medical surgical nursing:gastrointestinal disorder ppt
TRANSCRIPT
Gastrointestinal Disorder
Lecture Note
Chronic Inflammatory Bowel Disease (IBD) It is used to designate two
chronic inflammatory GI disorders:1) Regional enteritis (Crohn's Disease)2) Ulcerative Colitis:-It is very serious and high mortality rate.
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Regional enteritis (Crohn's Disease)
Epidemiology; commonly occurs in adolescents
or young adults. It is more common in older
women population (50 and 80). Most common affected areas are
the distal ileum and colon.
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Cont…d
Pathophysiologic feature of the lesion: Subacute and chronic inflammation
that extends through all layers. Lesions are not in continuous
contact with one another and are separated by normal tissue.
In advanced cases, the intestinal mucosa has a cobblestone appearance.
It is characterized by periods of remissions and exacerbations.
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Cont…d
Clinical ManifestationsInsidious onset
Prominent lower right quadrant abdominal pain (crampy).
Diarrhea Weight loss Malnutrition Secondary anemia
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Intra-abdominal and anal abscesses.
Ulcers in the intestinal membrane.
Fever Leukocytosis Fistulas Fissures
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Chronic symptoms include;diarrhea, abdominal painsteatorrheaanorexiaweight lossnutritional deficiencies
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Symptoms extend beyond the GI tract;Joint involvement (e.g, arthritis)Skin lesions (e.g, erythema nodosum)
Ocular disorders (e.g, conjunctivitis)
Oral ulcers.04/08/23 8
Cont…d
Assessment and Diagnostic Findings
Proctosigmoidoscopic examination (to determine the affected area).
Stool examination ( for identification of blood and abnormal fat).
Barium study on X-ray (most conclusive).
Endoscopy04/08/23 9
Cont…d
Intestinal biopsy CT scan ( for bowel thickness and
fistula formation identification) CBC ESR Albumin and protein levels
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Complications Intestinal obstruction/stricture
formation. Perianal disease. Fluid and electrolyte imbalances. Malnutrition. Fistula. Abscess formation.
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Ulcerative Colitis
It is a recurrent ulcerative & inflammatory disease of the mucosal layer of the colon &rectum.
It affects superficial mucosa of the colon & is characterized by multiple ulcerations & diffuse inflammations which end up with shading of colonic epithelium.
The lesions are contiguous, occurring one after the other.
The disease process usually begins in the rectum and spreads proximally to involve the entire colon.
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Cont…d
Etiology – unknown (may be mycobacterium), and an auto immune response to certain predisposing factors.
Predisposing factors:- Anxiety Tobacco Radiation
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C/M Diarrhea (10 t0 20 liquid stools
daily) Abdominal pain Intermittent tenesmus Rectal bleeding Hypocalcemia Anemia
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Anorexia Weight loss Fever Vomiting Dehydration Rebound tenderness may occur
in the right lower quadrant.
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Extraintestinal symptoms; Skin lesions (eg, erythema nodosum)
Eye lesions (eg, uveitis)Joint abnormalities (eg, arthritis),
Liver disease.
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Diagnostic evaluation Careful steel exam;
to r/o amoeba (dysentry) is positive for blood
CBCLow hgb & Hct levelElevated WBC
Sigmoidoscopy & barium enema
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CT scanning Magnetic resonance imaging Ultrasound Abdominal x-ray Barium enema
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Complication Perforation Hemorrhage Malignant neoplasm Toxic mega colon Osteoporosis
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Medical Management of Chronic Inflammatory
Bowel Disease Management depends on the disease location, severity, and complications.
The goal of the management is: -1.To reduce the inflammation2.To suppress in appropriate immune response3.To provide rest for the diseased bowel4.To improve quality of life and5.To prevent complications
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Cont…d
Nutritional therapy Advice to have a low residual, high
protein, high-calorie diet with supplemental vitamin therapy & iron supplement.
Advice to take oral fluids/ IV fluids as tolerated.
Advice to avoid any food (milk) which exacerbate diarrhea.
Advice to avoid smoking and cold foods.
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Pharmacologic therapy Sedatives Anti-diarrheal/ anti peristaltic Amino salicylate (eg, sulfasalazine) Corticosteroids (eg, prednisone) Antibiotics (sulfapyridine, metronidazole) Immunomodulators (eg, azathioprene, 6-
mercaptopurine, methotrexate, cyclosporin)
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Cont…d
Surgical management The surgical procedure is termed as
proctocolectomy with ileostomy. Indication includes;
Profuse bleedingPerforation/Stricture forming
ulcers.Development of cancerLake of improvement with medical
managements.04/08/23 23
Cont…d
Nursing management Education about diet, medications,
about management of the ostomy and referral to support groups.
Careful monitoring, parenteral nutrition, fluid replacement.
Emotional support if surgery is done.
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Comparison between UC and RE
See Medical-Surgical Nursing, 10th ed - Brunner & Suddarth, chapter 38, page 1041, table 38-4,
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Intestinal obstruction
Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract.
It can be classified as the following:-A) Mechanical obstruction Vs
FunctionalB) Small bowel Obstruction Vs Large
bowelC) Partial Obstruction Vs Complete
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Causes of Intestinal Obstructions
1) Causes of Small bowel obstruction Adhesion (the most common) Surgery Intestinal Tuberculosis Inflammatory Condition of intestine.
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Paralytic ileus Hernia Gallstones ileus Tumor Ascaris bolus Intusscusption (It is the small
bowel telescopes, as if it were swallowing itself by invagination. It is the commonest problem in infants.)
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Intusscusption
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C/M of SBO Sudden Colicky pain intermittent
with 10 -20 minute Interval. Initial Vomiting Normal Stool may be passed or
bloody. Restless, dehydration &cry Distention is late
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2) Cause of large bowel Obstruction Colorectal Cancer Adhesion Paralytic ileus Inflammatory bowel disease Volvulus (It is twisting of a
mobile loop bowel on its mesentery. It occurs mostly in sigmoid colon but it can affect small intestine & caecum.)
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Volvulus
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Cardinal S/S of large bowel Obstruction Colicky lower abdominal pain Absolute Constipation ( Flatus &
Feces ) Gross abdominal distention Nausea and Vomiting Abdominal x-ray reveals grossly
distended 2 limbs of sigmoid colon often with fluid - air level.
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Comparison of obstruction
SBO LBO Abdominal
crampy Vomiting early
S/S Constipation
late sign Abdominal
distention
Abdominal crampy
Constipation is early S/S
Grossly distended abdomen
Fecal vomiting04/08/23 34
Cont..d
SBO… LBO…
Diagnostic method-Hx & P/E.
Abdominal X-ray indicates abnormal quantities of gas &/or air in the bowel.
Decompression of the bowel through NG tube.
Diagnostic method-Hx & P/E.
Abdominal x-rays reveals abnormally distended colon.
Colonoscopy may be performed to untwist & decompress the bowel in high colon obstruction.
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Cont…d
SBO… LBO…
IV fluid ( N/S or R/L ) administered to replace electrolyte and water.
Surgical Intervention is needed.
More severe because most of the GI content are absorbed in this part.
In lower bowel obstruction rectal tube may be used for decompression.
Surgical Intervention if it is caused by tumor
Iv fluid administration. Minor unless necrosis
occurred.
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Cont…d
Diagnostic evaluation of Intestinal Obstruction
1) Hx2) P/E - pt is acutely sick looking
V/S: - B/P - decrease due to fluid loss & sepsis
PR:- Tachycardia To :-Increases if there is complication HEENT :- dry buccal mucosa
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AbdomenDistendedMild tenderness on palpationVisible loop but not alwaysTympanic on percussionBowel sound may be absent or increase
Empty rectum or hard stool04/08/23 38
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CBC Hgb V/A Abdominal x-ray
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Medical Management:A) General Management
Keep the patient NPO NG tube should be inserted for
small bowel obstruction to aspirate intestinal content.
Secure IV line ( Normal Saline or ringer Lactate )
Triple antibiotic ( Ampicillin, Gentamycin,& CAF )
Sedation04/08/23 40
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B) Specific RX Sigmoid Volvulus :-
Rectal tube is inserted for deflation but contraindicated if gangrenous.
Laparatomy.1) If loop is viable= de-rotation2) If gangrenous= resection & Colostomy
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Hernias
Def.:-It is a protrusion of bowel through a weak point in the musculature of the anterior abdominal wall or an existing opening.
Etiology Powerful muscular effort or strain. Weakness or defect to the
wall of abdominal cavity.04/08/23 42
Cont…d
Predisposing factors:- Constipation Ascites Previous abdominal surgery
Lifting heavy load Chronic Cough
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Classifications of hernias
1. Based on Sites of Hernias :I) Inguinal Hernia
The protrusion of bowel through the weak point in the inguinal canal which contains the spermatic cord in the male & the round ligament in the female.
It occurs more commonly in males than females.
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Inguinal Hernia
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Cont…d
Inguinal Hernia Can be:-A) Direct inguinal
HerniaPush their way directly forward through posterior wall of the inguinal canal, into a defect in the abdominal wall.
Less common (20%).Strangulate Rarely.
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Cont…d
B) Indirect inguinal HerniaPass through the internal inguinal ring & then through the external ring.
Common (80%)Can Strangulate
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Cont…d
Distinguishing direct from indirect hernias; The best way is to reduce the hernia & occlude the internal ring with 2 fingers. Ask the pt. to cough - if the hernia is restrained it is indirect; if it pops out it is direct.
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Cont…d
II) Femoral Hernia More Common in women than men. Bowel enters the femoral canal,
presenting as a mass in the upper middle thigh or above the inguinal ligament where it points down the leg, unlike an inguinal hernia which points to the groin.
It is frequently strangulate & irreducible.
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III) Para-umbilical Hernias: These occur just above or below the
umbilicus.
IV) Epigastric Hernias : These pass through linea alba above the
umbilicus.
V) Incisional Hernias: These follow breakdown of muscle
closure after previous Surgery. If obese, repair is not easy.
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Cont…d
VI) Umbilical Hernia: - Results from failure of
umbilical orifice to close. Occur most often in obese women
& children & in patients with cirrhosis and ascites.
C/F:- Only abdominal mass if not complicated.
Bowel sound on auscultation.04/08/23 51
Cont…d
2. Based on severityi) Reducible Hernia :- The protruding mass can be replaced in abdomen.ii) Irreducible Hernia :- The protruding mass cannot be moved back into abdomen.iii) Incarcerated: - An irreducible hernia in which the intestinal flow is completely obstructed.
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IV) Strangulated: - an irreducible hernia in which the blood & intestinal flow is completely obstructed.
C/F of Strangulation: Pain, vomiting Swelling of hernial sac,fever Lower abdominal sign of
peritoneal irritation04/08/23 53
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Treatment1) Mechanical ( reducible hernia
only) A truss is an appliance having a pad that is held snugly in the hernial orifice.
Does not cure a hernia - it prevents abdominal contents from entering hernial sac.
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Cont…d
2) Surgical Recommended to correct the
hernia before a strangulation occurs which then becomes on emergency situation.
I. Hernial Sac, is dissected freeII.Contents of sac, are replaced in
abdominal cavity.
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Cont…d
III. Neck of sac is legatedIV. Muscle and fascial layers are
sawed together firmely.V. Strangulated hernia requires
resection of ischemic bowel in addition to hernia repair.
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Disorders of the rectum
1) Haemorrhoids Def: - It is an enlarged & congested
patch of mucosa & sub-mucosa at anorectal junction or
Are dilated portions of veins in the anal canal.
Sites: - at 3, 7, 11 O'clock, on lithotomy position.
Hemorrhoid based on its site:-1) Internal hemorrhoid (if it is above internal
sphincter.)2) External ( if it is outside external
sphincter)04/08/23 57
Cont…d
C/F Bright red blood occurring at
the end of defecation (Late) Mass Per-rectum Peri-anal Discomfort Pruritus Mucosal Discharge
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Pain when complicated External hemorrhoids are associated with severe pain due to inflammation & edema caused by thrombosis. Clotting of blood (thrombosis) lead to necrosis & ischemia.
Internal Haemorrhoids are painless until they bleed.
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Classification of heamorhoids based on its
stage(severity)a) 1st degree:- Bleed but no prolapsed
b) 2nd degree :- Prolapsed but reduce spontaneously
c) 3rd degree :- but need manual replacement
d) 4th degree :- not returned.
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Cont…d
Etiology: - idiopathicPredisposing factor:-
Chronic Constipation Excessive use of purgative Pelvic masses ( Pregnancy ) Portal HTN
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Cont…d
Rx: Regulating bowel by laxatives
Avoid Constipation Advice high - residue diet that contain fruit.
Sitz bath
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Good personal hygiene & by avoiding excessive straining during defecation, haemorrhoid symptoms & discomfort can be relieved.
Non-operative Treatment:-1) Infrared Photocoagulation (rays)2) Bipolar Diathermy (Heat)3) Laser Therapy4) Injecting Sclerosing Solution
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Conservative Surgical Rx of internal Haemorrhoid;
A) Rubber - band ligation procedure: - The haemorthoid is visualized through the anoscape, & its proximal portion above the muco-cutaneous lines is grasped with an instrument. A small rubber band is then slipped over the hemorrhoid. Tissue distal to the rubber band becomes necrotic after several days & sloughs off. It may cause infection, pain & hemorrhage.
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Cont…d
B) Cryosurgical Hemorrhoidectomy Involves freezing the tissue of the
hemorrhoid for a sufficient time to cause necrosis.
Not used widely because the discharge is very foul-smelling & wound healing is prolonged.
C) Hemorrhoidectomy, or surgical excision, can be performed to remove all of the redundant tissue involved in the process.
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Ano-rectal Abscess
Def: It is an infection in the para-rectal spaces.
Risk Factors: Regional enteritis Immuno-defcient States (HIV/AIDS)
Many of these abscesses will result in fistulas.
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Cont…d
C/M: Abscess may occur in a variety of
spaces in & around the rectum. Pain Foul - Smelling pus In Superficial abscess, (Swelling,
redness & tenderness). Deeper abscess ( Fever, abdominal
Pain ) Fistula
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Cont…d
Mx :1) Palliative Rx;
Sitz Bath Analgesics
2) Surgical Rx:- Incision & drainage
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Anal fistula
Def:- It is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus.
Cause: Fistula usually results from an
infection. Trauma Fissures Regional Enteritis
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Cont…d
C/M Pus or stool may leak constantly from
the cutaneous opening Passage of flatus or feces from the
vaginal or bladder depending on the fistulas tract.
Fever
Mgx Surgery is always recommended Fistulectomy (excision of the fistulous
tract)04/08/23 70
Anal fissure
Def: It is a longitudinal tear or ulceration in
the lining of the anal canal Cause:
Trauma of passing a large firm stool Persistent tightening of the anal canal
secondary to stress or anxiety (leading to Constipation)
Child birth Trauma
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Cont…d
C/M Extremely Painful Defecation
Burning Bleeding
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Mgx Increase water intake Sitz bath Emollient Suppositories Corticosteroid Suppositories
(Relieve Discomfort) Surgery
*Most of the fissures will heal by conservative measures.
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Cancer of the large intestine:
Colon & Rectum Tumors of the small intestine are rare; conversely tumors of the colon & rectum are relatively common.
Cause: - Unknown
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Percentage distribution of colorectal cancer
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Cont…d
Risk factors:- Age: - incidence increases with age
(most patients are over age 55). It is the most common cancer in old age except for prostates cancer in men.
Family history of colon cancer Chronic inflammatory bowel
disease Polyp A diet high in fat, protein, & beef
& low in fiber04/08/23 76
Cont…d
C/M It is determined by the location,
stage of cancer & function of the intestinal segment. Unexplained anemia Anorexia Weight loss Fatigue
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Cont…d
Symptoms most Common in right side lesions;Abdominal PainMelena
Symptoms most commonly associated with left side lesions.Abdominal painCrampyConstipationDistention
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Symptoms associated with rectal lesion;TenesmusRectal PainFeeling of incomplete evacuation after a bowel movement
Alternating Constipation & Diarrhea
Bloody Stool04/08/23 79
Cont…d
Diagnostic Evaluation Fecal occult blood testing Barium enema Procto-sigmoidoscopy Colonoscopy Biopsy or cytology smears.
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Cont…d
Medical Mgx The patient with symptoms of intestinal obstruction is treated with IV fluids & nasogastric Suction.
Treatment depends on the stage of the disease & related complications.
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Cont…d
The most widely used staging method is duke's classification:- Class A- tumor limited to mucosa &
Sub-mucosa Class B- Penetration through bowel
wall Class C- Invasion into regional
draining lymph system. Class D- Advanced & widespread
regional metastasis
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Cont…d
Radiation Therapy Surgical Removal
It is primary treatment Indicated for most class A- lesions
& all class- B and C. Segmental Resection with
anastomosis Temporary Colostomy followed by
segmental resection & anastomosis Permanent Colostomy or ileostomy
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Cont…d
Complications of Colorectal Cancer Partial or Complete bowel
obstruction Hemorrhage Perforation
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Nursing Care for Patient with Colostomy
Colostomy; Is the surgical creation of an
opening (stoma) into the colon.
It can be temporary or permanent divertion.
It allows for the drainage or evacuation of colon contents to the outside of the body.
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Cont…d
Colostomy Irrigation; It is washing out of the intestinal
content through the stoma.Indicationa) It is done to permit escape of
feces when there is an obstruction of the large bowel or a known lesion, such as cancer, that will eventually cause an obstruction.
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Cont…d
b) It also may be done to permit healing of the bowel distal to it after an infection, perforation or traumatic injury since it diverts the fecal stream from the affected area.
c) It may be done as a palliative measure in the treatment of an obstruction caused by an inoperable growth of the colon or if the rectum must be removed to treat cancer.
d) It may be done to provide a permanent means of bowel evacuation.
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Cont…d
Purpose of colostomy irrigation1. To encourage a bowel motion in a
recently established colostomy and to ensure that the opening is patent.
2. To relieve constipation in patients who has difficulty managing their colostomy.
3. To teach the patient how to establish regularity of evacuation through the colostomy.
4. To reduce distention before closure of colostomy
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Cont…d
Read about/Remind your fundamentals of nursing course about; The equipments needed. The procedure. The special considerations.
Develop nursing care plan for a patient with colostomy.
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