7th Meeting of The

s of ESGENA Workshops on 1st November 2003 THE ROLE OF THE NURSE IN THE REHABILITATION OF THE PRESSURE, SENSITIVE AND COORDINATING ALTERATIONS OF THE ANAL SPHINCTER = BIOFEEDBACK Angeles Argaña. Digestive Motility and Endoscopy Unit. Institut Malalties Digestives. Hospital Clínic Barcelona. Spain. (Jesper @ retemail.es ) Biofeedback is a learning method in which a physiologic activity is monitored and registered in a computer screen. It consists in teaching and explaining the patient the register that is being making to him/her, so that he/she can notice the function that is being doing and try to modify it under monitor control. It is indicated and specially useful in the treatment of fecal incontinence and constipation of lower origin (anismus). To include a patient in a biofeedback program it is necessary that he/she has a minimum of physical attitudes, an acceptable cognitive level, motivation and willing to collaborate. He/she has to have a previous motility study with the following: In fecal incontinence: 1. A minimal pressure capacity with voluntary contraction. 2. A minimal rectal sensibility. In constipation (anismus): 1. Pressure elevation, absence of relaxation or irregular reactions (contraction–relaxation) in the different points of registration of the anal channel and/or lack or weak intrarrectal pressure elevation, during the expulsion maneuvers. 2. Negative expulsion test. The objective of the biofeedback in fecal incontinence is: a) to get that the patients learns how to increase the pressure and duration of the closing of the anal channel. b) to improve the capacity of perception of rectal occupation and, c) to coordinate both phenomenons perfectly. The objective in the constipation (anismus) is: a) to increase the abdominal pressure and to get a complete relaxation of the sphincters with the expulsion maneuvers. Section 4 – Hall Londres The methodology to follow for the treatment of fecal incontinence is: 1to teach the anatomy/physiology of continence–defecation. To explain the functional alterations detected in their case. To teach the necessity of the efforts and collaboration. To establish good nurse-patient relationship and to motivate it. To show and explain registration in a screen. 2 to teach to increase the pressure and duration of the closing of the anal channel with voluntary contraction. 3 to improve the capacity of perception loosening the intrarrectal balloon with different volumes until getting the minimum volume able to start the motor sequence desired. 4 to teach to coordinate with the minimum sensation of rectal occupation, a quick and effective voluntary contraction. The average number of sessions is: the first 3 every 15 days, later on 1 a month, and then a daily exercise program is given to do it at his/her home, 10 minutes in the morning, 10 at night. In constipation (anismus): 1. To get that he/she learns how to differentiate two independent pressures: abdominal pressure and anal channel pressure. 2. To learn to carry out the expulsion maneuver (increase abdominal pressure) without contracting the anal sphincter at the same time. 3. To try that he/she relaxes the anal channel. The number of sessions required is variable (2-10). The review of the literature shows that around 70% of patients recover or improve the fecal continence, and that biofeedback is useful in 60-65% of the patients with constipation of lower cause. In a study carried out in our Unit, we observed that almost all the patients, one month after finishing the biofeedback had recovered the continence or had reduced the number of escapes in more than 75% (except 14%) and that these results stayed in long term. 94% of the patients stated that the treatment had gone well and 91% that it had improved the quality of their lives when reestablished social activities that had been stopped to carry out, all this because they had acquired a better control of the escapes. NUTRITIONAL STATUS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE Ma José Cros Carulla, RN. Endoscopy Unit. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain [email protected] Inflammatory bowel diseases are chronic processes of unknown origin which comprise ulcerative colitis and Crohn’s disease. Patients with IBD present with a large spectrum of nutritional deficiencies that result in anomalies in both anthropometric and biochemical parameters. Aims of treatment of IBD are the following: to induce and maintain remission and to prevent relapse of the disease allowing patients to have better quality of life. Therapeutic options include: medical therapy, nutritional support, psychological and social assistance, and finally, surgical approach. In the last decades, the significance of nutrition and its relationship with health has been recognized. As part of this recognition, there is an emergent interest on the role of diet and nutrients as protective agents against disease. The objectives of nutritional support in patients with IBD are to induce and maintain a correct nutritional status and to prevent nutritional deficiencies. As a general rule, patients with IBD must ensue a complete and balanced diet. In some patients, within a severe flare of the disease it can be necessary to put the patient into bowel rest and give nutritional support. It has not been recognized any food that can initiate a flare of IBD, however it is important that patients do recognize any aliments that can worsen or exacerbate their disease and avoid them. There are several nutritional approaches in IBD: intravenous or enteric nutrition as primary treatment of the disease, diet without milk and derivatives and poor in fiber, probiotic supplementation, etc. Except for enteric nutrition in pediatric patients with Crohn’s disease, there are no controlled trials that support nutritional measures as unique treatment in patients with IBD. Our IBD Unit recommends IBD patients to ensure a complete and equilibrate diet. From February 2003 to May 2003 we have performed a study to evaluate the nutritional status and dietetic habits of our patients with IBD. We have included 160 patients that filled out a questionnaire with epidemiological data, clinical activity of the disease, medications, and dietetic habits. Nutritional parameters (proteins, albumin, cholesterol) were also compiled. Results will be presented at the meeting. HOW IMPORTANT IS THE UNSPOKEN COMMUNICATION BETWEEN NURSE AND PATIENCE. Ma DOLRES FUSTÉAPDO. CORREOS 67. PICANYA 46210VALENCIAESPAÑA “ A person who doesn’t understand a sight, he won’t ever understand a long explanation” as an arabic proverb says. The word is not the only communicatior’s element that form messages:sight, gesture, posture, touch, voice tone, provide us and project information from the patience to nurse and viceversa. Section 4 – Hall Londres In porcentage terms, 93 per cent of the communication is NON SPOKEN. The face is potentially rich sending information. It is a multimessage system which transmits facts related to emotional status of patiences. It works like a conversational regulator,openning and clossing communication channels. Face expressions show us doubt, anger, sadness, fear among others. The sight is the first link of the communication: It is a recognition gesture, of reception, and openess. It is an indicator that we are not repeling the other one. How many times have we demand services from one of other onstitucion, and the person on dutty didn’t rise his face to look at us, as if we were an annoying presence? How have we felt? The non spoken language consist of a non written codec, which without a doubt everybody feels and undertand it. It is essential to analize and interpretate all the communication flows that is shown through face, gesture, positiion, touch, voice tone and the way and intensity of the sight. It cannot be appreciate in all its content the importance that have for a patience that someone can hold his/her hand, touch his shoulder, place right his pillow or mope his front. For all this, it is necessary that men and women nurses develop eficient interpersonal communication abilities so as it will help us to identify the perception that the patience himself has over his needs and problems. It is a way to achieve our most important objective which is to provide an optimal care to the patience and his/her family. A basic component of the eficient communication is the ability that we have to produce empathy answers. Sanz Ortiz points out that communication with the patience is an important part of the therapy, and sometimes it is the only one. As a result from the communication and the empathy power is the colaboration. From a practical point of view, we should learn a lot about distances and it is interesting to be opened to an intensive formation in afective care. Recently studies high light that what patients wish is the human touch. This is the one which definitely permit us objectify the human relationship and the solidarity. It is in the touch porximity where the emotional integration is made easier. It makes the patient feel a human being and not a medical problem. The uncertainly produced by not knowing what would happen and the ability to understand the events feeds a feeling of loneliness and defencelessness that we should consider. THE ENDOSCOPE FROM ANOTHER PERSPECTIVE Navarro Sánchez Anna, Hospital Sagrat Cor. Digestive Endoscopy Service. Barcelona, Spain. e-mail: [email protected]. To discover the interior of an endoscope, will be useful to us to know the origins of small operation deficiencies dog be that could be solved by infirmary personnel. Do we know the endoscope as an instrument of refined interior technology?. Our objective is: a) To visualize how it works interiorly. b) To know which components are more fragile and are more exposed to erosions. c) To improve their handling and to avoid aggressions. d) The care and setting for the next uses. e) Their correct handling from the moment of their extraction of the patient until their new uses or storage. Risk factors: Damages in the distal end of the endoscope. Bites, squashing from doors and suitcases. Perforations of the work channel due to needles, biopsy forceps, deficient wash brushes, pinpoint catheters. Perforation of the aspiration channel for bending of the insert section cone or for the one of the light source connector. Glasses breaks from hits. Escapes: the escapes can origin in the endoscope, in the operative channel, in the rubber of the distal end, control boxes and covers of the protective plug because of the waste of the tip. Section 4 – Hall Londres When the escape takes place, it breaks the security, and the risk of contamination of patient and the entrance of corrosive liquids inside the endoscope arrise, damaging its internal parts until the end of damaging definitively the microcamera. The penetration of liquids produces corrosion of all the internal metallic parts and curved section, taking place the stiffness of the controls, cables and chains. Test of escapes: never process an endoscope without having carried out the test of escapes; this one, supposes a case of malfunction detection, saving repairing time and cost. Manipulation: The correct manipulation of the endoscope for the transport supposes to hold the distal end and the light source connector, both with the same hand and to transfer it to the exploration or cleaning area, being aware of the importance to avoid even light aggressions. Storage: It has to be carried out in a dry and ventilated place, in vertical position, without valves or security plug, having lubricated the valves and plug. The correct drying after each disinfection is with compressed air, not overcoming the pressure of 30 cm3 since you could damage the lenses and perforate the channels. Conclusion: we believe that this information on the knowledge of the endoscope will be good to us to improve the quality, its maintenance and its uses. THIS CAN HAPPEN TO YOU-Emergency situations, problems and solutionGwen E. Kreitzman, Tel-Aviv, Israel When talking about emergency situations in Gastro., we should first consider the different types of emergencies. There are emergency endoscopies: these are unscheduled endoscopies in which the indications render them urgent. We can prepare for the specific exams. We catagorize them : We have the Upper GI bleeders Lower GI bleeders foreign body removals emergency ERCP Caustic ingestion and others We cannot however predict the outcomes, for each case is different just as each patient is different. In my opinion a major difference between scheduled and emergency exams is the inability to be totally prepared. There is no time for patient teaching to lower the anxiety, the patient and his family are stressed. We the staff as prepared and professional as can be are also somewhat stressed. There are also, emergency situations that arise during endoscopy: these are situations that arise just before, during, after or as a result of endoscopy thus requiring immediate intervention. For the past 16 years working in GI endoscopy, I have been involved in educating nurses on various issues concerning Gastroenterological nursing. My main supposition being twofold. One a firm believer in the saying that knowledge is power and two being prepared. For, if something can happen it usually will. Most of my presentation is based on the rich experiences of me and my collegues. In dealing with emergencies we have to be resoursefull. Drawing on our knowledge and experience. Each situation has its own unique solution. We as nurses specializing in the field of endoscopy can share our experiences in order to minimize the element of surprise. Most importantly we should try to keep cool, prepare as best as possible, gathering information and listening to fellow staff members, families ,and patients. THIS CAN HAPPEN TO YOU! Your patient may say to you "Is this the ex-ray dept? I am to do a chest exray" don’t convince him otherwise he may be right but on the otherhand sometimes the patient has mental disorientation and only thinks he should be elsewhere. Education of Patients – the Doctor’s or the Nurse’s Role ? Christiane S. Neumann, City Hospital, Birmingham, B17 9RT, UK e-mail: [email protected]