Assisting the Patient In Bowel Examination:
Insertion of Suppository:
Definition:
To introduce medicament in a solid form per rectally for local or systemic action.
Equipment:
Rectal suppository
Water soluble lubricating jelly.
Clean gloves.
Draping sheet or screen.
Types:
Evacuating
(i). Glycerine suppository:-
Glycerine is hygroscopic, so it causes evacuation by withdrawing fluid from the mucous membrane and tissue.
(ii). Bisacodyl Suppositoy:-
It increases mucous secretion from the mucous membrane and also stimulates peristalsis of large bowel.
2. Analgesic:-
Aspirin suppository.
3. Retaining:-
(i) Aminophylline Suppository:-
In broncho spasm or chronic bronchial asthma.
(ii) Steroids:-
Hydrocortisone / Prednisolone suppositories in
proctitis and ulcerative colitis.
Pre-requisites:
Check for Doctors order, drug name, form. time of administration.
Check clients name.
Provide privacy.
Explain procedure and give Sim’s position. Keep client draped with only anal area exposed.
Arrange articles at bedside.
Procedure:
Do hand washing.
Apply disposable gloves.
Remove suppository from wrapper and lubricants rounded end with lubricating jelly. Lubricate index finger with a water soluble lubricant to reduce friction.
Ask client to take slow deep breaths through mouth and relax anal sphincter to reduce pain.
Retract buttocks with the other hand, insert suppository gently into the rectum, above the level of internal anal sphincter and against rectal wall for eventual absorption and therapeutic action.
Withdraw finger and apply pressure to hold buttocks together.
Remove and discard gloves.
Ask client to retain suppository, at least fo 20 minutes to prevent expulsion of suppository.
Do hand washing.
Observe for effects of suppository at times that co-relate with the medications onset, peak and duration to evaluate effectiveness of medication and relief of clients symptoms.
Do recording and reporting after the procedure.
HISTORY COLLECTION
INTRODUCTION:
PATIENT PROFILE:
NAME :
AGE :
IP NO. :
UNIT / WARD :
EDUCATION :
OCCUPATION :
INCOME :
RELIGION :
DATE OF ADMISSION :
DIAGNOSIS :
NAME OF SURGERY :
DATE OF SURGERY :
ADDRESS :
DATE OF CARE STARTED :
DATE OF CARE ENDED :
CHIEF COMPLAINTS :
MEDICAL HISTORY
PRESENT HISTORY
PAST HISTORY (general health status, infectious diseases immunization, chronic systemic disease, medications, hospitalizations, injuries, blood transfusion)
SURGICAL HISTORY
PRESENT HISTORY
PAST HISTORY (surgery – indications, name of hospital, type of anesthesia, any complications)
FAMILY HISTORY
Hereditary diseases – systemic illness, psychiatric illness, communicable diseases
Family Tree
Pedigree keys:
□ - Male
○ - Female
— - Relationship
● - Died
- Patient
Family composition:
| SL. No. | Name of the Family Members | Age/ Sex | Relationship with head of family | Education | Occupation | Income | Health Status |
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OBSTETRIC HISTORY
Menstrual History:
Age of menarcy, menstrual cycle regular / irregular, no. of days in a cycle, problems.
Obstetrical History:
No. of pregnancy, miscarriages, abortions, labour and
delivery.
G–Gravida, P–Para, L–Live children, A – Abortion,
D–Dead.
PERSONAL HISTORY
Sleep pattern, exercise pattern, appetite, diet pattern, Hobbies, habits, hygiene, dressing, personality, allergies, and relationship with others.
SOCIO ECONOMIC HISTORY
Monthly family income, bread winner of family, sources of income, financial status, type of house, own / rented, facilities- ventilation, electricity, drainage, lighting, water, waste disposal and latrine facility. Availability of hospital, clinics, health centers, markets, temple, school and transportation.
PHYSICAL EXAMINATION AND SYSTEMIC EXAMINATION
INVESTIGATIONS:
| Date | Name of the Investigations | Patient Value | Normal Value | Remarks |
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Other Investigations:
MEDICATION:
| Drug | Dose | Route | Freq | Action | Side Effect | Contra Indication | Nurses Responsibility |
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(* Drugs to be written with generic name)
REVIEW OF RELATED SYSTEM – ANATOMY AND PHYSIOLOGY
KNOWLEDGE OF DISEASE CONDITION
Definition, incidence, risk factors, etiology, pathophysiology, manifestations and diagnostic evaluation (compare book picture with patient picture), complications, management- medical, surgical and nursing.
LIST OF NURSING DIAGNOSIS
NURSING PROCESS
| ASSESSMENT | NURSING DIAGNOSIS | GOAL | PLANNING / INTERVENTION | RATIONALE | IMPLEMENTATION | EVALUATION |
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Subjective Date:
Objective Data:
(should be a measurable or observable data)
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DIET PLAN
Menu planning with caloric calculation.
HEALTH EDUCATION:
RECORDING AND REPORTING:
CONCLUSION:
BIBLIOGRAPHY (alphabetical order):
1. Suzzane C. Smeltzer, Brenda G Bare, “Brunner and Suddarth’s Text Book of Medical Surgical Nursing”, 10th Edition, Philadelphia, Lippincott.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Consciousness : Conscious / semi-conscious / coma
Orientation : Oriented to time, place & person.
Signs of distress : Pain / dyspnea / fatigue
Body built : Trim / muscular / obese /
excessively thin
Posture and gait : Normal / co-coordinated /
uncoordinated
Body movements : Purposeful / tremors / immobile
Hygiene, grooming and dress : Neat / appropriate / unhygienic
Mood and affect : Stable / depressed / elated /
mood swings
Facial expression : Smiling / blank / apathetic
Speech : Understandable & paused / rapid /
slow
VITAL SIGNS
Temperature :
Pulse :
Respiration :
Blood Pressure :
MEASUREMENTS
Height :
Weight :
Circumference
(head, chest, midarm) : in children alone
SKIN
Color and Vascularity : pink / brown / flushed / pallor /
cyanosed / jaundiced / tan brown /
pigmentation.
Moisture : moist / dry / sweating
Temperature : Warm / cold / clammy / feverish
Texture : Smooth / rough / thin / thick / coarse
scaly / puffy
Turgor : Normal / elastic / wrinkled
Edema : Dependent / pitting pedal edema /
orbital edema
Integrity : Intact / lesions / birth marks / moles
and scars / rashes
Nails : Koilonychias / splinter hemorrhages /
paronchyia
HEAD AND SCALP
Skull-size, shape, contour : normal / hydrocephalus, acromegaly,
nodules, masses, lumps
Scalp : Dandruff /pediculus / lesions / clean
Hair : color / fine / thick / straight / curly /
shiny / dry / brittle / distribution /
alopecia / hirsutism
Face : shape / symmetry / sensation /
disfigurement – reason
EYES
Eye brows : Shape-curved / straight, thin / thick /
sparse
Eyelids : Swollen / infected / stye / ptosis /
entropion / ectropion / masses
Eye lashes : Long / short / curved / none / artificial
Sclera : white / yellow / red / discharges
Conjunctiva : pale / pink / red / inflamed /masses
Cornea and Iris : color / opaque / cloudy / intact
Pupils : PERRLA (pupils equal round reacting
to light, accommodation)
Eye movements : normal / nystagamus / esotropia /
exotropia
Lacrimal gland : tender / non-tender / swollen / tearing
Visual fields : intact and normal
Vision : normal ( 6 /6 or 20/20) / myopia /
presbyopia
EARS
Pinnae – size / shape : large / small / symmetry / redness
Position : equal to outer canthus of eyes / low
set / high set
Ear canal : clean / discharges / cerumen / nodules
foreign objects
Tympanic membrane : whitish and intact / redness / bulging /
perforated
Hearing : normal (whisper test, Weber and
Rinne test)
NOSE
Size and shape : long / short / swollen / flaring of
nostrils
Septum : midline / deviated / perforated
Nasal mucosa : pink/red/discharge/rhinitis/epitaxis
Patency : patent / obstructed
Sinuses : tender / non-tender
MOUTH AND PHARYNX
Lips : color (pale, pink, cyanosed), smooth /
dry / cracked / fissure / angular
stomatitis
Teeth : color / stained / caries / alignment /
dentures
Gums : pink / swollen / bleeding / gingivitis /
ulcerated / spongy
Buccal mucosa : color / dry / moist / intact / ulcers /
chancre / cleft lips and palate
Tongue : dry /white coated / fissures / cracked /
bluish / microglossia
Tonsils : enlarged / redness / dysphagia / ulcer
Uvula-mobile / midline / gag reflex
NECK
Appearance : long / short / masses / symmetrical /
non-symmetrical / jugular vein diste-
-nsion / carotid bruits
Thyroid : palpable / nodules / tenderness
Trachea : midline / deviated
Lymph nodes : palpable / not palpable /mobile /hard /
firm
Movements : ROM possible / not possible
CHEST
Thoracic configuration : size and shape – symmetrical /
diameters / pigeon / barrel shape
Respiratory pattern – retractions /
respiratory rate / visible pulsation
Tenderness and fremitus
Breast : size / shape / symmetry / nipple
retractions / discharges / peaud
orange / galactorrea / nodules / lumps
Lung Sounds : crackles / rhonchi / wheeze / pleural
friction / air entry
Heart Sounds : s1, s2, other sounds – murmurs, heart
rate
ABDOMEN
Size and shape : flat/ rounded/ ascites/ umbilical
bulging/ striaca/ scars/ rashes
Bowel sounds : present/ absent/ hyper active/ hypo-
-active
Fluid Collection : present/ absent/ dullness or tympany
on percussion
Organomegaly : palpable spleen, liver/ tenderness/
inquinal or femoral hernia
GENITALIA
Female genitalia : ecchymosis/ haemotoma/ pseudo-
- hermaphroditism/ foul smelling
discharges/ cystocele/ uterine proplase
/ perineum-intact
Male genitalia : phimosis/ priapism/ epispadias/ hypo-
-spadias/ hydrocele/ hernia
ANUS AND RECTUM
Hemorrhoids / inflammation/ lesions/ fissures/ skin tags/ rectocele/ patency
BACK
Spinal curvature : kyphosis/ lardosis/ scoliosis
Vertebrae : intact/ tenderness/ spondilysis/ spinal
Lesions : rashes / lesions
ROM : possible / limited
EXTREMITIES
Size and symmetrical : normal/ symmetrical/ non-symmet
rical/ swollen/ edema/ deformities/
rashes/ prosthesis/ varicose veins
Muscle tone and strength : firm/ muscular/ flabby/ flaccid/
spastic/ atrophy/ tremors
ROM of each joint : possible/ limited
Bowel Habits : normal/ diarrhea/ constipation
/frequency
Bladder Habits : frequency/ incontinence/ retention
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Inspection : Respiration - rate/ tachypnea/
bradypnea/ apnea/ laboured/ shallow/
gasping
: Shape & symmetry – symmetrical/
barrel, pigeon, funnel shape
: Rhythm – regular / irregular
: Movement of chest wall – intercostals
and accessory muscle retraction
: AP & transverse diameter – 1.2
: Lesions, cyanosis and scars.
Palpation : tenderness, lumps, crepitus, thoracic
excursion, fremitus
Percussion : resonance/ dullness/ flatness/ tympany
Auscultation : normal lung sounds/ adventitious
breath sounds- crackles/ wheeze/
rhonchi/ pleural friction rub/ stridor
CARDIO VASCULAR SYSTEM
Inspection : visible pulsation/ heaves/ jugular vein
distention/ edema (0-4)
Palpation : pulse and heart rate/ thrills/ Allen’s test
Auscultation : s1/ s2/ s3/ s4/ murmurs (I-VI)/ split
GASTROINTESTINAL SYSTEM
Inspection : conitor, enlargement, ascities, umbel-
icus, movements, visible peristalis, scar
lesions, striae
Auscultation : bowel sounds- present/ barborogymi/
paralytic ileus
Percussion : fluid collection- thrill/ dullness
Palpation : soft/ firm/ hard/ tenderness/ organom-
egaly
RENAL SYSTEM
Inspection : redness in flank region/ edema/
Palpation : tenderness / palpable
Urine Output : amount/ frequency/ color/ turbidity
MUSCULO SKELETAL SYSTEM
Inspection : size, symmetry, shape, edema, def-
-ormity, prosthesis gait, ROM of
each joint
Palpation : muscle tone, strength (0-5)
REPRODUCTIVE SYSTEM
Female : discharges/ lumps/ masses/ mens-
-trual abnormalities/ proplase/ cys-
-tocele/ rectocele
Male : Phimosis/ priapism/ epispadias/
hypospadias/ hydrocele/ hernia
CENTRAL NERVOUS SYSTEM
Mental status : alertness/ orientation/ memory/
language and speech/ mood and
affect/ abstract thinking/ intellectual
capacity
Cranial nerve assessment : I – XII
Motor function : muscle strength and co-ordination
Sensory function : pain, touch, temperature, vibration,
taste, smell
Reflexes : abdominal, Achilles, corneal, biceps
patellar, plantar, brudzinskis reflex.
INSERTION OF FLATUS TUBE
Definition:
A rectal tube inserted into the rectum relieves the flatulence and gaseous distention of the abdomen.
Articles:
22 – 23 French tube (Rectal Tube)
Water based lubricant.
A bowl with water.
Gloves.
Procedure:
Explain the procedure to the patient.
Provide privacy.
Make the patient comfortable in a side lying position. Do hand washing and gloving.
Lubricate the rectal tube to reduce irritation in muscular membrane.
Separate the buttocks, insert about 4 – 6” into the anal canal.
Do not force the tube if it does not insert easily.
The tube is left in place for not more than 20 minutes to avoid sphenctis damage.
Keep the other end of the tube inside the bowl which has water, to watch for expulsion of gas which is indicated by the bubbling of water.
If gas does not expel, ask the patient to change the position, to help move flatus along the intestinal tract toward the anus.
If distention is not relieved, use the rectal tube intermittently every 2 – 3 hours if necessary.
Enema
Definition:
An enema is the introduction of fluid into the rectum and sigmoid colon for cleansing.
Purpose:
To remove fecal matter.
To relieve constipation and gaseous distention.
To promote visualization of lower GI tract during X-ray (or) endoscopic examination.
To prevent involuntary defecation during surgery.
To reduce fever (or) cerebral edema.
Before delivery, surgery and specific procedures.
To induce rectal anesthesia.
To administer nutrients and medications in retention enema.
To relieve retention of urine in chronic constipation.
Contraindications:
Acute Pelvic Inflammation.
Perforation of the Bowel.
Paralytic Ileus.
Acute Appendicitis.
Peritonitis.
Painful Perineal conditions.
Equipment:
a). A tray containing
1. Enema can with tubing and glass connection.
2. Rectal Tube
Adult - 22 30 fr.
Child - 12 18 fr
3. Artery Clamp and Extension tube.
4. Disposable gloves.
5. Water soluble lubricant.
6. Pint measure.
7. Lotion thermometer.
b). Warm Solution in a Jug.
Adult : 750 - 1000 ml.
Infant : 150 - 250 ml
Toddler : 250 - 350 ml
School Age : 300 - 500 ml
Adolescent : 500 - 750 ml.
c) Bed Pan
d) I V Pole
e) Clean Linen
f) Mackintosh
g) Metal Syringe
h) Fine Catheter
i) Rag Pieces
j) Kidney Basin
Take articles as per methods used
Classification of Enema
Evacuant Enema Retained Enema
Simple Medicated Cold
Stimulant Nutrient Emolient Anesthetic Sedative
Oil Purgative Astangent Antihelmenthic Carminative
Oil Enema:
These are given to soften fecal matter in case of severe constipation before the first bowel movement after operation on rectum and perineum. It should be returned for half an hour to 1 hour, followed by soap and water enema.
1. Solutions Used:
- Olive oil
- Gingerly oil (or) Sweet oil.
- Castor oil & olive oil (1:2)
2. Amount - 115 - 175 ml.
3. Temperature - 1000F (37.50C)
Purgative Enema:
It causes the bowel to contract actively and to evaluate its contents.
Solutions used:
- Pure glycerin - 15 – 30 ml
- Glycerin and water - 1:2
- Ox gall - 15 – 30 ml
- Glycerin and castor oil - 1:1
- Mgso4 - 60 – 120 ml
2. Amount - 115 – 175 ml
3. Temperature - 1000F
Carminative Enema (Antispasmodic):
To relieve gaseous distention of the abdomen by causing peristalsis.
Solutions Used:
a) Turpentine - 8 to 16 ml of turpentine mixed thoroughly
with 600 – 1200 ml of soap solution.
b) Tr. Asafoetida - 8 to 16 ml of Tr. Asafoetida mixed
thoroughly with 600 – 1200 ml of soap
solution.
c) Milk & Molasses - 90 -130 ml of molasses well mixed with
equal quantity of warm milk.
Antehelmenthic Enema:
To destroy and expel the worms from the intestines. Soap water enema is followed by this
Solutions Used:
a) Infusion of quassia - 15 gms of chips to 600 ml of
water.
b) Hypertonic Saline - Nacl – 60 ml with 600 ml of H2O.
Amount - 250 ml.
Astringent Enema:
It contracts the tissues and blood vessels. Checks bleeding and inflammation, lessens the amount of mucus discharge and gives a temporary relief.
Solutions Used:
a) Tannic Acid - 2gms to 600 ml of H2O.
Alum - 30gms to 600 ml of H2O.
2% Ag No3 - Dissolved with distilled H2O.
Temperature - As the client can stand.
Cold Enema:
To decrease the body temperature in hyperpyrexia and heat stroke.
Stimulant Enema:
To treat shock and collapse.
Solutions Used:
a) Black Coffee - 1 table spoon coffee powder to 300 ml
of H2O.
b) Brandy - 15 ml of brandy added to 120-180 ml of
glucose saline.
c) Amount - 180 – 240 ml.
d) Temperature - 108 – 110oF
Sedative Enema:
To induce sleep.
Drugs:
Paraldehyde.
Chloral hydrate.
Potassium bromide.
Anesthetic Enema:
To produce anesthetic effect.
Drugs:
Avertin 150 – 300 mg / Kg of body weight.
Emolient Enema:
For soothing (or) relieving irritation on an inflamed mucus membrane.
Solution Used:
1. Starch and opium - Tr. opium 1 – 2 ml
120 -180 ml of starch (or)
rice water.
2. Starch Mucilage Alone
3. Amount - 120 – 180 ml.
4.Temperature - 100 – 105oF
(37.8oC – 40.5oC)
Nutrient Enema:
To supply food and fluids to the body.
Solutions Used:
Normal Saline
Glucose Saline - 2 5 %
Petonized milk - 120 ml.
Amount - 1100 – 1700 ml in 24 hours.
(or)
180 – 270 ml at Q4 hourly.
5. Temperature - 100oF (37.8oC)
Methods Used:
a) Enema Can and Tube:
Explain the procedure and provide privacy.
Arrange all the articles.
Make the patient to lie in side lying position above the mackintosh, at the edge of the cot.
Pour the prepared solution into can and clamp it, check for air bubbles.
Suspend the enema can with solution on IV stand with the height of 18” from the bed.
Lubricate 3 – 4” of rectal tube.
Separate the buttocks and insert the tube gently into anus, encourage to take deep breath.
Allow the fluid to flow freely.
Encourage the patient to take deep breath during the administration of fluid.
Stop procedure temporarily if the patient has urge to defecate (or) feels discomfort.
Clamp the can, after the solution has run over fully. Ask the patient to hold for 10-15 minutes.
Remove the rectal tube with rag pieces. Hold a rag piece around the tube and firmly against the anus.
Position the patient and assist to toilet (or) provide bed pan.
Replace after washing the equipments.
Document the time, type of solution, quantity used.
b) Funnel and Catheter (e.g. Oil Enema):
Explain the procedure.
Keep the oil in water (warm) to keep the oil warm.
Position the patient with the foot end raised.
Hold the funnel not more than 8” from the anus.
Pour the oil through the funnel anal ask the patient to retain for 2-6 hours.
Now proceed by soap and water enema to expel the fecal matter.
c) Glycerin Syringe:
Explain the procedure and position the patient. Do hand washing.
Air is expelled from the metal syringe and the tube.
Now insert rubber catheter attached with glycerin syringe into anus.
d) Drip Method:
Explain the procedure and position the patient. Raise the foot end.
Instead of rectal tube, use a fine catheter to diminish the stimulation of defecation reflex.
The reservoir is raised above the anus for the solution to run into rectum slowly, refulated by a Murphy drip and a clamp.
Retain the patient for 2 hours. for the absorption of nutrients.
Pain Assessment:
Nurses need to approach pain management systematically to understand client’s pain and to provide appropriate intervention.
Characteristics of Pain:
Onset and Duration:
Ask question to determine the onset, duration and sequence of pain.
When did the pain begin?
How long has it lasted?
Does it occur at the same time?
Is it chronic or acute?
Location:
Ask to point out the area.
Ask whether it is Superficial, Deep, Referred (or)
Radiating.
Intensity:
Ask whether it is mild, moderate (or severe. Use scales to describe the pain.
Pain Scale:
Numerical
A
1 2 3 4 5 6 7 8 9 10
No Pain Severe Pain
Visual Analogue
B
1 2 3 4 5 6 7 8 9 10
No Pain Unbearable Pain
Descriptive
C
No Pain Mild Pain Moderate Severe Unbearable Pain
Pain Pain
0 - 3 → Mild Pain
0 - 3 → Moderate Pain
0 - 3 → Severe Pain
Wrong – Baker Faces Pain Rating Scale:
0 1 2
No Hurt Hurts Little Bit Hurts Little More
3 4 5
Hurts Even More Hurts a Lot Hurts Worst
Ask the child to point the face as per the child’s intensity.
Bowel Wash / Enteroclysis / Colonic Lavage:
Definition:
Introduction of large amount of fluid into the colon (or) large intestine under low pressure for treatment (or) to clear the colon of faeces.
Purpose (or) Indications:
To clean the colon of faeces, gas, barium etc.,
To Stimulate peristalsis.
To reduce body temperature.
To dilute and remove any of the toxic agents that may be present in large intestine.
To apply medications locally.
To prepare for diagnostic examinations and bowel surgeries.
To relieve inflammation.
To relieve pain and bring about circulatory charges in organs like pelvis and abdomen.
To supply the body with fluid and electrolytes that are absorbed from the intestine.
Contra-Indications:
Painful and bleeding haemorrhoids.
Loose anal sphinctes
Rectal Surgeries.
Chronic Diarrhea.
Rectal polyps.
Fistula in Anus.
Tumors of the rectum.
Solutions Used and Ratio:
Plain water.
Normal saline for cleansing and absorption.
2% Na2co3 for removing mucus.
Cold water ( ice enema).
Turpentine enema 1:1000 for distension.
Potassium permanganate 1:6000 for dysentery.
Silver Nitrate 1:5000.
Thymol 1:100.
Alum 1:100.
Boric Solution 1 -2%
Tannic Acid 1:100.
Temperature of the Solution:
1. To clean - 40 - 41oC
2. To Supply - 43 - 46 oC
3. To decrease body Temperature - 27 - 32 oC
Equipments:
Colonic lavage set (sterile) with tubing and gas connection.
Rectal tube (sterile).
Vaseline (or) Water Soluble Jelly.
Kidney Basin – 2.
Mackintosh
Solutions as ordered.
Rag pieces.
Bucket.
Jug with hot and tepid water.
IV stand.
Gloves (sterile)
Apron.
Towel.
Methods:
By using Funnel and Catheter.
By using ‘Y’ connection and a rectal tube.
By using ‘2 tube’ method.
Preparation:
I. Funnel and Catheter Method:
Explain the procedure to the patient.
Allow the patient to be in side lying position at the edge of the table.
Arrange all the articles at the bedside and do hand washing.
Prepare the required solution and check the temperature.
Attack the tubing and the rectal tube with the funnel, check for any leakage.
Hang the Enema can.
Lubricant the tip of the rectal tube about 10 cm.
Expel the air out by running the fluid through the tube.
Insert the tube about 10 cm and turn the funnel down for the flatus to escape.
Now hold the funnel upright and pour about 200 – 300 ml of solution. Pinch the tube before the funnel gets empty to prevent the air entry.
Now lower the funnel to the bucket and allow the return flow.
Repeat the same until the return flow is clear. Stop the procedure if the patient complaints of discomfort.
II. “Y” connection Method:
Y-Connection is attached to the rubber tubing, which permits the regulations of the inflow and outflow.
Two tubes are attached to the prongs of the Y-Connection, for inflow and outflow. The stem is connected to the rectal tube.
Pour the solution in the inflow tube, make sure the outflow tube is closed (or) clamped.
As soon as the solution is poured, close the inflow tube and open the outflow tube for the fluid to drain out.
Do the same alternatively until the outflow is clear.
III. Two Tube Method:
Fill the can with solution, lubricate the rectal tube and insert into anus after lubricating.
Insert another catheter into the anus, 2” below the rectal tube, and leave the free end into the bucket.
Allow the fluid to run into rectum and the washed out fluid will drain out through the catheter.
After Care:
Give Comfortable position after the procedure is over.
Record the procedure, solution used and any abnormalities found.
Replace all the articles.
DISCHARGE/TRANSFER’S/REFERRAL/LAMA/ABSCONDED
DISCHARGE :
It is the preparation of the patient to leave the hospital to return to his/her own environment.
It is planned when he is admitted in the hospital. This process involve the patient, family, hospital and the community health care teams.
Purpose :
to ensure continuity of care to patient after discharge.
to acknowledge patients right in deciding to leave hospital.
to assist patient to return to a state of optimal independent caring.
to assist the patient in discharge process.
Reasons or methods of discharging:
Discharged to home.
Transfer to other hospital (Referral).
Discharge Against Medical Advice (AMA) or Leaving Against Medical Advice (LAMA).
Death.
Procedure:
Check doctor’s written order for discharge atleast a day before.
Inform the patient and relatives.
Help the patient to wear his/her own dress. Handover the valuables after counter checking to the relatives.
Complete the discharge registers, case sheet and other records.
Send chart to billing section with all the information’s clearly furnished, like..
Diet Bill.
Return the excess/unwanted drugs to the pharmacy and make sure patient is repaid.
Oxygen/ventilator summary, doctor or surgeon fees, OT charges (if any), Investigation.
Once the bill is ready, get it settled and inform the MRD Incharge.
Help the patient to obtain discharge summary/prescription, Investigation and Medical certificate.
Instruct the patient regarding the follow up, medication, Exercise..
Ambulate the patient accordingly till the hospital gate/vehicle.
TRANSFER/REFERRAL :
It is the preparation of a patient and the referral records to shift the patient to other department within the hospital or to another hospital.
Purpose :
to provide specialized care.
to provide necessary diagnostic tests and procedures.
to provide treatment and nursing care.
Types :
Referral/Transfer to other Hospital
Referral/Transfer to other department within the hospital.
Procedure :
Check for doctor’s written order.
Inform the patient and the relatives.
Inform the ward sister/other hospital about the transfer of the patient to know the vacancy.
Provide verbal report about the patient.
Fill and file up all the records.
Complete the needed information.
Cancel/transfer the diet.
Make arrangements for the ambulation according to the patients condition.
Shift the patient with all the records and reports along with emergency equipments.
Handover patient documents, valuables to the ward sister.
Collect back the ward articles.
Inform to M R Department.
Clean unit thoroughly.
ABSCONDED : Escaping/Running away from the hospital without the knowledge of the hospital staff is defined as absconding.
Inform to the concerned doctor and record the time and date.
Close the file as absconded and send the file to MRD.
The MRD Officer will inform the nearby police station, giving all the relevant information about the client. This helps to prevent legal issues.
LAMA :
The Patient / Relative may refuse to continue the treatment in the same hospital. In that case, a consent should be obtained duly signed by the Relative / Patient.
It is stated that the Relative / Patient leaving the hospital is responsible for the risk or crisis after leaving.
It helps to medico-legal issues and a sort of protection to the hospital authorities who can be send in the court.
None of the reports / records should be given to the patient during discharge.
CARE OF THE UNIT AFTER DISCHARGE :
Strip the bed
Take off all the sheets and send it to laundary.
Carbolise the bed, locker and bedside furniture thoroughly.
Place the mattress, pillows and blankets in the sun for 4-6 hours.
Disinfect the utensils, dry and replace.
Incase of infectious case, fumigate the room as per protocol.
Ventilate the room.
Reset the unit to receive a new patient.
Insertion of Suppository:
Definition:
To introduce medicament in a solid form per rectally for local or systemic action.
Equipment:
Rectal suppository
Water soluble lubricating jelly.
Clean gloves.
Draping sheet or screen.
Types:
Evacuating
(i). Glycerine suppository:-
Glycerine is hygroscopic, so it causes evacuation by withdrawing fluid from the mucous membrane and tissue.
(ii). Bisacodyl Suppositoy:-
It increases mucous secretion from the mucous membrane and also stimulates peristalsis of large bowel.
2. Analgesic:-
Aspirin suppository.
3. Retaining:-
(i) Aminophylline Suppository:-
In broncho spasm or chronic bronchial asthma.
(ii) Steroids:-
Hydrocortisone / Prednisolone suppositories in
proctitis and ulcerative colitis.
Pre-requisites:
Check for Doctors order, drug name, form. time of administration.
Check clients name.
Provide privacy.
Explain procedure and give Sim’s position. Keep client draped with only anal area exposed.
Arrange articles at bedside.
Procedure:
Do hand washing.
Apply disposable gloves.
Remove suppository from wrapper and lubricants rounded end with lubricating jelly. Lubricate index finger with a water soluble lubricant to reduce friction.
Ask client to take slow deep breaths through mouth and relax anal sphincter to reduce pain.
Retract buttocks with the other hand, insert suppository gently into the rectum, above the level of internal anal sphincter and against rectal wall for eventual absorption and therapeutic action.
Withdraw finger and apply pressure to hold buttocks together.
Remove and discard gloves.
Ask client to retain suppository, at least fo 20 minutes to prevent expulsion of suppository.
Do hand washing.
Observe for effects of suppository at times that co-relate with the medications onset, peak and duration to evaluate effectiveness of medication and relief of clients symptoms.
Do recording and reporting after the procedure.
HISTORY COLLECTION
INTRODUCTION:
PATIENT PROFILE:
NAME :
AGE :
IP NO. :
UNIT / WARD :
EDUCATION :
OCCUPATION :
INCOME :
RELIGION :
DATE OF ADMISSION :
DIAGNOSIS :
NAME OF SURGERY :
DATE OF SURGERY :
ADDRESS :
DATE OF CARE STARTED :
DATE OF CARE ENDED :
CHIEF COMPLAINTS :
MEDICAL HISTORY
PRESENT HISTORY
PAST HISTORY (general health status, infectious diseases immunization, chronic systemic disease, medications, hospitalizations, injuries, blood transfusion)
SURGICAL HISTORY
PRESENT HISTORY
PAST HISTORY (surgery – indications, name of hospital, type of anesthesia, any complications)
FAMILY HISTORY
Hereditary diseases – systemic illness, psychiatric illness, communicable diseases
Family Tree
Pedigree keys:
□ - Male
○ - Female
— - Relationship
● - Died
- Patient
Family composition:
| SL. No. | Name of the Family Members | Age/ Sex | Relationship with head of family | Education | Occupation | Income | Health Status |
|
|
|
|
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|
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OBSTETRIC HISTORY
Menstrual History:
Age of menarcy, menstrual cycle regular / irregular, no. of days in a cycle, problems.
Obstetrical History:
No. of pregnancy, miscarriages, abortions, labour and
delivery.
G–Gravida, P–Para, L–Live children, A – Abortion,
D–Dead.
PERSONAL HISTORY
Sleep pattern, exercise pattern, appetite, diet pattern, Hobbies, habits, hygiene, dressing, personality, allergies, and relationship with others.
SOCIO ECONOMIC HISTORY
Monthly family income, bread winner of family, sources of income, financial status, type of house, own / rented, facilities- ventilation, electricity, drainage, lighting, water, waste disposal and latrine facility. Availability of hospital, clinics, health centers, markets, temple, school and transportation.
PHYSICAL EXAMINATION AND SYSTEMIC EXAMINATION
INVESTIGATIONS:
| Date | Name of the Investigations | Patient Value | Normal Value | Remarks |
|
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|
|
|
Other Investigations:
MEDICATION:
| Drug | Dose | Route | Freq | Action | Side Effect | Contra Indication | Nurses Responsibility |
|
|
|
|
|
|
|
|
|
(* Drugs to be written with generic name)
REVIEW OF RELATED SYSTEM – ANATOMY AND PHYSIOLOGY
KNOWLEDGE OF DISEASE CONDITION
Definition, incidence, risk factors, etiology, pathophysiology, manifestations and diagnostic evaluation (compare book picture with patient picture), complications, management- medical, surgical and nursing.
LIST OF NURSING DIAGNOSIS
NURSING PROCESS
| ASSESSMENT | NURSING DIAGNOSIS | GOAL | PLANNING / INTERVENTION | RATIONALE | IMPLEMENTATION | EVALUATION |
|
Subjective Date:
Objective Data:
(should be a measurable or observable data)
|
|
|
|
|
|
|
DIET PLAN
Menu planning with caloric calculation.
HEALTH EDUCATION:
RECORDING AND REPORTING:
CONCLUSION:
BIBLIOGRAPHY (alphabetical order):
1. Suzzane C. Smeltzer, Brenda G Bare, “Brunner and Suddarth’s Text Book of Medical Surgical Nursing”, 10th Edition, Philadelphia, Lippincott.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Consciousness : Conscious / semi-conscious / coma
Orientation : Oriented to time, place & person.
Signs of distress : Pain / dyspnea / fatigue
Body built : Trim / muscular / obese /
excessively thin
Posture and gait : Normal / co-coordinated /
uncoordinated
Body movements : Purposeful / tremors / immobile
Hygiene, grooming and dress : Neat / appropriate / unhygienic
Mood and affect : Stable / depressed / elated /
mood swings
Facial expression : Smiling / blank / apathetic
Speech : Understandable & paused / rapid /
slow
VITAL SIGNS
Temperature :
Pulse :
Respiration :
Blood Pressure :
MEASUREMENTS
Height :
Weight :
Circumference
(head, chest, midarm) : in children alone
SKIN
Color and Vascularity : pink / brown / flushed / pallor /
cyanosed / jaundiced / tan brown /
pigmentation.
Moisture : moist / dry / sweating
Temperature : Warm / cold / clammy / feverish
Texture : Smooth / rough / thin / thick / coarse
scaly / puffy
Turgor : Normal / elastic / wrinkled
Edema : Dependent / pitting pedal edema /
orbital edema
Integrity : Intact / lesions / birth marks / moles
and scars / rashes
Nails : Koilonychias / splinter hemorrhages /
paronchyia
HEAD AND SCALP
Skull-size, shape, contour : normal / hydrocephalus, acromegaly,
nodules, masses, lumps
Scalp : Dandruff /pediculus / lesions / clean
Hair : color / fine / thick / straight / curly /
shiny / dry / brittle / distribution /
alopecia / hirsutism
Face : shape / symmetry / sensation /
disfigurement – reason
EYES
Eye brows : Shape-curved / straight, thin / thick /
sparse
Eyelids : Swollen / infected / stye / ptosis /
entropion / ectropion / masses
Eye lashes : Long / short / curved / none / artificial
Sclera : white / yellow / red / discharges
Conjunctiva : pale / pink / red / inflamed /masses
Cornea and Iris : color / opaque / cloudy / intact
Pupils : PERRLA (pupils equal round reacting
to light, accommodation)
Eye movements : normal / nystagamus / esotropia /
exotropia
Lacrimal gland : tender / non-tender / swollen / tearing
Visual fields : intact and normal
Vision : normal ( 6 /6 or 20/20) / myopia /
presbyopia
EARS
Pinnae – size / shape : large / small / symmetry / redness
Position : equal to outer canthus of eyes / low
set / high set
Ear canal : clean / discharges / cerumen / nodules
foreign objects
Tympanic membrane : whitish and intact / redness / bulging /
perforated
Hearing : normal (whisper test, Weber and
Rinne test)
NOSE
Size and shape : long / short / swollen / flaring of
nostrils
Septum : midline / deviated / perforated
Nasal mucosa : pink/red/discharge/rhinitis/epitaxis
Patency : patent / obstructed
Sinuses : tender / non-tender
MOUTH AND PHARYNX
Lips : color (pale, pink, cyanosed), smooth /
dry / cracked / fissure / angular
stomatitis
Teeth : color / stained / caries / alignment /
dentures
Gums : pink / swollen / bleeding / gingivitis /
ulcerated / spongy
Buccal mucosa : color / dry / moist / intact / ulcers /
chancre / cleft lips and palate
Tongue : dry /white coated / fissures / cracked /
bluish / microglossia
Tonsils : enlarged / redness / dysphagia / ulcer
Uvula-mobile / midline / gag reflex
NECK
Appearance : long / short / masses / symmetrical /
non-symmetrical / jugular vein diste-
-nsion / carotid bruits
Thyroid : palpable / nodules / tenderness
Trachea : midline / deviated
Lymph nodes : palpable / not palpable /mobile /hard /
firm
Movements : ROM possible / not possible
CHEST
Thoracic configuration : size and shape – symmetrical /
diameters / pigeon / barrel shape
Respiratory pattern – retractions /
respiratory rate / visible pulsation
Tenderness and fremitus
Breast : size / shape / symmetry / nipple
retractions / discharges / peaud
orange / galactorrea / nodules / lumps
Lung Sounds : crackles / rhonchi / wheeze / pleural
friction / air entry
Heart Sounds : s1, s2, other sounds – murmurs, heart
rate
ABDOMEN
Size and shape : flat/ rounded/ ascites/ umbilical
bulging/ striaca/ scars/ rashes
Bowel sounds : present/ absent/ hyper active/ hypo-
-active
Fluid Collection : present/ absent/ dullness or tympany
on percussion
Organomegaly : palpable spleen, liver/ tenderness/
inquinal or femoral hernia
GENITALIA
Female genitalia : ecchymosis/ haemotoma/ pseudo-
- hermaphroditism/ foul smelling
discharges/ cystocele/ uterine proplase
/ perineum-intact
Male genitalia : phimosis/ priapism/ epispadias/ hypo-
-spadias/ hydrocele/ hernia
ANUS AND RECTUM
Hemorrhoids / inflammation/ lesions/ fissures/ skin tags/ rectocele/ patency
BACK
Spinal curvature : kyphosis/ lardosis/ scoliosis
Vertebrae : intact/ tenderness/ spondilysis/ spinal
Lesions : rashes / lesions
ROM : possible / limited
EXTREMITIES
Size and symmetrical : normal/ symmetrical/ non-symmet
rical/ swollen/ edema/ deformities/
rashes/ prosthesis/ varicose veins
Muscle tone and strength : firm/ muscular/ flabby/ flaccid/
spastic/ atrophy/ tremors
ROM of each joint : possible/ limited
Bowel Habits : normal/ diarrhea/ constipation
/frequency
Bladder Habits : frequency/ incontinence/ retention
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Inspection : Respiration - rate/ tachypnea/
bradypnea/ apnea/ laboured/ shallow/
gasping
: Shape & symmetry – symmetrical/
barrel, pigeon, funnel shape
: Rhythm – regular / irregular
: Movement of chest wall – intercostals
and accessory muscle retraction
: AP & transverse diameter – 1.2
: Lesions, cyanosis and scars.
Palpation : tenderness, lumps, crepitus, thoracic
excursion, fremitus
Percussion : resonance/ dullness/ flatness/ tympany
Auscultation : normal lung sounds/ adventitious
breath sounds- crackles/ wheeze/
rhonchi/ pleural friction rub/ stridor
CARDIO VASCULAR SYSTEM
Inspection : visible pulsation/ heaves/ jugular vein
distention/ edema (0-4)
Palpation : pulse and heart rate/ thrills/ Allen’s test
Auscultation : s1/ s2/ s3/ s4/ murmurs (I-VI)/ split
GASTROINTESTINAL SYSTEM
Inspection : conitor, enlargement, ascities, umbel-
icus, movements, visible peristalis, scar
lesions, striae
Auscultation : bowel sounds- present/ barborogymi/
paralytic ileus
Percussion : fluid collection- thrill/ dullness
Palpation : soft/ firm/ hard/ tenderness/ organom-
egaly
RENAL SYSTEM
Inspection : redness in flank region/ edema/
Palpation : tenderness / palpable
Urine Output : amount/ frequency/ color/ turbidity
MUSCULO SKELETAL SYSTEM
Inspection : size, symmetry, shape, edema, def-
-ormity, prosthesis gait, ROM of
each joint
Palpation : muscle tone, strength (0-5)
REPRODUCTIVE SYSTEM
Female : discharges/ lumps/ masses/ mens-
-trual abnormalities/ proplase/ cys-
-tocele/ rectocele
Male : Phimosis/ priapism/ epispadias/
hypospadias/ hydrocele/ hernia
CENTRAL NERVOUS SYSTEM
Mental status : alertness/ orientation/ memory/
language and speech/ mood and
affect/ abstract thinking/ intellectual
capacity
Cranial nerve assessment : I – XII
Motor function : muscle strength and co-ordination
Sensory function : pain, touch, temperature, vibration,
taste, smell
Reflexes : abdominal, Achilles, corneal, biceps
patellar, plantar, brudzinskis reflex.
INSERTION OF FLATUS TUBE
Definition:
A rectal tube inserted into the rectum relieves the flatulence and gaseous distention of the abdomen.
Articles:
22 – 23 French tube (Rectal Tube)
Water based lubricant.
A bowl with water.
Gloves.
Procedure:
Explain the procedure to the patient.
Provide privacy.
Make the patient comfortable in a side lying position. Do hand washing and gloving.
Lubricate the rectal tube to reduce irritation in muscular membrane.
Separate the buttocks, insert about 4 – 6” into the anal canal.
Do not force the tube if it does not insert easily.
The tube is left in place for not more than 20 minutes to avoid sphenctis damage.
Keep the other end of the tube inside the bowl which has water, to watch for expulsion of gas which is indicated by the bubbling of water.
If gas does not expel, ask the patient to change the position, to help move flatus along the intestinal tract toward the anus.
If distention is not relieved, use the rectal tube intermittently every 2 – 3 hours if necessary.
Enema
Definition:
An enema is the introduction of fluid into the rectum and sigmoid colon for cleansing.
Purpose:
To remove fecal matter.
To relieve constipation and gaseous distention.
To promote visualization of lower GI tract during X-ray (or) endoscopic examination.
To prevent involuntary defecation during surgery.
To reduce fever (or) cerebral edema.
Before delivery, surgery and specific procedures.
To induce rectal anesthesia.
To administer nutrients and medications in retention enema.
To relieve retention of urine in chronic constipation.
Contraindications:
Acute Pelvic Inflammation.
Perforation of the Bowel.
Paralytic Ileus.
Acute Appendicitis.
Peritonitis.
Painful Perineal conditions.
Equipment:
a). A tray containing
1. Enema can with tubing and glass connection.
2. Rectal Tube
Adult - 22 30 fr.
Child - 12 18 fr
3. Artery Clamp and Extension tube.
4. Disposable gloves.
5. Water soluble lubricant.
6. Pint measure.
7. Lotion thermometer.
b). Warm Solution in a Jug.
Adult : 750 - 1000 ml.
Infant : 150 - 250 ml
Toddler : 250 - 350 ml
School Age : 300 - 500 ml
Adolescent : 500 - 750 ml.
c) Bed Pan
d) I V Pole
e) Clean Linen
f) Mackintosh
g) Metal Syringe
h) Fine Catheter
i) Rag Pieces
j) Kidney Basin
Take articles as per methods used
Classification of Enema
Evacuant Enema Retained Enema
Simple Medicated Cold
Stimulant Nutrient Emolient Anesthetic Sedative
Oil Purgative Astangent Antihelmenthic Carminative
Oil Enema:
These are given to soften fecal matter in case of severe constipation before the first bowel movement after operation on rectum and perineum. It should be returned for half an hour to 1 hour, followed by soap and water enema.
1. Solutions Used:
- Olive oil
- Gingerly oil (or) Sweet oil.
- Castor oil & olive oil (1:2)
2. Amount - 115 - 175 ml.
3. Temperature - 1000F (37.50C)
Purgative Enema:
It causes the bowel to contract actively and to evaluate its contents.
Solutions used:
- Pure glycerin - 15 – 30 ml
- Glycerin and water - 1:2
- Ox gall - 15 – 30 ml
- Glycerin and castor oil - 1:1
- Mgso4 - 60 – 120 ml
2. Amount - 115 – 175 ml
3. Temperature - 1000F
Carminative Enema (Antispasmodic):
To relieve gaseous distention of the abdomen by causing peristalsis.
Solutions Used:
a) Turpentine - 8 to 16 ml of turpentine mixed thoroughly
with 600 – 1200 ml of soap solution.
b) Tr. Asafoetida - 8 to 16 ml of Tr. Asafoetida mixed
thoroughly with 600 – 1200 ml of soap
solution.
c) Milk & Molasses - 90 -130 ml of molasses well mixed with
equal quantity of warm milk.
Antehelmenthic Enema:
To destroy and expel the worms from the intestines. Soap water enema is followed by this
Solutions Used:
a) Infusion of quassia - 15 gms of chips to 600 ml of
water.
b) Hypertonic Saline - Nacl – 60 ml with 600 ml of H2O.
Amount - 250 ml.
Astringent Enema:
It contracts the tissues and blood vessels. Checks bleeding and inflammation, lessens the amount of mucus discharge and gives a temporary relief.
Solutions Used:
a) Tannic Acid - 2gms to 600 ml of H2O.
Alum - 30gms to 600 ml of H2O.
2% Ag No3 - Dissolved with distilled H2O.
Temperature - As the client can stand.
Cold Enema:
To decrease the body temperature in hyperpyrexia and heat stroke.
Stimulant Enema:
To treat shock and collapse.
Solutions Used:
a) Black Coffee - 1 table spoon coffee powder to 300 ml
of H2O.
b) Brandy - 15 ml of brandy added to 120-180 ml of
glucose saline.
c) Amount - 180 – 240 ml.
d) Temperature - 108 – 110oF
Sedative Enema:
To induce sleep.
Drugs:
Paraldehyde.
Chloral hydrate.
Potassium bromide.
Anesthetic Enema:
To produce anesthetic effect.
Drugs:
Avertin 150 – 300 mg / Kg of body weight.
Emolient Enema:
For soothing (or) relieving irritation on an inflamed mucus membrane.
Solution Used:
1. Starch and opium - Tr. opium 1 – 2 ml
120 -180 ml of starch (or)
rice water.
2. Starch Mucilage Alone
3. Amount - 120 – 180 ml.
4.Temperature - 100 – 105oF
(37.8oC – 40.5oC)
Nutrient Enema:
To supply food and fluids to the body.
Solutions Used:
Normal Saline
Glucose Saline - 2 5 %
Petonized milk - 120 ml.
Amount - 1100 – 1700 ml in 24 hours.
(or)
180 – 270 ml at Q4 hourly.
5. Temperature - 100oF (37.8oC)
Methods Used:
a) Enema Can and Tube:
Explain the procedure and provide privacy.
Arrange all the articles.
Make the patient to lie in side lying position above the mackintosh, at the edge of the cot.
Pour the prepared solution into can and clamp it, check for air bubbles.
Suspend the enema can with solution on IV stand with the height of 18” from the bed.
Lubricate 3 – 4” of rectal tube.
Separate the buttocks and insert the tube gently into anus, encourage to take deep breath.
Allow the fluid to flow freely.
Encourage the patient to take deep breath during the administration of fluid.
Stop procedure temporarily if the patient has urge to defecate (or) feels discomfort.
Clamp the can, after the solution has run over fully. Ask the patient to hold for 10-15 minutes.
Remove the rectal tube with rag pieces. Hold a rag piece around the tube and firmly against the anus.
Position the patient and assist to toilet (or) provide bed pan.
Replace after washing the equipments.
Document the time, type of solution, quantity used.
b) Funnel and Catheter (e.g. Oil Enema):
Explain the procedure.
Keep the oil in water (warm) to keep the oil warm.
Position the patient with the foot end raised.
Hold the funnel not more than 8” from the anus.
Pour the oil through the funnel anal ask the patient to retain for 2-6 hours.
Now proceed by soap and water enema to expel the fecal matter.
c) Glycerin Syringe:
Explain the procedure and position the patient. Do hand washing.
Air is expelled from the metal syringe and the tube.
Now insert rubber catheter attached with glycerin syringe into anus.
d) Drip Method:
Explain the procedure and position the patient. Raise the foot end.
Instead of rectal tube, use a fine catheter to diminish the stimulation of defecation reflex.
The reservoir is raised above the anus for the solution to run into rectum slowly, refulated by a Murphy drip and a clamp.
Retain the patient for 2 hours. for the absorption of nutrients.
Pain Assessment:
Nurses need to approach pain management systematically to understand client’s pain and to provide appropriate intervention.
Characteristics of Pain:
Onset and Duration:
Ask question to determine the onset, duration and sequence of pain.
When did the pain begin?
How long has it lasted?
Does it occur at the same time?
Is it chronic or acute?
Location:
Ask to point out the area.
Ask whether it is Superficial, Deep, Referred (or)
Radiating.
Intensity:
Ask whether it is mild, moderate (or severe. Use scales to describe the pain.
Pain Scale:
Numerical
A
1 2 3 4 5 6 7 8 9 10
No Pain Severe Pain
Visual Analogue
B
1 2 3 4 5 6 7 8 9 10
No Pain Unbearable Pain
Descriptive
C
No Pain Mild Pain Moderate Severe Unbearable Pain
Pain Pain
0 - 3 → Mild Pain
0 - 3 → Moderate Pain
0 - 3 → Severe Pain
Wrong – Baker Faces Pain Rating Scale:
0 1 2
No Hurt Hurts Little Bit Hurts Little More
3 4 5
Hurts Even More Hurts a Lot Hurts Worst
Ask the child to point the face as per the child’s intensity.
Bowel Wash / Enteroclysis / Colonic Lavage:
Definition:
Introduction of large amount of fluid into the colon (or) large intestine under low pressure for treatment (or) to clear the colon of faeces.
Purpose (or) Indications:
To clean the colon of faeces, gas, barium etc.,
To Stimulate peristalsis.
To reduce body temperature.
To dilute and remove any of the toxic agents that may be present in large intestine.
To apply medications locally.
To prepare for diagnostic examinations and bowel surgeries.
To relieve inflammation.
To relieve pain and bring about circulatory charges in organs like pelvis and abdomen.
To supply the body with fluid and electrolytes that are absorbed from the intestine.
Contra-Indications:
Painful and bleeding haemorrhoids.
Loose anal sphinctes
Rectal Surgeries.
Chronic Diarrhea.
Rectal polyps.
Fistula in Anus.
Tumors of the rectum.
Solutions Used and Ratio:
Plain water.
Normal saline for cleansing and absorption.
2% Na2co3 for removing mucus.
Cold water ( ice enema).
Turpentine enema 1:1000 for distension.
Potassium permanganate 1:6000 for dysentery.
Silver Nitrate 1:5000.
Thymol 1:100.
Alum 1:100.
Boric Solution 1 -2%
Tannic Acid 1:100.
Temperature of the Solution:
1. To clean - 40 - 41oC
2. To Supply - 43 - 46 oC
3. To decrease body Temperature - 27 - 32 oC
Equipments:
Colonic lavage set (sterile) with tubing and gas connection.
Rectal tube (sterile).
Vaseline (or) Water Soluble Jelly.
Kidney Basin – 2.
Mackintosh
Solutions as ordered.
Rag pieces.
Bucket.
Jug with hot and tepid water.
IV stand.
Gloves (sterile)
Apron.
Towel.
Methods:
By using Funnel and Catheter.
By using ‘Y’ connection and a rectal tube.
By using ‘2 tube’ method.
Preparation:
I. Funnel and Catheter Method:
Explain the procedure to the patient.
Allow the patient to be in side lying position at the edge of the table.
Arrange all the articles at the bedside and do hand washing.
Prepare the required solution and check the temperature.
Attack the tubing and the rectal tube with the funnel, check for any leakage.
Hang the Enema can.
Lubricant the tip of the rectal tube about 10 cm.
Expel the air out by running the fluid through the tube.
Insert the tube about 10 cm and turn the funnel down for the flatus to escape.
Now hold the funnel upright and pour about 200 – 300 ml of solution. Pinch the tube before the funnel gets empty to prevent the air entry.
Now lower the funnel to the bucket and allow the return flow.
Repeat the same until the return flow is clear. Stop the procedure if the patient complaints of discomfort.
II. “Y” connection Method:
Y-Connection is attached to the rubber tubing, which permits the regulations of the inflow and outflow.
Two tubes are attached to the prongs of the Y-Connection, for inflow and outflow. The stem is connected to the rectal tube.
Pour the solution in the inflow tube, make sure the outflow tube is closed (or) clamped.
As soon as the solution is poured, close the inflow tube and open the outflow tube for the fluid to drain out.
Do the same alternatively until the outflow is clear.
III. Two Tube Method:
Fill the can with solution, lubricate the rectal tube and insert into anus after lubricating.
Insert another catheter into the anus, 2” below the rectal tube, and leave the free end into the bucket.
Allow the fluid to run into rectum and the washed out fluid will drain out through the catheter.
After Care:
Give Comfortable position after the procedure is over.
Record the procedure, solution used and any abnormalities found.
Replace all the articles.
DISCHARGE/TRANSFER’S/REFERRAL/LAMA/ABSCONDED
DISCHARGE :
It is the preparation of the patient to leave the hospital to return to his/her own environment.
It is planned when he is admitted in the hospital. This process involve the patient, family, hospital and the community health care teams.
Purpose :
to ensure continuity of care to patient after discharge.
to acknowledge patients right in deciding to leave hospital.
to assist patient to return to a state of optimal independent caring.
to assist the patient in discharge process.
Reasons or methods of discharging:
Discharged to home.
Transfer to other hospital (Referral).
Discharge Against Medical Advice (AMA) or Leaving Against Medical Advice (LAMA).
Death.
Procedure:
Check doctor’s written order for discharge atleast a day before.
Inform the patient and relatives.
Help the patient to wear his/her own dress. Handover the valuables after counter checking to the relatives.
Complete the discharge registers, case sheet and other records.
Send chart to billing section with all the information’s clearly furnished, like..
Diet Bill.
Return the excess/unwanted drugs to the pharmacy and make sure patient is repaid.
Oxygen/ventilator summary, doctor or surgeon fees, OT charges (if any), Investigation.
Once the bill is ready, get it settled and inform the MRD Incharge.
Help the patient to obtain discharge summary/prescription, Investigation and Medical certificate.
Instruct the patient regarding the follow up, medication, Exercise..
Ambulate the patient accordingly till the hospital gate/vehicle.
TRANSFER/REFERRAL :
It is the preparation of a patient and the referral records to shift the patient to other department within the hospital or to another hospital.
Purpose :
to provide specialized care.
to provide necessary diagnostic tests and procedures.
to provide treatment and nursing care.
Types :
Referral/Transfer to other Hospital
Referral/Transfer to other department within the hospital.
Procedure :
Check for doctor’s written order.
Inform the patient and the relatives.
Inform the ward sister/other hospital about the transfer of the patient to know the vacancy.
Provide verbal report about the patient.
Fill and file up all the records.
Complete the needed information.
Cancel/transfer the diet.
Make arrangements for the ambulation according to the patients condition.
Shift the patient with all the records and reports along with emergency equipments.
Handover patient documents, valuables to the ward sister.
Collect back the ward articles.
Inform to M R Department.
Clean unit thoroughly.
ABSCONDED : Escaping/Running away from the hospital without the knowledge of the hospital staff is defined as absconding.
Inform to the concerned doctor and record the time and date.
Close the file as absconded and send the file to MRD.
The MRD Officer will inform the nearby police station, giving all the relevant information about the client. This helps to prevent legal issues.
LAMA :
The Patient / Relative may refuse to continue the treatment in the same hospital. In that case, a consent should be obtained duly signed by the Relative / Patient.
It is stated that the Relative / Patient leaving the hospital is responsible for the risk or crisis after leaving.
It helps to medico-legal issues and a sort of protection to the hospital authorities who can be send in the court.
None of the reports / records should be given to the patient during discharge.
CARE OF THE UNIT AFTER DISCHARGE :
Strip the bed
Take off all the sheets and send it to laundary.
Carbolise the bed, locker and bedside furniture thoroughly.
Place the mattress, pillows and blankets in the sun for 4-6 hours.
Disinfect the utensils, dry and replace.
Incase of infectious case, fumigate the room as per protocol.
Ventilate the room.
Reset the unit to receive a new patient.
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