Bowel Management in Adults with Spinal Cord Injury
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The American Society of Colon and Rectal Surgeons' Clinical Practice
CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation Ian M. Paquette, M.D. • Madhulika Varma, M.D. • Charles Ternent, M.D. Genevieve Melton-Meaux, M.D. • Janice F. Rafferty, M.D. • Daniel Feingold, M.D. Scott R. Steele, M.D. he American Society of Colon and Rectal Surgeons for functional constipation include at least 2 of the fol- is dedicated to assuring high-quality patient care lowing symptoms during ≥25% of defecations: straining, Tby advancing the science, prevention, and manage- lumpy or hard stools, sensation of incomplete evacuation, ment of disorders and diseases of the colon, rectum, and sensation of anorectal obstruction or blockage, relying on anus. The Clinical Practice Guidelines Committee is com- manual maneuvers to promote defecation, and having less posed of Society members who are chosen because they than 3 unassisted bowel movements per week.7,8 These cri- XXX have demonstrated expertise in the specialty of colon and teria include constipation related to the 3 common sub- rectal surgery. This committee was created to lead inter- types: colonic inertia or slow transit constipation, normal national efforts in defining quality care for conditions re- transit constipation, and pelvic floor or defecation dys- lated to the colon, rectum, and anus. This is accompanied function. However, in reality, many patients demonstrate by developing Clinical Practice Guidelines based on the symptoms attributable to more than 1 constipation sub- best available evidence. These guidelines are inclusive and type and to constipation-predominant IBS, as well. The not prescriptive. -
Rectal Suppository & Enema Administration to Administration Unlicensed Assistive Personnel (UAP) Module/Skill Checklist
Delegation of Medication Rectal Suppository & Enema Administration to Administration Unlicensed Assistive Personnel (UAP) Module/Skill Checklist Objective At the completion of this module, the UAP should be able to administer rectal suppository & enema medications. NOTE: 1) The RN or LPN is permitted to delegate ONLY after application of all components of the NCBON Decision Tree for Delegation to UAP and after careful consideration that delegation is appropriate: a) for this client, b) with this acuity level, c) with this individual UAP’s knowledge and experience, and d) now (or in the time period being planned). 2) Successful completion of the “Infection Control” module by the UAP should be documented prior to instruction in medication administration by this or ANY route. Procedure for: SUPPOSITORY 1. Perform skills in General Medication Administration Checklist. 2. Provide privacy. Have client void before procedure. 3. Put on clean gloves. 4. Position the client on their left (preferred) side with the top leg bent slightly. 5. Remove the foil or wrapper from the suppository, if present. 6. Apply a small amount of lubricant to the suppository and your gloved index finger on your dominant hand – the hand holding the suppository. 7. Separate the buttocks with your gloved, non dominant hand. 8. Ask the client to breathe slowly and deeply through the mouth. 9. Place tip of suppository against anus and gently insert the suppository about 4- inches along the rectal wall. Avoid putting the suppository in stool. 10. After removing your finger, squeeze buttocks together for a few minutes to help client hold in the suppository for as long as possible. -
A Sign It's Time for BOTOX®
When OAB* due to MS† makes matters worse… A sign it’s time for BOTOX® Ask your patients if they still have leakage or can’t tolerate their current OAB medication *Overactive bladder. †Multiple sclerosis. Indication Detrusor Overactivity Associated With a Neurologic Condition BOTOX® for injection is indicated for the treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition (eg, SCI, MS) in adults who have an inadequate response to or are intolerant of an anticholinergic medication. IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING WARNING: DISTANT SPREAD OF TOXIN EFFECT Postmarketing reports indicate that the effects of BOTOX® and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening, and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity, but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat Cervical Dystonia -
Autonomic Dysreflexia – a Medical Emergency a Guide for Patients
Autonomic Dysreflexia – A Medical Emergency A guide for patients Only applicable to T6 level and above Key Points • Autonomic Dysreflexia (AD) is a medical emergency that occurs due to a rapid rise in blood pressure in response to a harmful or painful stimulus below the level of your Spinal Cord Injury (SCI) • It occurs in people with SCI at T6 and above but has in rare occasions been reported in individuals with SCI as low as T8 • If left untreated your blood pressure can rise to dangerous levels, risking stroke, cardiac problems, seizures, even death • Typically there is a pounding headache as your blood pressure rises. Other symptoms can include redness and sweating above the level of your SCI, slow heart rate, goosebumps, nausea, nasal congestion, blurred vision, shortness of breath and anxiety • Some or all of the symptoms may be present • AD can be triggered by any continuous painful or irritating stimulus below the level of your lesion. The most common causes are related to the bladder or bowel • Relieving the cause of the AD will resolve your AD episode • If the cause cannot be found or treated, medication is required to lower your blood pressure which may require a visit to your nearest emergency department • All people with SCI at T6 and above should carry their Autonomic Dysreflexia Medical Emergency Card at all times • The best treatment for AD is prevention • People at risk of AD often carry an ‘AD Kit’ with them – items useful to resolve AD such as catheters and prescribed medication 1 What is Autonomic Dysreflexia? Autonomic Dysreflexia (AD) is a medical emergency. -
Treatment of Autonomic Dysreflexia for Adults & Adolescents with Spinal
Treatment of Autonomic Dysreflexia for Adults & Adolescents with Spinal Cord Injuries Authors: Dr James Middleton, Director, State Spinal Cord Injury Service, NSW Agency for Clinical Innovation. Dr Kumaran Ramakrishnan, Honorary Fellow, Rehabilitation Studies Unit, Sydney Medical School Northern, The University of Sydney, and Consultant Rehabilitation Physician & Senior Lecturer, Department of Rehabilitation Medicine, University Malaya. Dr Ian Cameron, Head of the Rehabilitation Studies Unit, Sydney Medical School Northern, The University of Sydney. Reviewed and updated in 2013 by the authors. AGENCY FOR CLINICAL INNOVATION Level 4, Sage Building 67 Albert Avenue Chatswood NSW 2067 PO Box 699 Chatswood NSW 2057 T +61 2 9464 4666 | F +61 2 9464 4728 E [email protected] | www.aci.health.nsw.gov.au Produced by the NSW State Spinal Cord Injury Service. SHPN: (ACI) 140038 ISBN: 978-1-74187-972-8 Further copies of this publication can be obtained from the Agency for Clinical Innovation website at: www.aci.health.nsw.gov.au Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation. © Agency for Clinical Innovation 2014 Published: February 2014 HS13-136 ACKNOWLEDGEMENTS This document was originally published as a fact sheet for the Rural Spinal Cord Injury Project (RSCIP), a pilot healthcare program for people with a spinal cord injury (SCI) conducted within New South Wales involving the collaboration of Prince Henry & Prince of Wales Hospitals, Royal North Shore Hospital, Royal Rehabilitation Centre Sydney, Spinal Cord Injuries Australia and the Paraplegic & Quadriplegic Association of NSW. -
Robert Jenkinson, MD
8/26/14 LIFE-THREATENING, INTRAOPERATIVE HEMODYNAMIC INSTABILITY IN A QUADRAPLEGIC Robert H. Jenkinson, M.D. Department of Anesthesiology University of Wisconsin Madison, WI Background o 57 year old quadraplegic male, remote C4-C5 spinal injury presenting for cystoscopy. n PMHx: Autonomic dysreflexia, OSA, neurogenic bowel/bladder. n Allergies: Sulfa drugs o Prior history of systolic blood pressure (SBP) near or above 200 mmHg while under GA for cystoscopy on multiple occasions. n Required nitroglycerine infusions. n Stable blood pressure with spinal anesthesia on one prior occasion. Case Description o L4-L5 spinal performed in OR n Intravenous midazolam (2mg) & fentanyl (50 mcg) n Intrathecal hyperbaric bupivacaine (12.5 mg) n Intravenous cefazolin (2g) o On return to supine position: n SBP rapidly decreased from baseline of 140 mmHg to 60 mmHg. n The patient became tachycardic. n Breathing pattern became shallow and bradypneic. n Level of responsiveness quickly decreased. 1 8/26/14 Case Description o Vasopressin and epinephrine boluses given. o Trachea intubated. Intra- arterial BP monitoring & central venous access established. § Vasopressin & epinephrine infusions started. o Diffuse blanching erythema noted. n No mucosal edema or wheezing. Case Description o Procedure cancelled. n Transported to medical ICU. n Weaned off vasopressors & extubated in 3 hours. n Serum tryptase 125 mcg/L (reference range 0.4 – 10.9). o Skin testing to bupivacaine: n No cutaneous, gastrointestinal, cardiovascular or respiratory symptoms. n No evidence of IgE-mediated hypersensitivity to bupivacaine. Discussion o Initial working diagnosis was a high or total spinal. o Tachycardia, skin changes and markedly elevated tryptase most consistent with anaphylactic reaction. -
Bowel Preparation Instructions Fleet Enema
66 BOWEL PREPARATION INSTRUCTIONS FLEET ENEMA Please read these instructions before you have your enema and follow carefully. If you need more advice before using the enema, please telephone the Endoscopy Unit on Tel: 01246 512197 You have been given a phosphate enema, which should be kept and used at room temperature. This is to be used on the day you are coming to hospital for your flexible sigmoidoscopy procedure. Instructions: • The enema must be given at least one hour before you leave home to attend hospital. e.g. if your appointment is at 2.00pm and you will be leaving at 1.30pm you must give the enema at 12.30pm. • To give the enema, you need to lie down on your side with both knees bent and pulled up towards your chest. • Remove the enema cap and throw it away. • Relax and gently insert the full length of the nozzle into your rectum (back passage). • Do this without using undue force. The tip of the nozzle is already lubricated to make insertion easier • Squeeze the bottle until it is completely empty. The bottle may be rolled up (like a tube of toothpaste) ensure it empties. Then gently withdraw the bottle while still squeezing to keep it rolled up. • Hold the liquid in your back passage for as long as you can (by clenching your buttocks) 66 MAKE SURE YOU ARE CLOSE TO A TOILET AS THE ENEMA WILL RESULT IN A RAPID EMPTYING OF YOUR BOWELS • Return the used enema to its carton and throw away safely in your domestic waste. -
About Your Surgery Pre-Operative Instructions Prior to Surgery Post-Operative Instructions How to Reach Us
www.fpminstitute.com About Your Surgery Pre-operative Instructions Prior to Surgery Post-operative Instructions How to Reach Us www.fpminstitute.com Pre-operative Instructions Please Note Patient Name: Procedure: Vaginal Colpopexy Enterocele / Rectocele Repair A physician at The Institute for Female Pelvic Medicine & Sacral Colpopexy Colpocleisis / Colpectomy Reconstructive Surgery is available for emergencies 24 hours per day. Hysterectomy Removal / Revision Uterosacral Vault Suspension InterStim® Office hours are Monday through Friday, 8 a.m. to 4 p.m. Colporrhaphy Pubovaginal Sling After hours and on weekends, you can leave non-urgent messages Other: that will be returned the next business day. For urgent situations, Surgery Date: the answering service can page the physician on call. Medical Clearance Blood work at Lab Blood work on Admit. You are required to be medically cleared for surgery by your primary care physician and/or cardiologist within 30 days of your scheduled surgery. You have been given a medical clearance form that your physician will need to complete, as well as a script for an EKG and bloodwork. Please contact your physician and schedule your medical clearance appointment for the week of (not before this www.fpminstitute.com date). If your physician sends you to a lab for bloodwork, we suggest you do this at least two to three days before your appointment, but not before the date indicated above. We will need copies of your test results and completed medical clearance form faxed to us at the number on the form at least three (3) business days prior to your surgery. If you have any questions, please contact our nursing department. -
Revised 6/1/11 1 INDEX Books on Child Care...4 Care of the Newborn
Revised 6/1/11 INDEX Books on Child Care ......................................... 4 Fever… ............................................................. 14 Care of the Newborn......................................... 4 Feeding ............................................................. 15 Dosing Charts for Medication............................ 23 Head Injury........................................................ 16 Well Child Evaluations & Immunizations........... 7 Headache.......................................................... 16 General Information .......................................... 2 Jaundice............................................................ 16 Kidney-Urinary Problems ..................................16 COMMON MEDICAL PROBLEMS Lumps, Lymph Nodes, & Kernels...................... 16 IN CHILDREN Mouth Problems ................................................ 17 Poisoning .......................................................... 17 Allergies, Recurrent Colds, & Ear Infections ..... 8 Rashes… .......................................................... 17 Attention Deficit Disorder (ADD or ADHD) ........ 8 Scabies and Lice............................................... 18 Antibiotics.......................................................... 9 Sore Throat ....................................................... 19 Bed Wetting ...................................................... 9 Spitting Up......................................................... 5 Bites… ............................................................. -
ILEX Skin Protectant ILEX SKIN PROTECTANT Is A
DESCRIPTION - ILEX Skin Protectant ILEX SKIN PROTECTANT is a topical skin barrier for use on intact or broken skin, a variety of dermal wounds and stomal irritations. Ilex adheres to moist weeping wounds to form an occlusive barrier against urinary and faecal material, digestive enzymes and wound exudates. Ilex is alcohol free so it is safe to use on all skin types, from babies to the elderly. Ilex can be used in conjunction with other prescribed treatment such as topical steroid and antibiotic therapy. • Helps maintain a moist environment that maximizes healing with a unique 0.00cm/hr MPR (moisture penetration rate). • The occlusive barrier formed by the paste helps to prevent external microbial filtration and therefore helps prevent infection. • Adheres to moist weeping tissue (broken skin) using copolymer bioadhesives which forms an occlusive barrier - particularly effective against digestive & urinary acids and wound exudates • Soft, flexible and easy to apply - minimises pain and disturbance to wounds. • Inert and non-toxic; contains no alcohol or latex and is not absorbed systemically so it’s safe to use on fragile skin, paediatric and elderly • Bio-compatible with medical and surgical devices and ostomy appliances • Ilex may be used in conjunction with prescribed topical agents such as antifungal and antibacterial. INGREDIENTS Calcium/ Sodium PVM/MA Copolymers, LiquiparPE, Cornstarch, Zinc, Sodium Carboxymethyl Cellulose, Petroleum jelly INDICATIONS: Prevention and treatment of a wide range of skin irritations and excoriations due to: • Skin irritation and breakdown, caused by urinary and faecal incontinence. Ilex provides an effective barrier against the devastating effects of urine and faeces. Ilex contains no alcohol, and will adhere to denuded weeping tissues, without discomfort to the patient. -
Autonomic Hyperreflexia Associated with Recurrent Cardiac Arrest
Spinal Cord (1997) 35, 256 ± 257 1997 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/97 $12.00 Autonomic hyperre¯exia associated with recurrent cardiac arrest: Case Report SC Colachis, III1 and DM Clinchot2 1Associate Professor and 2Assistant Professor, Department of Physical Medicine and Rehabilitation1, Director, SCI Rehabilitation, The Ohio State University, College of Medicine, Columbus, Ohio, USA Autonomic hyperre¯exia is a condition which may occur in individuals with spinal cord injuries above the splanchnic sympathetic out¯ow. Noxious stimuli can produce profound alterations in sympathetic pilomotor, sudomotor, and vasomotor activity, as well as disturbances in cardiac rhythm. A case of autonomic hyperre¯exia in a patient with C6 tetraplegia with recurrent ventricular ®brillation and cardiac arrest illustrates the profound eects of massive paroxysmal sympathetic activity associated with this condition. Keywords: autonomic hyperre¯exia; spinal cord injury; ventricular ®brillation Introduction Autonomic hyperre¯exia is a condition of paroxysmal by excessive sweating and ¯ushing. Past episodes of re¯ex sympathetic activity which occurs in response to autonomic hyperre¯exia were generally attributed to noxious stimuli in patients with spinal cord injuries re¯ex voiding, position changes and the presence of above the major splanchnic sympathetic out¯ow.1±3 pressure sores. The heightened sympathetic activity during an episode The attendant had completed the patient's morning of autonomic hyperre¯exia accounts for several of the bowel program, hygiene and dressing activities, and clinical features commonly observed including sudo- started to exit the apartment when he heard gasping. motor and pilomotor phenomenon,1,4 ± 6 vasomotor He returned to ®nd him pulseless, apneic, and sequelae,1 ± 4,7 and alterations in cardiac inotropic and cyanotic. -
Salicylic Acid
Treatment Guide to Common Skin Conditions Prepared by Loren Regier, BSP, BA, Sharon Downey -www.RxFiles.ca Revised: Jan 2004 Dermatitis, Atopic Dry Skin Psoriasis Step 1 - General Treatment Measures Step 1 - General Treatment Measures Step 1 • Avoid contact with irritants or trigger factors • Use cool air humidifiers • Non-pharmacologic measures (general health issues) • Avoid wool or nylon clothing. • Lower house temperature (minimize perspiration) • Moisturizers (will not clear skin, but will ↓ itching) • Wash clothing in soap vs detergent; double rinse/vinegar • Limit use of soap to axillae, feet, and groin • Avoid frequent or prolonged bathing; twice weekly • Topical Steroids Step 2 recommended but daily bathing permitted with • Coal Tar • Colloidal oatmeal bath products adequate skin hydration therapy (apply moisturizer • Anthralin • Lanolin-free water miscible bath oil immediately afterwards) • Vitamin D3 • Intensive skin hydration therapy • Limit use of soap to axillae, feet, and groin • Topical Retinoid Therapy • “Soapless” cleansers for sensitive skin • Apply lubricating emollients such as petrolatum to • Sunshine Step 3 damp skin (e.g. after bathing) • Oral antihistamines (1st generation)for sedation & relief of • Salicylic acid itching give at bedtime +/- a daytime regimen as required Step 2 • Bath additives (tar solns, oils, oatmeal, Epsom salts) • Topical hydrocortisone (0.5%) for inflammation • Colloidal oatmeal bath products Step 2 apply od-tid; ointments more effective than creams • Water miscible bath oil • Phototherapy (UVB) may use cream during day & ointment at night • Humectants: urea, lactic acid, phospholipid • Photochemotherapy (Psoralen + UVA) Step 4 Step 3 • Combination Therapies (from Step 1 & 2 treatments) • Prescription topical corticosteroids: use lowest potency • Oral antihistamines for sedation & relief of itching steroid that is effective and wean to twice weekly.