Transcript nur_317_lesson_7_endoscopy_ostomy_pouch_carex

Outline ;
ENDOSCOPY
INDICATIONS, CONTRAINDICATIONS
COMPLICATIONS
NURSING RESPONSIBILITIES
COLOSTOMY CARE
COLOSTOMY IRRIGATION
REVIEW OF GASTROINTESTINAL SYSTEM
(ALIMENTARY CANAL AND ITS ACCESSORY ORGANS)
MOUTH
INTESTINE
PHARYNX
COLON
ESOPHAGUS STOMACH, SMALL
RECTUM
ANAL CANAL
ANUS.
ENDOSCOPY PROCEDURE
NONSURGICAL PROCEDURE USED TO PERFORM:
 DIAGNOSTIC PROCEDURES
• EXAMINE A PERSON'S DIGESTIVE TRACT
• VISUALIZE THE GI TRACT
• CERTAIN AND THERAPEUTIC PROCEDURES
THERAPEUTIC PROCEDURES
• REMOVE COMMON BILE DUCT STONES
• DILATE STRICTURES
• TREAT GASTRIC BLEEDING AND ESOPHAGEAL VARICES.
AN ENDOSCOPE HAS :
 ( FLEXIBLE TUBE WITH A LIGHT AND CAMERA AND CAN BE INSERTED THROUGH
THE RECTUM OR MOUTH, DEPENDING ON WHICH PORTION OF THE GI TRACT IS
TO BE VIEWED
 MULTIPURPOSE CHANNELS (AIR INSUFFLATIONS, IRRIGATION, FLUID
ASPIRATION, AND THE PASSAGE OF SPECIAL INSTRUMENTS )
AN ENDOSCOPE (WITH A WATER-SOLUBLE LUBRICANT) IS PASSED SMOOTHLY
AND SLOWLY ( BACK OF THE MOUTH
UPPER PART OF THE SMALL
INTESTINE.
THE PATIENT WEARS A MOUTH GUARD TO KEEP FROM BITING THE SCOPE.
IMAGES OF DIGESTIVE TRACT ARE PRODUCED THROUGH A VIDEO SCREEN
MONITOR.
http://www.youtube.com/watch?v=W1faSbFuLl8
CAPSULE
ENDOSCOPY
 CAPSULE ENDOSCOPY UTILIZES AN INGESTIBLE CAMERA DEVICE RATHER THAN AN
ENDOSCOPE.
 SWALLOWING A CAPSULE (CAMERA DEVICE), WHICH PASSES THROUGH THE
DIGESTIVE SYSTEM WHILE TAKING PICTURES OF THE INTESTINE.
 CAPSULE (ABOUT THE SIZE OF A LARGE VITAMIN CAPSULE) THAT TAKES MULTIPLE
DIGITAL PHOTOS OF THE SMALL BOWEL. THE IMAGES ARE TRANSMITTED VIA
SMALL SENSORS ATTACHED TO THE ABDOMEN WITH ADHESIVE STICKERS OR
TRANSMITTED WIRELESSLY FROM THE CAPSULE TO RECORDING DEVICE BELTED TO
THE PATIENT'S WAIST.
CAPSULE
ENDOSCOPY
 No sedation or anesthetic is required.
The small bowel is about 6 meters long and the capsule takes about
8 hours to travel through it
After approximately 8 hours, the recording device is removed, the
physician downloads image data from the recorder to a PC and views
the images to make a diagnosis.
The capsule will be excreted naturally through the digestive tract.
INDICATIONS
CONTRAINDICATIONS
 DYSPHAGIA.
 ESOPHAGEAL REFLUX SYMPTOMS THAT PERSIST OR RECUR DESPITE
APPROPRIATE THERAPY.
 PERSISTENT VOMITING OF UNKNOWN CAUSE.
 FOR CONFIRMATION AND SPECIFIC HISTOLOGIC DIAGNOSIS OF
RADIOLOGICALLY DEMONSTRATED LESIONS
 IN PATIENTS WITH ACTIVE GI BLEEDING OR RECENT BLEEDING.
 WHEN SAMPLING OF TISSUE OR FLUID IS INDICATED.
 TREATMENT OF BLEEDING LESIONS SUCH AS ULCERS, TUMORS,
 REMOVAL OF FOREIGN BODIES.
 PLACEMENT OF FEEDING OR DRAINAGE TUBES (EG, PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY).
Acute MI
Peritonitis
Acute perforation
Patients who are
taking anticoagulants
COMPLICATIONS
 CARDIOPULMONARY COMPLICATIONS RELATED TO SEDATION AND ANALGESIA
(MOST COMMON TYPES)
 ASPIRATION PNEUMONIA ( ASPIRATION OF GASTRIC CONTENTS INTO THE LUNGS
IS COMMON, AND MAY RESULT IN DEATH).
 INFECTIOUS COMPLICATIONS RELATED TO DIAGNOSTIC ENDOSCOPY (PROCEDURE
ITSELF , CONTAMINATED EQUIPMENT)
 PERFORATION.
 BLEEDING (INJURY TO GASTRIC OR ABDOMINAL WALL VESSELS)
NURSING INTERVENTIONS

BEFORE THE PROCEDURE
1)
EXPLAIN THE FOLLOWING TO THE PATIENT:
1)
THE TYPE OF PROCEDURE, ADVISE THAT SOMEONE MUST ACCOMPANY
THE PATIENT TO DRIVE HOME DUE TO THE PATIENT BEING SEDATED.
2)
NPO FOR 8 TO 12 HOURS BEFORE THE PROCEDURE TO PREVENT
ASPIRATION AND ALLOW FOR COMPLETE VISUALIZATION OF THE
STOMACH.
3)
REMOVE DENTURES AND PARTIAL PLATES TO FACILITATE PASSING THE
SCOPE AND PREVENTING INJURY.
4)
INFORM THE HEALTH CARE PROVIDER OF ANY KNOWN ALLERGIES AND
CURRENT MEDICATIONS. MEDICATIONS MAY BE HELD UNTIL AFTER THE TEST
IS COMPLETED.
DESCRIBE WHAT WILL OCCUR DURING AND AFTER THE PROCEDURE TO
THE PATIENT :
1) THE THROAT WILL BE ANESTHETIZED WITH A SPRAY OR GARGLE.
2)
AN I.V. SEDATIVE WILL BE ADMINISTERED.
3)
THE PATIENT WILL BE POSITIONED ON THE LEFT SIDE WITH A
TOWEL OR BASIN AT THE MOUTH TO CATCH SECRETIONS AND TO
PROVIDE EASY ACCESS FOR THE ENDOSCOPE.
4)
A PLASTIC MOUTHPIECE WILL BE USED TO HELP RELAX THE JAW
AND PROTECT THE ENDOSCOPE. EMPHASIZE THAT THIS WILL NOT
INTERFERE WITH BREATHING.
5) ASK PATIENT TO SWALLOW ONCE WHILE THE ENDOSCOPE
IS BEING ADVANCED BUT DO NOT TALK, OR MOVE
TONGUE. SECRETIONS SHOULD DRAIN FROM THE SIDE OF
THE MOUTH, AND THE MOUTH MAY BE SUCTIONED.
6) AIR IS INSERTED DURING THE PROCEDURE TO PERMIT BETTER
VISUALIZATION OF THE GI TRACT. MOST OF THE AIR IS
REMOVED AT THE END OF THE PROCEDURE. THE PATIENT MAY
FEEL BLOATED, BURP, OR PASS FLATUS FROM REMAINING AIR.
AFTER THE PROCEDURE
1) NPO UNTIL THE GAG REFLEX RETURNS (IN 1 TO 2 HOURS)
2) ASSESS OR TEST GAG REFLEX
3) AFTER THE PATIENT’S GAG REFLEX HAS RETURNED, THE
NURSE CAN OFFER SALINE GARGLE, AND ORAL
ANALGESICS TO RELIEVE MINOR THROAT DISCOMFORT.
4) PLACE THE PATIENT IN THE SIM’S POSITION UNTIL HE OR SHE
IS AWAKE AND THEN PLACE THE PATIENT IN THE SEMIFOWLER’S POSITION UNTIL READY FOR DISCHARGE.
5) OBSERVE FOR SIGNS OF PERFORATION, SUCH AS PAIN, BLEEDING,
UNUSUAL DIFFICULTY SWALLOWING, AND AN ELEVATED
TEMPERATURE.
6) BED REST UNTIL FULLY ALERT ( FOR SEDATED PATIENTS).
7) MONITOR PR AND BP FOR CHANGES THAT CAN OCCUR WITH
SEDATION.
8) INSTRUCT THE PATIENT NOT TO DRIVE FOR 10 TO 12 HOURS IF
SEDATION WAS USED.
COLOSTOMY
• OPENING THROUGH THE ABDOMINAL WALL IN THE COLON
• A SURGICAL PROCEDURE IN WHICH AN OPENING (STOMA) IS
FORMED BY DRAWING THE HEALTHY END OF THE LARGE
INTESTINE OR COLON THROUGH AN INCISION IN THE
ANTERIOR ABDOMINAL WALL AND SUTURING IT INTO PLACE.
• THIS OPENING, IN CONJUNCTION WITH THE ATTACHED
STOMA APPLIANCE, PROVIDES AN ALTERNATIVE CHANNEL
FOR FECES TO LEAVE THE BODY.
• IT MAY BE REVERSIBLE OR IRREVERSIBLE DEPENDING ON THE
CIRCUMSTANCES.
COLOSTOMY
OSTOMY APPLIANCE CONSIST OF :
• SKIN BARRIER
• POUCH – CAN BE CLOSED OR DRAINABLE
• ADJUSTABLE OSTOMY BELT
CLASSIFICATION OF COLOSTOMY
1. ACCORDING TO STATUS
A. PERMANENT – TO PROVIDE MEANS OF ELIMINATION WHEN THE RECTUM
OR ANUS IS NON FUNCTIONAL ( BIRTH DEFECT / CANCER)
B. TEMPORARY – FOR TRAUMATIC INJURIES OR INFLAMMATORY CONDITIONS
OF THE BOWEL, ALLOWING THE BOWEL TO REST AND HEAL
CLASSIFICATION OF COLOSTOMY
2. ACCORDING TO CONSTRUCTION OF THE STOMA
a.
SINGLE – ONE END OF THE BOWEL IS BROUGHT OUT
THROUGH AN ABDOMINAL OPENING
B. LOOP – LOOP OF BOWEL IS BROUGHT INTO THE
ABDOMINAL WALL AND SUPPORTED BY A PLASTIC
BRIDGE , OR A PIECE OF RUBBER TUBING; HAS TWO
OPENINGS (PROXIMAL AND DISTAL)
CLASSIFICATION OF COLOSTOMY
2. CONSTRUCTION OF THE STOMA (CONT.)
C. DIVIDED COLOSTOMY – TWO EDGES OF BOWEL
BROUGHT OUT INTO THE ABDOMEN BUT SEPARATED
FROM EACH OTHER
D. DOUBLE BARREL - PROXIMAL AND DISTAL LOOPS
OF BOWEL ARE SUTURED TOGETHER FOR ABOUT
10 CM AND BOTH ENDS ARE BROUGHT UP INTO THE
ABDOMINAL WALL
Divided colostomy –
Double barrel
INDICATIONS
• COLON CANCER
• DIVERTICULITIS – INFLAMMATION OF SMALL,
BULGING POUCHES THAT FORMS IN THE
LININGS OF THE DIGESTIVE TRACT
• INJURY -
• FECAL INCONTINENCE - IS A LACK OF CONTROL
OVER DEFECATION LEADING TO INVOLUNTARY
LOSS OF BOWEL CONTENTS—INCLUDING
FLATUS (GAS), LIQUID STOOL ELEMENTS AND
MUCUS, OR SOLID FECES.
OSTOMY MANAGEMENT
CONSISTS OF GROUP OF NURSING INTERVENTIONS THAT MAY BE NECESSARY AFTER FECAL
DIVERSION SURGERY
• STOMA ASSESSMENT
• APPLICATION OF STOMA TO COLLECT FECES AND PROTECT SKIN
• PROMOTION OF SELF CARE
ASSESSMENT
Assess for:
Normal
Abnormal
Color
Healthy pink, red and slightly
moist
Dusky pink / bluish (cyanosis) suggest inadequate
circulation to the stoma
Size and shape
New stoma are swollen;
swelling decreases in 2-3
weeks or as long as 6 weeks
Protrude slightly from the
abdomen
Failure to recede may indicate blockage
Position
Must remain on the abdominal
surface
If stoma retracts, feces may enter the abdominal
cavity and cause peritonitis;
Prolapse must be reported to the doctor
Stomal bleeding
Slight bleeding
Report other bleeding
Complaints
Burning sensation under the skin may indicate skin
breakdown
Abdominal discomfort / distention
CHANGE OF OSTOMY APPLIANCE
• ORDINARILY THE POUCH MUST BE EMPTIED OR CHANGED A COUPLE OF TIMES A DAY
DEPENDING ON THE FREQUENCY OF ACTIVITY
• CAN BE APPLIED FOR UP TO 7 DAYS
• TWICE A WEEK
• CHANGE WHENEVER THE STOOL LEAKS ONTO THE PERISTOMAL SKIN
• EVERY 24 – 48 HRS IF THE SKIN IS ERYTHEMATOUS, ERODED, DENUDED OR ULCERATED
• MORE FREQUENT CHANGES IF CLIENT COMPLAINS OF PAIN OR DISCOMFORT
• THE POUCH IS EMPTIED WHEN IT IS ONE THIRD TO ONE HALF FULL
• IF THE POUCH OVERFILLS, IT CAN CAUSE SEPARATION OF THE SKIN BARRIER AND STOOL
COMES IN CONTACT WITH THE SKIN
PURPOSE OF CHANGING OSTOMY APPLIANCE
• TO ASSESS AND CARE FOR PERISTOMAL SKIN
• TO COLLECT STOOL FOR ASSESSMENT OF THE AMOUNT AND TYPE OF OUTPUT
• MINIMIZE ODORS FOR THE CLIENT’S COMFORT AND SELF ESTEEM
COLOSTOMY IRRIGATION
• A WAY TO REGULATE BOWEL MOVEMENTS BY EMPTYING THE COLON AT A SCHEDULED TIME
• INVOLVES INFUSING WATER INTO THE COLON THROUGH THE STOMA STIMULATING THE COLON TO
EMPTY.
• ALLOWS FOR THE PERSON TO NOT WEAR A POUCH, BUT RATHER JUST A GAUZE CAP OVER THE
STOMA
• SCHEDULED IRRIGATION IS DONE FOR TIMES THAT ARE CONVENIENT
• TO IRRIGATE, A CATHETER IS PLACED INSIDE THE STOMA, AND FLUSHED WITH WATER, WHICH ALLOWS
THE FECES TO COME OUT OF THE BODY INTO AN IRRIGATION SLEEVE.
• MOST COLOSTOMATES IRRIGATE ONCE A DAY OR EVERY OTHER DAY, THOUGH THIS DEPENDS ON THE
PERSON, THEIR FOOD INTAKE, AND THEIR HEALTH
REFERENCES
• KOZIER & ERBS’ FUNDAMENTALS OF NURSING . EIGHTH ED. 2008
• POTTER PERRY. BASIC NURSING 6TH ED..MOSBY, MISSOURI, 2006.
• HTTP://WWW.CANCER.ORG/TREATMENT/TREATMENTSANDSIDEEFFECTS/PHYSICALSIDEEFFEC
TS/OSTOMIES/COLOSTOMYGUIDE/COLOSTOMY-IRRIGATION