Statement of enemas
The reception, which involves the introduction of any liquid substance into the intestine through the rectum( water, medicine, oil, etc.) is called an enema. This is a medical-diagnostic manipulation, which is an introduction to the lower part of the colon of various fluids.
Depending on the purpose( to remove the contents of the intestine or, conversely, to introduce a substance into it with a liquid), the curative enemas are divided into two types. The first type includes cleansing and loosening enemas, the second type - medicinal, drip and nutritious.
Extraction of the contents of the large intestine by the natural way - defecation - a reflex reflex act taking place with the participation of the central nervous system. Liquid contents from the small intestine pass into the thick part of the intestine, where it lingers for 10-12 hours, sometimes more.
When passing through the thick intestine, the contents gradually become denser due to vigorous absorption of water, turning into feces. In the intervals between emptying, stool masses move in the distal direction of the intestine due to peristaltic contractions of the musculature of the large intestine, descend to the lower end of the sigmoid colon and accumulate there. Further their advancement into the rectum is prevented by the third sphincter of the rectum. The urge to defecate occurs in humans only when the stool enters the rectum and accumulates in its cavity. It is caused by mechanical and chemical stimulation of the receptors of the rectum wall, especially by stretching the ampulla of the intestine. Outside the defecation of the anal sphincters( the outer - from the transverse musculature, the inner - from the smooth muscles) are constantly in a state of tonic contraction.
The tone of the sphincter rises when the feces enter the rectal cavity. When there is a urge and during the defecation, the tone of the sphincters is reflexively reduced - they relax. This removes the obstacle to the exit of stool to the outside. At this time, under the influence of stimulation of the receptors of the rectum, the ring muscles of the intestinal wall and pelvic floor are reduced.
Promotion of feces from the sigmoid colon in a straight line, and out of the latter - to the outside helps reduce the diaphragm and abdominal muscles with delayed breathing. A person can exercise or delay defecation. The extinction of the reflex from the ampulla of the rectum leads to proctostatic constipation.
Irritation of the rectum, especially the dilatation of its ampoule, reflexively affects the function of the overlying parts of the digestive apparatus, organs of excretion, etc. The enema acts as such a mechanical stimulus. In addition to active peristaltic contractions of the musculature of the wall of the colon, an anti-peristaltic contraction occurs, which contributes to the fact that even in a small amount introduced into the rectum, the fluid quickly passes to the overlying parts of the large intestine and quickly appears in the caecum.
In the colon, absorption of the injected fluid occurs, and it depends on various conditions. The greatest importance in this case is the composition of the liquid and the degree of mechanical and thermal stimulation provided, as well as the state of the intestine itself.
The warm hypotonic solutions of glucose are best absorbed - 1%, the salt - 0.7%.Drinking water left in the intestines, although it irritates it, is also absorbed gradually. When atony of the intestines, the absorption increases, with increased peristalsis it occurs to an insignificant degree, with prolonged spasm, the absorption can be complete.
Diagnostic enemas allow you to determine the capacity of the large intestine, enter a contrast agent for X-ray examination of the large intestine.
Contrast enema is used for radiological examination of the intestine and allows to enter into the lumen of the intestine a contrast solution( barium sulphate).Following the screen of an X-ray machine or an electronic-optical transducer, the doctor can determine the nature of the progress of the contrast mass in the gut and identify various pathological formations in its lumen or wall.
Contrast mass is poured into the bulb of Bobrov's apparatus, which is connected to the tip inserted into the gut with a rubber tube. Apparatus Bobrov - a glass tank in the form of a large bottle, tightly closed rubber stopper with two glass tubes( short and long).The tightness of the closure is provided by the screw device located in the plug. The patient is placed on the table of the X-ray apparatus, the tip is injected into the rectum to a depth of 10-12 cm. Using a rubber pear in the bulb of Bobrov's apparatus, the pressure increases, which expels the contrast mass through the connecting rubber tube into the intestine. For carrying out of an irrigoscopy it is usually enough to introduce into the lumen of the large intestine 2 liters of contrast mass.
Cleansing enemas is used for mechanical emptying of the colon with constipation and stool retention of any origin, food poisoning, preparation for surgical interventions( not only in the gastrointestinal tract), childbirth, x-ray examination of the abdominal cavity and pelvis, and before applicationmedicinal, drip and nutritional enemas.
Contraindications to cleansing enemas:
• acute inflammatory purulent diseases( appendicitis, etc.) and ulcerative processes in the anus and colon area;
• Inflammation of the peritoneum( peritonitis);
• gastric and intestinal bleeding;
• the first days after surgery on the organs of the abdominal cavity;
• cracks in the anus and its gap, prolapse of the rectal mucosa.
There are two ways of introducing fluids into the rectum:
• from a reservoir above the body level - a hydraulic method;
• injection by means of appropriate instruments - injection method.
To perform a hydraulic enema, it is necessary to have:
• a reservoir for injected liquid( Esmarch mug, glass funnel, rubber cup) with a capacity of 1 to 5 m;
• rubber tube, conductive liquid, about 1.5 m in length and not less than 1 cm in diameter( the tube must be thick-walled);
• intestinal tube - a tip inserted into the lumen of the rectum, made from various materials( thick-walled rubber, ebonite, glass), at least 15 cm long with a rounded intestinal end;
• thermometer for measuring liquid temperature.
Between the rubber tube and the tip is placed a special connecting tube with a tap, designed to regulate the amount of liquid introduced into the gut. Introduced fluid, providing mechanical, thermal and chemical effects, enhances peristalsis, loosens stool and facilitates their excretion.
The mechanical action of the enema is the greater, the greater the amount of fluid, the pressure and the rate of administration.
For the enema of an adult take on average 1 liter of water( from 750 ml to 2 liters), for infants - 30-150 ml, from 1 to 5 years - 150-300 ml, from 6 to 14 years - 300-500 ml.
The higher the tripod and, consequently, the Esmarch mug hangs( 0.5-1 - 1.5 m), the higher the pressure of the injected liquid. The speed of its arrival is regulated by a crane.
In addition to mechanical action, the low temperature of the injected liquid contributes to the enhancement of peristalsis. With an atonic lock, the temperature of the liquid can be 20 ° C.With spastic constipation apply warm or hot enemas( 30-40-42 ° C), relaxing the smooth musculature of the bowel. The optimum temperature is 25-30 ° C.
It should be remembered that the higher the temperature of the injected liquid and the higher the Esmarch mug, the greater the likelihood of absorption through the intestinal mucosa of the injected fluid, and this, in turn, causes "caloric intoxication".
When repeating cleansing enemas, you can increase the location of the Esmarch mug( raise it), thereby contributing to better and better cleansing of the intestine.
The patient with his legs bent and tucked to the abdomen is laid on the couch or bed on the left side nearer to the edge;if you can not move, they put him on his back. Under the buttocks, a ship and an oilcloth are placed, the free edge of which is lowered into the bucket in case the patient does not retain water. In the Esmarch mug pour 1 - 1.5 liters of room temperature water, lift it up, drop the tip down, release a small amount of water, and togetherwith it air. Filling the system, without lowering the mug, close the valve on the rubber tube. Check the integrity of the tip, lubricate it with petroleum jelly and, spreading the patient's buttocks, light rotational movements inject the tip to a depth of 10-12 cm. Initially, for 3-4 cm, the tip is inserted towards the navel, then parallel to the coccyx. After insertion of the tip, the faucet is opened, the Esmarch mug is raised by 40-50 cm and fluid is introduced, gradually raising the mug to a height of 1 m. If water does not enter the intestine, the tip position should be slightly changed by extending it by 1-2 cm, or by increasing itPressure, raising Esmarch's mug higher. If this does not help, you need to remove the tip, with a stream of water to restore its patency and re-enter. At the end of the infusion, the tip is carefully removed.
The injected liquid can penetrate into all parts of the colon, up to the blind, causing an increase in peristalsis and a urge to defecate, which the patient should delay for 5-10 minutes.
Children should be injected slowly, without too much pressure, and after removing the tip, squeeze the baby's buttocks for a few minutes, helping them to delay the urge to emptying. In the presence of gases and the appearance of a sense of bursting - immediately drop the mug below the bed level and after the gases escape again gradually raise it. Leaving some water on the bottom to prevent air from entering the intestine, close the tap that regulates the flow of liquid and remove the tip. It is advisable that the patient keep water for 10 minutes. To do this, he must lie on his back and breathe deeply.
At the end of the procedure, Esmarch's mug is washed, wiped dry and subjected to mechanical cleaning, disinfection and sterilization.
When setting the cleansing enema, it is necessary to monitor that at the same time no more than 1.5-2 liters of liquid are injected.
Siphonic enemas are used to flush the colon( more often with Hirschsprung's disease before surgery), they are used in cases where the usual cleansing enemas have no effect, and also with a therapeutic purpose( to eliminate the curvature of the long sigmoid colon).At the heart of the siphon washing is the principle of communicating vessels. One of them is the intestine, the other is the funnel on the outer end of the rubber tube inserted into the rectum.
Main indications:
• no effect from cleansing enemas and taking a laxative;
• removal from the intestine of products of enhanced fermentation and putrefaction, mucus, pus, poisons that enter the intestines through the mouth;
• after operations on the abdominal cavity( except for cases of intestinal surgery), when the patient can not activate the act of defecation by reducing the musculature of the abdominal wall.
Contraindications are the same as for cleansing enemas.
For a siphon enema, a sterilized tube 75 cm long and 1.5 cm in diameter is required, with a hopper containing about 0.5 liters of liquid, a pitcher, 10-12 liters of disinfectant( weak sodium bicarbonate solution) or boiled water( isotonicsolution).The temperature of the fluid is determined by the doctor in each case.
The patient is placed on the left side or on the back, an oilcloth is placed under the buttocks. At the bed put a bucket for a sink and a jug with a liquid. The end of the tube inserted into the rectum is abundantly lubricated with petroleum jelly and advanced forward by 20-30 cm. It is necessary to ensure that the tube does not fold in the ampoule of the rectum, controlling it, if necessary, with the finger.
The funnel should be kept slightly above the patient's body in an inclined position. Then, gradually filling it with liquid, raise it over the body to a height of 1 m. Water begins to pass into the intestine. As soon as the level of descending water reaches the narrowing of the funnel, it is lowered over the bucket( or pelvis), without turning, until the water from the intestine fills the funnel. With this position of the funnel, bubbles of air and lumps of feces are clearly visible - this content is poured into a bucket and again the funnel is filled with water. The procedure is repeated several times until the gases escape and the clean water does not start to enter the funnel.
After finishing the procedure, the funnel is removed, disinfected and sterilized. The rubber tube is left in the rectum for 10-12 minutes, lowering its outer end into the pelvis for outflow of liquid residues and gassing. Then they take it out, wash it, disinfect it and sterilize it.
The nurse carries out cleaning and siphon enemas with the younger nurse. There should be a quiet, calm atmosphere. It is advisable to conduct enemas in a special room. It can be a bathroom or toilet, in which there is a medical couch, a bathroom, etc.
If the patient can not move, the enema can be staged in the ward. In ideal conditions, such a patient should be in a special box or ward. If the patient is in a general ward, the patients who are allowed to move are asked to leave for a certain time. From the rest, left in the ward, the patient is fenced off with a screen. Before the procedure, the nurse conducts an explanatory conversation with all patients, observing all ethical rules of conduct.
Drip enemas belong to the category of medicinal enemas, since they are used to compensate for the loss of blood or fluid( restoring the volume of circulating fluid, blood).Usually 5% glucose solution with isotonic solution of sodium chloride is drip-fed.
Use the same devices as for cleaning. The device for drop enemas consists of a mug of Esmarch, a rubber tube, a dropper inserted between its lengths, a connecting and intestinal tube. Before the dropper on the rubber tube strengthen the clamp. With its help, the flow of liquid into the dropper is regulated( 60-100 drops for adults and 15-20 drops for children).The patient lies in a comfortable position on the back. A solution is poured into the mug, heated to 37 ° C, they fill the tube system, adjusting the frequency of the drops with a clamp. Then enter the intestinal tube into the rectum of the patient to a depth of 20-30 cm. The tube is suspended on a tripod.
The same solutions, as well as a 15% solution of amino acids( nourishing enema) can be injected with a rubber balloon into the rectum 2-3 times a day for 150-200 ml. A drop enema is a more expedient way of introducing medicinal fluids into the body, since, entering the intestine with droplets and sucking, they do not stretch the intestine, intensify intestinal peristalsis, and do not provoke an act of defecation.
Drip enemas are easily tolerated by patients, do not cause painful sensations and allow the introduction of a large amount of fluid without overflowing the bloodstream. If there are no contraindications, then before the dropping enema it is desirable to perform a purifying or siphon enema, remembering that each of them is a hard-to-carry manipulation for the patient.
The goal of indulgent enemas is not mechanical and thermal irritation of the colon with the subsequent intensification of intestinal peristalsis, but laxative action, i.e.strengthening the secretory function of the intestine and regulating intestinal peristalsis, which should not be violent.
During the procedure, which lasts for several hours, the sister must follow her to:
• due to the inflexion of the tubes, the flow of liquid into the intestine did not stop;
• a certain infusion rate was maintained;
• did not cool the solution, for which the Esmarch mug is placed in a cotton swab, and a bottle of boiling water is put in the solution.
To do this, use vegetable oil, solutions of medium salts, various infusions in the amount of 100 ml, injected with rubber cylinders. At the end of the procedure, the patient must lie down so that the liquid does not flow out of the rectum. The chair appears, usually after 12-16 hours.
If the administration of drugs is not possible in another way, they can be injected through the rectum. Absorbed through the hemorrhoidal veins, they, bypassing the liver, quickly enter the blood.
Medicinal enemas are divided into local and general.
Mastical medicinal enemas are used to reduce the phenomena of irritation, inflammation, elimination of the spastic state of a given segment of the intestine, healing of erosions and ulcers in the large intestine, as well as to treat the inflammation in the pararectal tissue and pelvic cavity.
General enemas are used to administer medicinal or nutrient substances and effects on the body as a whole.
For 30-40 minutes before the drug is put cleansing enema. Medications are administered after bowel movement.
Medicinal enemas - mainly microclysters, their volume does not exceed 50-100 ml. Medicinal substances are collected in a 20-gram syringe, a Janet syringe or in a rubber can of 50-100 ml. The temperature of the drug substance must be at least 40 ° C.At a lower temperature there are desires for defecation, and the medicine does not have time to absorb.
The patient lies on the left side, legs are bent at the knees and pulled up to the stomach. Pushing the buttocks with your left hand, use a right-angled motion to inject a 15-20 cm catheter into the rectum with a sterile vaseline oil. The catheter is then connected to a syringe or canister in which the drug is placed, and this solution is slowly squeezed into the catheter in small portions under low pressure. Further, by holding and squeezing the outer end of the catheter to prevent the liquid from returning from it, carefully remove the can from the catheter, inject air into it, re-insert it into the catheter and blow to push through the remaining liquid. In order not to cause mechanical thermal and chemical stimulation of the intestine, drugs must be administered in a relatively low concentration, diluted with warm isotonic sodium chloride solution or in a coating substance( 50 g of starch broth).
Most often, microclysters are administered painkillers, soothing and hypnotics. Starch enemas are used to reduce peristalsis and as an enveloping, emollient for acute colitis. To do this, 5 g of starch( potato, rice, corn, wheat) is bred in 100 ml of cool water and, stirring, gradually add 100 ml of boiling water. Then cool the solution to 40 ° C and enter the rectum.
Chloral hydrate enemas are prescribed for cramps and sudden arousal. Chlorohydrate( 1 g) is diluted in 25 ml of distilled starch( at a rate of 1:50), since chloral hydrate has irritating effect on the rectal mucosa.
Hypertensive enemas cause a laxative effect without sharp intestinal motility. Usually, a 5-10% solution of sodium chloride, a 20-30% solution of magnesium sulfate or sodium sulfate is used. In the rectum, inject 100-200 ml of a warm solution with a rubber balloon - "pear".Contraindications: inflammatory and ulcerative processes in the lower part of the large intestine.
Oily enemas are used in obstinate constipation, when the introduction of large volumes of fluid is ineffective or contraindicated. To do this, use vegetable oils: sunflower, olive, hemp, vaseline. For one enema, take 50-100 ml of preheated oil to 37-38 ° C.Introduce the oil usually with a rubber balloon, syringe or catheter, pushing it into the rectum by 10 cm. The oil spreads over the wall of the intestine, relaxes the intestinal muscles, contributing to the excreta of feces. The patient should lie quietly for 10-15 minutes so that the oil does not leak.
Prepare 2 cups of chamomile infusion( 1 tablespoon chamomile flowers per 1 tbsp boiling water).1 yolk whisk with 1 teaspoon of sodium hydrogencarbonate and pour infusion of chamomile, adding 2 tbsp.tablespoons of vaseline oil or glycerin.
In cases where drips can not be injected through the mouth, they are injected through the rectum. The use of nutritional enemas is very limited.
In the lower part of the large intestine, water, isotonic sodium chloride solution, glucose solutions and alcohol are absorbed. Partially absorbed proteins and amino acids.
For 30-40 minutes before the nutritional enema put a cleansing enema. The volume of the nutritional enema should not exceed 1 cup.
In a rubber canister, take a warm solution and add 5 drops of opium tincture. The spout is sprayed with vaseline oil, the air is released into it and inserted into the rectum. Press the balloon slowly, so that the liquid enters the intestine gradually, without irritating the mucous membrane. After this, the patient should lie quietly so that there is no urge to defecate.