Б – water is poured into the funnel and goes into the intestinal tract; b – after lowering the funnel contents of the intestinal tract starts to come out through it

To give enemas in the forcing way special rubber cylinders with the capacity of 200-250 ml with a solid intestinal cannula or Janet’s syringe are used; at present complex forcing devices (Colongidromat) are used as well.

Analeptic enemas (oily and saline) are used when introduction of large amount of liquid accompanied by peracute peristalsis is undesirable or ineffective. Necessary equipment: 100-200 ml of warm vegetable oil or 50-100 ml of hypertonic solution, a rubber bag or Janet’s syringe, a rubber cannula.

Oily enemas are appropriate in cases of hyperkinetic constipation and inflammatory diseases of the large intestine. Usually 100-200 ml of vegetable oil (sunflower, linen, hempseed) or liquid paraffin warmed up to 37-38°С is used. A pear-shaped rubber bag or Janet’s syringe with rubber cannulas on them are used for introducing. The liquid should be introduced slowly to prevent the oil from running away, thus the patient should lie calmly. Oily enemas are usually given in the evening, defecation takes place in 10-12 hours. After use the equipment is thoroughly washed out with hot water with soda and boiled.

For saline enemas 50-100 ml of warmed hypertonic solutions (10 % solution of sodium chloride or 20-30 % solution of magnesium sulfuricum) is introduced through the same devices as oily ones. The patient should refrain from defecation for 20-30 minutes.

Medicinal enemas. Hydraulic way is used when giving rectal drip. This type of enema is used for introducing a large amount (up to 2 l) of normal (0,85 %) saline or 5 % solution of glucose in cases of dehydration, intoxication, before or after operation.

The device consists of Esmarch's irrigator, a rubber tube with a drip bulb inserted between its pieces, a connecting hose and an intestinal tube. A screw clamp is fixed on the rubber tube higher than the drip bulb. By means of it, it is possible to adjust the coming in of the liquid into the drip bulb (usually 60-100 drops a minute for an adult and 15-20 drops for a child). The patient lies in a comfortable position on the back and may sleep during the procedure. A warmed up to 43°С solution is poured into the irrigator, the system of the tubes is filled up with the solution and the periodicity with which the drops fall is adjusted by the clamp. Then the intestinal tube is introduced into the patient’s rectum of 20-30 cm deep and the irrigator is hung on the stand. During procedure, which lasts several hours, the nurse must see to the following:

1) the coming in of liquid should not stop because of the twists of the tubes;

2) a certain speed of falling drops must be maintained;

3) for the solution not to cool down, Esmarch's irrigator is placed in a cotton wool cover, and a bottle with boiling water is put into Esmarch's irrigator(directly in the solution!) filled with the solution.

Small enemas. This term is usually used to denote enemas during which only a small amount of liquid (50-100 ml) is introduced. During medicinal enemas medicines of systemic effect are introduced: drugs made of foxglove, hydrochloride, sodium salicylate, etc. A pear-shaped cylinder or Janet’s syringe with a rubber cannula on it is used for introduction.

During a nutrient enema the same solutions are introduced into the rectum along with 150-200 ml of 15 % solution of amino acid 2-3 times a day with the help of the rubber cylinder (forcing way).

 

 

Preparation of the patient for roentgen examination of the large intestine

This kind of examination is carried out by means of irrigoscopy (from Latin irrigatio – irrigation, washing and Greek skopeo – I examine) introducing barium magma into the large intestine through the anus with the help of enema. Barium magma is prepared on the basis of: 200 gr of barium and 10 gr of tannin for 1 l of water.

Diseases of the rectum and its sphincter (inflammation, growth, fistula, sphincter fissure) are contra-indications to this examination. Prolapsus of the rectum or weakness of the sphincter make this examination impracticable because the patient cannot keep back the liquid introduced into the intestinal tract.

The aim of preparation is full purgation of the large intestine of the remains of food, liquid, gases, slime.

The preparation starts 3 days prior to the examination – a special diet restricting consumption of carbohydrates and fiber, excluding milk, rye bread, potatoes, vegetables, apples, grapes is prescribed. Liquid, easily absorbed dishes not irritating the intestinal tract are recommended: kissel, kefir, wheat cream, omelet, white bread, cooked meat, fish, etc.

On the eve before dinner the patient is given 30 gr of castor oil. The use saline laxatives is not recommended, as they irritate the intestinal tract and do not contribute to passage of flatus. In the evening before the examination the patient’s large intestine is twice lavaged by cleansing enemas with an interval of one hour. The patient does not have supper. In the morning 3 hours prior to the examination the patient is given a light morning meal to stimulate the reflex movement of contents of small intestine into the large one. Immediately after the breakfast to the patient is given the first, and in half an hour the second, cleansing enema. 30-40 minutes prior to the examination colonic tube is introduced.

 

Collecting feces

To perform this procedure it is necessary to have the following: a bedpan, a glass bottle, a rectal tube.

For the general feces analysis (coprological survey) all feces of the last 24 hours are delivered to the laboratory. Two days prior to the examination drugs containing iron, bismuth, coal, barium salts are discontinued. To examine feces for the presence of protozoa fresh feces are put into a glass bottle; for pathogenic microbes – into sterile glasswear.

For dysentery analysis a special glass rectal tube is used, which is introduced into the anus 7-8 cm deep, when the patient is in lateral position with half-bent legs. By rotary movements of the tube the contents is taken out and the same end is put in a sterile test-tube with a preservative mixture. The material is promptly delivered to the laboratory.

Fecal occult blood test is prescribed in cases of stomach and duodenum peptic ulcer, cancer of stomach, ulceration in the intestinal tract caused by tuberculosis and abdominal typhoid, as well as in cases of other diseases when the hemorrhage can be small and it is impossible to see blood admixtures in feces with the naked eye. The patient is prescribed a three day's dairy-vegetable diet, without fruits, it is also necessary to be make sure that the patient does not have bleeding sickness of gums, nasal hemorrhage and hemoptysis (to not obtain a false positive result).

 

Observing and attending patients
with diseases urinary system

Normal physiology urinary system

In clinical practice various diseases of kidneys and urinary tracts occur fairly often. In diagnostics of these diseases various laboratory and instrumental diagnostic techniques are applied. An important role in differentiating diseases urination organs is played by roentgen diagnostic techniques: plan radiography of kidneys, computerized tomography, etc.

The process of urine excretion during a certain period of time is called diuresis and the total amount of urine excreted by the man within 24 hours – daily diuresis. Its volume is between 1000 and 1800 ml, however it can increase or decrease depending on physiological conditions, amount of consumed liquid, food, type of work, temperature, air humidity or presence of certain diseases. In normal conditions 60-80% of daily amount of urine is excreted in daytime – from 8 a.m. till 8 p.m. It is also necessary to take into account that under normal conditions the man breathes out about 300-400 ml, and during physical exercise – up to 500 ml, of water through the lungs. The man loses about 300-400 ml of water a day through the skin, about 100 ml is excreted with shaped stool and in case if diarrhea – much more. Daily diuresis can decrease during physical exercise and hyperhidrosis, in hot weather.

 

Pathologic symptoms of diseases of kidneys

and urinary tracts and the bases of general attendance if they develop

1. Oliguria – reduction of daily diuresis to 500 ml and less. It can develop in cases of acute and chronic glomerulonephritis, toxic kidney, nephrocolic, ureter invasion, abdominal and small pelvis growths with compression, etc.

2. Anuria – sudden reduction (daily diuresis less than 200 ml) or full absence of urine. It characterizes a severe course of disease with unfavourable prognostic, which can end by the patient’s death.

3. I schuria – urinary retention caused by inability to empty the urinary bladder.

4. Polyuria – increase of daily diuresis up to more than 2000 ml, is often accompanied by polydipsia and increase in consumption of liquid. It can develop not only during diseases of kidneys but also during other diseases. For example, in case of diabetes mellitus and insipidus the patient can excrete several litres of urine a day.

5. Pollakiuria – hurried urination, over 6-7 times a day. Most often it occurs in cases of blennocystitis, adenoma of prostata gland as well as in cases of diseases accompanied by polyuria.

6. Nycturia – night polyuria when most of urine is not excreted in the day-time as it should be normally but at night. Nycturia is one of initial symptoms nephritic pathology especially in seniors. Quite often it is accompanied by urinary incontinence (enuresis) in elderly patients.

7. Enuresis – urinary incontinence. In elderly men it is often a display of adenoma of prostata gland.

8. Stranguria – painful urination which develops fairly often in cases of acute cystitis and urethritis.

One of the exigent conditions that accompany kidneys diseases is nephrocolic, which is a common symptom of urolithiasis. A sudden disorder of outflow of urine leads to pressure rise in renal pelvis, torsion deformity of renal capsule and paroxysm. Terebration is localized in the lumbus area, runs along the ureters and to the inguinal region and genitals. First aid consists in application of heat (a hot-water bottle on the lumbar area or a hot bath with water temperature of 38-39°С for 10-20 minutes). Besides antispasmodic and analgesic drugs are prescribed.

First aid in cases of urinary retention consists in immediate removal of urine from the urinary bladder. The sound of water flowing from the tap, irrigation of genitals with warm water, application (if there are no contra-indications) of hot-water bottle on the pubic region can stimulate independent urination. If these actions are ineffective, urinary catheterization is resorted to.

A common symptom of kidneys diseases is arterial hypertension. When it is disclosed, it is necessary to control AP regularly and to take antihypertensive drugs.

Acute renal failure is caused by nephrotoxic poisoning, disorder of outflow of urine from kidneys, by shock and declares itself by general grave condition with disorder of consciousness, signs of cardiovascular insufficiency, vomiting, oliguria and in some cases results in death of the patient. In such cases hemodialysis, gastric lavage and antishock actions are taken.

Chronic renal failure results from long-term chronic kidneys disease and is characterized by gradual depression of concentrating ability of kidneys. When observing and attending such patients a low-protein diet with 30-40 gr of proteins a day and in severe cases – 20-25 gr a day is prescribed with limited consumption of table salt (3-2 gr a day). In cases of uremic affect of the gastrointestinal tract repeated gastric lavages and cleansing enemas with 2 % solution of sodium hydrogencarbonate are used, correction of acid-base balance is made, in severe cases – hemodialysis.

 

Attending patients with diseases of kidneys and urinary tracts

A special place in attending patients with diseases of kidneys is occupied by observing changes of properties and amount of excreted urine. The patient or medical personnel must determine diuresis daily and put it down in the temperature form as a numeral (in ml). Thus liquid consumed by the patient with medicines, as well as liquid introduced parenterally, soup, tea, juices, etc. is taken into account. The whole of urine excreted by the patient during 24 hours is poured into a jar; all indices of drunk and excreted liquid are summarized estimating which one prevails. If the amount of drunk liquid prevails, it is emuresis, if the excreted liquid prevails or the parameters are equal – it is ecuresis.

Patients with urinary disorder demand more attention. The bed for a patient suffering from urinary incontinence is prepared by covering the mattress with an oilcloth and the bedsheet is spread above it. The skin is carefully washed with baby soap and the hands, feet, physiological folds are greased with baby cream. In cases of urinary incontinence intimate washing of the patient must be done after each urination to prevent bedsores and skin infections; the diet must be controlled.

 

Taking urine for laboratory analysis

For general urine analysis the morning portion of urine is used. It is taken after careful toilet of externalia. 100-200 ml of urine is collected in dry, clean glassware and taken to laboratory within 1-1,5 hours after collecting. In case with serious patients and women during menstruation urine for analysis is taken with the help of a catheter. When making general urine analysis its color, clarity, smell, reaction, relative density. Estimating relative density of urine in three-hour portions within 24 hours allows to specify the concentrating ability of kidneys (Zmirnitskij urinalysis). During chemical analysis of urine presence of proteins, sugar, ketone bodies (KET), bilirubin and urobilin bodies, mineral substances is tested. Microscopy of uropsammus, which consists of erythrocytes, leukocytes, casts, epithelial cells, crystals and shapeless salt masses, is carried out.

Methods of quantitation of formed elements in urine include Addis sediment count and Nichiporenko urinalysis. For Addis sediment count urine is collected into separate glassware during 24 hours and the number of formed elements excreted into urine during 24 hours is counted. To prevent putrefaction of microorganisms and, accordingly, shift of рН to the alkaline condition (which causes degradation of formed elements) preservative is added to urine (4-5 drops of formaldehyde or 10 ml carbolic acid) and it is stored in a refrigerator. If it is impossible to observe these conditions, urine is collected during a 10-hour period. For this purpose at 10 p.m. the patient evacuates the urinary bladder, this urine is poured out. During the next 10 hours the patient does not urinate and at 8 o'clock in the morning the whole of urine is collected and sent to laboratory. A portion received within 12 minutes (1/50 of the total volume of urine) is taken from the whole of urine. Nichiporenko urinalysis is used much more often, since it is technically more simple. Only an average portion of morning urine is taken for the analysis and the number of formed elements in 1 ml of urine is counted.

In cases of infectious inflammatory diseases of kidneys and urinary tracts (a pyelonephritis, urethritis, cystitis, etc.) a bacteriological urine analysis is carried out: 10 ml of urine in a sterile test-tube is sent to bacteriological laboratory for inoculation on special nutrient mediums.

To define daily proteinuria or glucosuria urine is collected during 24 hours – from 8 o'clock in the morning till 8 o'clock in the following morning – into a vessel (three-liter can) which must be stored in a cool place. Total amount of urine is measured, 200 ml is sent to laboratory.

 

 

Urinary catheterization

Rubber, plastic or metal catheters with different diameters, up to 25 cm long are used depending on the state of urethra and prostata gland in men. For urinary catheterization in women the short straight female catheter up to 15 cm long is used. Metal and rubber catheters are sterilized by boiling for 30-40 minutes after preliminary washing in warm water with soap, and right before introduction they are greased with sterile liquid paraffin or glycerin. Catheterization is carried out after examination of urethral area and careful toilet of externalia. If there are any changes, catheterization is carried out by the doctor. The whole procedure is carried out in gloves observing all rules of asepsis and antiseptics.

Catheterization in women: catheter is taken with a clamp 4-5 cm lower than the end and is introduced in the urethra 4-5 cm deep, then the clamp is removed or moved 4-5 cm lower again. The excreting urine is poured in dry clean glassware. Catheter is removed before all urine is excreted, so that the remaining urine washes out the urethra (Fig.36).