Theme 03.

Theme 03.

Providing of diagnostic and therapeutic process in the Pediatric Hospital.

 

CARE OF PATIENTS WITH RESPIRATORY PATHOLOGY

The respiratory system ensures the constant delivery of oxygen to the living body and removal of carbon dioxide and water from it. The gas exchange process consists of external and internal (tissue) respiration. External respiration is ensured by pulmonary ventilation and by the exchange of gases between the atmosphere and the blood in the lungs.

There are potential symptoms associated with respiratory disorders: cough, chest pain, dyspnea, hemoptysis.

A cough is one of the most important protective reflexes of the respiratory system. A cough can be productive and dry. Effective coughing clears the tracheobronchial tree of excessive secretions, particulate matter, and sometimes even large pieces of debris (food).

Care of coughing patients depends on the particular disease. For example, in acute respiratory diseases (acute laryngitis or tracheitis), dry and painful coughs are controlled by medicinal preparations taken per os, or by inhalation of sodium hydrocarbonate and hot steam. Mustard plasters, mustard foot baths, and hot compresses on the chest are used as counter-attractive therapy.

An irritating nonproductive cough in persons without congestion may be appropriately treated with suppressants.

Suppressants are drugs that depress a cough reflex. Codeine, which is present in many cough preparations, is generally considered the preferred cough suppressant ingredient. Inappropriate suppression of the cough in a person with respiratopy congestion can result in harmful retention of the secretions.

If the cough is moist and the patient expectorates much sputum (bronchiectasis), the patient should assume a position in which he can more easily expectorate sputum. Antitussives are given to patients before night sleep.

Apnea refers to periods during which there is no breathing. This is a serious situation in which brain damage occurs if it is suppressed for more than 4 to 6 minutes.

Under normal conditions, healthy adults breathe approximately 16 to 20 times per minute. During illness, the respiratory rate may vary from normal. Dyspnea is difficult or

labored breathing.

Pronounced dyspnea which develops suddenly is called asphyxia. Paroxysmal attacks of dyspnea are called asthma. It can be of pulmonary or cardiac etiology, i.e. bronchial or cardiac asthma, respectively.

A dyspnetic client is likely to demoonstrate rapid, shallow breathing. Dyspnetic patients usually appear to be anxious and worried as they experience inefficient breathing. Dyspnetic persons frequently find some relief if they assume an upright position. The condition of being able to breathe easier in this manner is known as orthopnea. A sitting or standing position uses gravity to lower organs in the abdominal cavity to fall away from the diaphragm. This gives more room for the lungs to expand within the chest, thus taking in more air with each breath.

During attacks of dyspnea or asthma, the patient’s chest should be stripped of all clothing and the patient should be helped to assume a semiprone position to facilitate the respiratory movements. Fresh air should also be admitted to the room (ward) and oxygen given to the patient.

In some cases we can use a special small portable apparatus for inhalation of medicinal preparations with a bronchodilated effect. To that end it is necessary to chake the container, to bring to the patient’s mouth and to make 2-3 pressing movements during the patient’s deep inhalations.

 

Oxygen therapy is helpful in many diseases of the cardiovascular and respiratory system, especially if signs of hypoxia   develop.   Breathing   an   air-oxygen   mixture   quickly alleviates hypoxia.

Oxygen may be given to correct hypoxemia resulting from such disorders as chronic obstructive pulmonary disease, pulmonary edema, pneumonia, atelectasis, and adult respiratory distress syndrome. Supplemental oxygen increases the amount of alveolar oxygen available for diffusion across the alveolocapillary membrane. This, in turn, decreases the respiratory effort required to meet the body’s demand for oxygen.

In a cardiac emergency, oxygen therapy helps meet the increased myocardial work load as the heart tries to compensate for hypoxemia. Oxygen administration is particularly important for a patient whose myocardium is already compromised — perhaps from a myocardial infarction or cardiac arrhythmia.

When metabolic demand is high — in cases of massive trauma, burns, or high fever, for instance — oxygen administration supplies the body with enough oxygen to meet its cellular needs. For a better therapeutic effect, the mixture should contain about 50 % oxygen and be given to breathe for a sufficiently long time.

Pure oxygen quickly inhibits the respiratory centre, and if inhaled for a long time, the patient may faint and develop convulsions. In this connection, a mixture of 95 per cent oxygen and 5 per cent carbon dioxide is given to inhale for 10-30 minutes in cases of CO poisoning, because carbon dioxide excites the respiratory centre. In all cases where the patient is given oxygen his condition should be watched attentively, and inhalation discontinued immediately if the patient complains of unpleasant sensations.

The oxygen must be moistened to prevent dryness and burning of the mucous. To that end we can use wrapped in several layers of wet gauze or a special bottle filled with water Bobrov’s apparatus is installed between the oxygen cylinder and the nasal tube or the mask.

The adequacy of oxygen therapy is determined by arterial blood gas analysis, oxymetry monitoring, and clinical examinations. The patient’s disease, physical condition, and age will help determine the most appropriate method of administration.

 

Methods of oxygen therapy

Oxygen can be giveot only for breathing. It can be given subcutaneously or in oxygen baths; it can be administered in the pleural and abdominal cavity, into the stomach and the intestine; it can be used for irrigating wounds. Oxygen partly compensates for hypoxia and also produces local and reflectory effects. Oxygen for medical use, contains 99 % pure oxygen and 1 % nitrogen. It is kept in cylinders that should be handled with care and protected from blows and jerks. It is necessary to remember that oxygen combines with oils and fats to produce an explosive mixture. The storage temperature should not exceed 35° C. No smoking or an open flame is allowed in the room where oxygen cylinders are stored. A jet of pure oxygen directed at the eye can impair vision.

 

 Oxygen tent and chamber

 

The oxygen flow from the bag is controlled by the tap. When only a little oxygen remains in the bag, it can be expressed from it by hand. The disadvantage of an oxygen bag is that it is impossible to control the oxygen concentration and the rate of its

delivery into the lungs.

Oxygen can be given through a tube directly from an oxygen cylinder. The cylinders should be kept outside the ward in a special room and delivered to the bed-side by a pipeline. Each oxygen cylinder is provided with a reducing valve which lowers the oxygen pressure from 150 atm to 1.5-5 atm. The cylinder is also provided with a flowmeter which controls the oxygen delivery to the patient. Within the hospital, the cylinders should be earned on special shock-absorbing carts.   Each   oxygen   delivery   system   has   particular   indications, advantages and disadvantages and delivers different concentrations of oxygen. Safe effective therapy hinges on choosing the proper delivery system and the correct mix of oxygen and humidity for each patient.

Oxygen delivery systems come in two basic types: low-flow and high-flow. Low-flow systems supplement room air with oxygen, providing an approximate concentration of oxygen to the patient. These systems include nasal cannulas, simple face masks, trach collars, face tents, and T tubes.

High-flow systems deliver oxygen at more precise concentrations. They include Venturi masks and continuous positive airway pressures (CPAP) masks. Although the face tent and T tube are essentially low-flow systems, they can function as high-flow systems when attached to a Venturi jet nebulizer.

Some oxygen delivery devices are designed for neonates and children. These include Isolettes, oxygen hoods, and croup tents, all of which completely envelop the patient in an oxygen-enriched atmosphere.

Hemoptysis is the coughing up of blood. It may indicate cardiopulmonary disease or, in some cases, a potentially life-threatening bleeding problem. A small amount (1 teaspoon) of frankly  bloody   sputum   is  seen  in  tuberculosis,  bronchogenic carcinoma, and pulmonary infraction. Large amounts (more than 100 ml — pulmonary bleeding) may be seen in persons with acute chest trauma or chronic pulmonary diseases (tuberculosis, bronchoectasis, cancer). Hemoptysis may occur in persons who’s pulmonary vessels are ruptured during respiratory treatments, such as postural drainage. The hemoptyssis, even insignificant, is dangerous, since it is impossible to be sure that it is not turning into life threatening problem for the patient or a pulmonary bleeding needing urgent measures.

Pulmonary   hemorrhage   must   be   differentiated   from gastrointestinal hemorrage. Pulmonary hemorrhage is characterized by excretion of foamy blood with an alkaline reaction and no coagulation. In gastrointestinal hemorrhage dark clots of blood mixed with pieces of food is more commonly excreted. It has an acid reaction. Hemoptysis and pulmonary hemorrhage, in contrast to gastrointestinal hemorrhage, as rule isn’t accompanied with shock or syncope. Threat of life is connected with disturbance of the lung function due to collection of blood in respiratory tract.

The patient with any bleeding must be reassured, to help him to have complete mental and physical rest, and he must not talk and smoke. It is necessary to put the patient in a raised position, to put cold water bottle on his chest and to give a container for the blood. Then a nurse carries out the prescriptions prescribed by physician.

 

 

Collection of the sputum for analysis

Sputum (primarily of tuberculosis patients) can be the source of infection for the surrounding people. The patient should therefore observe the rules of personal hygiene. The tuberculosis patient should abstain from coughing in the immediate vicinity of other people: if he is unable to control coughing, he must lake all possible measures to prevent contamination of the surroundings. The patient must not spit on the floor because sputum dries up to become  an air-borne source of infection.  Sputum should be collected in a bottle with a screw cap containing 3 % chloramine. (Fig.56). The collected sputum should be decontaminated by lime chloride or a 5 % chloramine solution and discarded into the sewage.

Bottle for the sputum

 

Sputum is the collected secretions and debris of the respiratory airways, coughed up, and expectorated through the mouth. Specimens are collected for both gross and microscopic examination, looking for cellular abnormalities, and for cultures and sensitivities. Ideally, the client coughs deeply and expectorates sputum without assistance. If the client is unable to cough because of lowered level of consciousness, extreme pain, or discomfort, or has an endotracheal tube or tracheostomy in place, the nurse removes sputum through suctioning.

The patient expels sputum into the specimen container, which is made from a dark glass with measuring divisions and tight cap. If possible, collect the specimen early in the morning, before breakfast, to obtain an overnight accumulation of secretions. The patient must rinse his mouth with water to reduce specimen contamination by oral bacteria and food particles. Avoid mouthwash or toothpaste because they may affect the mobility of organisms in the sputum sample. Then he coughs deeply and expectorates directly into the specimen container. The amount of a sputum for the usual analysis should be 3-5 ml.

 Collection of the sputum

 

Theurse pastes a label on the container with the patient’s name and room number, the doctor’s name, date and time of collection, and initial diagnosis and sends it to the laboratory. The specimen container for sputum should always be clean. For this purpose it is necessary to wash them in warm water and to boil 30 minutes with 2% sodium hydrocarbonate solution. For disinfection the specimen container with sputum is flooded with a solution of chloraminum and then contents is put out in a sewer network.

 

Preparation of the patient for a bronchoscopy

The bronchoscopy is the endoscopic method. Bronchoscopy involves the passage of a flexible, fiber optic tube into the tracheobronchial tree. This allows direct inspection of the larynx, trachea, and bronchi in order to locate sources of bleeding or tumors. Bronchoscopy may also be used to obtain specimens for tissue biopsy or secretion samples, to remove foreign bodies and mucus plugs, and to implant medications for tumor treatment.

Bronchoscopy is usually performed under local anasthesia with sedation. However, in some cases, general anesthesia may be required. The client should have parenteral nutrition maintained for at least 6 to 8 hours before the procedure. Make the person to remove any dentures, and note the presence of any loose tooth. After the procedure, keep the person’s head elevated. Monitor vital signs and assess breath sounds and respiratory rate and rhythm. Let the person know that fluids will be permitted after the gag and swallow reflexes return, usually about 2 hours after the procedure. Throat discomfort and temporary voice loss are common, so provide the person with paper and pencil to facilitate communication. Warm saline gargles and lozenges may help soothe the throat.

 

Simple Medical Procedures

Various procedures are used to produce the desired effect on a patient’s blood circulation, both local and general. These procedures include hot water-bottles, cups, mustard plasters, compresses, ice bags, etc. These procedures have their effect on both healthy and sick individuals through thermal, mechanical or chemical stimulation. The skin is the main site of application of these procedures. When irritated, various reflexes are activated in the skin. Ivan Pavlov showed that during thermal stimulation of the skin, inhibition develops in the cerebral cortex. For example, sleepiness develops after a warm bath or even after local application of heat. Thermal effects decrease or even remove pain, decrease skin sensitivity, and prevent transmission of pathological impulses into the central nervous system. Temperature stimulants reflectory changethe lumen of the blood vessels to alter the blood distribution in the body. When the cutaneous vessels dilate, the vessels of the abdominal organs contract, and vice versa, when the skin vessels narrow, the vessels of the abdominal viscera dilate.

The application of a warming compress is accompanied by local dilation of blood vessels and enlargement of blood circulation in tissues, that in this area of inflammatory processes produces painful and resorptional action. The warming compresses are used in treatment of various local infiltrations, for example, postinjection ones, some diseases of muscles and joints, chronic inflammatory diseases.

The warming compress can be dry or moist.

The dry warming compress (usual cotton-gauze bandage) is more often intended for protection of those or other sites of a body or head, for example neck or ear from cold exposure.

Moist warming compress is prepared from 4-th layers. 

 

 

At the beginning a piece of a tissue, moistened with warm water (50-60°C) or with solution of 40% alcohol is put on a skin. Then it is coated with a piece of the oilskin, polyethylene film or of a waxed paper. At last a layer of cotton wool is placed there. Each subsequent layer of a compress should be bigger, than the previous one. Above the compress a bandage is placed.

The duration of application of a moist warming compress is 6-8 hours. While taking off a compress the skin should be sponged with water or alcohol and then wiping with a towel to prevent maceration of the skin. If there is irritation of the skin, it is better to avoid further applying of moist compresses.

The contraindications for applying warming compresses are various skin diseases (dermatitises, furunculosis) and injuries of the skin.

 

The local warming effect can be received with the help of a heater (hot water bottle). In its application, reflex dilatation of the blood vessels of the organs of abdominal cavity and the relaxation of a smooth musculature, that, in particular, is accompanied by disappearance of spastic pains will occur. In the treatment of a peptic ulcer, renal or hepatic colics, radiculitis, the effect of a heater may be painfull.

Hot water bottles in the volume from 1 to 3 liters are more often applied. Before using the hot water bottles it is filled with hot water (60-70°C) approximately 2/3 of its volumes, air is carefully evacuated. It is necessary to tightly screw hot water bottle with a cap and overturn it with the purpose to check this. Before giving it to the patient wrap it in a towel.

 

Hot water bottle

 

The heaters are contraindicated in obscure abdominal pains (in such diseases, as an acute appendicitis, acute cholecystitis, acute pancreatitis), in malignant tumors, in the first day after a trauma, in outside and interior bleedings, in the patients with the impaired skin sensitivity, and also in unconscious patients.

The application of a mustard powder is based on the fact that evaporated etheral oil causes an irritation of a skin receptors and its hyperemia, resulting in a reflex dilation of blood vessels located deep in the internal organs and it causes resorption of some inflammatory processes.

Standard mustard plasters are sheets of a dense paper of the size 8612,5 cm, covered with a layer of the unoiled mustard powder. Mustard plasters are applied on skin, previously having moistened it with 40’C water, and are taken off after 10 — 15 minutes.

Mustard plasters are applied in treatment of neurologic diseases (myosites, neuralgia), catarrhal diseases (bronchites, pneumonia), in angina pectoris (on the left-hand half of thoracal cell) and headaches (on area of a nape).

 

Mustard plasters

 

If the skin is very sensitive mustard plasters should be applied over a thin sheet of paper or gauze. General mustard baths help alleviate catarrhs of the airways, bronchitis or pneumonia, usually in children. Mustard powder should be added to water in the bath, 40-60 g per 10 liters. The solution is passed through a gauze to separate undissolved lumps. The temperature of the water in the bath should be 37-38 degree of Celsium.

 

Ice bag

 

Treatment with cold is called cryotherapy. Ice bags are commonly used. Cold causes contrac.ion of the blood vessels, thus decreasing the sensitivity of the peripheral nerves. Cold is applied as a first aid measure for acute inflammation of abdominal organs (acute appendicitis, pancreatitis, cholecystitis, etc.), for hemorrhage, contusion, bone fractures, delirium associated with fever, and also for anesthesia.

Moist cold compresses are used for the first hours with injuries, nasal and hemorrhoidal bleedings, high fever. Rolling some layers a piece of a soft tissue, it is moistened with cold water and put on the relevant area of the forehead or bridge (of the nose). As the moist cold compress soon reaches the temperature of the body, it is necessary to change it every 2 — 3 minutes.

For more prolonged local cooling it is more convenient to use an ice-bag, which represents a flat rubber bag with a wide hole filled with small pieces of ice. The ice-bag is expedient, but overcooHng should be avoided by to hanging it (above a head or a stomach), making ten-minutes breaks every half an hour.

bath should be 37-39°C; the procedure should last for 8-10 minutes for adults and 5-6 minutes for children. The patient should be then wiped dry with a warm towel, dressed, and allowed to rest.

 

Cups give stronger vasculodilated activity, than mustard plasters and are applied widely in bronchites, pneumonia , neuralgias, neuritises, myosites.

Cups are represented glass vessels with a spherical bottom and thickened edges of volume 30 — 70 ml. They are put on the body with well developed muscular and subcutaneous fat, flattening bony formations (subclavial, subscapular, interscapular areas).

Cups

To avoid burns the skin is preliminarily sponged with vaselinum. Then a burning cotton plug moistened with alcohol is put on the inside of every cup for 2 — 3 sec. After that with prompt and vigorous motion the cupping-glasses are moved in a circle of a wide area over the surface of the skin. Due to reduction of the air inside a cup (cupping-glass) slight pulling of the skin occurs. The skin becomes a pink or purple color. Duration of cup application is usually from 10 to 15 minutes. The number of cups depends on the size of the surface to which they should be applied. To take it off, it is enough to press with a finger on the skin   near  to  the  edge   of the  cupping-glass,   simultaneously wedging it from the bottom in the opposite side.

The patient should then be wrapped in blankets and allowed to lie for 30-60 minutes. If the cups remain attached for a longer time, dark red spots and even vesicles filled with fluid may develop on the skin.

The cupping-glasses are contraindicated in tumors, active tuberculosis, pulmonary bleedings, diseases of a skin and its hypersensitivity.

 

CARE OF PATIENTS WITH GASTROINTESTINAL DISEASES

The main complaints of the patients with gastrointestinal diseases are pain in the abdomen, nausea, vomiting, hemorrhage, diarrhoea, obstipation, meteorism.

Complaints of patients with diseases of the digestive system are quite varied and depend on the part of the digestive tract that is pathologically affected.

Patients with affections of the stomach complain of poor appetite, regurgitation, heartburn, nausea, vomiting, abdominal pain, and bleeding.

 Care of the vomiting patient

A nurse should remember, that vomiting is a sigot only of a disease of the stomach, but also many other diseases. The reasons for vomiting could be:

– exacerbation of a peptic ulcer of a stomach and ulcer of

duodenum;

acute pancreatitis;

poisoning with substandard nutrition;

insult;

hypertonic crisis;

tumor of a brain.

In the occurrence of vomiting in the patient, it is necessary to immediately inform the doctor, to note the time of occurrence of vomiting and the character of the vomit.

Mostly vomit corresponds to the character of food eaten before, the particles of which are in different stages of digestion and have an acidic smell. In a long-term delay of nutrition to the stomach, its contents are decayed and a putrefactive smell occurs. With vomiting on an empty stomach, vomit is colored with bile, because it enters from the duodenum. After vomiting, from a central origin, relief as a rule does not come. Frequently repeated vomiting results in a dehydration and cachexia.

The most serious complication of vomiting is aspiration with gastric contents, that can lead to the reflex of stopping respiration and development of respiratory pneumonia.

The patient’s condition permitting, he should sit on the side of the bed with his feet on the floor. A basin, should be placed between his feet.

 

Care of the vomiting patient

 

It is necessary to take out tooth prostheses, to cover his breast and knees with an apron (oil-cloth, towel) and to support the head of the patient.

If the gravity of his condition does not allow the patient to sit, it is necessary to lay the patient down on one side, the head of the patient should be turned down from his bed; to put an oil-cloth and a piece of a sheet under the head. After vomiting it is necessary to give the patient some water to rinse his mouth cavity. For termination(discontinuance) of vomiting, it is possible to give the patient mint drops, slightly cold acid water, 0,5 % a solution of Novocainum.

In some cases (poisoning, infectious diseases) it is necessary to collect the vomit in dry clean glass and send it to the

laboratory with the label explaining the name of examination, the department name, the patient’s full name, his age, diagnosis, the doctor full name, date.

The vomited material should be disinfected like faeces.

 

Care of the patient with hematemesis

The condition of the patient with hematemesis is drastically impaired due to the loss of blood. The patient is weak, he experiences dizziness and nausea; his arterial pressure falls. The pulse is often, weak, cold extremities, the loss of consciousness all are possible- A physician should be summoned in such cases. The patient should be placed in bed and an ice bag is applied to the epigastrium. It is necessary to collect the blood in dry clean glass to check its amount and determine volume of treatment. Neither drinks nor medicines should be given per os.

 

Care of the patient with hematemesis

 

The nurse prepares all necessary medicinal preparations and the system for intravenous injection with solutions. The reason for a hernatemesis could be:

a bleeding ulcer of the stomach and an ulcer of duodenum;

a carcinoma of the stomach;

liver cirrhosis;

varicose phlebectasia of an esophagus;

poisoning with caustic alkalis. Attributes of hematemesis.

Impurity of fresh blood colors vomit of pink color. If blood delays in the stomach under the action of hydrochloric acid of gastric juice the hemoglobin is transmuted inlo a hydrochloric hematin (brown color), the vomit looks like ” coffee grounds”. A day after vomiting, stool (faeces) may be dark due to bleeding (melena).

 

Gastric lavage

Many diseases of the stomach can be caused by poisoning with medicines, bad foodstuffs, alcohol. The patient complaints on the pain in the stomach, nausea, vomiting, diarrhoea. In there cases we must make gastric lavage. Its action is to clean the stomach.

The indications for gastric lavage (washing, irrigation):

1.    poisoning with medicines, bad (of poor quality)
foodstuffs, fungi, alcohol etc. poisons(venom);

2.       delay of nutrition in the stomach because of pyloric stenosis;

3.       atony of a stomach with the phenomena of stagnation of food masses in it;

4.    acute gastritis.
Contraindications:

1.                stenocardia;

2.       liver cirrhosis;

3.    peptic ulcer of a stomach and duodenum with
predilection to gastrointestinal bleeding;

4.    idiopathic hypertensia (serious shape).
Gastric lavage is done by using:

·                     disinfected gastric rubber tube with external diameter lOii;

·          irrigation syringe or funnel of a capacity of 0,5-1 L;

·          container(capacity) of 8-10 L boiled water 28-32° C.

·          2 % of sodium hydrocarbonate solution (in poisonings with acids), 0,1 % of a citric acid solution (in poisonings with alkalis);

·          basin or bucket for irrigation water;

·       a mouth dilator, tongue-holder, forceps, laryngoscope (can be used, if the patient is in an unconscious state).

Before procedure, it is necessary to carry out a psychological preparation of the patient, if he is conscious. To explain to the patient the purpose and order of carrying out the procedure and the rules of behaviour ot thc patient during procedure.

Before the procedure, demountable Prostheses (if they are presence) must be taken off.

During procedure, the patient 1S on a c,1air and leaning against its back.

The patient is given an oil-cloth aPron t0 PM on. The basin is placed between his legs on the floor.

The hands of the patient 2re fixed m such position, that it does not prevent him carrying out the procedure.

If the patient is not able to sit, put him on the left-hand side with his head, lower than his trunk, to decrease the hazard of breathing in lavaged waters.

The nurse takes the disinfected probe with clear hands and measures the length, which is necessary to insert in_t0 patient, from an umbilicus up to incisors, up to lobule of the auricle; then it is necessary to moisten the blind end of the propbe with water; to ask the patient to open his mouth atld t0 swallow it. After that the round end of the sonde is put on the base of the ton_gUe, the patient is asked to swallow and at this moment a sonde is put into esophagus. In the case of vomiting tne movement of the sonde should be stopped, the patient is advised to cover tne sonde by lips and to breath through the nose. After some time trie procedure is repeated before the sond will be inserted to the necessary mark.

If the sonde enters in the respiratory pathways the patient begins to cough, he is blue and l°ses his VO!C.e- Tn this case the sonde should be immediately taken out, and afrer the patient becomes quiet, the procedure should be continued (repeated).

If the gastric lavage is made with the funnel, it is necessary to sink a funnel up to the level of elbows of thte Patient and fill it with water; then gradually to lift the funnel above the head and let water enter into the stomach — a volume of 500-600 ml. It is necessary to follow carefully, so that not all water from the funnel reaches the stomach, because water caot be removed from a stomach again.. When in the funnel there is a small amount water it must be down ward again to the level of the elbows of the patient and lavage of water with mucous and with oddments of nutrition will be removed from the stomach. The amount of discharged water should be approximately equal to the amount of injected water.

This procedure should be repeated for several times, to pure (clean) lavaged water.

 

                   

Gastric lavage

 

With the occurrence of some blood in lavaged water the procedure should be stopped and the doctor should be called.

The syringe can be used instead of the funnel. In some cases, gastric lavage can be made by a tubeless method. In this case it is necessary to give the patient a drink of 2-3 glassfuls of mineral waters or light pink solution of a potassium permanganate; after that the patient will vomit artificially by pressing the index and medial fingers of one hand on the root of a tongue and irritating the back wall of the pharynx. Thus a gastric lavage is carried out to ” pure(clean) lavage waters “.

The tubeless method of a gastric lavage is contraindicative with a poisoning with acids, alkalis, benzine, and also patient in a unconscious position.

 

The main complaints of patients with intestinal diseases are pain, meteorism (inflation of the abdomen), constipation, diarrhoea, intestinal hemorrhages, and involuntary defecation.

No analgesics or warmth should be given to a patient with abdominal pain until its cause is established, because this will interfere with diagnosis and may be harmful (e.g. in cases of intestinal haemorrhage or acute appendicitis). If the pain is caused by spasms of the smooth muscles, spasmolitic drugs or a hot-water bottle can be used.

Meteorism is manifested by inflation and distension of the abdomen. Food rich in carbohydrates should be excluded from the diet because it intensifies the fermentation processes in the intestine intensifying gas formation. Activated carbon is prescribed in such cases: a teaspoonful 3-4 times a day; activated carbon (tablets) and camomile tea are also helpful.

 

In long standing meteorism the application of a colonic tube is indicative.

To that end it is necessary:

1.                a thick-walled colonic tube of a length of 30-40 cm and an outer diameter of 10 mm;

2.       vaselinum;

3.       oil-cloth;

4.       bedpan.

Under the patient’s pelvis an oil-cloth is placed. The patient is laid on the right side with the legs, moved toward the stomach. If the patient cannot be laid on his side, the procedure should be carried out in a position with the patient on his spine with bent knees and a little bit apart.

The round end of a tube is greased with Vaselinum;

The buttocks are apart and slowly with rotary motions a tube is introduced into a rectum to a depth 20-30 cm, the outside end is placed in a vessel with water (bedpan).

The tube is removed after 30-60 minutes and the anus wiped with a wet cotton pad.

 

The application of a colonic tube

 

Care of the patients with diarrhoea and constipation

If the patient has diarrhoea, he should use a bed-pan or some other vessel where his faeces can be collected for inspection and analysis. The patient should keep his body, clothes, and bed clean; he should wash his anus after defecation with a 2 per cent boric acid solution. Since diarrhoea is often the result of an infection (cholera, abdominal fever, dysentery, etc.), it is necessary to take special precautions even before the diagnosis is established.

To this end the patient should be placed in a separate room and the faeces and urine should be treated with chlorinated lime (1:2) and kept for an hour before discharging into the sewage.

Involuntary defaecation occurs in patients with severe affections of the brain, tumors, or injured rectum. These patients should be placed in separate rooms. A high-caloric and easily assimilated diet is given to the patient because the amount of faeces is small. A cleansing enema should be given every day. The patient should be placed on a special bed or a rubber pan. Such patients should be given special sanitary treatment to their bodies; their clothes, and bed sheets should be changed more frequently.

Constipation is a retension of stools for more than two days. Constipation is managed with a special diet, cathertics, and cleansing enemas. In some patients a considerable amount of hardened faeces accumulates in the rectum. An enema is useless in such cases and the faeces should be removed manually. A rubber glove lubricated with oil should be used for the purpose. A bed-pan is placed under the patient’s pelvis and the finger is inserted into the rectum to remove the hardened faeces. If not removed on time, the faeces will harden even more and press on the intestinal wall, causing sores. A cleansing enema or syphon clyster should be given after this manual procedur

 

Enemas

An enema is an injection of liquids into the large intestine through the anus.

The indications for use of a cleansing enema are:

1.                                              constipaton;

2.                      preparation of the parturient women for labor;

3. preparation of the patients for scheduled operations on gastrointestinal tract organs, small pelvis;

4.       preparation of the patient for an X-ray examination of

GIT organs, of small pelvis, pelvic bones, pelvic region of the spinal column.

5.       preparation of the patients for endoscopic examinations of the

intestine;

6.       poisoning.

Contraindications for use of a cleansing enema are:

1.        acute appendicitis;

2.       acute   inflammatory   processes   in   the   colon   with

3. a predilection to bleeding;

4. fissure of the anus;

5. bleeding from the gastrointestinal tract;

6. decay of a tumor of a rectum;

7. first days after operation on GIT organs;

8. prolapse of the rectum.

For the cleansing enema it is necessary:

an Esmarch’s irrigator (glass, enameled, rubber) capacity

1-2 L, with a tip (hand piece) and a tap;

water  with  a  temperature  of 27-32C,   1,5-2   L.   In

predilection of a spasmed intestine — temperature of the water — 37-39°C, in an atony — 18-20°C;

vaselinum;

support — rack;

bedpan;

bucket or basin;

oil-cloth.

If the state of the patient allows, the procedure of the cleansing enema will be carried out in a special toilet room, where there is a couch, support — rack for hanging a Esmarch’s irrigator, wach-bowl. The patient following a bed regimen is given this procedure in his bed.

For the procedure it is necessary:

To set up the Esmarch’s irrigator on a support of a height of lm above the patient, to pour out some water at a proper temperature, and about 1-1,5L, to unclose (open) the tap, to fill in a rubber tube and tip with some water, to close the tap. For simplification of removing of the faeces use 25-50 g castoric or olive oil, or 25 g of shaving soap which can be added in the water. After that the tip with Vaselinum is greased. Tie patient is laid on the left-hand side with the legs, pulled to a stomach; if the patient cannot turn, the procedure is carried out in a position with the patient on his back, a bolster (roller) is put under the patient’s pelvis.

 

Knees-elbows position.                                Left side position.

 

Allow the liquid to flow through the tube to remove air that is present. Clamp the tube.

Place a small amount of lubricant on your finger or on a tissue and spread the lubricant around the tip of the tube, being careful not to plug the holes with lubricant.

 

      

Covering the tip of the tube with lubricant.

Gently put the tube into the child’s rectum to the marked distance.

 

The buttocks are moved apart by I-st and II fingers of the left-hand with rotary movements a hand piece is carefully inserted into the anal hole; at first in a direction of the umbilicus 3-4 cm, then paralielly to the spinal column 8-10 cm. In the case where are folds of mucosa or hemorrhoidal, the hand piece is carefully introduced between them.

The tap is then opened. The liquid should flow gently from the flask. If the liquid does not pass from the flask, the position of the end-piece in the rectum should be changed slightly, or the pressure increased by raising the flask to a higher position. If the patient complains of pain, the flask should be lowered to slow down the rate of water outflow. If the end-piece becomes clogged with faeces, it should be cleaned and introduced again. If the faeces are hard, they should be removed from the rectum by a finger or a spatula. The administered liquid reaches the remain parts of the large intestine to intensify peristalsis and to cause the urge to defecate. The patient should retain the administered liquid for 5-10 minutes.

Then the patient empties his intestine into a toilet. If the procedure is carried out in the bed it is necessary, to promptly give the patient a bedpan.

The cleansing enema is considered to be effective, if some faeces masses are discharged with water within some minutes. If the clyster has not worked, the procedure can be repeated in some hours.

 

Amounts of water and salt for giving an enema for a child.

 

 

 Application of purgative clysters (Oil hypertonic emulsive)

A purgative enema is prescribed for persistent constipation or intestinal paresis when the administration of large amounts of liquid is ineffective or harmful. Oil and hypertonic saline solutions are used.

The purgative effect of an oil clyster is based on the fact that the oil envelops the faeces and facilitates its excretion. By the action of intestinal microflora and juice the oil is partially split and fatty acids, formed as a result of this process, have a weakening and irritating effect on the intestinal wall, which promotes a recommencing of a normal peristalsis.

The indications for application of an oil clyster are:

1.  steady or atony constipation.

2.  inflammatory  and  ulcerative  processes  of the large intestine.

For using the oil clyster it is necessary to take:

1.           a rubber ballon capacity of 150-200 ml;

2.     Janet’s syringe;

3.     colonic tube;

4.     vaselinum;

5.     oil-cloth;

6.           vegetable oil (corn, sunflower, olive).

Before the procedure it is necessary to carry out the psychological preparation of the patient and to explain to him, that after the procedure he should stay in bed for some time. It is better to give this procedure of some hours in the evening, so that the act — of defecation may take place in the morning. Oil is warmed up in a water bath to a temperature of 37-38°C, then a rubber bulb or Janet’s syringe is filled with oil. An oil-cloth is spread under the patient. The patient is laid on the left-hand side with the legs, moved towards the stomach. The anal orifice is exposed and an oiled colonic tube is introduced into the rectum by rotary movements to a depth of 10-15 cm. Janet’s syringe is connected with a tube and oil is inserted into the rectum. The patient must lie down quietly to keep the oil in a rectum.

The emulsive clyster is applied in constipation to the seriously ill patients.

You need 1 table spoonful of camomile is pour with one glassful of well boiled water. It is kept 15-20 minutes and then filtered.

The yolk of an egg, teaspoon of sodium hydrocarbonate and 2 table spoons of Glycerinum must be added to the tincture of camomile.

This mixture is collected in a Janet’s syringe or rubber ballon and injected into the rectum.

Evacuation of faeces from an intestine will occur in 15-20 minutes.

A hypertonic clyster is indicative in:

Atonic constipation.

Paresis of an intestine after surgical interventions on the

organs of the abdominal cavity. Contraindications for giving of a hypertonic clyster are:

1.        Acute inflammatory and ulcerative diseases of the inner

section of the intestine.

2.       A fissure in the field of an anus.

The action of a hypertonic clyster is osmotic character: for dilution of a hypertonic salt solution up to isotonic concentration in a lumen of the rectum through an intestinal wall, an intercellular fluid intensively enters and dilutes the faeces.

Also, the strong saline solution stimulates peristalsis, and as a result of such combined action, in 20 minutes evacuation of faeces from the intestine occurs.

A hypertonic saline enema consists of 50-100 ml of a 10 per cent sodium chloride solution or a 25 per cent magnesium sulphate solution- The hypertonic solutions should be warmed up before administration. The patient should not defaecate for 15-30 minutes after the enema.

A siphon enema is given when an evacuant enema and laxatives are ineffective to remove putrefactive material, poisons and toxic substances from the intestine and also for the diagnosis of intestinal obstruction. The absence of gas bubbles in the washings confirms the diagnosis of intestinal impatency. For the siphon clyster the following equipment is needed:

1.   2 thick gastric tubes of length 1 meter with an inner  diameter not less than 10 mm and connected to a glass tube and a funnel with the capacity not less than 1 L;

2.   10-12 litres of water of room temperature;
3.ajugoramug;

3.     a bucket for lavaged waters;

4.           an oil-cloth, apron, vaselinum.

The siphon clyster is a serious treatment for the patient, therefore it is necessary during the procedure to watch carefully the patient’s condition.

The patient assumes the same position as for a cleansing enema. The tip of the rectal tube is coated with vaseline and gradually inserted into the rectum to a depth of 20-25 cm. The funnel is held slightly above the patient’s body. Water is poured into the funnel from a jag and the funnel is raised 50 cm above the patient’s body. When the liquid level in the funnel descends to the funnel’s apex, the funnel is lowered over the basin and held in this position until the liquid containing intestinal material rises to its initial level. The liquid is then discarded into the basin. Clean water is poured into the funnel and the siphonage is repeated until the water returning to the funnel is clear. After use, the funnel and the tubes are cleaned.

 

A siphon enema

 

An evacuant enema is given for constipation, poisoning, before labour in women, before x-rays of the abdomen or the pelvic organs, and be/are giving medicinal or nutrient enemas. An evacuant enema is conlmindicMt.ed in gastric and intestinal haemorrhage, ulceration of the large intestine or the rectum, haemorrhoids, cancer of the rec­tum or the largo intestine, purulent and ulcerative processes in the huge intestine or the anus, in acute appendicitis and peritonitis, and in rectal prolapse.

Pure water is used for an evacuant enema (1-2 litres). To increase the cleansing effect, a camomile tea and 2-3 tahlespoonfuls of glycerol or vaseline oil should be added. The water temperature for atonic constipation should be 20°C and for spastic constipation, 37-39°C. An Esmarch flask is filled with water and its tap opened to displace air from the tube. The tap is then closed and the flask hanged from a stand at a height of 1-1.5 metre. A rubber, glass or ebonite rectal end-piece is used. The eft hand is used to separate the buttocks, while the end-piece lubri-•ated with vaseline is inserted into the rectum by the right hand and otated slightly about its axis until it reaches a depth of 10-12 cm. the end-piece should first he moved toward the umbilicus, and then ulteriorly, parallel to the coccyx. The tap is now opened. The liquid liquid flow quietly from the flask. If the liquid does not pass from the ask, the position of the end-piece in the rectum should be changed lightly, or the pressure increased by raising the flask to a higher position. If the patient complains of pain, the flask should be low-red to slow down the rate of water outflow. If the end-piece becomes logged with faeces, it should be cleaned and introduced again. If he faeces are hard, they should he removed from the rectum by the nger or a spatula. The administered liquid reaches the remote parts f the largo intestine to intensify peristalsis and to cause the urge to efaecafe. The patient should retain the administered liquid for 10  minutes.

A  purgative enema  is   prescribed   for  persistent  constipation  or itestitial edema when administration of large amounts of liquid ineffective or harmful.   Oil  and  hypertonic saline solutions are sell.

An oil enema is indicated for pronounced constipation when hard feces are accumulated in the rectum, and also in inflaminaton and ulcerative processes in the large intestine and the rectum.

 

              

Cleansing   enema:

a—filling Esmarch flask with tap water; fi—removing air from the tubing;

c—inserting the end-piece into the rectum

 

 

Sunflower seed oil, olive oil, vaseline oil or linseed oil are used for the purpose. Oil penetrates the space between the faeces and the intestinal wall to facilitate the discharge of the faeces. Oil also pro­duces a mild  irritating effect on the intestinal   wall   decreasing

inflammation and promoting the normalization of peristalsis. From

50 to 100 ml of oil is required for an enema. The temperature nf the oil should be 37-39°G. A Janet injector or a rubber bulb with a lube are used for giving an oil enema. The patient should lie in bed for a while after the procedure. The purgative effect should occur Within 8-12 hours.

After use the tools should be washed with hot water and sodium bicarbonate,  and boiled.

Hypertonic saline enema. This consists of 50-100 ml of a 10 percent solution or a 25 per cent magnesium sulphate solution. The enema is given in intestinal paresis and oedema of the intestinal wall. The enema is conlraindicated in ulceration of the large intestine and fissures of the anus. The hypertonic solutions should be warmed up before administration. The tools used for the purpose are the same as for giving an oil enema. The patient should not defaeoate for 15-30 minutes after the enema,

A siphon enema is given when an evacuant enema and laxatives are to remove putrefactive material, poisons and toxic substances from the intestine and also for the diagnosis of intestinal obstruction. The absence of gas bubbles in the washings confirmsthe diagnosis   of   intestinal   impatency.

A siphon enema requires a 1-2-litre glass funnel and piping: a 1.5-m long rubber tube, a short glass tube, and rectal tube. A jar, a basin and an oil-cloth are also required. Water (10-15 litres) should be warmed up before use. The patient assumes the same position as for an evacuant enema. The tip of the rectal tuba is coated with vaseline and inserted into the rectum to a depth of 20-25 cm. The funnel is held slightly above the patient’s body. Water is poured into the funnel from a jar and the funnel is raised. When the liquid level in the funnel descends to the funnel’s apex, the funnel is lowered over the basin and held in this position until the liquid containing intestinal material rises to its initial level. The liquid is then dis­carded into the basin. Glean water is poured into the funnel and siphonage is repeated until the water returning to the funnel is clear. After use, the funnel and the tubes are cleaned.

A drop enema or simply drip, is used for giving a large amount (up to 2 litres) of isotonic sodium chloride or glucose solution to manage intoxication, dehydration, etc. The apparatus includes an

 

 

Esmarch flack, a rubber tubing, a dropper, a glass tube, and a rectal tube. The rectal tube has lateral openings. The rate of liquid administration is controlled by a clamp. The patient should e on his back during the procedure. The solution in the Esmarch ask should be 41-42⁶ C. The rectal tube is inserted into the rectum a deplh of 20-25 cm. It is necessary to observe the rate of adminis-ation  and  the temperature of the solution.

Medicinal solutions that are given by enema are usually of local action – antibiotics, sulpha drugs, antipara-sitary preparations, and some others. A tepid solution (50-200 ml) is administered by a rubber bulb or a Janet injector provided with a 12-20-cm long rubber end-piece. The patient should try to keep the administered medicine in the intestine for at least 30 mililiters. The medicinal solution should be given 20-30 nii/iutes after an evacuant enema.

 

Medicamental clyster

 

The clysters of local action (medical microclysters) have antiinflammatory and enveloping activity and their amount should not exceed 200 ml. They are utilized in inflammatory processes of the large intestine. In clysters of local action oil (30-50 ml warm olive oil), starch (5 g of starch is diluted in 5 ml of cold water and, stirring, add 100 ml of boiled water) and others, can be used.

 

These are antispastics, antibiotics, sulpha drugs, antiparasitary preparations, and some others. A tepid solution (50-200 ml) is adininistered by a rubber bulb or a Janet injector provided with a 12-20-cm long rubber endoiece. The patient should try to keep the administered medicine in the intestine for at least 30 minutes. The medicinal solution should be given 20-30 minutes after an evacuant enema.

The medicinal clysters of general activity are given in cases, when it is impossible to introduce drugs through the mouth or parallelly with it. In this method of introduction the medicines are promptly absorbed into blood through hemorrhoidal veins, bypassing (passing) the liver. For general influence on an organism small volumes of medicines (up to 200 ml) can be introduced in medical microclysters.

For example, Chlorali hydras (1 gr of the drug is diluted in 25 ml of 0,9 % solutions of a sodium of Sodium chloridum and then add 25 ml of starch paste), apply in cramps and severe excitement to the patient.

A drop enema, or simply drip, is used for giving a large amount (up to 2 litres) of isotonic sodium chloride or glucose solution to treat intoxication, dehydration, etc. The apparatus includes an Esmarch flask rubber tubing, a dropper, a glass tube, and a rectal tube The rectal tube has lateral openings. The rate of liquid administration is controlled by a clamp. The patient should lay on his back during the procedure. The solution in the Esmarch flask through the rectal tube is inserted into the rectum to a depth of 20-25 cm. It is necessary to observe the rate of administration and the temperature of the solution.

Contraindications for all types of clysters are:

1.    acute inflammatory processes in the area of the anus;

2.    malignant tumors of the rectum in a stage of decay;

3.    gastrointestinal bleedings;

4.    acute abdomen.

 

Diagnostic lavage of the stomach is indicated in cases when tubercu­losis of the airways or stomach cancer is suspected. Tuberculosis mycobacteria can be found in the washings in cases of tuberculosis and cancer cells in gastric cancer; Diagnostic lavage should be per­formed on an empty stomach. A thin gastric tube with 5 or 6 openings at the distal end is swallowed by Ihe patient (a length of 45-50 cm), or the lube is introduced through the nose. A syringe with an isotonic sodium chloride solution is attached to the outer end of the tube and the solution is injected into the stomach and then withdrawn from it. The procedure is repeated several times using the same solu­tion so as to obtain the higher concentration of gastric mucus in the washings. The washings are poured into a clean container and sent to  the laboratory.

A gastric lube is used also to assess the gastric acid output and the evacuatory function of the stomach. One-time obtaining of gastric juice by a thick tube is now considered inexpedient since the inten­sity of gastric secretion varies not only in patients but in healthy individuals as well. Moreover, there are some  contraindications   to using a thick tube because it provokes vomiting and straining.

At the present time a thin tube (5 mm outer and about 3 mm inner diameter) is used for fractional obtaining of gastric juice. This is an elastic rubber tube with lateral openings at the distal end. Since the tube is soft it Cannot be forced into the stomach,, but should be swallowed by the patient. If swallowing provokes vomiting, the tube should be passed through the nose. The patient should remove any artificial teeth and sit on a chair. The leading end of the tube should be wetted with water and placed into the patient’s mouth beyond the tongue root. The patient is then asked to swallow the tube.

When the tube reaches the stomach, a clamp is placed on its outer end to prevent the spontaneous withdrawal of gastric acid. Accord­ing to Leporsky, the gastric secretion of a fasting stomach is with­drawn first. Then four 15-minute portions are taken. The patient is now given a test meal (a caffeine solution, 7 per c.enl cabbage decoc­tion, 300 ml of a 5 per cent alcohol solution). A stimulant (histamine, insulin, pentagastrin) is sometimes given parenlerally. Ten minutes after the administration of the gastric secretion stimulant a 10 ml portion is withdrawn. Then in 15 minutes the stomach is emptied. Then five 15-minute specimens of pure gastric juice are taken. If secretion is provoked by parenteral administration of a stimulant, four 15-minute portions of the gastric juice are collected within an hour. Each portion is collected in a separate vessel and’the volume is marked. All specimens are then delivered to the laboratory.

 

Preparing a patient )or x-rays of the stomach and smatl intestine. Radiological techniques (roentgenoscopy and roentgenography) give reliable information concerning pathology of the stomach and the intestine. X-raying has remained an important method of examina­tion in gastroduodenal pathology. X-rays are used to determine the shape and position of the stomach and the duodenum, and the relief of the mucosa in the stomach and small intestine (in the first instance of the duodenum). A barium sulphate suspension (100 g in 100 ml of boiled water) is used for radiological examination of the stomach and the intestine. The power to absorb x-rays accounts for the use of barium’sulphate in roentgenology. The suspension is given to the pa­tient per os.

The patient should be specially prepared for x raying (either roentgenoscopy or roentgenography). His stomach and the intestine should be emptied of food remains, liquids, and gases. Two days bo-fore the examination the patient’s diet should bo free from food that can cause flatulence, e.g. rye bread, milk, or potatoes, in order to decrease flatulence, 2-3 days before the examination the patient should be given a warm camomile tea (one tabfespoonful in a glass of water). On the eve of the examination, and also in the morning before the procedure, the patient should be given a cleansing enema.

Only mi empty stomach can he examined hy x-rays, and the patient is therefore warned thai he should abstain from eating (liquids or solids) 6-8 hours, before the x-ray  examination.

 

Duodenal probing is done for both diagnostic and therapeutic pur­poses. Many diseases of the bile ducts and the gall bladder are attend­ed hy bile congestion. When a duodenal tube enters the gall bladder, it contracts refleclorily to eject its contents into the duodenal lumen. Bile specimens are important diagnostically.

Taking specimens of duodenal contents is indicated: 1 — for Withdrawal of the bile congested in the gall bladder; 2 — for admin­istration of medicines info the duodenum; 3 — for laboratory examinations of bile; 4 — for artificial nutrition of patients with non-healing ulcers of the stomach.

Duodenal probing is conlraindicated in: 1 — exacerbation of gastric ulcer; 2 — cancer of the oesophagus and stomach; 3 — angina pectoris and myocardial infarction; 4 — heart failure; 5 — acute  cholecystitis   and   cholelithiasis.

A l.S-in long rubber tube with a diameter of 4-5 mm is used for the purpose. The: distal end of the tube mounts a metal olive with several perforations. The tube bears three marks to indicate the dis­tance from the teeth to the entrance to the stomach (50 cm), to the pylorus (70 cm), and to Hie middle of the duodenum (90 cm). The tube should be washed and boiled after each use. If an infectious disease is suspected, the tube should be disinfected for 2 hours in a   disinfectant   solution.

Two or three days before the procedure, the patient should be fed a diet free from foods causing intense fermentation in the intestine. Medicines which relieve spasms of the. gall bladder and bile ducts (belladonna, no-spa) should be given. On the eve of the procedure, the.patient should be given a cleansing enema. The procedure should bo (ions before breakfast. Dental prosthesis, if any, should be re­moved. The conditions in the room are important. Preferably a special room should he provided for the purpose, or the patient should at least be separated from others hy a screen. The patient must be observed   during  the  entire  procedure.

The procedure is as follows. The patient sits on the bed, unbuttons bis collar, unfusfens his belt, and takes hold of the pan with the duodenal tube. The patient himself, or assisted by the nurse, places the tube olive at the root of the tongue and makes several swallowing movements with his mouth closed. The patient should breathe deeply and swallow the olive together with the saliva. As soon as the lube descends to the first mark to indicate that it has entered the stomach,, the patient is placed on his right side and a hot water bag is put, under the right hypochondrium. The swallowing should now be resumed uiitihlhe tube is passed to the second marlc. Swallow-ing should   be gradual since  otherwise   the  lube   may    ctiil   up   in the  stomach.

As the tube moves in the stomach, the gastric con ten Is should be aspired into a special vessel by a syringe. The passage of Ibe lube through the pylorus into the duodenum should agree with the peri­odic opening of the pylorus. If the pylorus is contracted or affected by a spasm, it becomes impassible lor the tube. In order to accelerate the tube’s passage through the pylorus, 1 mi of a 0.1 per cent atropine solution should be given subcutaneously and the upper abdomen massaged. If the pylorus spasm is due to gastric hyperacidity, the gastric juice should be aspired by a syringe, or a glass of a \ ‘.\ per cent sodium hydrocarbonate (baking soda) solution given  per os.

 

Duodenal intubation

 

In some cases the necessity arises to check the position of Ibe olive–tip. The best visualizing technique is x-ray. The position of the lube’s tip can also be determined tentatively by the aspirate. If the olive-tip is inside the stomach, the aspired liquid is cloudy ami acid: litmus paper turns red. The gastric contents may be green and react alkaline (litmus paper turns blue) to indicate that the tube’s olive is in the duodenum. Still another method consists in injecting air by a syringe: if the olive is in the stomach the patient feels bubbling. No sound can be heard if the tube is in the duodenum.

If the olive has entered the duodenum, the aspirate is clear yel­low; it reacts alkaline (A bile). This ismixture of bile, gastric juice, and pancreas secretion. A stand with tost tubes is placed hy the patient’sy-bedside and the duodenal contents are collected in them. B bile (bile from the gall bladder) is obtained after stimulation with 40-60 ml of a warm (39-40°G) 25 per cent magnesium sulphate solution or 20 ml of vegetable oil, which are administered to tlio patient through lite lube. The gall bladder contracts upon (his stiinuI; iiion wliilu the Odili sphincter relaxes to admit B bile into the duodenum. I) bile is dark brown and tenacious. Part of the B bile collected  is used  forculture.

After the gall bladder has been emptied, a clear bile is drained again. This is a mixture of fluids secreted by the intrahepatic ducts, •the hepatic bile, or simply C bile. If the bile is to be examined for the presence of lamblia, the obtained specimens should immediately be seni to the laboratory, because when the bile cools, the parasites become immobile and  hence undetectable by microscopy.

Modern examination of the duodenal contents is often a multi-step procedure, In the presence of motor dysfunction of the gall bladder and the bile duels (biliary dyskinesia), and also in the presence of inflammation, antibiotics and other medicinal solutions are administered through the tube after taking C bile. In the pres­ence of excess fermentative and putrefactive processes in the intes­tine, lavage can also he performed through the tube. To this end, mineral water at a temperature of 39-40″C is passed through the tube for 10-15 minutes During the first lavage 1 litre of water is used; this quantity increasing to 2-4 litres in subsequent irrigations.

 

Preparing the patient for x-ray of the gall bladder and the bile ducts. The x-ray study of the gall bladder is called cholecystography. It can be done with the administration of radiopaque substances (per OS or intravenously). The x-ray study of the gall bladder and the bile duct.s is called cholecystocholangiography. Radiopaque material is given only by intravenous routes in this procedure. BiliLrast, chole-vid are. given per os and bilignost intravenously. The presence of iodine accounts for the x-ray opacity of these substances. When given per os or intravenously, radiopaque substances first enter the liver  and then (through the bile ducts) the gall bladder.

Cholecystography is used for determining the shape and position of the gall bladder, its motor function, and also in cases when bile stones are suspected. Cholecystography is contraindicated in pro­nounced circulatory insufficiency, severe liver affections, acute nephri­tis, and hypersensitivity to iodine. No special regimen or diet is necessary before this procedure. If the patient is likely to develop constipation, ho should be given a cleansing enema on the eve or in the morning of the day of the procedure. Since-the highest concen­tration of bilitrast in the gall bladder is attained 15 hours after the administration, the preparation should be given 18-19 hours before the procedure (on the eve of the examination). Bilitrast is.given in 1-1.5 g doses at 20-minute intervals. The total dose is 3-3.5 g. Each dose sliould be given with a glass of sweet tea. At 22.00 the patient is given 100 ml of a 40 per cent glucose solution. X-ray pictures are taken the next morning at 9.00 or 10 . 00. By another method the patient is givencleansing enema   at 18.00   or   19.00,   then 3-3.5 g bilitrast, and placed on his right side for 30 minutes. The patient is given porridge or vegetable puree, and a cup of tea with bread for a supper. Before night sleep, the patient is given 5-7 drops of an opium tincture and a tablespoonful of activated carbon. The x-ray examination is conducted in the morning, at 9.00 or 10.00, after an overnight fast. If the shadow of the gall bladder is absent, another picture is taken in three hours. If the shadow is visible, two or three egg yolks are given to the patient and another picture is taken in 90 minutes. Possible side-effects of bilignost are nausea, vomiting, or nettle rash.

 

If the results of cholecystography with peroral administration of radiopaque preparations are negative, cholecystocholangiography with intravenous administration is used to study the bile ducts and for a rapid diagnosis of colic. Contraindications for cholecystocholangio­graphy are the same as for cholecystography. A cleansing enema is given to the patient on the eve of the examination, and preparations that might affect the motor function of the gall bladder (opium, cholagogics,  etc.) are not administered.

The radiopaque preparation is given intravenously. The patient should be preliminarily tested for sensitivity to iodine by admini­strating 1-2 ml of a 20 per cent solution of the preparation on the eve of the examination. If side-effects are absent, 30-40 ml of the preparation (preheated to normal body temperature) are injected. The preparation is injected slowly, over the course of 4-0 miu. Side-effects are more likely to occur with rapid administration (nausea, vomiting, heat, fall of the arterial pressure). In emergency cases the patient’s sensitivity to the preparation is tested immediately be­fore the examination: 1-2 ml of a 20 per cent bilignost solution is ad­ministered, and if there are no adverse reactions for 2-3 min the re­maining quantity (30-40 ml) of the solution is injected.

Bile ducts are visible 10-15 minutes after administration; the picture becomes more distinct in 25-40 min. The gall bladder be­comes visible in 40-45 min. The maximum opacity of the gall bladder is attained in 90 min. In 24 hours the radiopaque preparation fills the large intestine (through which its main bulk is eicreted). The prepa­ration is usually well tolerated by patients. Some patients may experience dizziness, chills, nausea, vomiting, a drop in arterial pressure, and fever. These phenomena subside spontaneously. If necessary, oxygen can be given to breathe, or 1 ml of a 5 per cent ephedrine solution injected subcutaneously. If the patient has a histo­ry of allergic reactions, he should be given diphenylhydramine hydro­chloride or some other antihistamine preparation (pipolphen, supra-stin) 2 or 3 days before the procedure.

Care of patients with intestinal dysfunction. The main complaint of patients with intestinal diseases are pain, meliorism (inflation of the abdomen), constipation, diarrhoea, intestinal haemorrhages, and involuntary defecation.

No analgesics or warmth should be given to a patient with abdominal pain until its cause is established, because this will interfere with diagnosis and may be harmful (e.g. in cases of  intestinal haemor­ rhage or acute appendicitis). If pain is caused by spasms of smooth muscles, peroral or subcutaneous administration of atropine or bella­ donna is indicated often together  with other analgesics, e.g. morphine or promedol.        

Meteorism is manifested by inflation and distension of the abdo­men. Food rich in carbohydrates should be excluded from the diet because it intensifies the fermentation processes in the intestine in­tensifying gas formation. Activated carbon is prescribed in such cases: a teaspoonfuj 3-4 times a day; activated carbon (tablets) and camomile tea are also helpful. Cleansing enemas give considerable re­lief to the patient. If these methods prove ineffective, a 5Q-cm long rubber tube with a diameter of 1 cm should be inserted into the rectum to a depth of 20-30 cm. The rounded tip of the tube, which has lateral openings, should first be coated with vaseline. The other end of the tube is placed in a bed-pan in order to protect the linen from occasional soiling by the intestinal contents. An oil-cloth can be used for the same purpose. The tube is removed after 30-60 min­utes and the anus wiped with a wet cotton pad.

If the patient has diarrhoea, he should use a bed-pan or some other vessel where his faeces can be collected for inspection and analysis. The patient should keep his body, clothes,” and bed clean; he should wash his anus after defaecntion with a 2 per cent boric acid solution. Since diarrhoea is often the result of an infection (cholera, abdomi­nal fever, dysentery, etc.), it is necessary to take special precautions even before the diagnosis is established. To this end the patient should he placed in a separate room and a rug wetted with a disinfec­tant solution   placed   at the threshold.

The patient’s plates, glasses, and silverware should be washed with soap and soda, boiled for 15 minutes, and kept separately from others. All objects that are used for his care should also be Washed with soap and hot-water. Linens should be collected in a special bin fitted with a cover and then boiled for 15 minutes with soap and soda. The bed-pan should be washed in a disinfectant solution’, rinsed in water, closed with a cover, and placed on a sheet of paper which should be burned after each use. The faeces and urine should be treat­ed with chlorinated lime (1:2) and kept for an hour before,discarding into the sewage. Food remains should be treated in the same  way.

The room and other premises where the patient may touch various objects should be cleaned two or three times a day using a wet rag. The floor should bo washed with hot water, soda, and soap. The door handles, taps, w.c.pans and floor in the lavatory should be treated with a disinfectant solution. The patient’s room and the rooms for common use should be aired several times a day. The personnel who take care of infectious patients or those suspected of having infectious diseases should wear overalls made of easily washable fabric. Alter contact with the patient or after washing bis plates and silverware and the bed-pan, or after cleaning the rooms, the worker should wash his hands with soap using a brush. When the attending person­nel leave the room or other premises where the patient is present, they should take off their overalls and wipe their feet on the rug wetted with the disinfectant solution.

 

Constipation is a retension of stools for more than two days. Con­stipation is managed with a special diet, cathertics, ami cleansing enemas. The number of daily defaecations should be counted and the amount of faeces in each defaecation assessed. In some pillion Is a considerable amount of hardened faeces accumulates in the rectum. An enema-is useless in such cases and the faeces .should he removed manually. A rubber glove lubricated with oil. A bed-pan is placed under the patient’s pelvis and the finger is inserted into the rectum to remove the hardened faeces. Cleansing   (evacuant)  enema should be given after this manual procedure.

If intestinal haemorrhage develops (which is manifested by tarry stools), the patient should stay in bed, and the physician should he informed. An ice-bag should he placed on the abdomen and 100-200 ml of compatible blood infused. If this does not help, surgery is indicated. During the course of the first 24 hours, the patient should abstain from food. The intake of liquids should also be limited.. Cold or slightly warmed semiliquid food should be given. Peroral administration of medicines should be suspended.

Haemorrhage may be only slight in peptic ulcer, in cancer and some other diseases, and blood traces in the faeces can only be detected in the laboratory. When haemorrhage is suspected the patient should be given a meat-free diet for three days before the examination, since meat can be responsible for a positive occult blood test. Faeces are not tested for blood if the patient is suffering from gum or nasal bleeding, or haemorrhage after tooth extirpation.

 

Involuntary defaecation occurs in patients with severe affections of the brain, tumours, or injured rectum. These patients should be kept in separate rooms. A high-caloric and easily assimilated diet spares the patient because the amount o.^F faeces is small, A cleansing enema should be given every day. The patient should he placed on a special bed or a rubber pan. Such patients should be given special care with frequent sanitary treatment of their body; their clothes and sheets should be changed more frequently.

 

Preparing a patient for an x-ray study oj the large, intestine. A bari­um sulphate suspension is usually given by enema before irrigoradio-scopy. The patient’s large intestine must, be emptied before the procedure. Three days before the examination the patient should be fed a low-carbohydrate diet. In cases of meleo’rism, the patient should be given camomile tea and activated carbon. On the eve of the examination, the patient is given 30-40 ml of castor oil before his dinner. An enema is given before the night sleep and in the morning before the examination. A rectal tube is inserted into the rectum 30 minutes before the examination to release gases. A barium suspension- is used as a radiopaque material. U is prepared from 200 g of barium sulphate and 10 g of tannin in I litre of water.

 

CARE OF PATIENTS WITH URINARY DISEASES

Urine collection technique for women

1.     Wash hands with soap and water

2.     Spread labia with 1 hand and hold apart for collection

3.     Use three povidone-iodine swabs to clean area

1.     Wipe down one side, front to back, with one swab

2.     Wipe down other side, front to back, with second swab

3.     Wipe down center, front to back, with last swab

4.     Dry area with sterile gauze

5.     Void into toilet for a few seconds and then collect

6.     Avoid stopping urine flow while positioning cup

1.     Stopping flow increases risk of contaminated sample

7.     Collect in sterile container

8.     Cap and avoid touching inside of container

Urine collection technique for men

9.     Wash hands with soap and water

10. Retract foreskin if needed

11. Use povidone-iodine swabs to clean tip of penis

1.     Clean glans penis

2.     Clean urethral opening

12. Dry area with sterile gauze

13. Void into toilet for a few seconds and then collect

14. Collect in sterile container

15. Avoid stopping urine flow while positioning cup

1.     Stopping flow increases risk of contaminated sample

16. Cap and avoid touching inside of container

Urine collection technique for infants (urine bag)

17. Wash hands with soap and water

18. Use povidone-iodine swabs to clean as above

19. Place sterile urine bag over penis or labia

20. Reclean and replace new urine bag if no urine in 30 min

21. Empty bag into sterile urine container

 

24-Hour Urine Collection

(24-hour urine, urine volume)

 

What is a 24-hour urine collection?

 

A 24-hour urine collection is a simple diagnostic procedure that measures the components of urine. The test is noninvasive (the skin is not pierced), and is used to assess kidney (renal) function.

Twenty-four hour urine collection is performed by collecting a person’s urine in a special container over a 24-hour period. The container must be kept cool during this time until it is returned to the lab for analysis.

Urine consists of water and dissolved chemicals such as sodium, potassium, urea (formed from protein breakdown), and creatinine (formed from muscle breakdown), along with other chemical compounds. Normally, urine contains specific amounts of these waste products. If these amounts are not within a normal range, or if other substances are present, it may be an indication of a particular disease or condition. The results of a 24- hour urine collection may provide information to help your physician make or confirm a diagnosis.

Related procedures that may be used to diagnose kidney disease include kidney ultrasound, kidney scan, kidney biopsy, and renal arteriogram.

How does the urinary system work?

 

 

The body takes nutrients from food and converts them to energy. After the body has taken the nutrients it needs from the food, waste products are left behind in the bowel and blood.

The urinary system keeps chemicals, such as potassium, sodium, and water in balance, allowing the body to function properly. The kidneys also remove protein waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

Other important functions of the kidneys include blood pressure regulation, and the production of erythropoietin, which controls red blood cell development in the bone marrow.

 

Urinary system parts and their functions:

• two kidneys – a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids in the formation of red blood cells.
  The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
• two ureters – narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
• bladder – a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
• two sphincter muscles – circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder
• nerves in the bladder – alert a person when it is time to urinate, or empty the bladder
• urethra – the tube that allows urine to pass outside the body

Facts about urine:

• Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
• The volume of urine formed at night is about half that formed in the daytime.
• Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi.
• The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Reasons for the Procedure

Twenty-four hour urine collection is a quick, simple diagnostic test that helps to diagnose problems with the kidneys. It is commonly performed to determine how much creatinine clears through the kidneys, but may also be used to measure protein, hormones, minerals, and other chemical compounds. Creatinine clearance testing provides information about kidney function.

Like all organs in the human body, the kidneys may be affected by various genetic and environmental circumstances, leading to kidney disease. Kidney (renal) disease may be temporarily or permanently damaging. Acute kidney disease has an abrupt onset and is potentially reversible. Chronic kidney disease progresses slowly over at least three months and can lead to permanent kidney damage. The causes, symptoms, treatments, and outcomes of acute and chronic kidney disease are different.

Conditions that can cause kidney disease include, but are not limited to, the following:

• diabetic nephropathy – a result of uncontrolled diabetes, which can cause permanent changes, leading to kidney damage
• hypertension – abnormally high blood pressure, leading to permanent kidney damage
• lupus – a chronic inflammatory/autoimmune disease that can injure the kidneys, as well as the skin, joints, and nervous system
• frequent urinary tract infections  
• prolonged urinary tract obstruction or blockage 
• Alport syndrome – an inherited disorder that causes deafness, progressive kidney damage, and eye defects
• nephrotic syndrome – a condition that has several different causes. Nephrotic syndrome is characterized by protein in the urine, low protein in the blood, high cholesterol levels, and tissue swelling.
• polycystic kidney disease – a genetic disorder characterized by the growth of numerous cysts filled with fluid in the kidneys
• cystinosis – an inherited disorder in which the amino acid cystine (a common protein-building compound) accumulates within specific cellular bodies of the kidney, known as lysosomes
• interstitial nephritis or pyelonephritis – an inflammation in the small internal structures in the kidney

Twenty-four hour urine collection may be performed along with other diagnostic procedures, such as cystometry and cystography.

There may be other reasons for your physician to recommend 24-hour urine collection.

Risks of the Procedure

Twenty-four hour urine collection is a safe, noninvasive procedure that is usually done without direct assistance.

Certain factors or conditions may interfere with the accuracy of a 24-hour urine collection. These factors include, but are not limited to, the following:

• forgetting to collect some of your urine
• going beyond the 24-hour collection period and collecting excess urine
• losing urine from specimen container through spilling
• not keeping urine cold during collection period
• taking certain medications and/or eating certain foods

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure. 

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• Generally, no prior preparation, such as fasting or sedation, is required.
• You may be instructed to start the collection at a specific time.
• If possible, choose a 24-hour period when you will be at home so you do not have to transport your urine.
• If you are pregnant or suspect that you may be pregnant, you should notify your physician.
• Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Based on your medical condition, your physician may request other specific preparation.

During the Procedure

Twenty-four hour urine collection may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, 24-hour urine collection follows this process:

1.     You will be given one or more containers for collecting and storing your urine. A brown plastic container is typically used to store the urine. A specimen pan or urinal may be used to collect the urine. You will need to transfer the urine from the collecting container to the storage container where it will be kept cold.

2.     The 24-hour collection may begin at any time during the day after you urinate.  However, it is common to start the collection the first thing in the morning. It is important to collect all urine in the following 24-hour period.

3.     Do not save the urine from your first time urinating – the starting time. Flush this first specimen, but note the time. This will be the start time of the 24-hour collection.

4.     All urine, after the first (flushed) specimen, will be saved, stored, and kept cold, either on ice or in a refrigerator, for the next 24 hours.

5.     Try to urinate again at the same time, 24 hours after the start time, to finish the collection process, but if you cannot urinate at this time, it is not a problem.

6.     Once the urine collection has been completed, the urine containers will be taken to the lab. If you are doing the urine collection at home, you will be given instructions on how and where to transport the specimen.

7.     The procedure is concluded at this point. Depending on your specific medical condition, you may be asked to perform the test on several consecutive days.

A 24-hour urine collection is a simple diagnostic procedure that measures the components of urine. The test is noninvasive (the skin is not pierced), and is used to assess kidney (renal) function.

Twenty-four hour urine collection is performed by collecting a person’s urine in a special container over a 24-hour period. The container must be kept cool during this time until it is returned to the lab for analysis.

Urine consists of water and dissolved chemicals such as sodium, potassium, urea (formed from protein breakdown), and creatinine (formed from muscle breakdown), along with other chemical compounds. Normally, urine contains specific amounts of these waste products. If these amounts are not within a normal range, or if other substances are present, it may be an indication of a particular disease or condition. The results of a 24- hour urine collection may provide information to help your physician make or confirm a diagnosis.

Related procedures that may be used to diagnose kidney disease include kidney ultrasound, kidney scan, kidney biopsy, and renal arteriogram.

How does the urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the nutrients it needs from the food, waste products are left behind in the bowel and blood.

The urinary system keeps chemicals, such as potassium, sodium, and water in balance, allowing the body to function properly. The kidneys also remove protein waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

Other important functions of the kidneys include blood pressure regulation, and the production of erythropoietin, which controls red blood cell development in the bone marrow.

 

Urinary system parts and their functions:

• two kidneys – a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids in the formation of red blood cells.
  The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
• two ureters – narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
• bladder – a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
• two sphincter muscles – circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder
• nerves in the bladder – alert a person when it is time to urinate, or empty the bladder
• urethra – the tube that allows urine to pass outside the body

Facts about urine:

• Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
• The volume of urine formed at night is about half that formed in the daytime.
• Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi.
• The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Reasons for the Procedure

Twenty-four hour urine collection is a quick, simple diagnostic test that helps to diagnose problems with the kidneys. It is commonly performed to determine how much creatinine clears through the kidneys, but may also be used to measure protein, hormones, minerals, and other chemical compounds. Creatinine clearance testing provides information about kidney function.

Like all organs in the human body, the kidneys may be affected by various genetic and environmental circumstances, leading to kidney disease. Kidney (renal) disease may be temporarily or permanently damaging. Acute kidney disease has an abrupt onset and is potentially reversible. Chronic kidney disease progresses slowly over at least three months and can lead to permanent kidney damage. The causes, symptoms, treatments, and outcomes of acute and chronic kidney disease are different.

Conditions that can cause kidney disease include, but are not limited to, the following:

• diabetic nephropathy – a result of uncontrolled diabetes, which can cause permanent changes, leading to kidney damage
• hypertension – abnormally high blood pressure, leading to permanent kidney damage
• lupus – a chronic inflammatory/autoimmune disease that can injure the kidneys, as well as the skin, joints, and nervous system
• frequent urinary tract infections  
• prolonged urinary tract obstruction or blockage 
• Alport syndrome – an inherited disorder that causes deafness, progressive kidney damage, and eye defects
• nephrotic syndrome – a condition that has several different causes. Nephrotic syndrome is characterized by protein in the urine, low protein in the blood, high cholesterol levels, and tissue swelling.
• polycystic kidney disease – a genetic disorder characterized by the growth of numerous cysts filled with fluid in the kidneys
• cystinosis – an inherited disorder in which the amino acid cystine (a common protein-building compound) accumulates within specific cellular bodies of the kidney, known as lysosomes
• interstitial nephritis or pyelonephritis – an inflammation in the small internal structures in the kidney

Twenty-four hour urine collection may be performed along with other diagnostic procedures, such as cystometry and cystography.

There may be other reasons for your physician to recommend 24-hour urine collection.

Risks of the Procedure

Twenty-four hour urine collection is a safe, noninvasive procedure that is usually done without direct assistance.

Certain factors or conditions may interfere with the accuracy of a 24-hour urine collection. These factors include, but are not limited to, the following:

• forgetting to collect some of your urine
• going beyond the 24-hour collection period and collecting excess urine
• losing urine from specimen container through spilling
• not keeping urine cold during collection period
• taking certain medications and/or eating certain foods

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure. 

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• Generally, no prior preparation, such as fasting or sedation, is required.
• You may be instructed to start the collection at a specific time.
• If possible, choose a 24-hour period when you will be at home so you do not have to transport your urine.
• If you are pregnant or suspect that you may be pregnant, you should notify your physician.
• Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Based on your medical condition, your physician may request other specific preparation.

During the Procedure

Twenty-four hour urine collection may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, 24-hour urine collection follows this process:

8.     You will be given one or more containers for collecting and storing your urine. A brown plastic container is typically used to store the urine. A specimen pan or urinal may be used to collect the urine. You will need to transfer the urine from the collecting container to the storage container where it will be kept cold.

9.     The 24-hour collection may begin at any time during the day after you urinate.  However, it is common to start the collection the first thing in the morning. It is important to collect all urine in the following 24-hour period.

10. Do not save the urine from your first time urinating – the starting time. Flush this first specimen, but note the time. This will be the start time of the 24-hour collection.

11. All urine, after the first (flushed) specimen, will be saved, stored, and kept cold, either on ice or in a refrigerator, for the next 24 hours.

12. Try to urinate again at the same time, 24 hours after the start time, to finish the collection process, but if you cannot urinate at this time, it is not a problem.

13. Once the urine collection has been completed, the urine containers will be taken to the lab. If you are doing the urine collection at home, you will be given instructions on how and where to transport the specimen.

14. The procedure is concluded at this point. Depending on your specific medical condition, you may be asked to perform the test on several consecutive days.

 

 

Cardiopulmonary resuscitation (CRP)

CPR stands for cardiopulmonary resuscitation. It is a lifesaving procedure that is done when someone’s breathing or heartbeat has stopped. This may happen after drowning, suffocation, choking, or injuries. CPR involves:

·                 Rescue breathing, which provides oxygen to a child’s lungs

·                 Chest compressions, which keep the child’s blood circulating

This article discusses CPR in children ages 1 – 8.

Permanent brain damage or death can occur within minutes if a child’s blood flow stops. Therefore, you must continue CPR until the child’s heartbeat and breathing return, or trained medical help arrives.

 

Considerations

CPR can be lifesaving, but it is best done by someone trained in an accredited CPR course. The newest techniques emphasize compression over rescue breathing and airway, reversing long-standing practice.

The procedures described in this article are not a substitute for CPR training.

All parents and those who take care of children should learn infant and child CPR if they haven’t already. See www.americanheart.org for classes near you.

Time is very important when dealing with an unconscious child who is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 – 6 minutes later.

Machines called automated external defibrillators (AEDs) can be found in many public places, and are available for home use. These machines have pads or paddles to place on the chest during a life-threatening emergency. They use computers to automatically check the heart rhythm and give a sudden shock if, and only if, that shock is needed to get the heart back into the right rhythm.

When using an AED, follow the instructions exactly.

 

Causes

There are many things that cause an child’s heartbeat and breathing to stop. Some reasons you may need to do CPR on a child include:

·                 Choking

·                 Drowning

·                 Electrical shock

·                 Excessive bleeding

·                 Head trauma or serious injury

·                 Lung disease

·                 Poisoning

·                 Suffocation

 

Symptoms

CPR should be done if the child has the following symptoms:

·                 No breathing

·                 No pulse

·                 Unconsciousness

 

 

First Aid

 

Oct. 18, 2010 — New guidelines released today by the American Heart Association recommend that the three steps of cardiopulmonary resuscitation (CPR) be rearranged.

The new first step is doing chest compressions instead of first establishing the airway and then doing mouth to mouth. The new guidelines apply to adults, children, and infants but exclude newborns.

The old way was A-B-C — for airway, breathing and compressions.

The new way is C-A-B — for compressions, airway, and breathing.

 

 

The following steps are based on instructions from the American Heart Association.

1.              Check for alertness. Shake or tap the child gently. See if the child moves or makes a noise. Shout, “Are you OK?”

2.              If there is no response, shout for help. Tell someone to call 911 and get an AED (if available). Do not leave the child alone until you have done CPR for about 2 minutes.

3.              Carefully place the child on his or her back. If there is a chance the child has a spinal injury, two people should move the child to prevent the head and neck from twisting.

4.              Perform chest compressions:

o       Place the heel of one hand on the breastbone — just below the nipples. Make sure your heel is not at the very end of the breastbone.

o       Keep your other hand on the child’s forehead, keeping the head tilted back.

o       Press down on the child’s chest so that it compresses about 1/3 to 1/2 the depth of the chest.

o       Give 30 chest compressions. Each time, let the chest rise completely. These compressions should be FAST and hard with no pausing. Count the 30 compressions quickly: “1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30, off.”

5.              Open the airway. Lift up the chin with one hand. At the same time, tilt the head by pushing down on the forehead with the other hand.

6.              Look, listen, and feel for breathing. Place your ear close to the child’s mouth and nose. Watch for chest movement. Feel for breath on your cheek.

7.              If the child is not breathing:

o       Cover the child’s mouth tightly with your mouth.

o       Pinch the nose closed.

o       Keep the chin lifted and head tilted.

o       Give 2 rescue breaths. Each breath should take about a second and make the chest rise.

8.              Continue CPR (30 chest compressions, followed by 2 breaths, then repeat) for about 2 minutes.

9.              After about 2 minutes of CPR, if the child still does not have normal breathing, coughing, or any movement, leave the child if you are alone and call 911. If an AED for children is available, use it now.

10.          Repeat rescue breathing and chest compressions until the child recovers or help arrives.

If the child starts breathing again, place him or her in the recovery position. Periodically recheck for breathing until help arrives.

 

DO NOT

·                 If you think the child has a spinal injury, pull the jaw forward without moving the head or neck. Do NOT let the mouth close.

·                 If the child has signs of normal breathing, coughing, or movement, do NOT begin chest compressions. Doing so may cause the heart to stop beating.

·                 Unless you are a health professional, do NOT check for a pulse. Only a health care professional is properly trained to check for a pulse.

 

When to Contact a Medical Professional

·                 If you have help, tell one person to call 911 while another person begins CPR.

·                 If you are alone, shout loudly for help and begin CPR. After doing CPR for about 2 minutes, if no help has arrived, call 911. You may carry the child with you to the nearest phone (unless you suspect spinal injury).

 

Prevention

Most childreeed CPR because of a preventable accident. The following tips may help prevent some accidents in children:

·                 Teach your children the basic principles of family safety.

·                 Teach your child to swim.

·                 Teach your child to watch for cars and ride bikes safely.

·                 Make sure you follow the guidelines for using children’s car seats.

·                 Teach your child firearm safety.

·                 Teach your child the meaning of “don’t touch.”

Never underestimate what a child can do. Assume the child can move and pick up things more than you think. Think about what the child may get into next, and be ready. Climbing and squirming are to be expected. Always use safety straps on high chairs and strollers.

Choose age-appropriate toys. Do not give small children toys that are heavy or fragile. Inspect toys for small or loose parts, sharp edges, points, loose batteries, and other hazards. Keep toxic chemicals and cleaning solutions safely stored in childproof cabinets.

Create a safe environment and supervise children carefully, particularly around water and near furniture. Electrical outlets, stove tops, and medicine cabinets can be dangerous for small children.

 

 

 

 

 

Materials for preparing to the practical class were drawn up by assistant professor T.A. Kovalchuk, M.D.