Enema

Defaecation
Defaecation
Univ
University
iver
iv
ersi
er
sity
si
ty of
o Pécs
Pécs Faculty of Health
Hea
H
ealt
ea
lth
lt
h Sciences
Scie
Sc
ienc
ie
nces
nc
es
Inst
In
Institute
stitute
st
e of Nursing
N
ng and Patien
Patient
entt Care
en
C
Departme
De
ment
me
nt of N
Nursing Scie
ienc
ie
nces
nc
es
Department
Sciences
Not
N
ot within
within this
th
his lecture
• Anatomical
Anatomical and physio
ologicaal bas
sics of tthe
he
physiological
basics
diigestion
digestion
• Metabolism
Metabolissm p
rocess
process
intestinal
disorders
• Examinations
Exam
minations in
n ccase
asse of
of intestin
nall d
isorders
Dr. András
Andr
An
drás
dr
ás Oláh
Olá
O
láh1, No
Noém
Noémi
émi Fullér2, Zsuzsanna Germán
ém
Germ
rmán
rm
án3, Szilvia Szunomár
Szun
Sz
unom
un
omár
om
ár3
1
associate
associat
ate
at
e professor,
p
vice dean, head of the
e dep
d
department
epar
ep
artm
ar
tmen
tm
ent
en
professor,
p
deputy head of the department
depa
partme
pa
ment
me
nt
3 subject teacher
2 assistant
t
TThe
he observation of faecess
• number
number and
and amount of defae
defaecation
ecation
TThe
he number and amount of
defaecation
normal
defaecation
may
for
different
• tthe
he n
ormal d
efaecation habits m
ay vvary
ary fo
or d
ifferent
iindividuals
ndividualss
faeces
• the
the colour
colour of faec
ces
• stool odour
odour
• faeces are excreted
excrreted once or ttwice
w ic e d
aily/or 3 or 4
daily/or
times a w
week
eek
• the
the cconsistency
onsisteency of faeces
• iits
ts no
orm
malityy iiss determined by the emptying
em
mptying
normality
fr
requency
frequency
• the pathological components off ffaeces
aeces
• the amount of soft stool is 150-200gg
The colour of the faeces II.
TTypes
ypes of bloody faeces
TThe
he colour
colour of the faeces II..
•
physiologically
of the stool is brownish
phys
ph
ysio
ys
iolo
io
logi
lo
gica
gi
callllllyy the
ca
the colour
co
•
Yellow
Ye ow - in
in infants
inf
inf
nfan
ants
an
ts (breast
(bre
(b
reast milk)
re
•
Light-coloured,
Ligh
Li
ghtgh
t-co
tcolo
co
lour
lo
ured
ur
ed,, oily
ed
oi faeces - fat digestion
digest
stio
st
ion
io
n problems
pro
pro
robl
blems
bl
•
Dark green/and or yellow
bile
ye ow - excessive
exc
exc
xcessive amount
amou
ount
ou
nt of b
bil
ilile excretion,constipation,
consumption
chlorophyll
n of
of vegetables
veg
veg
eget
etab
able
ab
less ric
le
rrich
ich
ic
h in
i chlorophy
hyllll
hy
•
•
Light-coloured,
ductus
Ligh
Li
ghtgh
t-co
tcolo
co
lour
lo
ured, white,
whit
wh
ite, clay-coloured
it
clayy-co
ycolo
co
lour
lo
ured -obstruction of the
he du
duct
ctus
ct
us coledochus,
cole
co
ledo
le
dochus
do
us,
us
obstractional
obst
ob
stract
st
ctio
iona
io
nal ileum,
na
ileum
um, ga
um
gall bladder mobility disorders,
s, cholecystitis
cho
holecystitis
ho
•
Blac
Bl
Black,
ack,
ac
k, tar
tar-like
ar-l
ar
-lik
ike sto
ik
stool
tool
to
ol is ccaused by bleeding coming from the
he middle
midd
mi
ddle
dd
le section
sect
se
ctio
ct
ion of the GI
io
tract
wine,
blackcurrant,
trac
tr
actt or
ac
or by
by consumption
con
con
onsu
sump
su
mpti
mp
tion
ti
on of black pudding,offals, red
d win
w
ine,
in
e, b
bla
lackcu
la
curr
cu
rran
ant,
an
t, o
orr som
ssome
ome
om
medicaments
carbon
medi
me
dica
di
came
ca
ment
me
ntss (iron,
nt
(ir
(ir
iron,, ca
carb
rbon tablets)
rb
•
Malaena
pitch-black,loose
caused
bleeding
Mala
Ma
laen
la
enaa is
en
is pi
pitc
tchtc
h-bl
hblac
bl
ack,loose gelatinouss sto
ac
sstool
tool
to
ol caus
used by GI b
us
ble
leed
le
eding from the
ed
stomach
upper
stom
omac
om
ach
ac
h or
or upp
u
pper
pp
er regions or ass a complication
complicat
atio
at
ion
io
n of
of re
renal deficiency
deficie
ienc
ie
ncyy (on
nc
( the hospital
chart „M” is written)
•
colour
bleeding
consumption
beetroot
Reddish colou
ourr stoolou
sto
sto
tool
ol-- GI
ol
G bl
blee
eedi
ee
ding
di
ng or consumptio
ion of beet
io
etroot
et
•
Stool
stripes
forced
defaecation,
rupture
haemorrhoids
Stoo
St
ool with
oo
wit
ith
h blood
b
stri
st
ripe
ri
pes - force
pe
ced
ce
d def
d
efae
ef
aecation, or the rup
uptu
ture of h
tu
hae
aemo
ae
morr
mo
rrho
rr
hoid
ho
idss
id
•
Bloody,
Bloo
oody
oo
dy, mu
dy
mucous stooll - inf
iinflammatory
nflammatory intestinal disease, or ne
nf
neoplasm
•
haemorrhoidal
bleeding
Stooll coa
ccoated
oate
oa
ted with fresh, red blood - tumor or haemorrho
te
hoidal bl
ho
blee
eedi
ee
ding
di
ng
Slimy,
ulcerative
Slim
imy,
im
y, transparent
ttra
ransparent faeces - spasmic diarrhoea, ulcer
ra
erativ
er
ivee colitis
iv
c it
colit
itis
is
Stool odour
Physiologically - characteristically unp
pleasant odour
odour
• Physiologically
unpleasant
• rotten
digestive
rotten like,
like, very
very foul smell
smelll - protein
protein d
igestivee
dysfunction
dysfunction
• sour smell
carbohydrate
smelll of
of fermentation
fermentation - ca
arbohyydrate
indigestion
indigesstion
TThe
he consistency of faeces
stool
normal
• formed
form
fo
rmed
rm
ed st
stoo
ooll - nor
oo
n
ormal
or
berry
little
consumption
• hard,
hard
ha
rd,, be
rd
berr
rryy - lik
rr
llike
ikee stool-constipatio
ik
sstool-constipation,
ion,
io
n, llit
ittl
it
tlee flu
tl
ffluid
luid
lu
id consu
sump
su
mpti
mp
tion
ti
on
malabsorption,
excessive
• regular,
regu
re
gula
gu
lar,
la
r, pasty
pas
p
asty
as
ty stool - malabsorp
m
rpti
rp
tion
ti
on,, ex
on
excessiv
ivee foo
iv
ffood
ood
oo
intake,fruit with mild
effect
mild laxative
laxa
la
xative effe
xa
fect
fe
ct (apricot,
(apr
pric
pr
icot
ic
ot, plum)
ot
• loose
e sto
sstool
tool
to
ol - emptied
e
ed on
once or several times
es ca
can be considered
cons
co
nsid
ns
ider
id
ered
er
ed
diarrhoea
diar
di
arrh
ar
rhoe
rh
oea
oe
• stronger
fermented
sttronger ferm
mented smell - after thee consumption
consump
ption of
of
hard
harrd liquour,
liquour, brandy
inflammations
non• bloody,
bloo
bl
oody
oo
dy, mucoid
dy
id stool
st
- intestinal inflammat
atio
at
ions of non
io
on-on
infectious
infe
fect
fe
ctio
ct
ious origin
• sweetish, extremely foul smell - empt
emptying
malaena
tyiing mal
laena
• Bloody-watery diarrhoea - dysentery
TThe
he p
pathological
athological componentss in
faeces
much
water-diarrhoea
• to
too
o muc
m
uch
uc
h wat
w
ater
at
er-d
er
-dia
-d
iarrhoea
large
pancreatitis,
• a la
larg
rgee amount
rg
amo
amo
moun
untt of
of fat-caused by pa
panc
ncre
nc
reat
re
atit
at
itis
it
is, malabsorption
is
malabs
ma
bsor
bs
orptio
or
ion
io
n
syndome,enteritis,
synd
sy
ndom
nd
ome,
om
e,en
e,
ente
en
teri
te
riti
ri
tis, a condition after
ti
afte
af
terr an
te
a enterocolectomy
entero
roco
ro
colectom
co
omyy
om
surg
su
rger
rg
eryy
er
surgery
• digested or fresh
h blood
blo
blo
lood
od
• foreign bodyy th
that
at ca
can
n cause
cau
cau
ause
se suppurative
suppurat
ativ
at
ivee and
iv
and bloody
blo
b
lood
lo
odyy
od
pathological
patholog
ogic
og
ical
ic
al change
ch
pus-enteritis
• pu
puss-ente
steritis
te
mucin-in
inflammation
irritation
(swallowed
• mu
muci
cinci
n-in
nin ca
case of inf
nflammation (colitis), irrita
nf
tati
ta
tion (swall
ti
llllow
owed
ow
ed
obje
objects),stress
ject
je
cts)
ct
s),stress
s)
• some
me ba
bacteria-pathogens
• undigested food-shell of legumes, corn
• intestinal worms
Examination of faeces, aim and
method
m
ethod for samplingg
• lab
off test:
lab sseries
e r i es o
microbiological
– chemical
chemical and
and microbiol
logical testss
examination
– microscopic
microscopic exa
amination
n
the following
tested:
folllowing ffeatures
eatures are tes
sted:
colour,
composition,pH,
colo
co
lour
lo
ur,, odour,
ur
odo
odo
dour,, form,density,
for
for
orm,
m,dens
m,
nsit
ns
ity, composition,pH
it
pH,, secretion
pH
ssecretion,mucus,
on,m
on
,muc
,m
ucus
uc
us,,
blood,
meatfibre,WBC,
content
bloo
ood,
oo
d, fa
fat,
t, meatfibr
bre,
br
e,WBC, bile, sugar conten
e,
ent
en
Stool sampling
sampling
means:
samp
sa
mplililing
mp
ng me
mean
ans:
an
s:
stool
content),
capsules
• st
stoo
ooll con
oo
ccontainer
onta
on
tain
ta
iner
in
er (20cm3 conten
ent)
en
t),, two
t)
two ca
caps
psul
ps
ules fo
ul
forr bacteria
b
cult
cu
ltur
lt
ures
ur
es,, det
es
d
etec
et
ecti
ec
ting toxin, parasi
site
si
te,, vir
te
vvirus
irus
ir
us antige
gen
ge
n
cultures,
detecting
parasite,
antigen
• Ty-container - for
for coll
llllec
ecting bloo
ec
ood
oo
d and
and faeces samples of
collecting
blood
typhoid
d pat
p
atie
at
ient
ie
nts
nt
patients
• Sa
Samp
mplililing
mp
ng from
om pe
perianal
al area with tape and
d cel
ccellophane
ellophanee cappe
el
ccapped
ped
pe
d
Sampling
wand
wa
nd fo
for detecti
ting
ti
ng ovules
detecting
Stool sampling
For
For microbiological
microbiological examination:
Patient
P
atien
nt ccan
an perform
perform the sampling
samplin
ng
faec
fa
eces
ec
es should
shou
sh
ould
ou
ld be stooled
d in
in the
the bed
be pan,
pan
an,, not
an
n in the
th toilet,
– faeces
because
bacteria
beca
be
caus
ca
usee of
us
o the bact
cter
ct
eria in it
er
– in case of home
home sa
sampling stool
stoo
ooll sho
oo
sshould
houl
ho
uld be taken from the
ul
uncontaminated
parts
contcact
with
toilet)
uncontam
amin
am
inat
in
ated
at
ed pa
part
rtss (not
rt
(
contc
tcac
tc
actt wit
ac
w
ith
it
h the
the to
toil
ililet
et))
et
sampling
stools,
sam
mpling sshould
hou
uld
d be made
made from 3 different
difffeerent sto
ools, in 3
following
days
foll
lowing d
ays
Stool sampling
„„F”
F” ccontainer
ontainer (in
(in Hungary)
b
bacterias,
acterias, ttoxin,
oxin, parasite,, vvirus
irus antige
antigen
en
TThere
here iiss a samp
plin spoo
one – two-t
thirds fill the
samplin
spoone
two-thirds
container
Send iitt w
itthin 4 h
ours to the lab
within
hours
sstorage
toraage in ffridge
ridge
„TY”” container
container – typhoid pat
patients
tien
nts + b
blood
lood
d
sample
Detection
D
etection of faecal occult blood
blo
ood
Detection
D
etection of faecal occult blood
blo
ood
Detection
D
etection of
of h
human
uman blood:
based
pseudoperoxydase
• gguaiac
uaiac ttrial:
rial: b
ased on pseu
udoperoxyd
dasee
rreaction
eaction (gFOBT)
(gFOBT)
bee m
mailed,
gguaiac
uaiac ttest
est iiss ffiltered
iltered on paper, can
nb
aileed, used
frequently
freequently
• immunochemical
immunoch
hemical methods
method
ds using
using antihuman
IG (iFOBT,
(iFO
OBT, FFIT)
IT))
sample
paper
saturated
with
1. sam
mple iiss put on a ttest
est pape
er sa
aturated w
ith reagent,
hydrogen
peroxyde
2. drop hydrog
gen p
eroxxyde on it, aand
nd
1-2
min.
disclorisation:
positive
3. read rresult
esullt in 1
-2
2 min
n. (blue discl
lorisation
n: pos
sitive
rresult)
esult)
methods
for
detecting
• m
ethods fo
or d
etecting hematoporphyrin
hematop
porphyrin
n
• faecal DNA test
special
order
sp
pecial diet should be followed in ord
der to
o avoid
avoid
pseudopositive
meat,
beetroot,
p
seudopositive results (red me
eat, b
eetroot,
days)
mushroom for a few d
ays))
Detection
D
etection of faecal occult blood
bllood
im
immunochemical
mmunochemical test:
detecting
• for
for d
etecting human globine,
glo
obine,
• no need
need for
for diet,,
• simpler tha
an gguaiac
uaiaac metho
od
than
method
tw
wo-p
phase procedure
procedu
ure
two-phase
• guaiacgu
uaiac- and immunochemical
immunochemical is combined
combineed
• specific
speecific to human globine,
• more sensitive to the former
IIndication
ndication of faeces
vertical line
line - formed ffaeces
aeces
• vertical
• slanted
diarrhoea
slanted lline
ine - diarrh
hoea
• red line o
orr letter
melaena
letter „M”–
„M””– m
elaena or
faecaal occult
occultt blood
blo
ood
faecal
• zero
zero
oo
orr crossed
crrossed
d zero - omission
omiission o
off
faaeces
faeces
• letter „E”- enema
Detection
D
etection of faecal occult blood
bllood
TThe
he procedure
procedure for detectingg the
the porphyrine
porph
hyriine
amount iin
n ffaeces
aeces
amount
haemoglobine
amount
• can
n show
show the h
aemoglo
obine amou
unt
Faecal DNA
DNA ttest
est
• there
theree are
are no
no positive
posiitive clinical res
sults
results
Diarrhoea
Means
M
eans to collect faeces
• Chux
Chux p
pad:
ad:
• lliquid,
iquid, lloose
oosse faeces is excreted
excreeted
more
• m
ore tthan
han tthree
hree timess
amount
larger
• or /and
/and
d its am
mount is la
arger tthan
han 200g
200g during
24 hours
• Sk
kin ccare:
ar e:
Skin
Tenesmus:
constant
Te
enesm
mus: ffrequent
requeent or cons
stant urge
urgge to
o
defecate
def
fecaate with llittle
ittle faeces or without
witho
out
• faecal
fae
ecal collector:
collecto
or:
they absorb
abso
ab
sorb
so
rb the
the liquid
l
nt of the
the faces
f
but the
the solid
solililid
so
– they
component
but
comp
co
mpon
mp
onen
on
ents
en
ts remain
re
ski
ski
kin
n and
and irritate
te it
components
on thee skin
ry to
toil
ililet
et paper, soup
up,, alc
up
aalcohol
lcoh
lc
ohol
oh
ol based agents and
– Avoid from dry
toilet
soup,
body powder
powd
po
wder
wd
er
– Preffered
ones:
wipes
Preffe
fere
fe
red
re
d one
o
nes: hypoallergenic
ne
hypo
hy
poal
po
alle
al
lerg
le
rgen
rg
enic creams,, wet
en
wet wi
wipe
pess
pe
– adhesive
adhe
ad
hesive bags, can be administered to the
he
cleaned
clea
eane
ea
ned and wiped dry area of the perineum
ne
m
– optimal for immobile patients
– leaking may happen
Means
M
eans to collect faeces
Anal pl
plug
ug::
ug
• Anal
plug:
– Similar
Simi
Si
mila
mi
larr to
la
to sup
ssuppositories
uppositories
up
Made from
ffro
rom
ro
m some
s
ke ma
mate
terial
te
– Made
foam-like
material
They ca
can
n be
b placed on the rectum
rec
ectu
ec
tum
tu
m
– They
leak
akin
ak
ingg in
in
i case of chronic
chro
ch
roni
ro
nicc diarrhoea
ni
d
– prevent the le
leaking
Constipation
•
•
•
•
•
•
•
•
•
•
•
dry,
hard
dry, h
ard consistency,lumpy
consistency,lumpy faeces
difficult
difficult to
to excrete
excrete
excessive sstraining,pain,
training,pain,, discomfort
discomforrt
excessive
person does
does not feel thatt h
is gut
gut is eempty
mpty
person
his
excretion takess p
place
lace less frequently
frequeently than 3 days
excretion
more
10
n lasts
lasts ffor
or m
ore than
n1
0 min.
min.
assocciated symptoms:
symp
ptomss: p
ain in thee sstomach,
tomach,
associated
pain
cramps,losss of
of ap
ppetite,reduced gases
gasses
cramps,loss
appetite,reduced
may
may lead
lead to
oh
hemorrhage
emorrhage
raarely life-threatening
rarely
cause anxiety
mayy cause
may reduce life quality
Means
M
eans to collect faeces
system:
• Faecal
Faec
Fa
ecal
ec
al sy
syst
stem
st
em::
em
– In case
immobility
faecal
case of iimm
mmobility and fae
mm
aeca
ae
call inc
ca
iincontinence
ncontine
nc
nenc
ne
nce
nc
Even
en fo
forr rin
rrinse
inse
in
– Ev
on of tthe balloo
oon
oo
n is
i a si
sili
lilicone catheter
– The continuation
balloon
silicone
Constipation
Rome II-criteria
TThe
he p
atient suffers
suffers from constipation
constipaation if
if thee following
following
patient
ssymptoms
ymptoms have
have lasted forr 1
2d
ayys iin
n thee past
pastt 1
2
12
days
12
m
onths (Drossman
(Drossman aet al)
all)
months
1. Straining is ch
haraccterisstic for 25
5 % of
of the
the faecal
characteristic
excretion
ns
excretions
2. Hard, lumpy
lumpy faeces
faecees is
is ch
haracteristic forr 25%
25% of
of the
the
characteristic
eexcretions
xcretions
3. Feeling
Feelin
ng inadequate
inadeequate clearance is characteristic
characcteristic for 25
25 % off
th
he eexcretions
xcretions
the
4. Jam
m iiss characteristic for 25% of the exc
cretiions
excretions
5. Man
nual aid is necessary for 25% of thee excretions
excreetions
Manual
6. The number of excretions is fewer than three
Constipation
Triggering
Trig
Tr
igge
ig
geri
ge
ring
ng factors
fact
fa
ctor
ct
orss for
or
for developing constipation
constipati
tion
ti
on
• lifestyle
lilife
fest
fe
styl
st
yle
yl
e factors:
fac
fac
acto
tors
to
rs:: inadequate eating
rs
ng habits,lowdietary
habi
ha
bits
bi
ts,l,l,low
ts
owdietar
ow
aryy fib
ar
ffibre
ibre
ib
re
intake,
inta
in
take
ta
ke,, le
ke
less
ss w
who
wholemeal
holemeal bread
ho
d pro
p
products,
rodu
ro
ducts, inade
du
inadequate
dequ
de
quatee flu
qu
ffluid
luid
lu
id
inta
in
take
ta
ke,l,l,lac
ke
ackk of
ac
of exercise, enemas
as
intake,lack
anxi
xiet
xi
ety,
et
y, depression,repression
depressio
ion,
io
n,repr
n,
pres
pr
ession of defecation
es
• psychic factors: an
anxiety,
• side-effects
ts of drugs:
dru
d
rugs
ru
gs:: an
gs
anti
antidepressants,
tidepressant
ti
nts,
nt
s, antiepileptic
ant
ntie
nt
iepi
ie
pile
pi
lept
le
ptic
pt
ic
drugs,antipsychotic
drugs,an
anti
an
tips
ti
psyc
ps
ychoticc dru
yc
d
drugs
rugs
ru
phys
ysio
ys
iolo
io
logica
lo
call changes:
cha
cha
hanges
es: pr
es
preg
egnancy, old agee
eg
• ph
physiological
pregnancy,
• diseases:
dise
di
seas
se
ases
as
es: neurol
es
neurological
olog
ol
ogical conditions (Parkinson
og
(Parkins
nson
on disease, sp
spin
spinal
inal
in
al
cord
co
rd in
inju
injury,
jury, SM, muscle dystrophy)Addison
ju
n disease,
dis
dis
isease, anal
anal
ruptures,haemorrhages,colon
inflammatoryGI
rupt
ptur
pt
ures
ur
es,haemorrhages,colon tumor, infla
es
lamm
mmat
ator
at
oryG
or
yGI
yG
diseases)
diseas
ases)
as
• changes in environment: holiday,travelling, hospitalisation
Lifestyle advice
•
consumption
cons
co
nsum
ns
umpt
um
ptio
pt
ion
io
n of
of high
high fi
fibre content foods
•
drinking
1.5-2ls
water
drin
dr
inking
in
ng 1.
1.55-2l
52ls of w
2l
wat
ater
at
•
physic
ical
ic
al activity
acti
ac
tivi
ti
vity
vi
ty
physical
•
el diary
diar
di
aryy
ar
writing a bowel
•
defecation
defe
de
feca
fe
cati
ca
tion
ti
on posture
postur
uree
ur
•
strengthening
stre
reng
re
ngth
ng
then
th
ening the pelvic
en
pelv
pe
lvic muscles
lv
•
biofeedb
dbac
db
ack treatment
ac
biofeedback
•
do not supress the urge
Care
C
are of the constipation
n
with
wi
th medicaments
medi
me
dicaments
di
laxative
ves
ve
s
• laxatives
(not within this
is le
lect
lecture)
cture)
ct
conservative
conserva
co
vati
va
tive
ti
ve care,
lifest
style
st
e advices,
adv
adv
dvices,
lifestyle
enema,
en
remo
re
mova
mo
vall of
va
of sk
skyb
ybal
yb
allu
al
lum
lu
removal
skyballum
Constipation
C
onstipation – proper position
posittion
Types of enema
base
based
sed
d on
on osm
o
osmolality:
smol
sm
olal
ol
alit
al
ity:
it
• hy
hypotonic
hypo
poto
po
toni
to
nic
ni
c
• hy
hype
pert
pe
rton
rt
onic
on
ic
hypertonic
• is
isot
oton
ot
onic
on
ic
isotonic
main groups:
grou
oups:
ou
-cleansing/evacuant
-cle
lean
le
ansi
an
sing
si
ng/evacuant
ng
enem
en
ema
em
a
enema
-ret
-r
etenti
et
tion
ti
on
-retention
Enema
Evacuant
Evac
Ev
acua
ac
uant
ua
nt enema
enem
en
emaa
em
Indications:
Indi
dica
di
cati
ca
tion
ti
onss: con
on
cconstipation,
onst
on
stip
st
ipat
ip
ation, postoperative cle
at
cleaning
lean
le
anin
an
ing off the
in
the lo
lowe
lower
wer part
we
of th
thee rec
rrectum
ectu
ec
tum
m and
and sigmoid intestine
ne,, bef
ne
b
efor
ef
oree deliver
or
d
eryy
er
intestine,
before
delivery
Classi
sifi
si
fica
fi
cati
ca
tion
ti
on::
on
Classification:
• Based on the amontt
• large volumee enema(500-1000ml),
ene
ene
nema
ma(5
ma
(500
(5
00-1
00
-1000ml),
-1
• Small volume
vol
olum
ol
umee enema
um
e ma (50-200ml)
(50(5
0-20
0200ml)
20
• Ba
Base
Based
sed
se
d on
on osmol
o
osmolality:
olal
ol
ality: hy
al
hypo
hypotonic,
poto
po
tonic, isotonic,, hyp
to
h
hypertonic
yper
yp
erto
er
tonic
Based
• Base
sed
se
d on
on the
t affected intestine:
• high
gh en
enema
• low enema
Enema
Soapsuds
Soapsuds enema,
enema, SSPA
• Soapy
Soapy water
waterr can
can be applied,
• its
its use
use is
is rare
rare due to the
the irritating
irritatin
ng effect
effecct in the
intestine
in
ntestine
p can
can be
be used, p
hytogenic based, less
• Castile soap
phytogenic
irritatingg
Pu
urgativve enem
ma
Purgative
enema
• Hypertonic
enema,
Hyypertonic solution: glycerol ene
ema, mixture
mixture off
glyccerol and water (1:2), and glyce
erol and
and castor
caastor oill
glycerol
glycerol
(1:1)
Enema
Cold
C
old e
enema
nema
Indications:
In
n dications:
heat
• Antipyretic
Antiipyretic treatment
treeatment (fever,
(ffever, h
eat sstroke)
troke)
treatment
• Antiinflammatory
Antiinflaammatory
treat
tmentt
((dysentery,
dysentery,
diarrhoea,
haemorrhages,
diarrh
hoea, haem
morrhages, ulcerative
ulcerrative ccolitis)
olitis)
degree
• 10-20
10-2
20 C de
egree (27-32C)
(2
27-32C) water
Enema
((medicated
medicated enema)
• R
etention eenema
nema
Retention
• tthe
he p
product
roduct sshould
hould be held
d iin
n the anus
anu
us (30-6
(30-60
60 min) in
accordance
with
regulations
acc
cordance w
ith the re
egulatio
ons
steroid-solution
• Mostly ster
roid-solu
ution enema ((for
for rreducing
educing iintestinal
ntestinal
inflammation
case
off ulc
ulcerative
inflamm
mation in cas
se o
cerative colitis)
colitiis)
antibiotic
solution
off local b
bacterial
• an
ntibiotticc solu
ution enema (in case o
actteriial
infection)
infe
ection)
Enema
SSedative
edative enema
enema
not
• n
ot aanymore
nymore
• P
romoting ssleep
leep
Promoting
Anesthetic enema
enema
• not an
nymore
anymore
• ttoo
oo m
uch ccomplication
ompliccation (death)
much
• hypert
hypertonic
tonic solution can be applied
Enema
Antihelmintic
A
ntihelmintic enema:
enema:
• G
oal: tto
o eeliminate
lim
minate and destr
roy w
ormss
Goal:
destroy
worms
First,
given
• Fi
irst, eevacuant
vacuant enema is giv
ven
anthelmintic
solution
• Special, anthelm
mintic drug sol
lution ((250ml)
250ml)
astringent
enema:
astrin
ngent ene
ema:
• IIndication:
ndicattio
on: ul
lcerative colitis and dyse
enttery
ulcerative
dysentery
• Age
ent of enema liquid: tannin, alum
Agent
Enema
Baarium en
nema
Barium
enema
• Be
Befo
Before
fore
fo
re th
thee contrast
con
con
ontr
tras
tr
astt X-ray
as
X
examination
Borium-sulphate
toxic
• Bo
Bori
rium
ri
um-s
um
-sul
-s
ulph
phat
ph
atee is
at
is the only borium
m compound
com
com
ompo
poun
po
und that
un
tha
hatt is
ha
is not
not to
toxi
xic
Oil enema
ene
ema
• Small amonut of solution
solu
so
luti
lu
tion
ti
on is given
• should be held
hel
eld
el
d in
in the
the anus
anus for longer
longe
gerr time
ge
tim
tim
imee (30
((30-60
30-6
30
-60
-6
0 min)
min)
• Indication
on: tr
on
trea
eatm
ea
tmentt of
tm
of conspitation
cons
nspi
ns
pitation following
pi
follow
owin
ow
ingg rectum
in
r tu
rectu
tum
m surgery
sur
sur
urge
gery
ge
ry
Indication:
treatment
(haemorrhages)
first
order
(hae
aemo
ae
morr
mo
rrha
rr
hage
ha
ges)
ge
s) before
b
e the
the fi
firs
rst bowel movement
rs
move
veme
ve
ment
me
nt in or
orde
derr to
de
t
prev
pr
prevent
even
ev
entt sur
en
ssurgical
urgica
ur
call wounds
woundss and
wou
a tension of wound
wou
ound
ou
nd sutures
suture
ress
re
• Oliv
ivee oli
iv
oli (180
(1 ml)
l) ccas
astor oil (60-120ml) gingelly
as
ginge
gellllllyy oil
ge
o (150-080ml)
(150
50-0
50
-080
-0
80ml
80
ml))
Olive
castor
mixt
xtur
xt
uree of
ur
o olive and castor oil (1:2)
mixture
• follow
followed
wed by large evacuant enema
Enema
Emollient
enema
Emol
Em
ollililien
ol
entt / st
en
starch
ch en
enem
ema
em
Indication:
diarrhoea
• In
Indi
dica
di
cati
ca
tion
ti
on:: soo
ssoothing
ooth
oo
thin
th
ingg mucus
in
m
irritation duee to
to dia
d
iarr
ia
rrho
hoea
ho
ea
• En
Enem
emaa liq
em
lliquid:
iqui
uid: st
ui
starch, opium an
and
d sta
sstarch
tarc
ta
rch
rc
h muc
m
ucoi
uc
oid
oi
d wat
w
ater.
at
Enema
mucoid
water.
Temperature:
37.8-40.5C
Temp
Te
mper
mp
erat
er
atur
at
ure:
ur
e: 37
37.8
.8-40.5C
.8
Stimulatin
ing enema
in
Stimulating
treating
fluid
• Indication: for tr
trea
eati
ea
ting
ng fatigue, loss
ss of fl
flui
uid or collapse, opium
ui
poisonong
liquid:
solution
tablespoon
• Enema liq
iqui
iq
uid:
ui
d: bl
black coffee
cof
offe
of
fee sol
fe
olut
ol
ution (1 tablesp
ut
spoo
sp
oon
oo
n of
of gro
gground
roun
ro
und
un
d black
black
bla
coffee,
300ml
pinch
42-43C
coff
ffee
ff
ee,, 300
ee
3
00ml water,
00
wate
wa
ter, a pin
te
p
inch
in
ch of salt, temperature:
tempera
rature
ra
re:: 42re
4
2-43
243C
43
C
• Sp
Spec
Special
ecia
ec
iall coffee
cof
cof
offeee enema
ene
ene
nema is used for treatin
treating
ingg cancer
in
c
r due
due to it
its
detoxification
deto
toxi
to
xifi
xi
fica
fi
cati
ca
tion effect
ti
effe
fect
fe
ct
Carminativ
Carminat
ativ
at
iv en
enema
• Small-scale enema is given with hypertonic
hyper
erto
er
toni
to
nicc sol
ni
ssolution
olut
ol
utio
ut
ion
io
n (MG
((MGV
MGV
MG
solution: 30ml magnesium, 60ml glycerol, 90 ml water)
Enema
Nourishing
Nou
urishing enema
enema
•
Indi
In
Indication:
dica
di
cati
ca
tion
ti
on:: in
on
in cas
ccase
asee of
as
of atrophy,
a
unconsciousness, nutri
nutrients
rien
ri
ents
en
ts ar
aree administered
a
thro
th
roug
ro
ugh
ug
h the
the an
anus
us
through
Dosage:
180-270ml
hours,
temperature:
Dosa
Do
sage
sa
ge:: 180
ge
1
80-2
80
-270
-2
70ml
70
ml in 4 hours,
h
1100-1700 ml in 24 ho
hour
urs, temp
ur
mperat
mp
atur
at
ure:
ur
e: 38C
38
•
Retu
urn-flow enema
enema (Harris flush)
flush
h)
Return-flow
•
Indication:
Indicati
tion
ti
on:: removal
on
rem
rem
emoval of flatus
us (gas)
(gas
(g
as) and increasing
as
incr
crea
cr
easi
ea
sing
si
ng peristalsis.It
peristalsi
sis.
si
s.It can be used after
s.
abdominal surgery forr reducing
red
red
educ
ucing intestinal
uc
intesti
tina
ti
nall distension
na
dis
dis
iste
tens
te
nsion and starting bowel
ns
movement
•
Enema liquid:
liqui
uid:
ui
d: 200ml
200m
20
0ml solution.
0m
solut
utio
ut
ion.
io
n. Temperature:
Temp
mper
mp
erature: 40.5-43C
er
3C (adults)
(adu
(a
dults)
du
s) 38C
38C (children)
(chililildr
(ch
dren
dr
en)
en
•
Procedure:
Proc
Pr
oced
oc
edure:
ed
e: liquid
liliqu
quid should
shou
sh
ould be ingested
ou
inge
in
gested the rectum from
ge
m a coantainer
co
er lifted
lift
fted
ft
ed above
abov
ab
ove
ov
thee height
hei
hei
eigh
ghtt of
gh
of rectum
r tum
rectu
m by
b 30-40cms (children:7.5cms)
s) and
an the tube
be should
shou
sh
ould be
ou
turned
of the
ed off.
off. Then
Th thee container
con
con
ontainer should be let below thee level
l
the patient’s
pat
pat
atient
nt’s
nt
rectum
um by 30.5-45.5cms and open the tube. After excretion,
excret
ex
etion, th
et
thee tube
tub
tub
ubee should
s ul
shoul
uld
be turned
turn
rned
rn
ed off and the conatiner should be lifted above
abov
ove the
ov
he level
leve
vell of
ve
of the
the rectum
um
by 30.5-45.5cms,
30.5-4
-45.
-4
5.5cms, open the tube and let 200ml fluid flow
5.
fl in the
the rectum.
rec
rec
ectu
tum.
tu
•
This procedure should be repeated 3 times
Contraindications
C
ontraindications of enema
enem
ma
enem
en
emaa should
em
sho
sho
houl
uld
ul
d not
not be applied as a primary treatment
tre
reat
re
atme
at
ment
me
nt of
• enema
cons
co
nsti
ns
tipa
ti
pati
pa
tion
on
constipation
diar
di
arrh
ar
rhoe
rh
oeaa
oe
• diarrhoea
arrh
ar
rhyt
rh
ythm
yt
hmia
hm
ia,, he
ia
hear
art attack
ar
• arrhythmia,
heart
gnos
osed
os
ed abdomi
mina
mi
nall pain(may
na
p n(
pain(
n(ma
mayy cause
cau
cau
ause perforation)
• in case of non-diagn
non-diagnosed
abdominal
• anus, intestine,
e, p
pro
rost
ro
statee surgery
st
s
prostate
• bleeding
ng or prolapse
prol
pr
olapse
ol
se of tthe rectum (styptic
ic en
enem
enema
ema can
an be
indi
dica
di
cate
ca
ted)
te
d)
indicated)
• ha
haza
zardou
za
ous:
ou
s: abd
bdom
bd
ominal he
om
hernia, in 12 weeks af
afte
ter abdominal
te
abdom
omin
om
inal
in
al
hazardous:
abdominal
after
surg
rger
rg
ery,
er
y, sseveree bloating,
blo
blo
loat
ating, sanaemia, acute lilive
at
verr failure,
ve
f
, an
aneu
euri
eu
rism
ri
sm,
sm
surgery,
liver
aneurism,
canc
ncer
nc
er of the colon, Crohn syndrome, (exception:
(excep
eption
ep
on: steroid,
on
ster
st
eroi
er
oid,
oi
d, ttsypt
ptic
ic
cancer
tsyptic
enem
ema)
em
a) ulcerative colitis, untreated HBP, co
conges
esti
es
tive
ti
ve he
hear
art failure
ar
re,
re
enema)
congestive
heart
failure,
aptient
ntss sho
nt
sshould
houl
ho
uld
ul
d be
be
• fluid intake restriction with dialysed aptients
considered
Risks of enema
•
•
•
•
•
•
•
•
•
•
•
•
•
•
addi
ad
addiction,
dict
di
ctio
ct
ion,
n, fflu
fluid
luid
id o
ove
overload,
verl
ve
rloa
rl
oad,
oa
d, intestinal irritation, reducti
reduction
tion
ti
on in mu
muscle to
tone
ne of anu
anus
nuss
nu
sphincter
enema)
sphinc
sp
ncte
nc
terr (fr
te
((frequent
freq
eque
eq
uent
ue
nt en
enem
ema)
em
stimulating
vagus
arrhythmia
(bradycardia)
stim
st
imul
im
ulat
ul
atin
at
ingg the
in
the va
vagu
guss nerves
gu
n
causing arrh
rhyt
rh
ythm
yt
hmia
hm
ia (bradycard
rdia
rd
ia))
ia
injury
inju
in
jury
ju
ry
reaction
tube)
allergic
ic reacti
tion (due to latex
ti
late
texx tu
te
tube
be)
be
perforation
irritation
pain, spasm, colon
on irr
rrit
rr
itat
it
atio
at
ion
io
n
electrolyte
upset elect
ctro
ct
roly
ro
lyte
ly
te ba
balancee (ph
((phosphate
phos
ph
osphatee enema)
os
e
damage
(tapwater,
chlorine,bacteria)
dama
mage
ma
ge to colon (t
(tap
apwater, cchl
ap
hlor
hl
orin
or
ine,
in
e,ba
e,
bacteria)
ba
repel
(soapsud
agents)
repe
re
pell int
pe
iintestinal
ntes
nt
esti
es
tina
ti
nal flora
ra (s
(soa
oapsud en
oa
enema-antibacterial agent
nts)
nt
liver
damage
lilive
verr dam
ve
d
amag
am
agee (oil
ag
( enema,vaseline,
enema
ma,v
ma
,vaseline, petroleum derivatives)
,v
s)
addiction
addi
dict
di
ctio
ct
ion
io
n
haemolysis,
haem
emol
olys
ol
ysis, renal failure, rectum ulcer (glycerol enema)
ys
hyponatraemia
age)
hyponatr
traemia (more than 1 enema a day under 10 years
tr
rs of age
ge))
ge
enema:4-6
weeks)
anaemia (lon term application of coffee and glycerol enema:4
:4-6
-6 weeks
ks))
TTherapy
herapy of faeces impactio
impaction
on
impacted faeces
faeces can be removed
removeed b
enem
ma, but
but
• impacted
byy enema,
generally tthe
he d
igital remov
val o
es iiss the eeffective
ffective
generally
digital
removal
off faece
faeces
therapy
therapy
• the patient
patieent is
is in
n a SSims-position
ims-position
n
skybaallu
um should
sh
hould be touched in a co
oncentric w
ay
• skyballum
concentric
way
• then
intestinal
n carefully
carefully disconnect it from thee int
testinall wall,
wall,
twist the finger into the faeces piecee
SStoma
toma care appliances
one-piece
oneon
e-pi
epiec
pi
ecee closed
ec
clo
clo
lose
sed
se
d app
aappliances
ppliances
pp
Stoma care
•
Thee most
Th
m t com
ccommon
ommon diseases (cancer, trauma, in
om
inflam
inflammation,
ammation,
am
diverticulis,perforation,
lower
dive
di
vert
ve
rtic
icul
ic
ulis
ul
is,p
is
,per
erfo
er
fora
fo
rati
ra
tion
ti
on, congenital disorders) of the lo
lowe
werr tra
we
ttract
ract
ra
ct of the GI
system
necessitate
permanent
syst
sy
stem
st
em ma
mayy nec
n
eces
ec
essi
es
sitate a temporary or pe
si
perm
rman
rm
anen
an
entt cha
en
cchange
hang
ha
ngee in
ng
i the
physiological
formation
eneterostoma
phys
ph
ysio
ys
iolo
io
logi
lo
gica
call route
ca
r te of the stoolor the forma
mati
ma
tion
ti
on of en
enet
eterosto
et
toma
to
ma
Classification
Cl
Clas
assi
as
sifi
si
fica
fi
cati
ca
tion
ti
on of enterostomas
en
:
According
• Acco
cord
rdin
rd
ingg to
in
t sites
– colostoma
• coecosto
toma
to
ma
coecostoma
• tr
tran
transversostoma
ansv
an
sver
sv
erso
er
sostoma
so
• si
sigm
gmoide
gm
deos
de
osto
os
toma
to
sigmoideostoma
– ileostoma
ilileost
stom
st
oma and continent
om
cont
co
ntinent ileostoma
nt
ile
leos
le
ostoma
os
• Ac
Acco
According
cord
co
rdin
rd
ing to duration
in
dur
urat
ur
ation (temporary, perman
at
permanent)
anen
an
ent)
en
t)
• Acco
According
cord
co
rding to forms (one-opening, double-spouted
rd
double-sp
spou
sp
outed
ou
d loop
loo
loo
oop
p stoma)
sto
sto
toma))
• Accord
According
rdin
rd
ing to purpose:
– input
– output
SStoma
toma care appliances
oneon
e-pi
epiec
pi
ecee ope
ec
o
pen
pe
n app
aappliances
ppliances
pp
one-piece
open
SStoma
toma care appliances
ttwo-piece
wo--piece ap
appliance
ppliance
Ostomy care and management
gguideline
uideline (2009. Toronto)
• Overall
Over
Ov
eral
er
alll assessment
al
asse
as
sess
se
ssme
ss
ment
me
nt of the patient including
ng physical,
phys
ph
ysic
ys
ical
al,
al
psychological,
religious
psyc
ps
ycho
yc
holo
ho
logi
lo
gica
cal, spiritual,
ca
sspi
piri
pi
ritual, cultural and re
ri
reli
liligi
giou
gi
ouss norms.
ou
n
• Maintenance
Main
Ma
inte
in
tena
te
nanc
na
ncee of
nc
of interdisciplinary
in
y cooperation
coo
coo
oope
peration related
rela
re
lated
la
d to
to
asse
sess
se
ssme
ss
ment
me
nt..
nt
assessment.
indivi
vidu
vi
dual
du
al care plan.
• Application of individual
• Development
relationship
Developmen
entt of
en
of therapeutic
ther
th
erap
er
apeu
ap
euti
eu
tic relations
ti
nshi
ns
hip with
hi
wit
ith
it
h patient.
pat
pat
atie
ient
ie
nt.
nt
• Preoperative
Preopera
rati
ra
tive
ti
ve treatment
trea
tr
eatmen
ea
entt inv
en
iinvolves
nvol
nv
olve
ol
ves the physical
ve
al and
and psychological
psyc
ps
ycho
yc
holo
ho
logi
lo
gica
gi
cal
ca
preparation
prep
pr
epar
ep
arat
ar
atio
at
ion off the
io
the patient
p ie
patie
ient
nt (identification
(ide
(i
dentification off the
de
the stoma
stom
st
omaa site)
sit
sit
ite)
e)
• Postoperative
complications,
care,
Post
Po
stop
st
oper
op
erat
er
ative treatment:
at
tre
reat
re
atme
at
ment: preventing compli
me
lilica
cati
ca
tions, their
ti
the
heir
he
ir ca
care
re,
re
regu
gula
gu
lati
la
tion of defecation
ti
regulation
• Patient
Patien
entt and
en
a relative education for care stoma
ma
• Ongoing consultation with stomatherapeutist
stomatherapeuti
tist
ti
st
• Promoting behaviour change to environment, life style
SStoma
toma care appliances
Accessoires
Acce
Ac
cess
ce
ssoi
ss
oire
oi
ress which
re
whi
whi
hich
ch en
enhance the application time
e of
of the
e
appliances:
appl
ap
plia
pl
ianc
ia
nces
nc
es::
es
• Belts
Belt
Be
ltss
lt
adhesive
• Paste,
Past
Pa
ste,
st
e, aadh
dhes
dh
esiv
es
ivee tapes,
iv
t
rings
• Powders
Powd
Po
wder
wd
erss
er
Care
C
are of
of the patient with stoma
Preo
Pr
eope
eo
pera
pe
rati
ra
tive
ti
ve assessment:
asse
as
sess
se
ssment:
ss
Preoperative
• id
iden
identification
enti
en
tifi
ti
fica
cati
ca
tion
on of th
the stoma site is an im
impo
important
port
po
rtan
rt
antt tas
an
ttask
askk don
as
d
done
one by
on
thee sto
th
sstomatherapeutist
toma
to
math
ther
th
erap
er
apeu
ap
eutist
Postoperative
Post
Po
stop
st
oper
op
erat
er
ativ
at
ive
iv
e ass
aassessment
ssessment
ss
Observ
rvat
rv
atio
at
ion:
io
n:
Observation:
• Stoma (colour,, op
open
enin
en
ing,
in
g, size, pleth
thor
th
oraa
or
opening,
plethora
• Fixing sut
utur
ut
uree
ur
suture
• Fo
Foll
llllow
owin
ow
ing the
in
he co
condit
itio
ion
io
n of
of th
the peristomall ski
sskin
kin
ki
n
Following
condition
• In case
se of dou
oubl
blebl
e-spou
eoute
ted loop stoma thee pos
te
p
osition off the
os
the
double-spouted
position
brid
br
idge
id
ge
bridge
• Chec
ecki
ec
king defecation and its character
ki
Checking
Necrosis
is: if it is black and cold
is
Necrosis:
Blood circulation failure: stoma becomes purple or dark red
TThe
he e
exchange
xchange of the stoma p
pouch
ouch