COLOSTOMY

a. A colostomy is a surgically created, artificial opening (stoma) into the colon through the abdomen. It may be temporary or permanent.
b. A temporary colostomy is normally made for diversion of fecal material. Fecal diversion is utilized in order to rest a portion of the colon following intestinal surgery, in preparation for further surgery, or in cases of severe inflammatory disease (such as diverticulitis).
c. A permanent colostomy serves as an artificial anus for the remainder of the patient's life. This procedure is done in conjunction with the removal of the lower bowel and rectum. Although there is no sphincter muscle control at the stoma, bowel movements may be controlled by a daily routine that encompasses diet, physical activity, and colostomy irrigation’s. Consistency of the bowel movements generally depends upon the location of the colostomy (see figure 1-5), but can be manipulated by the patient's choice of diet.
d. Whether temporary or permanent, a colostomy can be very distressing to the patient. Patients with colostomies require encouragement, understanding, and assistance in overcoming the negative emotions associated with a colostomy, and in learning independence and self-sufficiency in living with a colostomy.
e. Colostomy "training" should begin as soon as possible, with the permission of the physician, after surgery. The ease and skill with which the nursing personnel care for the patient with a colostomy are important in helping the patient physically and emotionally. The patient and his family will learn that a colostomy can be effectively managed to allow a full and active life.
f. There are several different surgical procedures that create different types of colostomies. The procedure used will depend upon the nature of the disease, the desired end result (temporary or permanent), and the physician's preference, among other things. For example:

Figure 1-5. Colostomy sites.

(1) Two stoma openings can be created at the abdominal surface (double barrel). One serves as a temporary artificial anus for the functioning part of the gastrointestinal tract, discharging feces, and flatus. The second opening leads to the nonfunctioning part of the colon and rectum. Mucous or serous secretions are normally discharged from this opening. This opening may also be utilized for irrigation of the resting colon. This procedure would be utilized when the colostomy is temporary. Later surgery would involve closing the stomas with re-anastomosis of the bowel.
(2) A single colostomy may be done at one of the sites illustrated in figure 1-5. The site chosen normally depends upon the portion of the bowel that must be removed. The colostomy site is created at a section of healthy bowel. The bowel distal to the colostomy is removed and the rectum surgically closed.

Isolation nursing (transmission-based precautions)

Specific precautions are required for some patients because their condition (e.g. a bone marrow transplant) puts them at particular risk of infection from others (protective isolation), or because they themselves are a potential source of infection (source isolation). Source isolation is usually only necessary to prevent contact, droplet or airborne transmission of micro-organisms, usually either in respiratory droplets or dust, as in the cases of Mycobacterium tuberculosis and methicillin-resistant Staphylococcus aureus (MRSA). Precautions might involve separating the infected or vulnerable person from other patients by placing them in a single room, and healthcare workers using barriers such as plastic aprons, disposable gloves and masks.
If a single room is used, you should keep the door closed to restrict the spread of infectious micro-organisms. Sometimes it may be more appropriate or the only option to keep infected patients together in one bay, or at one end of the ward. However, overcrowding increases the risk of transmission of airborne pathogens.
Where gross contamination of the environment is likely, for instance in the case of profuse diarrhoea, a single room may be preferable, but the most essential requirement is a separate toilet and wash basin to reduce the risk of transmission via contact with contaminated surfaces.
Healthcare workers must understand the relevance of the routes of transmission to care effectively for patients (e.g. isolating patients with malaria is unnecessary because they cannot transmit the disease to others and standard precautions alone are necessary). However, blood from these patients cannot be used for transfusion because of the risk of infection in the recipient. It is essential that isolating a patient in a single room is undertaken in a systematic and appropriate way following a comprehensive risk assessment, and is regularly reassessed.

A variety of isolation policies are used. Disease-specific isolation precautions have the advantage of eliminating unnecessary practices and can be incorporated into the care plan for the individual patient. However, the disadvantage is that staff need to identify the relevant precautions for each patient. Transmission-based precautions group together diseases requiring similar precautions. The disadvantage of this system is that some precautions may be used unnecessarily for some patients. However, staff need to learn fewer procedures and are therefore less likely to make mistakes.

Notices at the entrance to a patient’s room or by the bed, should indicate any special precautions that are being observed, while maintaining confidentiality. Isolation can be stressful for patients. It is therefore important that you discuss, agree and record the patient’s needs in a care plan. The recommended period of isolation varies for each infection, but usually precautions can cease once symptoms have resolved, or after a short course of antimicrobial therapy.

For detailed information about isolation precautions, refer to the US CDC guideline for isolation precautions in hospitals (1996). Always follow your local policies and seek advice from your local Infection Control Team.
page top

The safe disposal of sharps

Sharps injury with inoculation of blood and other potentially infectious body fluids is the most common route for transmitting hepatitis B and HIV to healthcare workers.

All work with sharps should be careful, attentive and unhurried. You should take special care when using needles and scalpels, handling sharp instruments, cleaning used instruments and disposing of sharps.

Sharps containers should comply with British Standard 7320, United Nations Standard 3291, or their equivalent. Sharps containers must:
• be puncture-resistant and leakproof, even if they fall over or are dropped
• be capable of being handled and moved whilst in use
• have a handle that is not part of the closure device and does not interfere with the normal use of the container
• have an opening that, in normal use, will inhibit removal of contents but allow disposal of items with one hand, without contaminating the outside of the container
• have a closure device attached for sealing when the container is three-quarters full or ready for disposal
• have a horizontal line to indicate when the container is three-quarters full and be marked with the words “Warning – do not fill above the line”
• be made of material that can be incinerated
• be yellow
• be clearly marked with the words “Danger”, “Contaminated sharps” and “Destroy by incineration” or “To be incinerated”.
Observe the following safety precautions when using and disposing of sharps:
• do not pass sharps directly from hand to hand, keep handling to a minimum
• avoid recapping, bending, breaking or manipulating used needles
• if removal of the needle from the syringe is unavoidable, use a sharps box with a needle-removing facility; or use forceps; or approach the needle carefully along the barrel of the syringe, using a gloved hand. Take extreme care
• discard disposable sharps in an appropriate sharps container (conforming to British Standard 7320, United Nations Standard 3291, or equivalent)
• do not overfill the container
• drop items in carefully; do not push items down.
Locate sharps containers in a safe position, not on the floor. Dispose of containers by the licensed route, according to your local policy. Consider the use of needle safety devices where there are clear indications that they will provide safer systems of working for healthcare workers.
Always follow your local policies.
page top

Education of patients, carer and healthcare workers

To improve outcomes and reduce healthcare costs, it is essential that everyone involved in providing care in hospitals and the community is educated about standard precautions and trained in hand decontamination, the appropriate use of protective clothing and the safe disposal of sharps. Adequate supplies of liquid soap, alcohol hand rub/gel, towels and sharps containers must be available wherever care is delivered.

NB: Adequate supplies of liquid soap, alcohol hand rub/gel, towels and sharps containers must be available wherever care is delivered.

Standard precautions – Summary
• Apply good basic hygiene practices with regular handwashing.
• Cover existing wounds or skin lesions with waterproof dressings.
• Avoid carrying out invasive procedures if suffering from chronic skin lesions on hands.
• Avoid contamination of clothes by using appropriate personal protective equipment.
• Protect mucous membranes of eyes, mouth and nose from splashes of blood or blood-stained fluids.
• Prevent puncture wounds, cuts and abrasions in the presence of blood or blood-stained body fluids.
• Avoid using sharps wherever possible.
• Use safe handling procedures for handling and disposal of needles and other sharps.
• Use approved procedures for sterilisation and disinfection of instruments and equipment.
• Clear spillages of blood and other body fluids promptly and disinfect contaminated surfaces.
• Institute a procedure for safe disposal of contaminated waste
• Follow statutory requirements for the safe disposal of used and infected linen
• Make sure the environment of patients' is visibly clean and free from dust and dirt.

pancreatitis symptom

Acute Pancreatitis SymptomsThe most common symptom of acute pancreatitis is pain. Almost everybody with acute pancreatitis experiences pain.

• The pain may come on suddenly or build up gradually. If the pain begins suddenly, it is typically very severe. If the pain builds up gradually, it starts out mild but may become severe.
• The pain is usually centered in the upper middle or upper left part of the belly (abdomen).
• The pain may feel as if it radiates through to the back.
• The pain often begins or worsens after eating.
• The pain typically lasts a few days.
• The pain may feel worse when a person lies flat on his or her back.

People with acute pancreatitis usually feel very sick. Besides pain, people may have other symptoms.

• Nausea (Some people do vomit, but vomiting does not relieve the symptoms.)
• Fever, chills, or both
• Swollen abdomen which is tender to the touch
• Rapid heartbeat (A rapid heartbeat may be due to the pain and fever, or it may be a compensation if a person is bleeding internally.)

In very severe cases with infection or bleeding, a person may become dehydrated and have low blood pressure, in addition to the following symptoms:

• Weakness or feeling tired (fatigue)
• Feeling lightheaded or faint
• Lethargy
• Irritability
• Confusion or difficulty concentrating
• Headache

If the blood pressure becomes extremely low, the organs of the body do not get enough blood to carry out their normal functions. This very dangerous condition is called circulatory shock or is referred to simply as shock.
Chronic Pancreatitis Symptoms
Pain is less common in chronic pancreatitis.Some people have pain, but most people do not experience pain. For those people who do have pain, the pain is usually constant and may be disabling; however, the pain often goes away as the condition worsens. This lack of pain is a bad sign because it probably means that the pancreas has stopped working.Other symptoms of chronic pancreatitis are related to long-term complications, such as the following:

• Inability to produce insulin (diabetes)
• Inability to digest food (weight loss and nutritional deficiencies)
• Bleeding (low blood count, or anemia)
• Liver problems (jaundice)

When to Seek Medical Care

In most cases, the pain and nausea associated with pancreatitis are severe enough that a person seeks medical attention from a healthcare provider. Any of the following symptoms definitely warrant medical attention:

• Inability to take medication or to drink and eat because of nausea or vomiting
• Severe pain not relieved by nonprescription medications
• Difficulty breathing
• Pain accompanied by fever or chills, persistent vomiting, feeling faint, weakness, or fatigue
• Pain accompanied by presence of other medical conditions, including pregnancy

The healthcare provider may tell the person to go to a hospital emergency department. If a person is unable to reach a healthcare provider, or if a person's symptoms worsen after having visited a healthcare provider, an immediate visit to an emergency department is necessary.
Exams and test

When a healthcare provider identifies symptoms suggestive of pancreatitis, specific questions are asked about the person's symptoms, lifestyle and habits, and medical and surgical history. The answers to these questions and the results of the physical examination allow the healthcare provider to rule out some conditions and to zero-in on the correct diagnosis.
In most cases, laboratory tests are needed. The tests check for several possibilities, including the following:

• Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)
• Signs of infections
• Blood cell counts indicating signs of anemia
• Pregnancy test
• Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level

Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and insulin.Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including gallstones.Diagnostic imaging tests may include the following:

1. X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of discomfort.
2. A CT scan is like an x-ray film, only much more detailed. A CT scan shows the pancreas and possible complications of pancreatitis in better detail than an x-ray film. A CT scan highlights inflammation or destruction of the pancreas.
3. Ultrasound is a very good imaging test to examine the gallbladder and the ducts connecting the gallbladder, liver, and pancreas with the small intestine.

• Ultrasound is very good at depicting abnormalities in the biliary system, including gallstones and signs of inflammation or infection.
• Ultrasound uses painless sound waves to create images of organs. Ultrasound is performed by gliding a small handheld device over the abdomen. The ultrasound emits sound waves that "bounce" off the organs and are processed by a computer to create an image. This technique is the same one that is used to look at a fetus in a pregnant woman.

Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging test that uses an endoscope (a thin, flexible tube with a tiny camera on the end) to view the pancreas and surrounding structures.

1. ERCP is usually used only in cases of chronic pancreatitis or in the presence of gallstones.
2. To perform an ERCP, a person is first sedated. After sedation, an endoscope is passed through the mouth, to the stomach, and into the small intestine. The device then injects a temporary dye into the ducts connecting the liver, gallbladder, and pancreas with the small intestine (biliary ducts). The dye makes is easier for the healthcare provider to see any stones or signs of organ damage. In some cases, a stone can be removed during this test.

Pancreatitis Treatment

Self-Care at HomeFor most people, self-care alone is not enough to treat pancreatitis. People may be able to make themselves more comfortable during an attack, but they will most likely continue to have attacks until treatment is received for the underlying cause of the symptoms. If symptoms are mild, people might try the following preventive measures:

• Stop all alcohol consumption.
• Adopt a liquid diet consisting of foods such as broth, gelatin, and soups. These simple foods may allow the inflammation process to get better.
• Over-the-counter pain medications may also help.

Medical Treatment

Medical treatment is usually focused on relieving symptoms and preventing further aggravation to the pancreas. Certain complications of either acute pancreatitis or chronic pancreatitis may require surgery or a blood transfusion.Acute Pancreatitis TreatmentIn acute pancreatitis, the choice of treatment is based on the severity of the attack. If no complications are present, care usually focuses on relieving symptoms and supporting body functions so that the pancreas can recover.

• Most people who are having an attack of acute pancreatitis are admitted to the hospital.
• Those people who are having trouble breathing are given oxygen.
• An IV line is started, usually in the arm. The IV line is used to give medications and fluids. The fluids replace water lost from vomiting or from inability to take in fluids, helping the person to feel better.
• If needed, medications for pain and nausea are prescribed.
• Antibiotics are given if the health care provider suspects an infection may be present.No food or liquid should be taken by mouth for a few days. This is called bowel rest. By refraining from food or liquid intake, the intestinal tract and pancreas are given a chance to start healing.
• Some people may need a nasogastric (NG) tube. The thin, flexible plastic tube is inserted through the nose and down into the stomach to suck out the stomach juices. This suction of the stomach juices rests the intestine further, helping the pancreas to recover.
• If the attack lasts longer than a few days, nutritional supplements are administered through an IV line.

Chronic Pancreatitis Treatment

In chronic pancreatitis, treatment focuses on relieving pain and avoiding further aggravation to the pancreas. Another focus is to maximize a person's a
ility to eat and digest food.

1. Unless people have severe complications or a very severe episode, they probably do not have to stay in the hospital.
2. Medication is prescribed for severe pain.
3. A high carbohydrate low fat diet; and eating smaller more frequent meals help prevent aggravating the pancreas. If a person has trouble with this diet, pancreatic enzymes in pill form may be given to help digest the food.
4. People diagnosed with chronic pancreatitis are strongly advised to stop drinking alcohol.If the pancreas does not produce sufficient insulin, the body needs to regulate its blood sugar,and insulin shots may be necessary.

Surgery

If the pancreatitis is caused by gallstones, an operation to have the gallbladder and gallstones removed (cholecystectomy) is likely.If certain complications (for example, enlargement or severe injury of the pancreas, bleeding, pseudocysts, or abscess) develop, surgery may be needed to drain, repair, or remove the affected tissues.

Appendicitis

Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasound. Treatment is surgical removal.
In the US, acute appendicitis is the most common cause of acute abdominal pain requiring surgery. Over 5% of the population develops appendicitis at some point. It most commonly occurs in the teens and 20s but may occur at any age.
Other conditions affecting the appendix include carcinoids, cancer, villous adenomas, and diverticula. The appendix may also be affected by Crohn's disease or ulcerative colitis with pancolitis.
Etiology
Appendicitis is thought to result from obstruction of the appendiceal lumen, typically by lymphoid hyperplasia, but occasionally by a fecalith, foreign body, or even worms. The obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation. If untreated, necrosis, gangrene, and perforation occur. If the perforation is contained by the omentum, an appendiceal abscess results.
Symptoms and Signs
The classic symptoms of acute appendicitis are epigastric or periumbilical pain followed by brief nausea, vomiting, and anorexia; after a few hours, the pain shifts to the right lower quadrant. Pain increases with cough and motion. Classic signs are right lower quadrant direct and rebound tenderness located at McBurney's point (junction of the middle and outer thirds of the line joining the umbilicus to the anterior superior spine). Additional signs are pain felt in the right lower quadrant with palpation of the left lower quadrant (Rovsing sign), an increase in pain from passive extension of the right hip joint that stretches the iliopsoas muscle (psoas sign), or pain caused by passive internal rotation of the flexed thigh (obturator sign). Low-grade fever (rectal temperature 37.7 to 38.3° C [100 to 101° F]) is common.Unfortunately, these classic findings appear in < name="sec02-ch011-ch011e-462">
Diagnosis

• Clinical evaluation
• Abdominal CT if necessary
• Ultrasound an option to CT

When classic symptoms and signs are present, the diagnosis is clinical. In such patients, delaying laparotomy to perform imaging tests only increases the likelihood of perforation and subsequent complications. In patients with atypical or equivocal findings, imaging studies should be done without delay. Contrast-enhanced CT has reasonable accuracy in diagnosing appendicitis and can also reveal other causes of an acute abdomen. Graded compression ultrasound can usually be done quickly and uses no radiation (of particular concern in children); however, it is occasionally limited by the presence of bowel gas and is less useful for recognizing nonappendiceal causes of pain. Appendicitis remains primarily a clinical diagnosis. Selective and judicious use of radiographic studies may reduce the rate of negative laparotomy.Laparoscopy can be used for diagnosis as well as definitive treatment; it may be especially helpful in women with lower abdominal pain of unclear etiology. Laboratory studies typically show leukocytosis (12,000 to 15,000/μL), but this finding is highly variable; a normal WBC count should not be used to exclude appendicitis.PrognosisWithout surgery or antibiotics, mortality is > 50%.With early surgery, the mortality rate is < name="sec02-ch011-ch011e-466b">

Treatment

1. Surgical removal
2. IV fluids and antibiotics

Treatment of acute appendicitis is open or laparoscopic appendectomy; because treatment delay increases mortality, a negative appendectomy rate of 15% is considered acceptable. The surgeon can usually remove the appendix even if perforated. Occasionally, the appendix is difficult to locate: In these cases, it usually lies behind the cecum or the ileum and mesentery of the right colon. A contraindication to appendectomy is inflammatory bowel disease involving the cecum. However, in cases of terminal ileitis and a normal cecum, the appendix should be removed.Appendectomy should be preceded by IV antibiotics. Third-generation cephalosporins are preferred. For nonperforated appendicitis, no further antibiotics are required. If the appendix is perforated, antibiotics should be continued until the patient's temperature and WBC count have normalized or continued for a fixed course, according to the surgeon's preference. If surgery is impossible, antibiotics—although not curative—markedly improve the survival rate. When a large inflammatory mass is found involving the appendix, terminal ileum, and cecum, resection of the entire mass and ileocolostomy are preferable. In late cases in which a pericolic abscess has already formed, the abscess is drained either by an ultrasound-guided percutaneous catheter or by open operation (with appendectomy to follow at a later date). A Meckel's diverticulum in a patient under the age of 40 should be removed concomitantly with the appendectomy unless extensive inflammation around the appendix prevents the procedure.