of the peristomal skin –the 5 to 13 cm (2 to 5 in) of skin surrounding the stoma should be noted. Transient redness after removal of the stoma is normal .

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 Assess

for amount ,color,odor and consistensy.  Pus or blood is an indication of abnormal discharge.

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 Client

complains of severe cramping during irrigation of colostomy. Prevention:  Slow infusion of tepid water into colostomy and hang irrigation bag no higher than 12 to 18 inches above the stomach.

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LEVEL III SKILLS PROCEDURE
ADMINISTERING CLEANSING ENEMA

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An enema is the introduction of solutions into the rectum and colon to stimulate bowel activity and to cause defecation.

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To promote defecation by stimulating peristalsis and loosening stool mass. 2. To cleanse the bowel prior to surgery, childbirth, or diagnostic exam. 3. To administer medication to exert a local effect on the rectal mucosa. 4. To relieve constipation, abdominal distention and fecal impaction.
1.

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1.

CLEANSING ENEMA -stimulates peristalsis by irrigating the colon and rectum or by distending the intestine with the volume of fluid induced.

Agents:  Soap suds: mild soap solutions stimulate and irritate intestinal mucosa. Strong soap solution can cause severe irritation of the mucous membrane of the colon. Dilute 3-5ml mild soap in 1000ml of water.

Tap water: Give with caution to infants or adults with altered cardiac and renal reserve.tap water is a hypotonic solution.

Saline: for normal saline enemas, use a smaller volume of solution. Hypertonic solutions draw fluid into the colon from the body tissues. These solutions are mildly irritating to the mucous membrane of the colon.

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A. Large volume enema/ High Enema
 -

To clean as much of the colon as possible The patient retains the fluid as long as possible to allow loosening and softening of the fecal material  For constipation  Bowel prep before surgery or visulization - 500 to 1000 ml of solution - 18 inches
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B. Small volume/ Low Enema
   

To clean the rectum and sigmoid colon only Cleans the colon but does not cleans the higher portion of the colon 500 ml 12 inches

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C. Prepacked Disposable Enema/ Fleet Enema
   

Small volume , used in preparation for test Contains biscodyl or sodium phosphate Retain sol. for 20 mins. 37 to 150 ml

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2. Oil Retention Enema/ Retention Enema Introduces oil into the rectum and sigmoid colon  Lubricates and softens stool Oil is retained 1-3 hours 90 -120 ml solution Mineral oil, castor oil

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3.    

Return Flow/ Harris Flash/ Colonic Irrigation Done to remove flatus, gas and stimulate peristalsis Large volume is used but instilled in small increments 100-200 ml/ 300-500ml NSS

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Non Retention Enema
Solution Height Temperature Time of Retention
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Retention Enema

Tap Water, Soap Suds, NSS 18 inches 115-125 F 5- 10 mins

Carminative Enema/ Oil Retention 12 inches 105-110 F C 1-3 hours 37.7- 40.5

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Enemas should not be used as a first-line treatment for constipation. Frequent use of enemas can lead to fluid overload, bowel irritation and loss of muscle tone of the bowel and anal sphincter.

Never deliver more than three consecutive enemas to treat a patient. A patient with diarrhea may not be able to hold an enema.
Enema administration must be used with caution in cardiac patients who have arrhythmias or have had a recent myocardial infarction Insertion of the enema tube and solution can stimulate the vagus nerve which may trigger an arrhythmia such as bradycardia.
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Enemas should not be given to patients with undiagnosed abdominal pain because the peristalsis of the bowel can cause an inflamed appendix to rupture. Enemas should be used cautiously in patients who have had recent surgery on the rectum, bowel, or prostate gland. If the patient has rectal bleeding or prolapsed of rectal tissue from the rectal opening, cancel the enema and consult with the physician before proceeding. Do not force the enema catheter into the rectum against resistance. This can cause trauma to the rectal tissue. Use only mild soap for soapsuds enemas because other soap preparations are too harsh and irritate the rectal tissue.
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quipment:
           

1. Clean trolley 2. Wash cloth, soap, water, towel and gauze swab 3. Rectal tube 4. Enema bag, tubing and clamp 5. Bath thermometer 6. Bedpan and cover or bedside commode and toilet paper 7. Bath blanket 8. Moisture proof under pad 9. Enema solution as per Doctor's prescription 10. Lubricant 11. Disposable gloves. 12. I. V. pole or bedside table elevated 30 - 45 cm. (12 - 18 inches)

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ASSESSMENT

RATIONALE

1. Check physician’s order for enema
2. Check client’s medical record to clarify rationale for enema. 3. Assess status of client: last bowel movement, normal versus most recent bowel pattern, presence of hemorrhoids, mobility, bowel sounds, and presence of abdominal pain. 4. Assess medical record for presence increased intracranial pressure, glaucoma, or recent rectal or prostate surgery. 5. Inspect abdomen for presence of distention.

To minimize the risk of error and comply with legal requirements
To determine the type and amount of enema to be administered. To monitor the patient’s bowel function

To prevent complications

To monitor for possible complications

6. Determine client’s level of understanding To assess factors that might affect the of purpose of enema. patient’s ability to cooperate or to undergo the procedure.
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1. Expected outcomes following completion of procedure:
•   Stool is evacuated. Enema return is clear Abdominal distention is absent; client’s discomfort is relieved.

2. to relieve constipation 3. Correctly identify client and explain the procedure.

Explanation helps to minimize anxiety and to obtain the patient’s consent and cooperation.

Implementation
1. Perform hand washing and apply gloves. Hand hygiene deters the spread of microorganism. Gloves protect nurses from microorganism in feces. 2. Provide privacy by closing curtains To avoid unnecessary embarrassment to around bed or closing the door. the patient and prevent discomfort during the procedure. 3. Raise bed to appropriate working height and raise side rail on opposite side.
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4. Assist client into left side-lying (Sim’s) position with right knee flexed. Children may also be placed in dorsal recumbent position. 5. Place waterproof pad under hips and buttocks. 6. Cover client with bath blanket, exposing only rectal area, clearly visualizing anus. 7. Separate buttocks and examine perianal region for abnormalities including hemorrhoids, anal fissure, rectal prolapsed. 8. Place bedpan or commode in easily accessible position. If client will be expelling contents in toilet, ensure that toilet is free.
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To facilitate flow of solution using contour of bowel

The waterproof pad/rubber sheet protects bed linen To avoid unnecessary embarrassment during the procedure To prevent complications

In case the patient feels the need to expel the enema solution before the procedure is completed.

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Administer prepackaged disposable fleet enema: a. Remove plastic cap from tip of container. To reduce irritation to the rectal and anal Tip of nozzle is already lubricated, but more mucosa water-soluble jelly can be applied as needed. b. Gently separate buttocks and locate This helps the patient to relax the external rectum. Instruct client to relax by breathing anal sphincter. out slowly through mouth. c. Expel any air from the enema. d. Insert nozzle of container gently into anal, angling towards the umbilicus.  Adult: 7.5-10 cm (3-4 inches)  Child: 5-7.5 cm (2-3 inches)  Infant: 2.5-3.75 cm (1-1 ½ inches) If air is instilled during the procedure, client experiences discomfort The tube/nozzle should be inserted past the external and internal sphincters, but further insertion may damage intestinal mucous membrane.

e. Squeeze bottle until all solution has To prevent solution from being drawn back entered rectum and colon. Instruct client to into the container. retain solution until the urge to defecate occurs, usually 2 to 5 minutes.
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Administer enema using enema bag/container: a. Add warmed solution to enema container Solution that are too hot or too cold can bag: warm tap water as it flows from faucet cause cramping and damage to rectal place saline container in basin of hot water mucosa before adding saline to enema bag, and check temperature of solution by pouring small amount of solution over inner wrist. Or lukewarm solution,105-110 F
b. Raise container, release clamp, and allow solution to run through tubing until air is removed. clamp tube c. lubricate 6-8 (3-4 inches) of tip of rectal tube with lubricating jelly. d. Gently separate buttocks and locate anus. Instruct client to relax by breathing out slowly through mouth.
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If air is instilled during procedure, client experiences discomfort as a result of distention of the colon. To prevent rectal injury This is done to stimulate contraction and relax the sphincter which will ease the catheter insertion by breathing into the mouth.
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e. Insert tip of rectal tube slowly by pointing tip in direction of client’s umbilicus. Length of insertion varies:  Adult: 7.5-10 cm (3-4 inches)  Child: 5-7.5 cm (2-3 inches)  infant: 2.5-3.75 cm (1-1 ½ inches) f. Hold tubing in rectum constantly until end of fluid instillation. g. Open regulating clamp, and allow If the flow is slow, client experiences solution to enter slowly with container fewer cramps. The client will also be at client’s hip level. able to tolerate and retain a greater volume of solution. h. Raise height of enema container To assist in fluid movement, gravity forces slowly to appropriate level above anus: the solution to enter the intestine. the  high enema- 30-45 cm (12-18 inches) amount of pressure determines the rate of  Regular enema- 30 cm (12 inches ) flow and pressure exerted on the intestinal  Low enema- 7.5 (3 inches ) wall. Instillation time varies with volume of solution administered.
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i. Lower container or clamp tubing if client complains of cramping or if fluid escapes around rectal tube. j. Clamp tubing after all solution is instilled. 9. Place layer of toilet tissue around tube at anus and gently withdraw rectal tube. 10. Explain to client that feeling of distention is normal, as well as some abdominal cramping. Ask client to retain solution as long as possible. While lying in bed. (For infant or young child, gently hold buttocks together for few minutes). 11. Discard enema container and tubing in proper receptacle, or rinse out thoroughly with warm soap and water if container is to be reused.
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These techniques help relax muscle and prevent expulsion of the solution.
To avoid introducing of air into the bowel. To avoid reflex emptying of the rectum The longer the solution is retained, the more effective the results.

This is a standard precaution. To avoid transfer of microorganisms.

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12. Assist client to bathroom or help to position client on bedpan. 13. Observed character of feces and solution (caution client against flushing toilet before inspection). 14. Assist client as needed to wash anal area with warm soap and water. 15. Remove and discard gloves and perform hand hygiene. 1. Inspect color, consistency, and amount of stool and fluid passed. 2. Assess condition of abdomen.

To evaluate the results

To promote patient’s comfort and avoid excoriation and infection. This is a standard precaution. It decreases transmission of microorganism. To monitor the patient’s bowel function to make sure total volume of the solution is expelled, if for strict I&O measurement.

1. Record type and volume of enema given, time administered, and characteristics of results. 2. Report failure of client to defecate and any adverse effects to physicians
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 

EVALUATION Client experiences increased comfort and relief from abdominal distention. Returns are clear if preparing client for diagnostic examination or surgery. Relief obtained from fecal impaction Return of solution and formed, soft feces is complete.

 

NURSING CONSIDERATIONS
1.

If client has the urge to defecate when tube is being withdrawn, ask the client to hold the buttocks together for a few seconds. If abdomen becomes rigid or distended , stop enema immediately and notify physician.

2.

3.

Repeated use of enemas destroys defecation reflex and leads to further alterations in bowel elimination.
A frail elderly is susceptible to fluid and electrolytes imbalances resulting from enema administration.t he nurse should monitor F&E status.
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4.

> Direct

visualization of the sigmoid colon and the anal canal Laxative at night before exam, NPO from midnight and enema or suppository in the morning of the procedure Observe rectal bleeding
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PROCTOSCOPY

Figure 1

Figure 2

Figure 3

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SIGMOIDOSCOPY

Figure 1

Figure 2

Figure 3

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SIGMOIDOSCOPY

Figure 4

Figure 5

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> Direct

visualization of the liquid diet 1 to 3 days

colon
Clear

prior Enema in am before the exam Observe stool and vital signs
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COLONOSCOPY

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 Occult

blood test (Guaiac test)  may be used to detect presence of blood in the aspirate (as it is also a test for occult blood in the stool)

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GUAIAC TEST
Positive guaiac test shown on right, as would be seen for this patient. Negative result (on left) included for comparison.

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END!!

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