This document provides an overview of fecal incontinence, including its:
1) Functional anatomy of the rectum and anal sphincter complex
2) Physiology of defecation and the rectoanal inhibitory reflex
3) Causes and risk factors such as aging, neurological diseases, and pelvic floor dysfunction
4) Evaluations including anorectal manometry and endoanal ultrasound
5) Treatments including diet, bowel training, biofeedback, plugs, and medications to reduce stool volume
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding Bowel Incontinence / Fecal Incontinence, and its management. Highly recommended for II B.Sc Nursing Students
science has an evolving nature. what happened today may not be tomorrow, what is not today may happen tomorrow.
No one is complete so reading and thinking may open the door to the hidden ground.
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding Bowel Incontinence / Fecal Incontinence, and its management. Highly recommended for II B.Sc Nursing Students
science has an evolving nature. what happened today may not be tomorrow, what is not today may happen tomorrow.
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Dumping syndrome is a set of a syndrome that can develop after gastric surgery due to rapid delivery of nutrients. Its symptoms can appear either within minutes of a meal or a few hours later. To get a detailed information on this, have a look at the attachment provided.
Overview of Hernias with special emphasis on Inguinal Hernias. Management of obstructed, strangulated hernia, Bassini repair, McVay's repair, Tanner's slide
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Urinary incontinence simply means involuntary leaking of urine.
Incontinence can range from leaking just a few drops of urine to complete emptying of the bladder.
Social and hygienic problem.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
3. The rectum:
• is a hollow muscular tube, 12 to 15 cm long,
composed of a continuous layer of
longitudinal smooth muscle that interlaces
with the underlying circular smooth muscle.
The anal canal
• The length of the anal canal is about 4 cm
(range, 3-5 cm), with two thirds of this being
above the pectinate line (the dentate line)
and one third below it.
4. The anal sphincter complex
• The IAS is a thickened expansion of the circular
smooth muscle of the bowel wall, a
predominantly slow-twitch, fatigue-resistant
muscle that contributes approximately 70% to
75% of the resting sphincter pressure but only
40% after sudden rectal distension and 65%
during constant rectal distension.
• The anus is therefore normally closed by the
tonic activity of the IAS that is primarily
responsible for maintaining anal continence at
rest.
5. • reinforcement during voluntary squeeze by the
EAS (voluntary sphincter) can contribute an
additional 25% of anal squeeze pressure. Because
the EAS is made up of fast‐twitch, fatigable fibers,
this increased tone cannot be maintained over a
prolonged period.
6. • The rectum contains three distinctive
semilunar mucosal folds, which help to
maintain its capacitance.
• The rectum can accommodate up to 300 mL
without any significant increase in
intraluminal pressure.
• Beyond 300 mL of volume, the intraluminal
pressure increases, followed by a feeling of
urgency
7. • The anal mucosal folds 1, together with the
expansive anal vascular cushions2, provide a
tight seal.
• These barriers are further augmented by the
puborectalis muscle 3, which when tonically
contracted forms a flaplike valve that creates a
forward pull and reinforces the anorectal angle.
10. The successful storage and evacuation of fecal
material relies on:
1. normal stool consistency and volume
2. bowel motility
3. rectal compliance
4. intact anal sphincter complex
5. the ability to voluntarily relax the puborectalis
muscle and EAS to facilitate defecation.
6. Intact mental function
11. • The physiology of voluntary bowel evacuation
relies on the rectoanal inhibitory reflex (RAIR).
• When a bolus of fecal material is delivered to
the rectum, increased rectal pressure and
distension causes transient relaxation of the
IAS, allowing a small sample of the rectal
contents to come in contact with the sensory
afferent somatic nerves innervating the
anoderm.
12. • The amplitude and duration of this relaxation
increases with the volume of rectal distension
and is mediated by the myenteric plexus.
• The RAIR facilitates the discrimination of gas,
liquid, or solid fecal material that is present in
the rectum and permits voluntary evacuation
in a socially acceptable manner.
• Once the conscious decision has been made
to permit evacuation, the puborectalis muscle
relaxes, increasing the anorectal angle and
allowing passage of solid fecal material.
14. • Fecal incontinence is defined as the inability to
defer the elimination of liquid or solid stool until
there is a socially acceptable time and place to do
so.
• Anal incontinence includes the inability to defer the
elimination of gas, which may be equally socially
embarrassing.
• Minor incontinence is the inadvertent escape of
flatus or partial soiling of undergarments with liquid
stool.
• Major incontinence is the involuntary excretion of
feces.
15. Prevalence of FI in elderly
After age of 65:
• 15% in community dwelling women
• 45% in nursing home residents
Many patients are embarrassed and do not
report their problem to their physician
16. • Aging has been consistently identified as a major
risk factor for the development of fecal
incontinence:
1. Decreased strength of EAS, Week anal squeeze
2. Decreased resting tone in IAS
3. altered rectal compliance
4. Decreased anal sensation
17. Risk factors
• Significant independent risk factors included:
• age, depression, dementia, neurological
diseases, immobility
• constipation
• Female sex, vaginal parity, and a history of
operative vaginal delivery.
• women with pelvic floor dysfunction (urinary
incontinence and/or pelvic organ prolapse).
23. Change fecal volume and consistency
• Patients with constipation or fecal overload
(e.g., diet, drugs)
• Patients with loose stools or diarrhea from any
cause (inflammatory bowel disease (IBD),
irritable bowel syndrome (IBS), or radiation
proctitis)
24. Altered mental control
• Patients affected by cognitive issues (such as
dementia, learning disabilities)
25. Neurological diseases
• due to:
1. Impaired rectal sensation
2. decreased motor function of the sphincter
complex.
• Patients with neurological disorders (e.g., multiple
sclerosis, spinal cord injury, stroke, DM related
neuropathy etc.),
• extensive straining at stool from constipation
leading to stretching of the pudendal nerves over
the ischial spines as the perineum descends.
26. Pelvic Floor Dyssynergia (Anismus)
• Pelvic floor dyssynergia:
• increase in rectal pressure during attempted
evacuation in conjunction with impaired rectal
emptying.
• women with no identified pelvic floor or colonic
abnormalities, have to resort to the use of enemas
or digital disimpaction to achieve relief.
29. Clinical assessment
• stool diary and clinical features.
• The history should initially focus on
determining:
• whether fecal incontinence is truly present,
and its severity.
• True incontinence must be differentiated
from frequency and urgency without loss of
bowel contents, which can occur in the setting
of inflammatory disease, irritable bowel
syndrome, and pelvic irradiation
30. • determining the onset, duration, frequency, and
severity of symptoms, precipitating events, and
obtaining history of prior vaginal delivery,
anorectal surgery, pelvic irradiation, diabetes,
neurologic disease, and whether symptoms occur
in a background of diarrhea or constipation.
• perineal pain, hematochezia or purulent drainage
(tumors, inflammatory bowel disease, radiation
proctitis, or benign anorectal conditions such as
hemorrhoids or fistula-causing disease) can
elucidate other diagnoses.
31.
32. Physical examination
• Should include a detailed physical and
neurological examination of the back and
lower limbs to evaluate for a systemic or
neurological disorder.
• Digital rectal examination can identify patients
with fecal impaction and overflow but is not
accurate enough for diagnosing sphincter
dysfunction or initiating therapy.
33. • Examine the external anoderm
• Test for an anal wink bilaterally
• Inspect for prolapsing hemorrhoids or other
obvious pathology
• Perform a digital examination while asking the
patient to bear down and to squeeze Having
the patient perform a Valsalva maneuver while
observing the perineum and perianal area may
show evidence of inappropriate perineal
descent, rectocele, cystocele, or rectal or
vaginal prolapse.
34. Investigations
1. Endoscopic evaluation of the rectosigmoid
region
2. Anorectal manometry with rectal sensory
testing
3. Anal endosonography
4. Defecography
5. Balloon expulsion test
6. Pudendal nerve terminal latency
35. 1. Endoscopic evaluation of the rectosigmoid region is appropriate for
detecting mucosal disease or neoplasia that may contribute to
fecal incontinence.
2. Anorectal manometry with rectal sensory testing is the preferred
method for defining the functional weakness of the external or
internal anal sphincter and for detecting abnormal rectal
sensation. Measurement of rectal compliance (reservoir function)
may be helpful in some patients.
3. Anal endosonography is the simplest, most widely available and
least expensive test for defining structural defects in the anal
sphincter and should be considered in patients with suspected
fecal incontinence.
4. Defecography Is useful in patients with suspected rectal prolapse
or those with poor rectal evacuation but is otherwise of limited
value.
5. Balloon expulsion test Can identify impaired evacuation in patients
with fecal seepage or in those with fecal impaction and overflow.
6. Pudendal nerve terminal latency :May be useful in the assessment
of patients prior to anal sphincter repair and is particularly helpful
in predicting the outcome of surgery.
36. Anorectal manometry with rectal
sensory testing
• It is most useful when it reveals an abnormally
low sphincter pressure demonstrating that a
sphincter defect is present.
• Decreased resting pressure suggests isolated IAS
sphincter dysfunction, while decreased squeeze
pressure suggests isolated EAS dysfunction.
• The anorectal inhibitory reflex can be
demonstrated by measuring the amount of
distension required to induce relaxation of the
IAS (typically 20 mL).
37.
38. • Rectal sensation can be assessed by inflating a rectal
balloon to detect the threshold (smallest volume of
rectal distension) for three common sensations:
• the first detectable sensation (rectal sensory
threshold),
• the sensation of urgency to defecate,
• and the sensation of pain (maximum tolerable
volume).
• However, the clinical significance of the last two
thresholds is less well-established than the first since
the rectal sensory threshold is valuable for determining
whether biofeedback will be helpful. Biofeedback is
unlikely to be helpful in patients in whom the rectal
sensory threshold is poor.
39. Pudendal nerve terminal latency
• is determined by measuring the time required
after stimulating the pudendal nerves with an
electrode as it crosses the ischial spine to
induce a contraction of the EAS.
• Normal delay is 2.0 msec;
• prolongation of the PNTL suggests damage to
the nerve.
40. Endorectal ultrasound and magnetic
resonance imaging
• Structural abnormalities of the anal
sphincters, the rectal wall, and the
puborectalis muscle
41.
42. Defecography
• Defecography is performed by instilling a
barium paste into the rectum
• the patient seated on a radiolucent commode.
• films are taken of the anorectal anatomy at
rest and during straining and defecation.
• Defecography can measure the anorectal
angle, evaluate pelvic descent, and detect
occult or overt rectal prolapse.
43. Electromyography
• Electromyography (EMG) activity of the anal
sphincter is helpful in evaluating neurogenic
or myopathic damage
• endorectal ultrasound may have rendered the
EMG obsolete in sphincter mapping because
of the discomfort associated with EMG.
45. Diet and lifestyle
1. Dietary modification is the initial step in the
treatment of incontinence.
– Intake of caffeine and alcohol should be avoided.
– identify foods that cause fecal incontinence, eg,
foodstuffs containing high concentrations of lactose,
fructose, or sorbitol. Elimination of these substances
from the diet may resolve the problem.
– A high-fiber diet and bulking agents should be tried
(The recommended daily allowance for fiber is 25 g)
– Try to drink 2 to 3 liters of fluid a day
46. 2- Control fecal impaction
• For the frail elderly and cases with neurologic
disorders, fecal impaction is often the cause for
overflow diarrhea and incontinence. In this subset
of patients, osmotic laxatives and bowel retraining
is effective treatment for incontinence in
approximately 60%.
• control soiling from fecal incontinence using
diapers
47. Bowel training
1. Keeping to a regular pattern is very important for a
bowel retraining program to succeed.
2. Set a regular time for daily bowel movements.
Choose a time that is convenient for you.
3. Keep in mind the daily schedule.
4. The best time for a bowel movement is 20 to 40
minutes after a meal, because feeding stimulates
bowel activity.
5. privacy can help
6. use digital stimulation to trigger a bowel
movement:(You can also stimulate bowel
movements by using a suppository (glycerin or
bisacodyl) or a microenema).
48. • After the stimulation, patient sit in a normal
position for a bowel movement. (on the toilet or
bedside commode). If confined to the bed, use a
bedpan. Get into as close to a sitting position as
possible. If unable to sit, lie on her left side.
• If no bowel movement within 20 minutes, repeat
the process.
• Instruct her to contract the muscles of the
abdomen and bear down while releasing the
stool. bend forward while bearing down. This
increases the abdominal pressure and helps
empty the bowel.
• Perform digital stimulation every day until the
patient start to have a regular pattern of bowel
movements.
49. 3- Anal sphincter and pelvic floor
exercises
• Anal sphincter exercises and pelvic floor
muscle training consists of repetitive
contractions of the sphincter and perineal
muscles,
50. BIOFEEDBACK
• A rectal plug is used to detect the strength of the rectal
muscles. A monitoring electrode is placed on the
abdomen.
• The rectal plug is then attached to a computer monitor.
• A graph displaying rectal muscle contractions and
abdominal contractions will show up on the screen.
• patient will be taught how to squeeze the rectal muscle
around the rectal plug. The computer display guides her
to do it correctly. the symptoms should begin to improve
after three sessions.
• Used when sphincters are structurally intact but week.
51. • There are three general mechanisms by which
biofeedback may improve fecal incontinence:
• Improved contraction of the striated muscles
of the pelvic floor
• Enhancement of the ability to perceive rectal
distension
• Improved coordination of the sensory and
strength components that are required for
continence
52. Sacral nerve stimulation
• Sacral nerve stimulation has been used to
treat patients with incontinence who have an
intact anal sphincter.
• Electrical stimulation increases squeeze
pressure of the external sphincter.
• Two reports of the long-term results of sacral
nerve stimulation suggest that there is a clear
improvement in the symptoms in patients
with fecal incontinence
53. anal continence plug
• is a polyurethane sponge wrapped in a water soluble
coat. The size of the plug outside the body is 15 mm by
30 mm.
• After placement in the rectum, the water-soluble coat
dissolves and the plug expands to 30 mm by 38 mm.
• The number of episodes of stool leakage and fecal
incontinence was reduced substantially when the plug
was worn, and patients felt more secure.
• The plug was inserted for an average of 12 hours per
day, and continence was achieved 82% of the time.
54. Pharmacologic treatment
• goal of drug therapy is to reduce the fecal
volume:
1. increased intestinal water and ion absorption
2. slowed motility.
55. Loperamide
• an opiate agonist.
• In addition to increasing absorption and slowing
motility, loperamide increases internal anal
sphincter pressure and diminishes the drop in
sphincter pressure associated with rectal
distention
• 2 mg four times a day is the usual starting dose.
56. Ion exchange resins
• Ion exchange resins such as cholestyramine
and colestipol may be very effective in
decreasing diarrhea and incontinence.
• Cholestyramine, 2 to 4 gm twice daily adjusted
to bowel habits. Colestipol, 1 to 2 gm twice
daily adjusted to bowel habits.
57. • Anticholinergic agents (such as hyoscyamine )
taken before meals may be helpful in patients who
tend to have leakage of stools after eating.
• low doses of the tricyclic
antidepressant amitriptyline for idiopathic fecal
incontinence. increase in colonic transit time.
• Phenylephrine gel , a selective alpha 1 adrenergic
agonist, increases internal anal sphincter tone
58. • Stool consistency can be improved by
supplementing the diet with a bulking agent
(such as methylcellulose 1 to 2 tablespoons per
day).
• This is particularly helpful in patients who
have low-volume, loose stools, but may
exacerbate incontinence in patients with
decreased rectal compliance (such as those
with radiation proctitis or a rectal stricture).
59. Surgical treatment
1. Sphincteroplasty (Sphincteroplasty is the preferred
treatment of an isolated tear in the external sphincter. The
most common cause of reparable injury is obstetrical
trauma.)
2. Muscle transposition (gracilius or gluteus muscle
transposition)
3. Artificial sphincter (for neurologic or muscular dysfunction
of the sphincter) An inflatable cuff is placed around the anal
canal. A pressure-regulating balloon is placed in the
abdominal cavity, with the pump control mechanism placed
subcutaneously. Pressure on the control mechanism will
decompress the cuff, allowing for defecation. The cuff
reinflates spontaneously after several minutes
4. Diversion colostomy (Diversion colostomy is indicated after
failure of all other therapies).
60. sphincter bulking therapies
• Injectable materials to augment the function
of the internal anal sphincter.
• Collagen injection
• Silicone biomaterial
• Carbon-coated microbeads
• Dextranomer-hyaluronic acid (Solesta)
• Stem cells (under trial)