WELL, FROM THE ULTIMATE
TO THE SUBLIME...ENEMAS.

THAT'S JUST WHAT
WE'RE DOING TODAY.

YOU KNOW, YOU GOT TO,
KIND OF...
- EBB AND FLOW.

- EBB AND FLOW THROUGH
THE STRESS LEVELS

AND SO THIS ISN'T EXACTLY HIGH
STRESS AND SO THAT'S GOOD.

WHAT WE NEED TO DO IS
TALK ABOUT SOME DIFFERENT KINDS
OF STOOL SPECIMENS.

WE'LL DO THAT FIRST.
AND THEN WHAT WE'RE GOING TO
DO AS FAR AS TESTING GOES,

THERE'S TWO PASS-FAILS
JUST TO TALK TO...

SPECIMEN COLLECTION
AND SOME ENEMA TYPES.

WE'LL TALK ABOUT
SOME ENEMA TYPES

AND THEN YOU'RE GOING TO GIVE
TWO DIFFERENT KINDS OF ENEMAS.

ONE IS JUST KIND OF
A MECHANICAL,

YOU'RE GOING TO GO THROUGH THE
DRILL, BUT SKIP THE WATER PART

AND JUST KIND OF DO IT,
BUT NOT DO IT,

BECAUSE MY MANNEQUINS
WILL EXPLODE IF YOU DO.

AND THEN WE'RE GOING TO DO
ANOTHER ONE WITH WATER BECAUSE
IT WORKS.

SO WE'RE GOING TO DO A CLEANSING
ENEMA, A HARRIS FLUSH

AND THEN TALK THROUGH
SOME PASS-FAIL SKILLS.

SO YOU'LL BASICALLY
BE DOING TWO ENEMAS --

SHOOT. I FORGOT.
I DON'T HAVE A STETHOSCOPE.

RYAN, WOULD YOU DO ME A FAVOR
AND GO ASK CONNIE FOR A
STETHOSCOPE?

I HAD IT THERE ABOUT THREE
TIMES, I GOT DISTRACTED
LOOKING AROUND.

ALRIGHT.

LET'S TALK ABOUT
SPECIMEN COLLECTION.

WE DO COLLECT SPECIMENS,
STOOL SPECIMENS.

AND WHEN YOU COLLECT
A STOOL SPECIMEN,

IT'S NICE IF YOU
CAN HAVE THE CLIENT

SEPARATE URINE FROM STOOLS
SO YOU CAN JUST GET
THE STOOL SEPARATELY.

THEY CAN DO THAT
BEDPAN-WISE, URINATE,

USE A URINAL, URINATE AND THEN
USE A BED PAN IF THEY CAN AND
THEN YOU HAVE IT SEPARATE.

ON A COMMODE IF YOU CAN HAVE
THEM SEPARATE THE TWO, GREAT.

BUT IT'S KIND OF HARD BECAUSE
THE BODY'S NATURAL INSTINCT
PERISTALSIS WISE IS THAT

YOU'RE URINATING AND
RELIEVING URINE AND

YOUR BODY KIND OF NATURALLY
RELAXES AND PERISTALSIS STARTS

AND THEN YOU'RE DEFECATING AND
YOU'VE GOT TWO PRODUCTS THERE.

SO IT JUST DEPENDS ON WHAT
YOU'RE COLLECTING
YOUR STOOL FOR,

IF THEY CAN BE MIXED
A LITTLE BIT.

BUT IF YOU CAN SEPARATE IT,
IT'S A LITTLE EASIER.

IF THEY CAN GET UP
AND GO TO THE BATHROOM,

THEN WHAT YOU NEED TO DO IS GET
TWO OF THE POTTY HATS
WE TALKED ABOUT

AND YOU HAVE ONE FACING
FORWARD,

THAT WOULD BE THE URINE AND
THEN TAKE THE OTHER ONE AND
FACE IT BACKWARDS

AND HOPEFULLY THAT'LL CATCH
THE STOOL AND THEN YOU'LL HAVE
YOUR TWO SPECIMENS.

ONCE YOU GET A SPECIMEN,
YOU NEED TO GET A --

LIKE A TONGUE BLADE
OR A SPOON,

A PLASTIC DISPOSABLE
SPOON OR SOMETHING.

AND THEN WHAT YOU WANT TO DO IS
SCOOP UP TWO TEASPOONS WORTH.

AND IF YOU CAN, IT'S NICE IF YOU
CAN PUT THEM IN THESE,
OPAQUE CONTAINERS

COS NO ONE LIKES
TO LOOK AT IT.

I MEAN, RIGHT?
SO YOU PUT IT IN THERE,

LABEL IT, AN ICE-CREAM
CONTAINER, MMM!

NICE SURPRISE, YEAH.

LABEL IT UP, PUT IT IN
YOUR BIO-HAZARD BAG
AND SEND IT OFF.

IF YOU CAN'T FIND ONE OF THESE
NICE, OPAQUE CONTAINERS,

THEN YOU CAN USE A REGULAR,
SPECIMEN CONTAINER
AND PUT THEM IN.

THERE'S NOTHING SPECIAL
OTHER THAN YOU CAN'T
SEE THROUGH HERE

AND THAT'S --

CONNIE WASN'T AVAILABLE,

SO SOMEBODY JUST WAS THERE
AND SHE WENT AND GOT ONE.

- THIS WILL GET THE JOB DONE.
- I FIGURED IT WILL WORK.

OKAY.

ANOTHER KIND OF SPECIMEN
THAT WE COLLECT

IF THEY ALLOW YOU AND THIS
DEPENDS TOTALLY ON
HOSPITAL POLICY,

ARE STOOLS FOR GUAIAC
OR STOOLS FOR OCCULT BLOOD. OB

WHAT DOES THAT MEAN? OCCULT?

SOMETHING TO DO WITH A CULT.

- OCCULT.
- HIDDEN.

THE HIDDEN DARK THINGS.

YOU HERE THAT IN THE SPIRITUAL
WORLD. OH, THE OCCULT.

BECAUSE IT'S HIDDEN.
IT'S DARK.

AND IT'S THE SAME THING WITH
STOOL. IT'S THE HIDDEN BLOOD.

THE OCCULT BLOOD, OB.

AND THEN GUAIAC IS THE OTHER
THING THEY'LL SAY.

AND THEY'LL SAY STOOL FOR OB
TIMES THREE. GUAIAC TIMES THREE.

AND WHAT THAT MEANS IS YOU
GET A STOOL SPECIMEN

AND IT'S EITHER IN THE BEDPAN
OR THE POTTY HAT
OR WHEREVER. GLOVES.

OKAY, YOU TAKE A LITTLE
STICK LIKE THIS

AND THESE ARE PROVIDED WITH
THESE HEMOCCULT SLIDES

AND THAT'S THE THIRD TERM,
HEMOCCULT, WHICH IS
HIDDEN BLOOD.

COULDN'T POSSIBLY BE TOM, WHO
SAYS, "DON'T TURN YOUR PHONES
ON FOR MY VIDEOTAPE."

WE'LL BE CUTTING THIS
PART RIGHT HERE.

OKAY. OH, PLEASE
CUT THAT PART.

I'LL DIE. OKAY.

YOU'RE GOING TO GET IN
HERE WITH YOUR STICKS

AND YOUR HEMOSLIDE, YOUR
HEMOSCREEN TO GET BLOOD.

AND YOU'RE GOING TO TAKE
ONE END OF THIS STICK

AND SCOOP A LITTLE
BIT OF STOOL.

YOU'RE GOING TO OPEN THE
FRONT OF THE SLIDE

AND IN THE FRONT OF THE
SLIDE ARE TWO SCREENS.

YOU'RE GOING TO PUT THE STOOL
AND SMEAR IT ON ONE SCREEN.

THEN YOU'RE GOING TO GO TO
THE OTHER SIDE OF THE STICK --

I'VE BEEN SPINNING IT SO MUCH
I DON'T KNOW WHICH ONE I USED.

BUT YOU'RE GOING TO GO TO
ANOTHER PART OF THE STICK

AND ANOTHER PART OF THE STOOL,

SCOOP ANOTHER PART AND SMEAR
IT ONTO THE SCREEN.

THRASH, CLOSE IT.

NOW, SOME OF YOUR HOSPITALS
WILL HAVE YOU SEND IT TO
THE LAB LIKE THIS,

BUT SOME WILL LET
YOU CHECK IT.

SO WHAT YOU DO THEN IS OPEN
UP THE BACK OF THE SCREEN

AND IF IN DOUBT READ
THE DIRECTIONS.

OPEN IT UP AND THEN YOU
GET HEMOCCULT DEVELOPER,

HEMOSCREEN DEVELOPER AND YOU
HAVE TO GET THE RIGHT
BRAND TO MATCH,

MAKE SURE IT HASN'T EXPIRED.

AND THEN WHAT YOU DO IS YOU
DROP ONE DROP ONTO EACH
OF THE SLIDE AREAS

AND YOU SEE IF IT TURNS BLUE.

IF IT TURNS BLUE,
THEN IT'S POSITIVE FOR BLOOD

AND IF IT DOESN'T, IT'S NOT.

AND YOU CAN TELL
THE COLOR OF BLUE IT IS

BY YOUR TEST STRIP
DOWN AT THE BOTTOM.

IF IT'S NEGATIVE THERE
IS NO COLOR CHANGE,

BUT IF IT IS POSITIVE IT
IS THAT COLOR OF BLUE.

AND SO I'LL PASS THAT AROUND
SO YOU CAN LOOK AT IT.

SOME DON'T ALLOW YOU TO DO
IT BECAUSE THEY WANT IT
TO BE A LAB VALUE

AND THAT'S ALL THERE IS TO IT.

WHEN YOU GO THEN TO DOCUMENT
YOU'LL SAY,

STOOL FOR GUAIAC POSITIVE
OR NEGATIVE AND THAT'S ALL.

IT'S NOT SO MUCH POSITIVE
OR SO MUCH NEGATIVE.
IT EITHER IS OR ISN'T.

- HOW DO YOU SPELL GUAIAC?

- G-U-I..

G-U-I-A-C. SEEMS LIKE THERE
SHOULD BE ANOTHER U IN THERE.

- THAT DOESN'T SEEM CORRECT.
- G-U-I-A-C. YEAH.

OKAY, SOMETIMES THE DOCTOR
STILL WANTS TO CHECK FOR

THE BLOOD IN THE STOOL, BUT THE
CLIENT'S GOING TO GO HOME.

SO YOU MAY SEND YOUR CLIENT HOME
WITH THREE OF THESE STRIPS
LIKE THIS.

AND YOU GIVE HIM THE SAME EXACT
INSTRUCTIONS THAT I GAVE YOU.

SEND HIM WITH STICKS, TELL HIM
TO TAKE TWO PARTS OF THE STOOL

AND SMEAR IT AND CLOSE IT.

AND THEN WHEN THEY FINALLY
HAVE THREE STOOL SPECIMENS

THEN THEY TAKE THIS SLIDE INTO
THE LAB AND THE LAB
WILL TEST IT.

YOU DON'T SEND THEM EVER HOME
WITH THE HEMOCCULT DEVELOPER

TO CHECK THEIR OWN,
BUT THEY CAN COLLECT THEM.

THERE'S NO TIME-FRAME,
BLOOD DOES NOT BE BLOOD

IN THREE DAYS OR
A WEEK OR WHATEVER.

THAT'S JUST WHAT THEY DO.

SOMETIMES, ELDERLY PEOPLE --

I'M KIND OF GETTING INTO THAT
AGE GROUP, NOT ME,
BUT MY PARENTS NOW.

LIKE FOR STOOL TO
CHECK FOR BLOOD,

THE INSURANCE COMPANIES WILL
SEND THEM SLIDES LIKE THIS PRIOR
TO COLONOSCOPIES

OR TO BE CHECKING PRIOR TO DOING
CANCER CHECKS OR SO FORTH.

AND SO THEY'LL SEND THESE SLIDES
SO THAT WE CAN BE CHECKING.

AND THEN THIS IS HEMOCCULT
DEVELOPER FOR THIS PARTICULAR
BRAND,

SO YOU JUST WANT TO
MATCH THEM UP.

AND THAT'S ALL YOU NEED
TO DO FOR THAT.
I THINK THAT'S A PASS-FAIL.

THERE IS ANOTHER INTERESTING
ONE THAT SHOWED UP A COUPLE
OF YEARS AGO

IN ONE OF THE NEO-NATAL
NURSERIES IN THE COMMUNITY.

SO IF YOU FIND SOMETHING NEW
ASK THEM IF I CAN HAVE IT.

BUT WHAT THIS IS,
IS ALSO TO CHECK FOR STOOL --

FOR BLOOD IN THE STOOL AND YOU
HAVE TO GET THESE LITTLE FILTER
PAPERS.

THEY COME LIKE THIS
WITH TABLETS.

YOU TAKE ONE OF THE LITTLE
FILTER PAPERS OFF,

YOU GET A STOOL SPECIMEN AND YOU
SMEAR IT ONTO THE FILTER PAPER.

THEN YOU GET A TABLET
FROM IN HERE.

IF I GET ONE. I DON'T LIKE
TO TOUCH THEM.
GLOVES WOULD BE COOL.

YOU GET A TABLET AND YOU PUT THE
TABLET ON TOP OF THE STOOL,

THEN YOU GET DISTILLED WATER

AND YOU DROP A DROP ONTO
THE TABLET,

THEN YOU DROP ANOTHER DROP

SO THAT THE WATER RUNS OFF
THE TABLET AND FINALLY
HITS THE STOOL.

THEN YOU HAVE TO KIND OF TAP
IT TO MAKE SURE THAT IT -

IS THIS THE MOST RIDICULOUS
THING YOU'VE EVER HEARD OF?

BUT EVENTUALLY AFTER TAPPING AND
DROPPING AND TAPPING
AND DRIBBLING

AND ALL OF THESE DIRECTIONS ARE
WONDERFULLY ON HERE FOR YOU.

IF IT TURNS BLUE ON THE FILTER
PAPER THEN YOU HAVE
A POSITIVE GUAIAC.

WHY WOULD ANYONE PICK THIS
OVER THIS?

IT'S BEYOND ME, BUT WHATEVER.

THAT'S WHAT THEY WERE USING IN
THE NURSERY AND THE STUDENTS
WERE LIKE,

"HAVE YOU EVER SEEN
SUCH A THING?"
AND I WAS LIKE, "NO."

- IS IT LESS EXPENSIVE?

I HAVE NO IDEA. I DON'T SEE HOW
IT COULD BE THAT MUCH LESS
EXPENSIVE

BECAUSE YOU'RE PAYING
FOR TABLETS AND PAPER.

YOU KNOW THEY ARE GOING TO
CHARGE YOU. I DON'T KNOW,

BUT ANYWAY I'LL LEAVE
THAT OUT.

HERE I'LL JUST PASS IT AROUND
AND YOU CAN HAVE A LOOK AT
THE LITTLE DIRECTIONS ON THEM.

OKAY.

WHAT OTHER STOOL SPECIMENS NOT
ON YOUR TEST? STOOL FOR O&P,

WHAT IS THAT?

OVA AND PARASITES.

WE CHECK FOR THOSE FREQUENTLY
ESPECIALLY, PEOPLE
THAT HAVE TRAVELED

OUT OF THE CONTINENTAL
UNITED STATES,

YOU MIGHT BE CHECKING
FOR PARASITES.

SO WHEN YOU DO A STOOL
FOR PARASITES,

YOU COLLECT HOWEVER MUCH THEY
NEED FOR THAT SPECIMEN.

SOMETIMES THEY WILL
NEED THE WHOLE STOOL.

THEY WON'T JUST WANT TWO
TEASPOONS, SO, YOU NEED
TO CHECK WITH THE LAB

WHEN YOU'RE GETTING
SPECIMENS FOR THAT.

ESPECIALLY, IF THEY'RE LOOKING
FOR SOMETHING IN PARTICULAR.

WHEN YOU DO A STOOL
FOR OVA AND PARASITES

WHAT DO YOU THINK ABOUT
REFRIGERATING VERSUS
NOT REFRIGERATING?

REFRIGERATE?

KILL THEM.

THEY WANT TO SEE
THE LIVE ONES.

SO, NO REFRIGERATION, GET
IT STRAIGHT TO THE LAB.

ALRIGHT, ANOTHER INTERESTING
PARASITE THAT WE CHECK FOR

THAT'S VERY, VERY COMMON
IS PINWORMS.

VERY, VERY COMMON ESPECIALLY
IN LARGE COMMUNITIES,

IN PRISONS, WHERE YOU
AROUND A LOT OF DIRT

AND WHERE THERE IS A LOT OF
ANIMALS.

A LOT IN THE SCHOOL SYSTEM
BECAUSE THEY'RE VERY,
VERY CONTAGIOUS.

THEY -- THE PARASITE GETS
IN FROM YOUR MOUTH,

NOSE USUALLY, FROM THE DIRT,
FROM FINGERNAILS

AND THEN THE CLIENT COMPLAINS OF
INTENSE ITCHING IN THEIR RECTUM.

WHAT HAPPENS IS THESE LITTLE
THREAD LIKE WORMS COME OUT AT
NIGHT TIME,

OUT OF THE ANAL AREA AND THEY
ITCH, ITCH, ITCH, ITCH,

SCRATCH, SCRATCH, SCRATCH,
SCRATCH.

THEY LAY ABOUT 10,000
EGGS A NIGHT EACH.

AND IF YOU SEE A WHOLE BUNCH OF
THE THREADY LITTLE WORMS --

I HAVE VISIONS.
MY CHILDREN HAD THEM. OOH

AND SO THEY SCRATCH
AND I JUST --

I COULD SEE THIS VISUAL OF JUST
EGGS ALL OVER MY HOUSE.

AND SO WHAT THEY DO CHECK -- I
MEAN, I SAW THE LITTLE WORMS,
RIGHT?

SCOTCH TAPE IS WHAT THEY DO.

I SAW THE WORMS, SO I DIDN'T
HAVE TO DO ANYTHING.
I MEAN, THEY WERE THERE.

BUT THEY'RE -- YOU'RE NOT
SURE, THEY'RE COMPLAINING
OF INTENSE ITCHING.

THEY HAVE YOU TAKE A PIECE OF
SCOTCH TAPE IN THE MORNING,

STICK IT TO THE RECTUM AND
THEN TAKE THE TAPE IN

BECAUSE ALL THE LITTLE
EGGS STICK TO THE TAPE.

AND THEN THEY WILL
DIAGNOSE FROM THAT.

WHEN SOMEBODY HAS PINWORMS
EVERYONE IN THE FAMILY HAS
TO BE TREATED,

LITTLE RED CHEW TAB TURNS
EVERYTHING RED. IT'S GREAT.

AND THEN -- IT'S AN INTENSE
CLEAN UP, IT'S KIND OF
LIKE HEAD LICE.

IT'S THE SAME THEORY AS
FAR AS CLEAN UP GOES.

A LOT OF VACUUMING, PILLOWS HAVE
TO BE BAGGED, LINEN BAGGED,

EVERYTHING WASHED IN AMMONIA,
VACUUM, VACUUM, CLEAN, CLEAN.

SOCKS ON LITTLE KIDS HANDS

SO THEY DON'T SCRATCH, KIND OF
THING, SO THEY DON'T GET UNDER
THE NAILS.

MAKE SURE PEOPLE WEAR
UNDERWEAR,

TIGHT UNDERWEAR SO IT --
I MEAN, NOT TO CUT OF
CIRCULATION,

BUT NOT LIKE BOXER KIND OF
THINGS. YOU KNOW WHAT I MEAN.

SO THAT IT TRAPS THE EGGS.

SO THAT'S FUN.

ALRIGHT. I THINK THAT'S
ENOUGH ON SPECIMENS.

LET'S TALK A LITTLE
BIT ABOUT ENEMAS.

THERE'S LOTS OF KINDS OF
ENEMAS.

AN ENEMA ISN'T JUST AN ENEMA,
YOU JUST DON'T PUT
WATER IN THEM.

WE'RE DOING THAT, OKAY.

SO WHAT KIND AND WHY ARE
YOU PUTTING IT IN?

THERE'S A LOT OF REASONS
WHY WE DO ENEMAS

AND A LOT OF DIFFERENT
KINDS OF ENEMAS.

SO I'VE GIVEN YOU --

I JUST LOVE THIS LITTLE
SHEET THAT I FOUND

THAT BASICALLY SUMMARIZES THE
FOUR DIFFERENT KINDS OF ENEMAS

AND THE VOLUMES OF ENEMAS
THAT WE GIVE.

BEFORE I GET INTO THE KINDS OF
ENEMAS AND WHY WE GIVE THEM,

I WANTED TO TALK ABOUT THE
KINDS OF SOLUTIONS

THAT WE WOULD PUT IN AN ENEMA.

AND BASICALLY, I WANT TO TALK
A LITTLE PATHOPHYSIOLOGY HERE.

HYPER, HYPO AND
ISOTONIC SOLUTIONS

THAT WE WOULD PUT INTO A
CLIENT.

IF YOU'RE GOING TO
PUT A SOLUTION

AND A COMMON SOLUTION
OR A COMMON ENEMA

THAT WE DO IS CALLED
THE CLEANSING ENEMA.

NOW, CLEANSING ENEMA
IS JUST THAT.

WE'RE TRYING TO GET STOOL OUT
AND WE'RE TRYING TO CLEANSE
THE BOWEL.

EITHER AS A BOWEL PREP SO
THAT THEY CAN DO A TEST

OR BECAUSE THEY'RE CONSTIPATED
OR IMPACTED OR SOMETHING.

WHEN WE DO A CLEANSING ENEMA

IT'S VERY COMMON THAT
WE GIVE A SALINE ENEMA,

NORMAL SALINE TO CLEANSE.

WHAT KIND OF SOLUTION
IS NORMAL SALINE?

IS IT HYPO? HYPER? ISO?
- ISO.

ISOTONIC. IT'S NORMAL
BODY FLUID.

SO WHAT HAPPENS IF YOU WERE TO
PUT IN AN ISOTONIC SOLUTION,

FOR EXAMPLE, IN A CLEANSING
ENEMA ON AN ADULT

WE CAN PUT UP TO ABOUT 1,000 CC
OF FLUID INTO THE RECTUM AREA.

IF YOU PUT THAT ISOTONIC
SOLUTION INTO THE VALVE,

- WHAT'S IT DOING
TO THE VALVE?
- IT'S DISTENDING.

IT'S DISTENDING IT.
DILATING IT. IRRITATING IT.

SO THAT IT WILL COS
PERISTALSIS.

DOES THE BODY ABSORB THE
ISOTONIC SOLUTION?

- NO.
- NO.

IT JUST GOES IN BECAUSE
IT'S NORMAL BODY FLUID.

IRRITATES, DILATES AND HOPEFULLY
THE STOOL WILL COME OUT.

SOMETIMES, WHAT WE USED TO DO
AND YOU STILL WILL SEE
ORDERED PERIODICALLY

IS WHAT IS CALLED THE TAP WATER
ENEMA AND THEY WILL SAY, TWE.

TAP WATER ENEMAS TO CLEAR
OR ENEMAS TO CLEAR

PRIOR TO SURGERY OR SOME EXAM.

- WHAT KIND OF A SOLUTION
IS TAP WATER? - HYPO.

HYPOTONIC. SO YOU LOAD UP THE
RECTUM WITH A HYPOTONIC
SOLUTION.

WHERE DOES THAT GO?

- IN THE BODY.
- INTO THE BODY BECAUSE

- WHAT DOES THE SALTS OF THE
BODY DO?
- ABSORB.

DRAWS THE HYPO
OR THE LESSER SOLUTION TO IT.

SO IF WE LOAD UP THE
BODY WITH ONE ENEMA,

ALRIGHT, PROBABLY NOT TOO BAD.
WE LOAD IT UP WITH TWO

BECAUSE IT'S STILL NOT CLEAR
WHEN THE ENEMA
COMES BACK, RIGHT.

I SAID TAP WATER ENEMAS
TO CLEAR.

WE GIVE AN ENEMA
AND STOOL COMES OUT,

BUT THERE'S STILL STOOL COMING
SO WE GIVE HIM ANOTHER ENEMA AND

STILL WE'RE SEEING FLECKS
OF BROWN STUFF
AND BROWN COLORING.

HOW MANY OF THOSE ENEMAS DO YOU
SUPPOSE WE CAN LOAD
SOMEONE UP WITH

BEFORE THEY BEGIN TO GET WHAT
WE CALL WATER INTOXIFICATION?

THEY BEGIN TO ABSORB SO MUCH
WATER THAT NOW THEY BECOME ILL.

SO WE HAVE A LIMIT OF ISO..

THE HYPOTONIC SOLUTIONS
THAT WE CAN GIVE

AND TYPICALLY NO MORE
THAN THREE.

ALRIGHT, YOU ALSO WANT TO MAKE
SURE THAT YOUR CLIENT
IS APPROPRIATE

FOR A TAP WATER ENEMA

AND THAT YOU WOULDN'T WANT
SOMEONE WITH CONGESTIVE
HEART FAILURE

GETTING A TAP WATER
ENEMA, RIGHT?

THEY ALREADY HAVE
CONGESTION PROBLEMS.

YOU MENTIONED ASCITES OR

YOU'RE GOING TO GIVE SOMEONE
THAT HAS LIVER FAILURE,
KIDNEY FAILURE,

NO, THAT'S NOT APPROPRIATE
FOR THEM.

SO YOU WANT TO BE THINKING ABOUT
NOT ONLY WHY YOU'RE DOING IT,

BUT WHAT YOU'RE DOING IT WITH.

WHAT'S THE SIDE EFFECTS
FOR THE CLIENT. ALRIGHT,

FINALLY WE HAVE A THIRD
TYPE OF SOLUTION

WHICH IS CALLED THE HYPERTONIC
SOLUTION WHICH WOULD BE WHAT?

- IT'S HYPERTONIC. -
HYPERTONIC WHICH..

- DRAWS WATER OUT THE BODY INTO
THE COLON.
- BUT WHAT'S IN IT?

- SALTS.
- SALTS. A LOT MORE SALTS.

IT'S TYPICALLY CALLED THE SALINE
ENEMA VERSUS NORMAL SALINE.

SO MAKE SURE YOU CLARIFY WHAT
KIND OF ENEMA YOU'RE GIVING,

NORMAL SALINE VERSUS SALINE
BECAUSE OF THOSE SALTS.

WHEN YOU DO A SALINE ENEMA,

IT'S A HYPERTONIC SOLUTION.
WHAT IS IT GOING TO DO?

- DRAW WATER OUT OF THE BODY.
- DRAW WATER FROM THE BODY
INTO IT,

SO WHO WOULD NOT BE A GOOD
CANDIDATE FOR THAT?

- DEHYDRATED.
- A DEHYDRATED CLIENT.

YOU WANT TO BE THINKING
ABOUT THAT.

THE NICE THING ABOUT THE SALINE
ENEMA IS THAT THEY
CAN BE SMALL VOLUME,

RIGHT? YOU'RE NOT GOING TO
LOAD SOMEONE UP WITH A 1,000 CC
OF SALTY WATER

SO THAT THEY CAN DRAW
MORE SALTY WATER.

YOUR POOR CLIENT.
THAT WOULD BE HORRIBLE.

SO THE ADVANTAGES OF WHAT
THEY TYPICALLY CALL
THE FLEET'S ENEMA,

THAT'S THE TRADE NAME,

BUT THE GENERIC NAME IS
THIS IS A SALINE ENEMA.

IS THAT YOU CAN USE A SMALL
AMOUNT, IT'S GOING TO DRAW
BODY FLUIDS TO IT,

THAT'S GOING TO DILATE
THEN IRRITATE THE BOWEL
AND THEY HAVE TO GO.

ALRIGHT, SO CLEANSING.

WE TALKED ABOUT THE TYPE.
LET'S TALK ABOUT HOW
WE WOULD USE THEM.

TO CLEANSE THE ENEMA BASICALLY
WE'RE LOOKING TO IRRITATE
THE COLON,

THE RECTUM BY DISTENDING IT

AND THEN HELP THEM
EVACUATE STOOL.

THERE IS A LOT OF DIFFERENT
KINDS.

WE TALKED ABOUT
TAP WATER, SALINE,

NORMAL SALINE, WHICH WOULD
BE MY PICK OF THE THREE,

BUT THE LAST KIND THAT'S
ON YOUR LIST HERE

THAT I WANTED TO TALK ABOUT
WAS THE SOAP SUDS ENEMA.

REMEMBER WHEN I TALKED ABOUT
SHAMPOOING THE HAIR?

AND THAT WE DON'T DO
SOAP SUDS VERY MUCH

AND YOU CAN STEAL THE LITTLE
CASTILE SOAPS OUT OF THE BUCKET.

THAT'S WHAT I WAS TALKING ABOUT.
IT LOOKS LIKE THIS.

AND WHAT WE DO IS WE GET OUR
ENEMA BAG OR ENEMA BUCKET,

FILL IT UP WITH WATER AND THEN
ADD ONE LITTLE PACKET
OF SOAP SUDS

AND THAT GIVES A LITTLE
MORE IRRITATION.

IT'S A MILD, MILD SOAP, BUT IT
IRRITATES THE BOWEL A LITTLE
BIT MORE

SO THAT IT WILL GET RID
OF THE STOOL.

THESE ARE REAL OLD ONES
THAT HAVE KIND OF DRIED UP,

THIS WHAT REAL CASTILE
SOAPS SHOULD LOOK LIKE.

SO IF YOU SEE THESE KIND, YOU'RE
KIND OF GOING...OLD.

BUT THAT'S THE SOAP FROM THEM.

ALRIGHT, THERE IS ANOTHER
KIND OF ENEMA THAT WE DO

AND IT'S CALLED THE
RETENTION ENEMA.

THE RETENTION ENEMA IS
WHEN WE GIVE SOMETHING

FOR A SPECIFIED
AMOUNT OF TIME,

IT'S SOMETHING THAT THEY'RE
GOING TO RETAIN.

IT CAN BE SO THAT THEY CAN
GET NUTRIENTS FROM
THAT PARTICULAR SOLUTION

OR IT COULD BE TO
SOFTEN STOOL.

THE MOST COMMON THAT I HAVE USED
IS AS FAR AS A RETENTION ENEMA

WOULD BE OIL RETENTION ENEMA.

FOR EXAMPLE, YOU HAVE SOMEONE
THAT'S VERY, VERY CONSTIPATED

AND OFTEN WHAT WE'RE ALLOWED TO
DO IS CALLED DIGITALLY
EVACUATE THE STOOL.

HONESTLY, IT'S NOT THAT BAD.

I DON'T LIKE SPUTUM, SO I DON'T
MIND DOING ALL THESE OTHER
LITTLE THINGS.

BUT YOU DOUBLE GLOVE
YOUR HAND,

YOU PUT SOME K-Y JELLY
ON YOUR INDEX FINGER

AND IF THEY'RE THE APPROPRIATE
CLIENT -- I'LL TALK ABOUT
THAT IN JUST A MINUTE.

YOU TAKE YOUR FINGER UP
INTO THE RECTUM

AND YOU ROTATE AROUND THE INSIDE
OF THE RECTUM TRYING TO
STIMULATE BOWEL MOVEMENT

AND THEN YOU USE YOUR FINGERS

TO PULL THE BOWEL OUT WHAT
YOU CAN REACH.

WELL, SOMETIMES -- I MEAN,
EVEN IN SPITE OF A DIGITAL
EVACUATION

YOU CAN'T EVEN REACH
THE STOOL.

IT'S SO HIGH AND ITS SO HARD
UP THERE AND IT'S LIKE YOU CAN'T
GET TO IT

AND THEY'RE MISERABLE.
SO WHAT DO WE DO?
WHAT ARE OUR OPTIONS?

WELL, YOU CAN TRY
A CLEANSING ENEMA,

BUT WHAT YOU MIGHT WANT TO DO IF
THE STOOL IS REALLY, REALLY HARD

IS TO DO AN OIL
RETENTION ENEMA

SO THAT YOU CAN SOFTEN THE STOOL
AND GIVE HIM THE SLIPPERY
SLIDE OUT.

SO OIL RETENTION ENEMAS COME
IN A FLEET SIZED CONTAINER
LIKE THIS

AND IT'S JUST EXACTLY THAT.
MINERAL OIL,

YOU PUT IT IN THE RECTUM AND
THEN YOU TELL HIM TO HOLD IT
FOR ABOUT THREE HOURS

AND IT JUST ABSORBS,
ABSORBS, ABSORBS

AND THEN SOFTENS AND SLIDES,
WOULD BE THE GOAL.

ALRIGHT, THAT'S A FUN ONE, BUT
YOU NEED TO REMEMBER THAT.

OKAY, AND THEN FINA--
THERE'S TWO OTHERS.

THE DISTENSION REDUCTION,
THE CARMINATIVE
AND THE RETURN FLOW.

THE CARMINATIVE IS ACTUALLY
PUTTING IN SOME SOLUTIONS

THAT HELP EXPEL FLATUS IS
WHAT WE'RE TRYING TO DO.

PEOPLE THAT HAVE A LOT
OF GAS POST SURGERY,

A LOT OF YOU GALS THAT HAVE HAD
BABIES, IT'S LIKE, "OH BABY."

YOU KNOW, GAS, GAS BECAUSE YOUR
BOWELS ARE ALL STIRRED UP.

AFTER SURGERY -- IF YOU GET
TO WATCH SOME SURGERIES,

THE ABDOMINAL SURGERIES,
THEY OPEN UP THE ABDOMEN

AND THEY ARE GOING FOR
SOMETHING ELSE

BUT THEY PLOP ALL THOSE BOWELS
OUT TO GET TO STUFF

AND BOWELS KIND OF GET STIRRED
UP AND SO THEN THE PERISTALSIS
GETS DISTURBED

AND THEY DON'T GO AND THEY BUILD
UP GAS, IT'S MISERABLE.

SO SOMETIMES WE CAN GIVE AN
ENEMA THAT WILL HELP RELIEVE
THE GAS.

ONE OF THE KINDS OF ENEMAS THAT
WE'RE GOING TO GIVE IS A HARRIS
FLUSH ENEMA.

AND WHAT THAT IS, IS YOU PUT
A LITTLE SOLUTION INTO
YOUR ENEMA BUCKET

AND YOU INSTILL SOME SOLUTION
INTO THE CLIENT.

AND THEN WITHOUT TAKING THE
TUBING OUT OF THEIR RECTUM

YOU LOWER LIKE A SIPHON,
THE BUCKET BELOW THEM

AND LET THE WATER
COME BACK OUT.

AND HOPEFULLY THAT WILL
PULL OUT THE GAS.

AND THEN YOU RAISE THE BUCKET
AND PUT THE SOLUTION BACK IN

AND THEN YOU LOWER
AND RAISE AND LOWER

AND GET ALL THE STUFF GOING.

BUT HOPEFULLY THAT WILL
STIMULATES SOME PERISTALSIS

AND THAT HELPS MOVE GAS OUT
AND GET THEM GOING

SO WE'RE GOING TO DO ONE OF
THOSE AND I'LL TALK A LITTLE
MORE ABOUT THAT.

FINALLY, THE LAST KIND OF ENEMA
IS THE MEDICATED ENEMA.

AND WE CAN PUT.. IT'S KIND OF
LIKE IF YOU HAVE AN ORIFICE
OF THE BODY

THEY CAN PUT SOMETHING IN IT
AND TAKE SOMETHING OUT OF IT.

BUT THEY FOUND THAT, THAT NEW
MUCOSAL MEMBRANE ABSORBS
MEDICATION WELL.

IN PARTICULAR A CLIENT
THAT MIGHT HAVE AN
ELEVATED POTASSIUM,

WE MIGHT NEED TO GET
THAT POTASSIUM DOWN.

WHAT'S THE PROBLEM IF YOUR
POTASSIUM GETS TOO HIGH?

- YOU GUYS TALKED ABOUT THAT
IN PATHO AND STUFF?
- HEART ATTACKS.

HEART ATTACKS, HEART PROBLEMS,
MUSCULAR PROBLEMS.

SO IF POTASSIUM IS HIGH,
IT CAN BE CRITICAL

AND WE GOT TO GET THAT
POTASSIUM LOW.

AND ONE OF THE WAYS THEY
FOUND WORKED IS IF WE PUT
A PRODUCT CALLED

KAYEXALATE. K BEING POTASSIUM
RIGHT, KAYEXALATE IT.

SO IF YOU PUT A MEDICATED ENEMA
YOU GET THEM FROM PHARMACY

AND YOU PUT THE MEDICINE IN
AND HAVE THEM RETAIN IT,

IT WILL DRAW TO ITSELF THE
POTASSIUM AND HELP LOWER
THE POTASSIUM.

AND SO AGAIN ANOTHER
USE FOR THE ENEMA.

NEOMYCIN ANTIBIOTIC SOLUTIONS,
AFTER VALVE SURGERIES,
AND SO FORTH.

ALSO AT THE TOP OF THIS
PARTICULAR SHEET IT HAS
THE VOLUMES

THAT YOU WOULD GIVE TO CLIENTS

BECAUSE OBVIOUSLY YOU
WOULDN'T GIVE THE SAME AMOUNT
TO AN INFANT AS AN ADULT,

BUT WE'LL BE GIVING TO AN ADULT
SO YOU CAN KEEP THAT MINDSET.

- ALRIGHT.
- WITH THE ELDERLY
WOULD THE AMOUNTS CHANGE?

- WE'RE GOING TO TALK ABOUT
THAT.

THERE ARE A LOT OF VARIABLES
IN GIVING AN ENEMA.

I JUST WANTED TO COVER BASICALLY
THAT PARTICULAR AMOUNT
OF INFORMATION.

ON THE BACKSIDE OF YOUR PAPER,

I GAVE YOU SOME
CRITICAL THINKING

BECAUSE AN ENEMA ISN'T
JUST AN ENEMA.

ITS NOT JUST, "OH, HERE'S SOME
WATER, YOU'RE GOING TO PUT IT IN

AND ALL IS GOING TO GO WELL AND
THEY ARE GOING TO HAVE A STOOL.

OH, IF IT WERE ONLY
THAT SIMPLE.

THINGS HAPPEN AND SO WE'VE
ADDED A CRITICAL THINKING
COMPONENT

TO THIS PARTICULAR EXAM.
WHAT YOU'RE GOING TO DO IS --

RIGHT NOW WE'RE JUST GOING TO GO
ON TO THAT CLEANSING ENEMA

AND TALK THROUGH SOME THE
ASPECTS OF ASSESSMENT AND WHAT
YOU'RE GOING TO DO.

BUT TOWARDS -- WHEN YOU'RE
GIVING THE ENEMA PART,

WE'RE GOING TO GIVE
YOU A CARD LIKE THIS.

AND I'M GOING TO FAN THEM OUT,
THEY WILL BE ALL BLANK
ON THIS SIDE,

ON ONE SIDE AND YOU GET
TO PICK YOUR FATE.

AND YOU WILL PICK SOMETHING AND
SOMETHING IS GOING TO HAPPEN

RELATED TO YOUR ENEMA BECAUSE
THEY DON'T JUST GO IN.

BUT I DIDN'T WANT IT TO
BE SO HARD THAT YOU HAD
TO JUST WING IT

AND SO THESE ARE THE
THINGS THAT HAPPEN

THAT ARE JUST A WHOLE
LOT OF FUN.

I WISH SOMEONE HAD GIVEN ME
THAT SHEET WHEN
I HAD STARTED ENEMAS

BECAUSE THEY JUST
HAPPENED TO ME.

SO WE WILL TALK ABOUT THOSE
WHEN WE GET TO THEM.

ALRIGHT, SO, THE FIRST ENEMA
THAT I AM GOING TO HAVE YOU DO

IS AGAIN THE CLEANSING ENEMA

AND WE CAN CONSIDER OURS
A TAP WATER ENEMA.

WE'RE JUST GIVING A TAP WATER
ENEMA, SO THAT'S WHAT WE'RE
GOING TO GIVE.

PRIOR TO GIVING AN ENEMA

YOU WANT TO MAKE SURE THAT YOUR
CLIENT IS A CANDIDATE FOR AN
ENEMA.

FOR ONE. WHO WOULD NOT BE
A CLIENT FOR AN ENEMA?

- SURGERY? - RECTAL SURGERY

- AND ANOTHER REALLY IMPORTANT
ONE, THERE ARE OTHERS BUT
- COLOSTOMY?

WELL, COLOSTOMY, IF --
YEAH. YEAH.

- BECAUSE THEY WOULDN'T
REALLY HAVE A RECTUM.
- AN ULCERATED VALVE, MAYBE?

YEAH.

HEART PATIENTS.

- CAUSES BRADYCARDIA.

- CAUSES BRADYCARDIA.

THE VAGAL NERVE, VAGAL
STIMULATION IS IN THE RECTUM.

SO THAT'S WHY REMEMBER WE
TALKED ABOUT RECTAL TEMPS,

YOU DON'T DO THOSE ON HEART
CLIENTS, RECTAL STIMULATION.

SAME THING. IF YOU GOT A HEART
CLIENT AND THEY ARE
CONSTIPATED,

ENEMAS ARE NOT YOUR METHOD
OF CHOICE HERE.

YOU'RE GOING TO BE GIVING
THEM A LAXATIVE.

YOU'RE GOING TO BE DOING
A LOT OF OTHER THINGS,

BUT YOU'RE NOT GOING TO BE
STIMULATING THE RECTUM.

BECAUSE -- WHAT IS THE
VALSALVA MANEUVER?

WHAT IS THE VAGAL NERVE?
WHAT HAPPENS?

- THEY DON'T EXHALE.

THEY BRADY DOWN.
THE VAGAL -- THE NERVE
STIMULATION

CAUSES THEIR HEART
TO SLOW DOWN.

WE DON'T WANT THAT, SO.

MAKE SURE THAT YOUR CLIENT
IS AN APPROPRIATE CANDIDATE
FOR AN ENEMA.

IT IS ALSO GOOD TO KNOW
WHY THEY'RE GETTING IT.

AND AGAIN IF IT IS ENEMAS TO
CLEAR YOU'RE GOING TO LIMIT
YOUR AMOUNT

THAT YOU'RE GOING TO GIVE.

YOU WANT TO LOOK AT YOUR
CLIENT'S PAST AND PRESENT
ELIMINATORY STATUS.

YOU WANT TO KNOW WHEN WAS
YOUR LAST BOWEL MOVEMENT

AND HOW OFTEN DO YOU
HAVE BOWEL MOVEMENTS.

I MEAN, SOME PEOPLE DON'T GO
BUT EVERY TWO OR THREE DAYS,

SOME GO TWICE A DAY,
MOST GO AT LEAST ONCE A DAY.

BUT YOU WANT TO FIND OUT
WHAT THEY NORMALLY DO,

YOU WANT TO LOOK AT THEIR DIET.
YOU WANT TO LOOK AT THEIR
ACTIVITY LEVEL.

YOU WANT TO GET A GOOD
SET OF VITAL SIGNS

BECAUSE ANYBODY, WHETHER THEY
HAVE A HEART PROBLEM OR NOT,

IF THEY HAVE VAGAL STIMULATION
CAN HAVE THE SIDE-EFFECT

OF THE VAGAL NERVE ACTIVITY
AND HAVE SOME BRADYCARDIA

SO WE WANT TO MAKE SURE THAT WE
HAVE A PULSE BEFORE WE DO THAT.

AND FINALLY -- WELL,
THERE'S A COUPLE MORE HERE
I OBVIOUSLY FORGOT.

YOU WANT TO CHECK WHEN THEIR
BLADDER WAS EMPTIED LAST AFTER
THE BED PAN

BECAUSE IF YOU'RE FILLING
UP THE BOWEL

AND THEY HAVE ALREADY
GOT A FULL BLADDER,

THEY WON'T BE ABLE TO TOLERATE
AS MUCH LIQUID.

YOU WANT TO ASSESS THEIR
CURRENT MEDICAL REGIMEN.

WHY WOULD YOU WANT TO DO THAT?

MEDS? LOOKING AT THEIR MEDS.

THEY'RE ON A DIURETIC ALREADY?

DIURETIC, MAYBE,
BUT THINK STOOL.

- A PAIN MEDICINE.

PAIN MEDICINE. WHAT KIND OF
MEDICINES ARE CONSTIPATING THEM?

AND WE TALKED ABOUT
LIKE YOUR DARVOCET,

ANY NARCOTIC. I KEPT
SAYING AT MY STATION.

SIDE-EFFECTS. SIDE-EFFECTS.

BECAUSE THEY WORK ON
THAT SMOOTH MUSCLE AND THEY
GET CONSTIPATED.

SO IS THIS ENEMA FOR NOT

OR ARE WE GOING TO HAVE TO
KEEP FOLLOWING UP AS FAR AS
THE BOWEL REGIME.

SO LOOK AT THEIR MEDS, SEE
WHAT'S CAUSING THE PROBLEM

AND SEE IF YOU CAN HELP THEM.
LOOK AT THEIR DIET HISTORY.

HOW ARE THEY EATING,
DO THEY GET ENOUGH ROUGHAGE,
DO THEY HAVE ENOUGH FLUIDS.

WHAT'S THE PROBLEM? OR IS THIS,
KIND OF, WHO THEY ARE.

AND THEN FINALLY, THE LAST THING
ON YOUR SHEET SAYS THAT,

SEE HOW MUCH THEY
CAN TOLERATE?

THIS IS WHEN WE, KIND OF,
RESPOND TO YOUR QUESTION.

YOU WANT TO ASK THE CLIENT
IF THEY HAVE EVER HAD
AN ENEMA BEFORE

AND HOW MUCH FLUID
COULD THEY HAVE IN.

WELL, ENEMAS AREN'T THAT
COMMON OF A TREATMENT.

I MEAN, WHEN WAS YOUR
LAST ENEMA, YOU KNOW?

SO IF THEY HAVEN'T
THEY WILL KNOW.

MY GRANDMOTHER TAKES ONE
EVERYDAY I FOUND OUT,
YOU KNOW.

AND SO SHE KNOWS EXACTLY
WHAT SHE CAN TOLERATE.

BUT IF YOU ASK ME, I'LL BE,
LIKE, "HECK IF I KNOW, YOU
KNOW".

SO IT GIVES YOU KIND OF A
POINT OF REFERENCE
IF THEY DO KNOW

AND THEN OTHERWISE WE'RE
JUST GOING TO GUESS.

BUT WE'RE GOING TO CHECK ONE
OTHER THING PHYSICALLY

WHEN WE DO OUR ASSESSMENT TO SEE
WHAT'S GOING TO HAPPEN

BECAUSE IF THEY DON'T TOLERATE
IT, IF THEY DON'T HAVE GOOD
SPHINCTER CONTROL,

YOU'RE PUTTING IT IN
AND IT'S SQUIRTING OUT.

AND THAT'S A MESS.

OKAY, SO WE'VE ASSESSED
OUR CLIENT AS FAR AS
GETTING PREPARED.

SO NOW WE'RE GOING TO.. WE'VE
CHECKED THE DOCTOR'S ORDERS

AND OUR CLIENT CARE PLAN
AND BOY,

IF YOU'RE THE NURSE THAT
GAVE AN ENEMA YESTERDAY,

GIVE THE NURSE FOR TOMORROW
A HEAD'S UP

SO THAT THEY KNOW THEY ONLY
CAN TOLERATE 500 CC,

NO SPHINCTER CONTROL,
PUT HIM ON A BED PAN,

GET HIM TO THE BATHROOM
POSTHASTE. GIVE THEM A CLUE,
SO IT'S NOT, YOU KNOW, SABOTAGE

AND HOPEFULLY YOU WILL LIKE
YOUR STAFF OR MAYBE YOU
WOULDN'T WANT TO.

RIGHT, NOW. OKAY, YOU'RE GOING
TO GATHER UP YOUR EQUIPMENT

AND THIS IS WHAT YOUR EQUIPMENT
IS GOING TO BE.

FIRST, YOU NEED AN ENEMA BAG.

WHEN YOU GET YOUR ENEMA BAG
FROM YOUR CENTRAL SUPPLY CART,

IT'S CLEAN AND SO YOU CAN
HANDLE IT WITHOUT GLOVES.

YOU WANT TO OPEN IT UP,
MAKE SURE IT'S ALL INTACT.

YOUR WATER IS GOING TO COME
IN HERE AT THE TOP.

YOU HAVE A TUBE THAT LOOKS
VERY MUCH LIKE A FEEDING BAG

AND THEN YOU HAVE
A SLIDE CLAMP.

THE TUBE IS GOING TO GO INTO
THE RECTUM ABOUT FOUR INCHES.

SO YOU WANT TO MAKE SURE THAT
THE SLIDE IS DOWN HERE
CLOSE ENOUGH TO

WHERE ITS GOING TO GO INTO THE
RECTUM THAT YOU CAN GET
TO THE SLIDE CLAMP

AND KEEP YOUR HAND HERE
TO HOLD IT IN PLACE

SO THEY DON'T SQUIRT OUT
AT THE END OF THE TUBE.

SO I AM GOING TO GO AHEAD AND
CHECK THIS AND THEN CLOSE
MY SLIDE CLAMP

BEFORE I PUT THE WATER IN.

I'VE GATHERED UP WATER.

AND FOR THE FIRST ENEMA YOU'RE
GOING TO PUT IN ABOUT 750
TO 1000 CC.

SO YOU CAN GET
THAT MUCH FLUID.

AND YOU WANT IT TO BE ABOUT
A 105 TO 110 DEGREES.

HAVE YOU SEEN ANY THERMOMETERS
AT YOUR INSTITUTION?

I HARDLY EVER SEE THEM. ONCE
I DID AND I WAS LIKE,
"OH, WOW."

SO YOU'RE GOING TO CHECK IT
WITH YOUR WRIST AND MAKE SURE
IT'S NICE AND WARM.

YOU DON'T WANT IT TOO HOT

BECAUSE YOU DON'T WANT
TO BURN THEM BECAUSE...

MOST OF YOUR HOT WATER HEATERS
ARE PRE-SET AT THE HOSPITAL
BECAUSE THEY DON'T WANT PEOPLE
GETTING BURNT.

BUT CHECK IT AND MAKE SURE
IT'S NICE AND WARM.

OKAY, I HAVE MY WATER. I'M GOING
TO HAVE A BED PAN NEARBY.

MAKE SURE YOU HANDLE THOSE BED
PANS WITH GLOVES, RIGHT.

YOU'VE ALREADY USED THEM AND
HAD THEM ON THERE, SO.

PUT THEM ON A BARRIER.
I NEED LOTS OF CHUCKS.

I NEED TO BE PREPARED
FOR CLEANING.

SO, I HAVE A TOWEL
AND A WASH CLOTH

AND I ALSO HAVE K-Y JELLY...
SOMEWHERE.

WELL, I DID HAVE K-Y JELLY.

K-Y JELLY. K-Y JELLY,
A LUBRICANT.

NEED A STETHOSCOPE TO LISTEN TO
BOWELS, YOU NEED A BATH BLANKET

AND YOU NEED AN IV POLE
TO HANG YOUR BAG ON.

SO, WE PUT IV POLES
BY ALL THE BEDS.

YOU WILL HAVE TO GATHER
THE REST OF YOUR STUFF.

OKAY.

WASHED MY HANDS.

GOOD MORNING, MR. CURRY,
I THINK.

MR. CURRY, I HAVE AN ENEMA
FOR YOU.

I HEARD YOU WERE REALLY
CONSTIPATED AND THIS WILL HELP.

ALRIGHT.

PRIVACY.

HAVE YOU EVER HAD
AN ENEMA BEFORE?

YOU HAVEN'T.

WELL, HOPEFULLY IT'S
NOT PAINFUL.

ALL I'M GOING TO DO IS PUT
A TUBE INTO YOUR RECTUM

AND THEN I'M GOING TO
INSTILL SOME WATER

AND YOUR RECTUM WILL START
FEELING FULL LIKE YOU'VE
GOT TO GO.

AND WHAT I WANT YOU TO DO IS
TELL ME IF DURING THE PROCESS

YOU HAVE ANY CRAMPS
AS IT'S GETTING FULL.

AND THEN I'LL STOP BECAUSE
I DON'T WANT YOU TO
BE TOO MISERABLE

THAT YOU CAN'T HOLD THE WATER IN
AND GET TO THE BATHROOM.

ARE YOU GETTING UP AND GOING
TO THE BATHROOM OKAY?

ALRIGHT, SO THAT WILL BE OUR
GOAL, TO GET TO THE BATHROOM.

AND THE OTHER THING I NEED
TO LET YOU KNOW IS THAT

I NEED YOU TO LAY ON YOUR LEFT
SIDE FOR THIS PROCEDURE.

BECAUSE WE GET SOME BETTER
RESULTS IF WE PUT YOU ON
YOUR LEFT SIDE.

DO YOU HAVE ANY QUESTIONS?

ALRIGHT, BEFORE YOU TURN ON YOUR
LEFT SIDE, DON'T TURN YET.

I DO WANT TO ASSESS YOUR ABDOMEN
AND GET VITAL SIGNS.

SO, THAT'S WHAT YOU WILL DO.

BECAUSE WE'RE DOING ANOTHER
DRILL WITH THE OTHER SEMESTER,

I DON'T HAVE THE BOWEL SOUNDS IN
AND I WISH I DID, BUT WE DON'T.

SO LET'S GO AHEAD AND GET AN
ABDOMINAL ASSESSMENT HERE.

WELL, I'M GOING TO JUST GO
AHEAD AND COVER YOU UP.

A BATH BLANKET WOULD BE
A GOOD CHOICE ON THIS.

SOMETIMES I JUST USE MY
SHEETS FOR PRIVACY,

BUT WHEN YOU'RE
DOING AN ENEMA,

THIS IS AN UNKNOWN ENTITY HERE

AND I'M GOING TO PROTECT THE
LINEN AS BEST AS POSSIBLE,

OR DO IT BEFORE YOUR
LINEN CHANGE.

ALRIGHT, ABDOMINAL ASSESSMENT.
WE'RE GOING TO EXPOSE
OUR ABDOMEN

AND SORRY, WE HAVE OSTOMIES
GOING SECOND SEMESTER.

IT'S BOWEL WEEK IN THE LAB.

SO, WE'RE GOING TO HAVE STOOL
AND BOWEL AND IT WILL BE FUN.

ALRIGHT, WE'RE GOING
TO FIRST..

-- WHAT'S THE FIRST THING YOU DO
FOR ABDOMINAL ASSESSMENT?
- INSPECTION.

INSPECT ALWAYS. SO WE'RE GOING
TO LOOK AT THE CONTOUR,

WHICH IS THE SHAPE WE'RE
LOOKING FOR. DISTENSION,
WHETHER IT'S CONCAVE.

WE'RE LOOKING FOR SYMMETRY,
WHICH WE LOOK FOR BY COMING
DOWN TO THE BASE.

WE LOOK FOR ANY SCARS,
LESIONS, DISCOLORATIONS.

INTERESTING, PEOPLE THAT ARE
REALLY CONSTIPATED, SOMETIMES
YOU CAN SEE BOWEL

LIKE A LITTLE LOOP OF
WHERE IT'S CONSTIPATED AND
KIND OF SITTING THERE.

ALRIGHT, SO WE'RE GONG
TO INSPECT AND WHAT'S
THE SECOND THING WE DO?

- OSCULTATE.

WE'RE GOING TO OSCULTATE.

OBVIOUSLY I DON'T HAVE THEM
IN AND YOU CAN'T HEAR EITHER.

WE'RE GOING TO START IN THE
RIGHT LOWER QUADRANT.

WHY?

- BECAUSE YOU TOLD US TO.
- BECAUSE I TOLD YOU TO.

"COS DIANE SAID."

BECAUSE IT'S WHERE THE
ILEOCECAL VALVE IS

AND THAT'S WHERE YOU'RE MOST
LIKELY TO HEAR BOWEL SOUNDS.

SO WE START RIGHT LOWER.

OBVIOUSLY IT'S NOT LIFE OR DEATH
OR THAT BIG A DEAL WHERE
YOU START.

BUT IT'S KIND OF NICE TO
HEAR THE BOWEL SOUNDS.

A MINUTE PER SECTION BEFORE YOU
CAN CLAIM NO BOWEL SOUNDS.

AND THEN FINALLY WE
WOULD PALPATE LIGHTLY,

WHICH IS JUST BARELY QUARTER
OF AN INCH TO SEE IF THERE IS
ANY TENDERNESS, PAIN,

IF YOU CAN FEEL THE BOWEL
GAS DISTENSION, AND SO FORTH.

ALRIGHT.

WELL...

MR. CURRY IF YOU COULD GO AHEAD
AND TURN OVER ON YOUR LEFT SIDE
THAT WOULD BE GREAT.

AND HE JUST DOES.
HE JUST ROLLS RIGHT OVER.

ALRIGHT, NOW IT'S NICE
IF THEY CAN COME A LITTLE
BIT TOWARDS YOU.

SO THAT YOU DON'T HAVE
TO REACH SO FAR.

LEAN ON THERE. THANK YOU.

OKAY.

YOU'RE GOING TO EXPOSE
THEIR BOTTOM HERE.

GOING TO LOAD THEM UP. THE
CHUX.

AFTER ABOUT THE SECOND OR THIRD
ENEMA ON THE MANNEQUINS,

EVEN THOUGH YOU WOULD NEVER
LEAVE YOUR CLIENT LAYING
ON A BLUE PAD, RIGHT?

NEVER. HOLD THAT THOUGHT.

PLEASE LEAVE A BLUE PAD
UNDERNEATH OUR MANNEQUINS
BECAUSE THEY LEAK.

AND WE'RE JUST GOING TO
BE IN A PUDDLE OF WATER
BY THE END OF THE DAY.

WHEN YOU'RE LOOKING, LISTENING
AND FEELING THE ABDOMEN,

WHAT ARE THE CONTRAINDICATIONS
TO CONTINUING WITH THE
PROCEDURE?

- WELL...
- I MEAN THEY ARE CONSTIPATED.

THERE AREN'T REALLY.
IF THEY HAVE --

IF THEY'RE TENDER YOU MIGHT HAVE
MORE TROUBLE WITH CRAMPING

SO THAT'S GIVING YOU AN
INDICATION AT THIS POINT

THAT YOU MIGHT NOT BE ABLE
TO DO AS MUCH FLUID
AS YOU'D LIKE.

BUT BASICALLY WE'VE ALREADY
ADDRESSED OUR CONTRAINDICATIONS.

SO IF THEY'RE CONSTIPATED,
WE'RE JUST GOING TO
GIVE IT A WHIRL.

I DON'T REALLY HAVE ONE --
- SO YOU JUST KIND OF
DO IT FOR FLUID?

I'M DOING IT SO
THAT I'LL BE ABLE TO ASSESS
THE RESULTS AFTERWARDS.

DID THE DISTENSION GO DOWN?

DID IT GET MORE DISTENDED?
DID THEY RETAIN THE FLUID?

IT'S GIVING ME A POINT OF
REFERENCE FOR EFFECTIVENESS

OR NOT EFFECTIVE AFTER
I GAVE THE ENEMA.

ALRIGHT.

ON YOUR SHEET..

- DID I ASTERISK, HAVE
A BED PAN NEARBY?
- NO.

I SHOULD'VE. THERE'S NOTHING
THAT'S REALLY..

- IS THERE ANYTHING ASTERISKED
ON THERE IN ENEMAS?
- LEFT LATERAL..

- OH, LEFT LATERAL SIMS. OKAY.
- OH NO YOU DID. IT'S SAYS
THERE BED PAN.

- BED PAN IS IT ASTERISKED?
- YES IT IS, 22.

HAVE A BED PAN NEARBY.

IT'S NOT LIKE CRITICAL LIFE AND
DEATH. IT'S A CRITICAL MESS.

OKAY, AND THIS IS WHAT I MEAN BY
NEARBY. I MEAN HERE.
I MEAN, LIKE, HERE.

I DON'T MEAN, LIKE, OVER HERE
OR IN THE DRAWER.
I MEAN, LIKE, HERE.

ALRIGHT, LET'S ALSO TALK ABOUT
LEFT LATERAL SIMS.
WHY LEFT VERSUS RIGHT?

WHY WOULD I MARK
THAT AS CRITICAL?

- BECAUSE THAT'S THE WAY
THE INTESTINE --

YES, THE INTESTINE. OKAY,

FIRST OFF, YOU KNOW, YOUR
ANAL OPENING HERE,

THE INTESTINE GOES KIND
OF STRAIGHT THERE FOR A BIT,
THE IMMEDIATE OPENING.

- BUT THEN WHAT HAPPENS TO
THE BOWEL?
- SHARP TURN.

- SO IF YOU TURN THIS WAY, WHERE
IS THE WATER GOING TO GO?
- DOWN.

DOWN AND IT WILL STAY IN
VERSUS IF IT'S UP,

THE WATER IS GOING TO TEND
TO WANT TO COME DOWN.

SO THAT'S WHY IT'S IMPORTANT
THAT WE GO LEFT,

LATERAL SIMS BEING
KIND OF STRAIGHT

AND THAT'S ONE LEG OVER THE
OTHER CROSSED TO HOLD
POSITION THERE.

CAN YOU REMOVE THE BLANKET
SO WE CAN SEE?

THERE. HOW IS THAT?
- PERFECT.

- ALRIGHT, WE MUST KEEP
MODESTY FOR THE FILM.

ALRIGHT.

CLEAN IF YOU NEED TO CLEAN.
AND ALSO...

I'VE GOT TO GET MY BAG
RIGHT HERE.

I'M GOING TO DOUBLE
GLOVE MY RIGHT HAND.

ALRIGHT, LET'S GO AHEAD
AND FILL THIS UP.

AND I DO WANT YOU TO
FILL THIS UP.

I JUST DON'T WANT YOU TO
PUT IT IN THE CLIENT.

JUST SO THAT YOU CAN PRACTICE
WORKING THESE CLAMPS

AND HANDLING THE STUFF,

HAVING A LITTLE SPILL
AND A LITTLE SQUIRT..

..AND SO FORTH.

OKAY, MY GOAL HERE IS THAT

I WANT THE BAG TO BE NO MORE
THAN 12 TO 18 INCHES ABOVE
THE ANUS.

SO, I'M ABOUT 12, IT CAN
PROBABLY GO A LITTLE BIT
HIGHER GRAVITY WISE.

REMEMBER THAT YOUR ADJUSTMENTS
GOING TO BE ACCORDING
TO HOW HIGH YOUR BED IS,

JUST BECAUSE THE POLE'S
ONE WAY,

YOU CAN ADJUST BASED
ON BED HERE.

ALRIGHT, THE OTHER THING I
WANT TO DO IS GO AHEAD

AND PRIME THE TUBING AND JUST
GET ALL THE AIR OUT JUST

BECAUSE IT'S A NICE THING
TO DO.

AND THEN -- OH, CATCH.
OH, IT'S SO SLIPPERY.

AND THERE WE GO.

OKAY.

GO AHEAD AND PUT K-Y JELLY.

WE HAVE A LOT OF DIFFERENT KINDS
OF MANNEQUIN LUBRICANTS

THAT WILL HAVE ALPS ANDSILICON
STUFF, BUT K-Y IS FINE FOR THIS.

AND I'M JUST GOING
TO COVER THE END.

A LOT OF THEM AREPRE-LUBRICATED
WHEN YOU GET THEM OUT
THE FIRST TIME,

OUT OF THE PACKAGE AND THEY
HAVE A LITTLE CATH ON THEM

SO THAT WILL GET THE JOB
DONE FOR YOU AS WELL.

ALRIGHT, THE NEXT THING
I WANT TO DO

IS I WANT TO CHECK FOR
SPHINCTER CONTROL.

SO, I'M GOING TO DO A LITTLE
DIGITAL EXAM HERE.

PUT A LITTLE K-Y ON MY FINGER
AND THEN I'M GOING TO TELL
THE CLIENT.

"I'M GOING TO PUT MY
FINGER IN YOUR RECTUM

AND HAVE YOU BEAR DOWN A
LITTLE BIT SO I CAN SEE

IF YOU GOT GOOD SPHINCTER
CONTROL TO HOLD THIS ENEMA IN."

IT ALSO GIVE ME THE OPPORTUNITY
TO SEE IF THERE IS STOOL THERE.

SO, I AM GOING TO PULL UP
THE UPPER GLUTEUS HERE.

AND THEN WHEN YOU LOOK AT THE
ANUS YOU WANT TO MAKE SURE

THAT THERE AREN'T HEMORRHOIDS OR
SORES BECAUSE, OH, HOW PAINFUL.

IF YOU'VE NEVER SEEN
A HEMORRHOID BEFORE

AND DON'T KNOW WHAT
ONE LOOKS LIKE,

COMING OUT OF THE ANUS ARE
LIKE THESE LITTLE RED PEAS,

OR LITTLE RED GRAPE SIZE.

IT CAN BE EVEN LARGER
THAN THAT,

BUT THEY'RE LITTLE FLAPS
LIKE SKIN TAGS, LIKE,

COMING OUT AND SO IT DOESN'T
MAKE THIS NICE SPHINCTER
LOOK HERE.

THEY'RE VERY ITCHY.
THEY'RE VERY PAINFUL.

AND SO YOU WANT TO BE CAREFUL
NOT TO POKE ON THEM.

SO, MOVE THOSE OUT OF THE WAY
AND STICK YOUR FINGER IN HERE.

AND USUALLY THAT'S NOT
PARTICULARLY PAINFUL, ONE FINGER

UNLESS THEY HAVE SOME PROBLEM
GOING DOWN THERE,

BUT YOU JUST FEEL AROUND AND
THEN ASK THEM TO BEAR DOWN.

SO YOU CAN SEE IS THEIR
SQUEEZE THERE.

ARE THEY GOING TO BE ABLE
TO HOLD THIS ENEMA IN.

IF THEY DON'T...

THAT'S HOW I AM DOING
MY ENEMA.

BECAUSE YOU NEED IT THIS WAY,
NOT UPSIDE DOWN, TO CHECK.

ALRIGHT, SO THEN ONCE
I DO THAT

THEN I CAN REMOVE MY GLOVE AND
HAVE TWO CLEAN HANDS HERE.

YOU DO HAVE TO HAVE AN ORDER TO
DIGITALLY DISIMPACT SOMEONE.

YOU CAN'T JUST DO IT.

BECAUSE IT'S INVASIVE EVEN
THOUGH THEY MAY NEED THE RELIEF.

- ALRIGHT.
- DO YOU NEED AN ORDER FOR
AN ENEMA?

- OH, YES.

YOU'RE GOING TO OPEN UP
THE RECTUM HERE

AND I'M GOING TO PUT THIS
IN ABOUT FOUR INCHES

AND THEN I'M GOING TO HOLD IT.

ALRIGHT.

AT THIS POINT YOU'RE JUST
GOING TO TALK THROUGH.

I DON'T WANT YOU TO PUT THE
WATER IN BECAUSE LIKE I SAID

WE HAVE RESERVOIRS IN THEM RIGHT
NOW, BUT THEY WON'T THAT MUCH.

YOU'RE GOING TO OPEN THIS UP

AND YOU'RE GOING TO PUT THE
FLUID IN. YOU'RE GOING
TO WATCH IT GO IN.

MY BACKS KIND OF TO YOU.
BUT YOU WATCH IT GO IN

AND YOU WANT IT TO GO IN OVER
ABOUT FIVE MINUTES OR SO,

ABOUT FIVE TO SEVEN, KIND
OF, A THING, SLOW.

ALL THE WHILE ASKING THEM, "HOW
ARE YOU DOING? ARE YOU HAVING
ANY CRAMPS?"

IF THEY'RE HAVING CRAMPS,

SLOW IT DOWN AND IF THE CRAMPS
AREN'T RESOLVED, THEN STOP

AND SEE IF THEY CAN GET
THEIR COMPOSURE OR RELAX.

AND SO THE CRAMPS WILL STOP.

AND THEN IF THE CRAMPS STOP,

YOU WANT TO TRY AND PUT IT
IN A LITTLE MORE,
PUT IN A LITTLE MORE.

ALRIGHT, IT'S AT THIS POINT --

MY HAND IS STILL ON THERE.

HOLDING, HOLDING, HOLDING,

THAT WE WILL COME UP TO YOU
AND YOU WILL DRAW YOUR FATE.

OKAY, SO LET'S JUST TALK ABOUT
SOMETHING THAT HAPPEN.

OH, THIS IS A GOOD ONE.

CLIENT EXPELS SOLUTION
PREMATURELY.

YOU'RE PUTTING THE ENEMA IN,

BUT THE ENEMA STARTS COMING
OUT. WHAT DO YOU DO?

GOGGLES.

- GOGGLES.
- YOU GET THEM ON
THAT BED PAN QUICKLY.

LEAVE THE TUBE IN, RIGHT.

BECAUSE IF THEY'RE NOT
GOING TO RETAIN IT,

YOU CAN HAVE THE TUBE IN..

OOPS CAN YOU LIFT UP
A LITTLE MR. CURRY.

YOU'RE ON YOUR TUBE.
THERE YOU GO.

YOU CAN HAVE THE TUBE IN

AND THEN YOU JUST KEEP
THE ENEMA GOING.

AND AT LEAST THEY'LL GET A RINSE
AND SOME STIMULATION.

AND THEN YOU CAN FINISH UP THE
ENEMA IF YOUR BED PAN
WILL HOLD IT.

IT WILL PROBABLY BE BETTER
TO HAVE THE BIGGER BED PAN

FOR THIS LITTLE MANEUVER.

BUT THAT'S WHAT YOU WOULD WANT
TO DO IF THEY'RE EXPELLING.

AND THEN, JUST FINISH
YOUR ENEMA,

ROLL THEM BACK OVER
AND CLEAN THEM UP.

THEY'RE DONE.

THANKFULLY THIS ISN'T A DRILL
IN MANNEQUIN MANAGEMENT.

UP.

ALRIGHT, SO CALM THEM AND
EASE THEIR DISTRESS.

OKAY, IN SEQUENCE WISE AS
FAR AS THEIR RESPONSE

CLAM THEM SECOND, GET
THEM ON THE PAN FIRST.

AND THEN SAY, "IT'S OKAY, THAT
HAPPENS TO A LOT OF PEOPLE."

BUT I AM NOT GOING TO
CALM AND REASSURE

WHILE THEY'RE SQUIRTING
OUT ALL OVER, RIGHT.

I AM TAKING CARE OF THE
CLIENT AND CONTAINING.

AND THEN JUST HOLD IT IN PLACE
AND CONTINUE THE ENEMA.

ALRIGHT, WE TALKED ABOUT
CRAMPING, THAT YOU WOULD
DO THAT.

LET'S TALK ABOUT -- YOU'RE
PUTTING THE ENEMA IN

AND THE FLOW STOPS. IT WON'T
GO IN. WHAT'S THE PROBLEM?

- IT'S STOOL. - IT'S STOOL.

YOU STUCK THE TUBE IN STOOL AND
IT JUST ISN'T GOING ANYWHERE.

- SO WHAT DO YOU DO? - MOVE
THE TUBE.

YOU CAN MOVE IT A LITTLE BIT
BUT BE EVER SO CAREFUL..

I'VE DONE THIS.
IT FEELS GREAT.

OH, MY GOSH. YOU KNOW,
VISIONS OF DISASTERS.

PULL IT A LITTLE BIT AND SEE
IF YOU CAN GET SOME MOVEMENT,

BUT IF YOU PULL IT TOO MUCH
SEE THESE LITTLE HOLES
ARE DOWN TO HERE

AND SO YOU'LL PULL IT
AND IT WILL RELEASE A
PHOOOSHK.

IT WILL START SQUIRTING
STOOL AND WATER

COS YOU GOT THIS THING OPEN
AND BLASTING, RIGHT?

BECAUSE THAT'S HOW IT SHOOTS
OUT. SO, JUST BE EVER
SO CAREFUL.

YOU MAY NOT BE ABLE TO
GET IT TO GO IN.

SO YOU CAN JUST PULL IT OUT AND
YOU MAY TRY TO DIGITALLY
DIS-IMPACT THEM.

AND IF IT'S HARD AND HIGH
AND YOU CAN'T GET IT,

WE'RE BACK TO THE OIL
RETENTION SCENARIO.

BUT YOU HAVE TO CALL AND
GET AN ORDER FOR THAT.

MY FAVORITE ORDER THAT DOCTORS
WRITE AND IF YOU'RE CALLING

IS THAT THEY'LL WRITE ENEMA OF
CHOICE. EOC SOMETIMES.

BECAUSE THAT GIVES YOU
THE FREEDOM TO JUST..

OIL RETENTION, YOU KNOW,
SALINE, SOAP SUDS,

DO WHATEVER YOU GOT TO
DO TO GET THE JOB DONE.

WHAT IS IT'S HARD AND YOU STICK
YOUR FINGERS UP THERE

AND YOU TRY TO GET IT,
WOULD YOU HAVE TO CHECK WITH
THE DOCTOR FIRST

BEFORE YOU DID THAT?

USUALLY YOU CAN DO THAT
IN THE MIDST OF..

IF THE ENEMA HAS BEEN ORDERED
IT'S, KIND OF,
PART OF PROCEDURE.

YOU JUST WANT TO MAKE SURE THAT
THERE'S NO CONTRAINDICATION

FOR YOUR CLIENT, BUT YEAH.

THEN I'D TELL THEM LATER, I NEED
ORDERS TO DIGITALLY DIS-IMPACT,

BUT YEAH, ONCE YOU'RE INTO
THE FLOW OF THINGS.

OKAY, HERE'S A GOOD ONE.

YOU GIVE THEM THE ENEMA

AND YOU PUT ALL 1000 CC
IN AND YOU TAKE IT OUT

AND THE CLIENT'S THERE AND
THE ENEMA DOESN'T COME OUT.

MASSAGE THEIR ABDOMEN.

MASSAGE THEIR ABDOMEN.
REPOSITION THEM.

TURN THEM ON THE OTHER SIDE
AND MOVE THEM AROUND.

MASSAGE THE ABDOMEN A LITTLE.

WHAT IF IT STILL
DOESN'T COME OUT?

MAKE THEM DO SIT UPS?

SIT UPS?

THAT WAS GOOD.

THERE IS NOTHING YOU CAN DO.
IT'S JUST IN THERE.

I MEAN THEY MAY
HAVE ABSORBED IT,

IT DEPENDS ON WHAT KIND OF
ENEMA YOU GAVE THEM, RIGHT?

AND SO IF YOU GAVE THEM A TAP
WATER AND THEY ABSORBED IT,

MAYBE THEY'RE A LITTLE
DEHYDRATED AND THEY
JUST TOOK IT ALL IN,

AND SO YOU WANT TO KEEP TRACK
OF THAT IN YOUR I&O.

BUT THERE'S JUST NOT A WHOLE LOT
YOU CAN DO OTHER THAN TURN THEM,

MASSAGE THEIR ABDOMEN A
LITTLE AND THEN WATCH.

SO, IF THEY'RE ABSORBING
UP ON TAP WATER ENEMA,

I PROBABLY WOULD CHANGE MY
SOLUTIONS

SO THAT I'D HAVE BETTER LUCK.

OKAY, ALSO THIS ONE SAYS
REPLACE THE TUBE

AND LOWER THE ENEMA BAG BELOW
THE LEVEL OF THE BED,

KIND OF HAVE TO DO THE HARRIS
FLUSH THING.

BUT IF IT'S STUCK UP THERE.
IT'S STUCK.

TRY TO RELIEVE AN IMPACTION,
BUT IT'S NOT RELIEVED.

YOU GAVE THEM AN ENEMA AND
IT DIDN'T WORK, THEN WHAT?

- SHOOT ANOTHER ENEMA.
- TALK TO THE DOCTOR.

OIL ANOTHER ONE.

TALK TO THE DOCTOR.

IF IT'S ENEMA OF CHOICE, TRY
ANOTHER ENEMA, YOU MIGHT
TRY AN OIL RETENTION,

CHECK THEM DIGITALLY, SEE IF
THINGS ARE BLOCKED UP

AND TRY ANOTHER ONE LATER.

ENEMA RETURNS ARE NOT
CLEAR PRIOR TO SURGERY.

OKAY, THIS WAS A.. BOY, I'VE
GIVEN LIKE 1,000 ENEMAS, I
THINK, IN MY LIFE.

I WORKED THE DAY SHIFT
ON A SURGERY FLOOR
AND WE GAVE ENEMAS.

SO ENEMAS, DON'T COME BACK
CLEAR. WHAT DO YOU DO?

- TILL YOU CAN DO IT. - YOU
JUST KEEP DOING IT AGAIN,

BUT MAKE SURE YOU GOT
THE RIGHT SOLUTION.

MAKE SURE YOU'VE SWITCHED TO
A NORMAL SALINE SOLUTION

SO YOU DON'T HAVE THE
SIDE-EFFECTS.

AND THEN ALSO BE WATCHING
YOUR VITAL SIGNS

SO THAT YOU'RE NOT CAUSING
THE BRADYCARDIA.

AND YOU MAY NEED TO GET
SOMETHING ORALLY.

BUT YOU MAY NEED A STRONGER
SOLUTION AS WELL.

SO MAYBE SOAP SUDS OR
SOMETHING LIKE THAT.

OKAY, AND LAST, BUT NOT LEAST,
CLIENT COMPLAINS OF SEVERE,
SEVERE PAIN.

NOT JUST SOME CRAMPING,
SEVERE DOUBLED-OVER,

SCREAMING OUT, SEVERE PAIN.
WHAT'S HAPPENED?

POSSIBLY PERFORATED THE VALVE,
WE'VE GONE THROUGH.

THIS IS VERY BAD.

SO, WHAT DO WE DO?

CALL THE DOCTOR, STAT.

STOP THE ENEMA, OBVIOUSLY.
BE DONE WITH IT.

WE NEED TO MAKE SURE THAT
THERE IS AN IV LINE AVAILABLE

BECAUSE THEY'RE GOING
TO HAVE TO GO TO SURGERY

AND TO GIVE APPROPRIATE
MEDICATIONS AND BE CHECKING
THEIR VITAL SIGNS.

- HAS THAT EVER
HAPPENED TO YOU?
- NO.

I WOULD HAVE A REALLY GOOD
STORY FOR YOU, BUT NO.

AND HOPEFULLY IT WILL
NEVER HAPPEN TO YOU.

BE CAREFUL,
ONLY GO IN FOUR INCHES

AND THAT'S REALLY IMPORTANT
WHEN YOU'RE PUTTING IT IN

BECAUSE WE'VE GOT PLENTY
OF ANUS OPENING THERE,

BUT IF SOMEONE'S GONE UP TO
HIGH, USUALLY YOU'RE
IN TO ROUGH.

ALRIGHT, WELL BACK
TO OUR ENEMA.

WE'VE HELD ON.
ALL HAS GONE WELL.

WE PUT THE WATER IN.
WE CLAMPED IT OFF.

WE TAKE THIS OUT. AND
WE ASK THE CLIENT

AND IT DOES DRIP AND DRIBBLE
ALL OVER THE PLACE.

WE ASK THE CLIENT IF THEY CAN
HOLD IT FOR A FEW MINUTES

OR DO THEY WANT TO GET UP RIGHT
NOW, AND GO TO THE BATHROOM?

WHATEVER THEY NEED TO DO,
DO IT.

WIPE THEM OFF. IF THEY CAN STAY
ON THEIR LEFT SIDE, BETTER.

YOU CAN, KIND OF, JUST TALK
THROUGH THE REST OF THIS.

COVER THEM UP, YOU CAN PUT THE
BED DOWN AND THE SIDE
RAILS UP.

AND...JUST LEAVE THEM TO BE OR
GET THEM TO THE BATHROOM.

WHEN YOU COME BACK, ONCE THEIR
READY, YOU CAN GET THEM
ON THE BEDPAN.

THEY CAN DO THEIR BUSINESS.
THEN CLEAN THEM UP.

TAKE CARE OF THE CLIENT FIRST.
ALWAYS.

CLEAR OUT YOUR CHUX.

AFTER THEY'RE ALL DONE.

OVER. YOU'RE GOING
TO BE NOTING OBVIOUSLY.

I'M LEAVING THEM ON THE CHUX,
JUST BECAUSE THEY'RE GOING
TO BE LEAKING.

AND YOU WONDER HOW
DIRTY THOSE ARE.

NOTE THE COLOR, QUANTITY,
AND THE QUALITY OF THE STOOL.

WE DON'T USUALLY DO I&O OF STOOL
AND MEASURE THE WATER
AND LIQUID.

ONLY IF THEY'RE ON STRICT I&O.

GET VITALS AGAIN
IF YOU NEED TO.

GET YOUR CLIENT TAKEN CARE OF

AND THEN YOU CAN TAKE THIS
STUFF TO THE REST-ROOM,

EMPTY IT, THROW AWAY YOUR
THRASH, CLEAN UP YOU EQUIPMENT.

AND THEN YOU'RE GOING
TO DOCUMENT ON I&O,

THE RESULTS OF YOUR ENEMA
AND HOW MANY AND ALL THAT.

ALRIGHT, ANY QUESTIONS
ON THAT ONE.

OKAY, SO THAT'S YOUR CRITICAL
THINKING EXERCISE.

THEN YOU'RE GOING TO
REGROUP A LITTLE BIT.

AND YOU'RE GOING TO
DO ANOTHER ENEMA.

AND IT'S PRETTY MUCH
THE SAME AS FAR AS...

THIS THING CAN GO UP HERE.

BUT WE'RE GOING TO USE A
DIFFERENT PIECE OF EQUIPMENT

AND A LITTLE DIFFERENT
VOLUME OF LIQUID.

- LBM STANDS FOR LAST BOWEL
MOVEMENT, RIGHT?
- UH-HUH, YES.

I'M DOING EVERYTHING ELSE
FOR THE NEXT PERSON.

OKAY, THIS TIME...

BASICALLY SAME SET UP,

BUT WE'RE GOING TO
DO AN ENEMA BUCKET.

WE'RE GOING TO DO A HARRIS
FLUSH. WHAT'S HARRIS FLUSH FOR?

- FLATULENCE.
- FLATULENCE, WHICH IS?

- GAS.
- GAS.

SO, AS FAR AS YOUR LIST OF
KINDS OF ENEMAS WHAT IS IT?

- CLEANISING?
- NO.

IT'S NOT A CLEANSING

- RETENTION? - IT'S NOT A
RETENTION BECAUSE THEY'RE
NOT GOING TO HOLD IT IN.

- EXPELMENT. EXPELS.
- DISTENTION.

DISTENTION REGIME.

OKAY, WE'RE GETTING RID OF
DISTENTION, GAS FILLS UP.

IT'S LIKE THAT FUNNY COMMERCIAL.
THOSE THREE LADIES AT MOVIE.

YOU KNOW IT'S KIND OF
THAT SAME THING.

WE'RE TRYING TO GET
RID OF GAS, OUR WAY.

ALRIGHT, SO WE'VE CHECKED
OUR DOCTOR'S ORDERS.

WE KNOW THERE IS NO
CONTRAINDICATIONS FOR THIS.

WE'VE CHECKED CARE PLAN
AND SO FORTH.

WE'RE GOING TO ALSO
THEN LOOK TO SEE

IF THERE'S ANY REASON OR WHAT'S
GOING ON WITH OUR CLIENT.

ONE OF THE THINGS I LIKE TO KNOW
IS ARE THEY PASSING ANY GAS?

WHEN WAS THEIR LAST
BOWEL MOVEMENT?

HOW ARE THEY EATING? WHAT'S
THEIR ACTIVITY LEVEL?

PEOPLE THAT HAVE A LOT OF GAS,
ARE THEY GETTING UP AND WALKING?

COS ONE OF THE BEST THINGS
FOR GETTING RID OF GAS
IS JUST MOVING.

GET THEM MOVING.
GET THEM WALKING AND
THAT HELPS PERISTALSIS.

SO IS YOUR CLIENT ABLE
TO GET UP AND AROUND?

AGAIN YOU'RE LOOKING
AT DIETARY HISTORY,
THEIR MEDICATION HISTORY,

VITAL SIGNS, WHEN IS THE
LAST TIME THEY EMPTIED
THEIR BLADDER

AND THAT KIND OF THING
PRIOR TO DOING THIS.

SO GET ALL THAT STUFF DONE, MAKE
SURE THAT THEY ARE
A GOOD CANDIDATE,

NO RECTAL SURGERY AND
NO HEART CLIENTS HERE.

ALRIGHT, I'VE GATHERING MY
EQUIPMENT, WHICH IS MY BUCKET,
MY WATER.

THIS TIME I AM ONLY GOING TO
USE ABOUT 300 CC OF WATER.

INTERESTINGLY ON YOUR PAPERS
AND IN YOUR BOOK IT SAYS

TO FILL THE BUCKET WITH
100 TO 200 OF WATER.

AND BEING, THE READ THE RULES

AND MEMORIZE THEM KIND OF A GIRL
THAT I WAS GOING TO SCHOOL.

AND THAT'S WHEN I DID MY FIRST
TWO OR THREE LITTLE
HARRIS FLUSHS.

AND I PUT THE 100 IN
AND WENT TO MY CLIENT

AND THEN I PUT THE BUCKET IN
AND I PUT THE 100 IN

AND THEN YOU'RE SUPPOSED TO
LOWER IT AND THEN 100 IS
SUPPOSED TO COME BACK OUT.

NOTHING CAME BACK OUT.
AND THEN I WAS OUT OF JUICE.

I'M NOT GOING TO GO BACK
AND FORTH WITH IT.

YOU KNOW, SO I GO,
"OH THIS IS NO GOOD."

SO I STARTED PUTTING ABOUT
300 IN MY BUCKET,

SO THAT I COULD PUT
IN LIKE ABOUT 100

AND THEN IF IT CAME BACK, WELL
GOOD FOR ME, I HAD SOME FLUID,

BUT IF DIDN'T I STILL HAD
SOMETHING TO WORK WITH IN
THE UP AND DOWN OF IT.

SO THAT I COULD GET SOMETHING
IN BECAUSE USUALLY,

EVENTUALLY IT DOES EQUALIZE
AND YOU GET SOME FLUID BACK.

SO THAT'S WHAT YOU'RE TRYING
TO ACCOMPLISH HERE.

SO AGAIN YOU WANT IT TO
BE 105 TO 110 DEGREES

OF TEMPERATURE AS
FAR AS THAT GOES.

AND YOU WANT A BED PAN
NEARBY, CHUX.

AND YOU GOT TO CHECK 1000.

ALRIGHT, WASHED MY HANDS

AND I AM GOING TO GO AND
IDENTIFY MY CLIENT.

GOOD MORNING, CAN YOU
TELL ME YOUR NAME?

MR. CURRY. ALRIGHT, MR. CURRY..

PROVIDE PRIVACY.

I HEAR -- WE TALKED EARLIER
THIS MORNING THAT YOU'RE
NOT PASSING SOME GAS.

SO I DID GET AN ORDER FROM THE
DOCTOR TO DO WHAT'S CALLED
A HARRIS FLUSH.

AND WHAT THAT IS IS A KIND
OF A SIPHONING ENEMA.

I'M GOING TO PUT A LITTLE
WATER INTO YOUR BOWEL

AND LOWER THIS BUCKET AND
LET THE WATER DRAIN OUT.

AND SOMETIMES JUST HAVING
THAT WATER GO IN AND OUT

KIND OF STARTS THINGS MOVING
DOWN THERE AND PULLS OUT
SOME OF THE GAS.

SO HOPEFULLY YOU'LL GET
SOME RELIEF FROM THAT.

AND THEN ONCE WE DO THAT IF YOU
CAN GET UP AND WALK IN THE HALLS

THAT WILL BE GREAT AND THAT WILL
HOPEFULLY GET THINGS MOVING.

ALRIGHT, WELL, FIRST
THING I WANT TO DO, THOUGH,

IS LOOK AT YOUR ABDOMEN AND
LISTEN TO YOUR BOWEL
SOUNDS AND...

SEE HOW THINGS LOOK NOW
SO YOU CAN TELL US IF
IT DID ANY GOOD.

SO GET VITAL SIGNS.

SORT OF HAND FOLD.

ALRIGHT.

ABDOMINAL ASSESSMENT,
INSPECT FOR?

CONTOUR, COLOR, HAIR
DISTRIBUTION, SYMMETRY.

THEN WE'RE GOING TO OSCULTATE,
RIGHT LOWER QUADRANT, BECAUSE?

- ILEALCECAL VALVE.
- ILEALCECAL VALVE.

MOST LIKELY TO HAVE BOWEL
SOUNDS, EACH QUAD, ONE MINUTE.

AND THEN WE'RE GOING TO
LIGHTLY PALPATE FOR?

- TENDERNESS.
- TENDERNESS, PAIN, GAS,

SOMETIMES WHEN
THEY'RE REALLY GASSY,

YOU CAN JUST, KIND OF, FEEL IT
AND YOU CAN HEAR IT RUMBLING
ALL OVER.

ALRIGHT, SO WE GOT AN IDEA
THEY'RE A LITTLE DISTENDED,
THERE'S GAS,

THE BOWEL SOUNDS ARE
HYPERACTIVE, YOU CAN JUST
HEAR THE GAS GOING.

THEY NEED A HARRIS FLUSH.

ALRIGHT, MR. CURRY COULD YOU
JUST ROLL OVER ON TO
YOUR LEFT SIDE PLEASE?

ALRIGHT, GET SOME GLOVES ON.

I SUPPOSE YOU CAN
CHECK SPHINCTER

AND YOU COULD DO THE RECTAL
EXAM, BUT WHY?

THIS IS ABOUT GAS.
SO I AM NOT CONCERNED THAT
THEY'RE HOLDING IT IN.

I'M NOT GOING TO PUT ENOUGH
IN FOR IT TO REALLY MATTER.

SO I DON'T THINK THE OLD
SPHINCTER CHECK IS THAT BIG OF
A DEAL HERE.

BUT I DO WANT MY BED PAN
NEARBY JUST BECAUSE

I'VE HAD MY SHARE
OF SQUIRTING OUT.

ALRIGHT, THESE BUCKETS
CAN BE A LOT OF FUN.

MAKE SURE THAT THIS TUBE
IS REALLY CONNECTED
INTO THAT BUCKET

BECAUSE SOMETIMES
THESE DISCONNECT

AND THESE GO SHOOTING OUT
AND THAT'S JUST EXCITING.

NONE OF THIS IS LIFE OR DEATH.
IT'S JUST VERY MESSY.
VERY, VERY MESSY.

- ALRIGHT?
- DO YOU LIKE WEARING DOWN.

YOU CAN. I USUALLY DON'T.

MY MISTAKE, PROBABLY,
GOGGLES I SHOULD, BUT.

I JUST NEVER THINK
IT WILL BE THAT BAD TILL
IT'S SQUIRTING AND GOING.

IT'S THE AFTER THOUGHT.

ALRIGHT, THERE ARE NUMBERS
ON HERE SOMEWHERE.

IT DOESN'T HAVE TO BE PERFECT.
I JUST WANT TO KNOW
HOW MUCH I HAVE

SO I KNOW WHAT I GOT BACK.
SO I PUT 400 IN MY BUCKET.

OH, AND THIS IS
A GREAT BUCKET.

THEY USUALLY HAVE THESE LITTLE
HANGERS HERE TO HOLD ON TO.

THESE HAVE BUSTED OFF. SO I'LL
BE DOING IT WITHOUT THEM.

I DON'T USE A POLE FOR THIS
EITHER
BECAUSE YOU HAVE TO HOLD IT.

NOTICE YOU HAVE TO HAVE GRAVITY
TO GET IT THROUGH.

I THINK ONE OF THE HARDEST
THINGS IS JUST MANAGING THE
LITTLE CLAMP FOR THIS.

ALRIGHT, AGAIN K-Y JELLY.

AND MR. CURRY, I AM GOING TO
PUT THIS TUBE IN YOUR RECTUM.

PULL UP, EXPOSE, AGAIN CHECKING
FOR HEMORRHOIDS OR SORES
OR ANYTHING.

AND I AM GOING TO PUT IT IN
ABOUT FOUR INCHES,
AND HOLD IN PLACE.

ALRIGHT.

I AM GOING TO RELEASE
THE CLAMP

AND I AM GOING TO PUT IT UP AND
I'M GOING TO PUT IN ABOUT 100.

THEN I AM GOING TO
DROP IT DOWN.

OH, WE GOT SOME.

THAT'S GOOD. THAT'S WHAT
IT'S SUPPOSED TO DO.

AND THEN YOU COME AND
YOU PUT IT BACK UP.

AND YOU DO THIS SIX TIMES OR
SEVEN OR EIGHT OR WHATEVER.

BUT I ONLY WANT YOU TO DO IT
TWICE, THAT'S GOOD ENOUGH.

PUT IN ABOUT 100 AND COME BACK
DOWN AND TRY TO DRAIN IT ALL
BACK OUT.

NOW I TOLD YOU THE FIRST
TWO OR THREE TIMES

I DID ONE OF THESE IT
FELT PATHETIC.

NOTHING CAME OUT. I MEAN, EVEN
IF SOME WATER CAME OUT,

NO GAS CAME OUT
AND THEY WERE JUST..

AND I THOUGHT WHAT
A DUMB PROCEDURE,

BUT YOU KNOW THEY ORDER
IT, SO YOU DO IT.

SO ABOUT THE FOURTH OR FIFTH ONE
I DID. OH, IT WAS A GOOD ONE.

I PUT IT IN AND I PUT IT DOWN

THE GAS STARTS COMING
AND THE GAS STARTS COMING.

I NEVER THOUGHT ABOUT
THAT PART.

OH, MAN, IT WAS SO POTENT.
IT WAS LIKE, "FEELING BETTER?"

YOU KNOW BECAUSE IT WAS
WORKING GOOD.

NOW, ANOTHER THING
THAT HAPPENS WHEN THEY WORK
GOOD IS YOU PUT IT..

WELL STUFF COMES OUT,
STOOL COMES OUT

AND THIS CAN GET KIND OF MURKY
AND THAT CAN KIND OF GROSS
YOU OUT.

BUT IT'S THEIR STOOL AND SO YOU
KEEP GOING BACK
AND FORTH ANYWAYS

UNLESS IT GETS TOO MURKY
TO PASS.

SO I NEVER REALLY HAD
TOO MUCH PROBLEM.

I HAD IT GET FAIRLY MURKY,
BUT...IT WOULD STOP.

SO YOUR LAST PASS IS DOWN,

GET BACK AS MUCH AS YOU CAN
AND PLEASE GET AS MUCH AS
YOU CAN OF THE WATER

BECAUSE THE MANNEQUINS
GET PRETTY FULL.

SO THIS IS KIND OF OUR
SIPHONING BACK PROCESS.

AND THEN ONCE IT'S DONE YOU
WANT TO CLAMP OFF HERE

BECAUSE LOOK WHAT HAPPENS
EVEN AS I COME UP.

THE WATER STARTS GOING BACK.

SO YOU NEED IT TO BE IN
THE LOW POSITION TO CLAMP

BECAUSE YOU DON'T WANT TO
LEAVE THEM WITH WATER IN.

THAT'S NOT THE IDEA. IT'S THAT
YOU DRAINED EVERYTHING OFF.

ALRIGHT, SO CLAMP IT.

AND THEN AGAIN MY GOAL..

I DON'T KNOW. DID ANY OF YOU
PAY ATTENTION TO HOW HIGH I
WAS RAISING IT?

YOU'RE STILL NOT SUPPOSED TO
GO MORE THAN 12 TO 18 INCHES.

HOW HIGH DID I GO?

HOW HIGH IS THAT?

- 3 FEET.
- IT'S ABOUT 18. TWO FEET
AT THE MOST PROBABLY.

DID YOU HEAR THAT? WHOOSH.

OUT, VERY GASSY,
MY MANNEQUINS ARE GASSY.

ALRIGHT, CLEAN THEM UP.

HAVE YOUR CLIENT LAY
ON THEIR SIDE

AND THEN IF THEY NEED
TO GO TO THE BATHROOM
IN A LITTLE BIT,

THEY CAN GO TO THE BATHROOM.
BUT THEN YOU WANT TO ENCOURAGE

THEM TO GET UP AND AMBULATE.

YOU WANT TO BE NOTING THE
RESULTS OF YOUR HARRIS FLUSH.

IF YOU GOT GOOD RESULTS. IT'S
KIND OF SUBJECTIVE I MEAN.

IF YOU SEE A LOT OF GAS, IT
FEELS LIKE IT WAS GOOD.

SO BASICALLY YOU JUST
HAVE TO ASK THEM.

CLEAN THEM UP. DO PERI CARE...

COS THEY GOT GOOD RESULTS
AND IF THEY'RE PASSING GAS.

AND THEN YOU CAN COME BACK AND
CHECK THEIR ABDOMEN AGAIN
FOR DISTENTION.

IF NECESSARY YOU CAN CHECK
VITAL SIGNS AFTERWARDS.

CLEAN UP YOUR EQUIPMENT.

PUT THE BED DOWN.

AND DOCUMENT.

DID I DO EVERYTHING?

ALRIGHT, SO THAT'S
WHAT YOU DO.

WE'LL TALK YOU THROUGH
THOSE TWO OR THREE
SPECIMEN COLLECTIONS,

PASS-FAIL, REAL QUICK. AND IF
IT'S X-OUT, I DON'T WANT TO
HEAR ABOUT IT.

I JUST WANT YOU TO TELL ME
WHAT'S NOT.

IN OTHER WORDS I AM GOING
TO SAY SALINE ENEMA,

HOW MUCH SOLUTION DO YOU PUT IN
AND HOW LONG DO YOU HOLD IT?

OIL RETENTION, HOW LONG
DO YOU HOLD IT?

QUICKLY TELL ME HOW YOU'RE
GOING TO GET --

OR HOW MUCH DO YOU NEED
FOR A STOOL SPECIMEN?

AND ON THE OTHER ONE TELL ME HOW
YOU WOULD GET A STOOL
FOR GUAIAC.

SO AND ON PASS-FAILS ALL YOU
HAVE TO SAY IS HIGH FIVE
AND THEN MOVE ON.

ONLY WHEN YOU'RE GETTING TESTED
FOR A GRADE DO YOU HAVE TO
ITEMIZE EVERY SINGLE ONE,

FOR A TEST GRADE.

ALRIGHT, AND THEN YOU'LL DO A
HARRIS FLUSH AND THEN
YOU'LL DO AN ENEMA

FROM START TO FINISH.

HIGH FIVE, WASH YOUR HANDS,
DOCUMENT, PUT THE BED DOWN,

AND THEN START ALL OVER.

WE DO THAT SO YOU CAN START
GETTING A ROUTINE
FOR YOURSELF.

- ALRIGHT.
- ON THE PASS-FAIL YOU DON'T
WANT US TO DO HIGH FIVE?

JUST SAY HIGH FIVE,
JUST SAY IT.

YOU DON'T HAVE TO
ITEMIZE IT ALL OUT.

I'VE CHECKED MY DOCTOR'S ORDERS,
I MEAN, I KNOW.

WE DO THAT FOR HERE.
GETTING YOUR THOUGHTS
AND YOUR EQUIPMENT SET UP.

ALRIGHT, ANY QUESTIONS?

- NO.
- ALRIGHT.