Bowel Care Guidelines For Adults

Bowel Care Guidelines

For Adults

Bowel Care Guidelines for Adults Page 1 of 49

BOWEL CARE GUIDELINES FOR ADULTS

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Document Type Clinical Guidelines

Unique Identifier CL-117

Document Purpose Provide nurses with the support, knowledge and evidence of good practice necessary to enable them to manage bowel care safely and competently

Document Author Elaine Sutcliffe; Continence Nurse Specialist

Target Audience These guidelines are relevant to all staff undertaking bowel care for adults, with the exception of stoma care.

Responsible Group Clinical Policies Group

Date Ratified 28th October 2013

Date Updated 6th December 2013

Expiry Date 28th October 2016

mailto:[email protected]


Version History

Version Circulation Date

Job Title of Person/Name of Group circulated to

Brief Summary of Change

V1 20/1/13 Continence Team Changes to procedures in appendix

V2 29/1/13 Community Pharmaceutical Advisor, Nurse Consultant Complex Disabilities, Quality Governance Manager

Amendments regarding retention enemas, aperients

V3 2/2/13 Continence Team Expanded section on faecal incontinence References updated General changes to style and layout

V4 11/2/13 Nurse Consultant in Infection Prevention and Control

Use of word 'urinary catheter', amendments to procedures

V5 11/2/13 Specialist Practitioner Facilitator Amended section on delegation to HCAs, training and competence of staff

V6 26/2/13 Clinical Policies Group Extended circulation list Competency framework produced in line with RCN, Skills for Health Procedures in line with Royal Marsden guidance

V7 23/05/13 Continence Team Matron Tenbury Hospital Pharmacist Nurse Consultant Complex Disabilities Specialist Practitioner Facilitator Nurse Consultant Infection Prevention and Control District Nurse Team Leader Redditch Quality Governance Manager Head of Healthcare HMP Hewell Clinical Nurse Specialist, Palliative Care District Nurse Team Leader, Wyre Forest Locality Manager Wyre Forrest Locality Manager Redditch and Bromsgrove Clinical Services Operational

General comments on style and layout Amendment to section 17.2 Discussed with training and development how will assess experienced, qualified nurses' competence.


Lead Clinical Services Operational Lead General Manager Quality Lead Community Care SDU Quality Lead South Worcester District Nurs /Quality Lead Wyre Forest Quality Lead Redditch and Bromsgrove Macmillan Nurse Specialist Malvern/POWCH Training and Development Manager OAMH Enhanced Care Team Leader Evesham and Pershore OAMH Modern Matron AMH Locality Manager Community Nurse Learning Disability Community Learning Disability Manager Training and Project Officer Stoma Nurse Specialist WRH Funded Nursing Care Manager

V8 August 13 Clinical Policies Group Minor amendments

V9 December 2013 Clinical Policies Administrator Amendments to Appendices 2 & 3

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Document translation; and

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Please refer to the intranet page: http://nww.hacw.nhs.uk/a-z/services/translation-services/ for full details of the service, how to book and associated costs.

Training and Development

Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training.

All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development.

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Contents Page

1. Introduction 6

2. Scope of Guidelines 6

3. Competencies Required 7

4. Patients Covered 8

5. Responsibility and Accountability 8

6. Consent 8

7. Bowel Assessment 8

8. Acute bowel Problems 9

9. Understanding Faecal Incontinence 11

10. Management of Diarrhoea 13

11. Management of Constipation 14

12. Laxatives 15

13. Suppositories 16

14 Enemas 16

15. Bowel Care Interventions for Patients with a Colostomy 17

16. Transanal/rectal Irrigation 18

17. Digital Rectal Examination and Manual Removal of Faeces 18

18. Digital Stimulation 20

19. Bowel Care Interventions for Patients with Spinal Cord Injury 21

20. The Effect of Spinal Cord Injury on Bowel Function 21

21. Nurse Prescribing 23

22. Monitoring tool 24

23. References 25

Appendix 1 Glossary of Terms 27

Appendix 2 Assessment of competency for Digital Rectal Examination 28

Appendix 3 Assessment of competency for Digital Removal of Faeces 30

Appendix 4 Guidelines for the Management of Diarrhoea in Primary

Healthcare 33

Appendix 5 The Bristol Stool Form Scale 34

Appendix 6 A Stepped approach to the Management of Constipation

in Primary Healthcare 35

Appendix 7 Insertion of Suppository 36


Appendix 8 Insertion of Enema 38

Appendix 9 Performing a Digital Rectal Examination 41

Appendix 10 Performing Manual Removal of Faeces 43

Appendix 11 Digital Stimulation 46

Appendix 12 Gastro Colic Reflex 48

Appendix 13 Abdominal Massage 49


1. Introduction

a. ''Bowel care is a fundamental area of patient care that is frequently overlooked, yet it is of paramount importance for the quality of life of our patients, many of whom are hesitant to admit to bowel problems or to discuss such issues.'' (RCN 2012)

b. Nurses have a crucial contribution to make in providing effective advice and care to patients and clients suffering from common bowel disorders.

c. Additionally, clarity is required with regard to the professional and legal aspects of digital rectal examination (DRE) and manual removal of faeces. Because of the invasive nature of these procedures and fears of accusations of abuse, some nurses are uncertain over whether they should go ahead with these procedures. (RCN, 2012)

d. Recent advances in oral, rectal and surgical treatments for bowel care has reduced the need for DRE and manual removal of faeces. However, for some patients/clients in certain circumstances, these procedures are necessary and for other patients/clients they form part of their regular bowel care regime. In these circumstances nurses need to be reassured that it is legitimate to carry out these procedures safely and competently.

e. DRE is not to be used as first line treatment.

f. Refer to Appendix 1 for glossary of terms.

2. Scope of the Guidelines

a. The purpose of the guidelines is to:

Establish a framework for bowel care management for adults;

Establish a framework for the management of diarrhoea, constipation and faecal incontinence;

Provide nurses with the support, knowledge and evidence of good practice necessary to enable them to manage bowel care safely and competently;

Clarify the use of Digital Rectal Examination (DRE) and Manual Removal of Faeces; and

Clarify the procedure for DRE and Manual Removal of Faeces.

b. These guidelines cross reference with the following Worcester Health and Care NHS Trust (WHCT) policies and national guidance:

Consent to Treatment Policy;

Infection Control Policy and Procedures (particularly links to care and management of Clostridium difficile and care and management of viral gastroenteritis);

Simple Medications Policy;

Nurse Prescribing;

Safeguarding Adults Policy;

Management of lower bowel dysfunction, including Digital Rectal Examination and Digital Removal of Faeces (RCN 2012);

Faecal Incontinence, The management of faecal incontinence in adults (NICE 2007); and


Accountability and delegation: What you need to know (RCN 2011).

c. These guidelines are relevant to all staff undertaking bowel care for adults, with the exception of stoma care.

d. It is recommended that this policy may also be adopted by independent care homes within Worcestershire, in order to promote best practice care.

e. This policy does not include rectal examination for the purpose of prostate assessment.

f. Health care assistants working within the WHCT, once deemed competent following training, assessment and regular supervision may administer laxative suppositories/micro enemas under delegation from a registered nurse. (Refer to section 17.1)

3. Competencies Required

a. All practitioners undertaking bowel care must have a theoretical understanding of bowel anatomy, physiology, function, dysfunction and a working knowledge of current legislation, national guidelines, organisational policies and procedures. They must have attended a training course, normally accessed through the Community Continence service. Bowel study days are available via the Continence Service throughout the year relating to bowel care including practical sessions on DRE using a manikin. At the end of the session every participant will have performed one supervised practice and their competency assessed.

b. Competence will be achieved through observation, relevant practice and supervision in the clinical setting by a competent assessor and using the competency framework. (See Appendix 2 and 3.) The Training and Development department will keep a record of competent practitioners and it is recommended this is achieved by the following:

Observed Supervised

DRE Two Two

Manual removal Two Two

c. A competent assessor is defined as a practitioner who has undergone training, workplace assessment and who practice the technique as an integral part of their clinical role.

d. Staff who feel confident and competent and are presently performing DRE and manual removal of faeces can continue to do so and attend an update including an assessment of competence a minimum of every 5 years. It is the individual’s personal responsibility to satisfy themselves they are familiar with these guidelines.

e. Staff entering the Trust who have been trained in another Trust or Health Organisation must produce evidence of training and competence and be assessed once using the competency framework by a competent assessor. (See Appendix 2 and 3.)

f. Practitioners and assessors must maintain their competence through clinical practice, retraining and personal study. It is recommended staff refresh their knowledge and skills a minimum of every 5 years. Retraining can be accessed through the Continence Service.


4. Patients Covered

a. These guidelines apply to adult patients (over the age of 18 years) under the care of staff in WHCT.

5. Responsibility and Accountability

a. All practitioners who perform bowel care for patients should be aware of the contents of these guidelines. Nurses carrying out bowel care interventions are reminded that they should at all times adhere to the NMC Code of Professional Conduct: standards for conduct, performance and ethics and work within their competence and job description. They also have a responsibility to take account of their patient’ informed choices.

b. Registered nurses have a responsibility to ensure they feel confident and competent in the knowledge and skills of practice (NMC 2008) and if they do not feel competent to undertake this role they must inform their immediate manager to discuss training needs.

c. The Line Manager is responsible for ensuring any training required is identified as appropriate and measures taken to ensure that the nurse is able to obtain required competence.

d. Registered nurses who delegate bowel care interventions to health care assistants under specific direction, are reminded that they are at all times accountable for the delegated task.

e. Further information about accountability and delegation is available from RCN (2011).

6. Consent

a. Consent is an individual’s freely given agreement to examination, treatment or an act of care based on information about, and an understanding of, what is proposed. In order to give consent, a person must be deemed to be competent (Kennedy and Grub, 1994 as cited in Mallett, 2000).

b. The Consent to Treatment Policy endorses the patient’s right to have a full and clear explanation of proposed treatment, risks involved and alternatives, before giving consent. Nurses should refer to the guidelines for advice on types of consent, how to obtain consent and how consent should be recorded.

c. The nursing interventions in these guidelines would not be classified as those requiring written consent but verbal, expressed consent would be required. Therefore all interventions should be comprehensively documented in the patient’s record and written in such a way that demonstrates the patient’s informed consent.

d. The Consent to Treatment Policy gives guidance on a person’s capacity to consent. Nurses are advised to be aware of these guidelines.

7. Bowel Assessment

a. Bowel care deals with intimate and private parts of the body. All interventions relating to assessment and treatment require discretion and sensitivity.

b. Assessment of bowel continence and function should form part of the holistic patient assessment. Bowel assessment includes obtaining a history and carrying out relevant clinical examinations. It also includes carrying out and interpreting relevant baseline observations and tests.

c. Bowel assessment should be completed using the Bowel Care pathway and information in the Appendices.


8. Acute Bowel Care Problems

a. Nurses need to know what constitutes a bowel care emergency, and be able to act without delay to prevent further complications.

b. The table below lists the most common bowel care emergencies, presentation and management.

Type of Emergency Management

Autonomic Dysreflexia.

Life- threatening complication of spinal injury, level T6 or above.

Abnormal response to pain/ stimulus mayresult in seizure, stroke and death.

Triggers include constipation, digitalstimulation, manual evacuation and enemas and irrigation

Management plan for all patients at risk.

Patient and all care staff should be aware of triggers, symptoms and management plan.

Bowel Obstruction

No bowel activity.

Abdominal pain and Distension.

Vomiting.

Possible dehydration.

Serious condition requiring immediate medical attention.

If untreated, bowel may rupture, leak its contents causing peritonitis.

Seek urgent medical attention.

Perforation

Hole in the bowel - allows leakage of intestinal contents into abdominal cavity.

High fever.

Nausea.

Severe abdominal pain, worse on movement.

Intense vomiting leading to dehydration.

If untreated causes peritonitis.


Recent Change In Bowel Habit.

Can include any of the following when not associated with lifestyle changes.

Stool consistency.

Unintentional Weight loss.

Rectal bleeding.

Anaemia.

Increased mucous and wind.

Full assessment.

Referral to medical practitioner.


Strangulated Hernia

Blood supply to the bowel cut off.

May lead to ischemia, necrosis, or gangrene.


Diarrhoea

Many causes e.g.

Colitis

Small bowel disease

Pancreatic

Endocrine

Infection

Drug induced

May lead to dehydration, and electrolyte imbalance

Full assessment - history and physical assessment to exclude impaction.

Exclude impaction - if constipated follow constipation plan.

Send stool sample for culture.

Undiagnosed Rectal Bleeding

Many causes e.g.

Haemorrhoids

Anal fissure

Proctitis

Diverticular Disease

Colitis

Polyps

Ulceration

Malignancy

Full assessment.

Referral to medical practitioner.

Faecal Impaction

If not treated can cause an obstruction.

Full assessment.

Macrogol 3350 (Movicol) or Laxido is licensed to treat faecal impaction and should be used to resolve this before giving rectal medication.

Phosphate enemas should only be given as a last resort, with caution and close monitoring.

Manual evacuation may be appropriate for patients with impaction.

(RCN 2012)


9. Understanding Faecal Incontinence

9.1 Assessment

Complete bowel assessment form including diet and stool diary

9.2 Initial Management

9.2.1 Diet

Take into account existing therapeutic diets.

Ensure overall nutrient intake is balanced

Consider use of a food & fluid diary

Advise patient to modify one food at a time

Encourage people with hard stools and/or clinical dehydration to aim for intake of at least 1.5 litres of fluid per day (unless contra-indicated)

Consider screening people for malnutrition or risk of malnutrition.

9.2.2 Bowel Habit

Interventions should promote ideal stool consistency and predictable bowel emptying.

Encourage bowel emptying after a meal.

Ensure toilet facilities are private, comfortable and can be safely used with

sufficient time allowed.

Encourage people to adopt a sitting or squatting position where possible while

emptying the bowel and avoid straining.

9.2.3 Toilet Access

Ensure locations of toilets are made clear and any equipment or help needed to access the toilet is provided

Offer advice on easily removable clothing.

Refer for home and mobility assessment if appropriate

9.2.4 Medication

Consider alternatives to drugs contributing to Faecal Incontinence (FI).

Prescribe anti-diarrhoeal drugs, in accordance with summary of product characteristics, for people with loose stools and associated FI once other causes have been excluded. Loperamide is suggested as first drug of choice. (It is noted this is an unlicensed indication, however it is recognised practice.)

Consider Loperamide syrup for doses less than 2 mg.

Offer codeine phosphate or co-phenotrope if unable to tolerate Loperamide.

Introduce at very low dose and escalate as tolerated until desired stool consistency is reached.

Advise that dose can be altered up or down in response to stool consistency and lifestyle.

Do not offer Loperamide to people with hard or infrequent stools, acute diarrhoea without a diagnosed cause or acute flare up of ulcerative colitis.


9.2.5 Coping Strategies

a. Offer advice on:

Continence products;

Emotional and psychological support;

Talking to friends and family; and

Planning travel and carrying a toilet access card or RADAR key.

b. Offer people with FI:

Choice of disposable products;

Anal plugs;

Skin care, odour control and laundry advice; and

Discuss use of disposable gloves.

c. Do not generally recommend reusable absorbent products.

9.2.6 Review

a. Ask whether FI has improved.

b. If symptoms persist discuss further treatment options.

c. If individual does not wish to progress further in care pathway provide long term strategies:

Advice on preservation of dignity and independence;

6 monthly review of symptoms;

Discussion of other management options (including specialist referral);

Contact details for relevant support groups; and

Advice on coping strategies and skin care.

d. Specific management will be needed for people with the following:

Faecal loading;

Limited mobility;

Neurological/spinal disease;

Learning difficulties, cognitive or behavioural issues;

Severe or terminal illness; and

Acquired brain injury.

9.2.7 Specialised Management

a. Consider specialised management options, which may be provided by a specialist continence service. These may include:

Pelvic floor muscle training;

Bowel retraining;

Specialised dietary assessment and management;

Biofeedback;

Electrical Stimulation; and


Rectal irrigation.

b. Consider whether people with neurological or spinal disease/injury resulting in FI could benefit from specialised management.

9.2.8 Specialist Assessment

a. Refer patients with continuing FI for consideration for specialist assessment including:

Anorectal physiology studies;

Endoanal ultrasound (if unavailable consider MRI, endovaginal ultrasound and perineal ultrasound); and

Other tests including proctology as indicated.

(NICE 2007)

10. Management of Diarrhoea

a. Diarrhoea can be defined as “an abnormal increase in the quantity, frequency and fluid content of stool and is associated with urgency, perianal discomfort and incontinence”. (NICE 2012)

b. Sudden onset, acute diarrhoea is common and is usually self-limiting, often lasting only a few days. (Mallett, 2000) It often requires no investigation or treatment. Common causes can be for example – food poisoning, traveller’s diarrhoea and viral gastro-enteritis. In the case of acute diarrhoea, if symptoms are not resolved in 2-3 days the patient should be seen by a doctor.

c. Chronic or persistent diarrhoea generally lasts longer than 2-4 weeks (Metcalf 2007) and may have more complex origins. Common causes can be for example – inflammatory bowel disease, neoplasms, diverticulitis. In these circumstances the patient will need to be seen by a doctor to determine treatment options.

d. Once the cause of diarrhoea has been established, management should focus on resolving the cause of the diarrhoea and providing physical and psychological support for the patient. The prevention and correction of dehydration is the first step in managing an episode of diarrhoea and the nurse can take simple measures such as:

Encouraging the patient to drink fluids to suit individual taste;

Adding ice to drinks; and

Sucking ice cubes or ice lollies.

e. The nurse should be aware that overflow, faecal movement, resembling diarrhoea can occur as a result of colonic obstruction and therefore this should be ruled out when the patient presents with diarrhoea.

f. In the case of patients in residential units or hospital wards in particular, the nurse should be aware of the risks of cross infection and is reminded that all episodes of diarrhoea should be considered potentially infectious until proved otherwise.

g. For further guidance on recommended management of diarrhoea, refer to the ‘Guidelines for management of diarrhoea in primary healthcare’ (see Appendix 4).

11. Management of Constipation

a. Constipation as defined in the British National Formulary, Sept 2012, No 64 as – the passage of hard stools less frequently than the patient’s own normal pattern”.


People may normally have anything between 3 bowel movements a day to only 3 bowel movements a week. Therefore constipation is more easily confirmed in a patient when there has been a significant change in normal bowel habit (Norton 2006).

b. Assessment and the identification of the underlying cause of constipation is important therefore in achieving the successful management of constipation.

c. Many factors may affect normal bowel functioning, these may include:

Change in diet;

Change in fluid intake;

Lack of exercise;

Use of drugs e.g. analgesics, iron preparations, use of over the counter products;

Lack of privacy e.g. use of shared toilet facilities especially in hospital;

Change in persons normal routine;

Disease process e.g. neoplasm; and

X-ray investigation of bowel involving use of barium.

d. A careful history of a patient’s bowel habits should be taken with particular note taken of:

Use of laxatives or other bowel medication (including over the counter products);

Any changes in usual bowel action;

The frequency, volume, consistency and colour of stool (Bristol Stool Form Scale, Heaton, K, 1992: See Appendix 5);

The presence of blood, mucus or an offensive odour; and

Pain or discomfort on defaecation.

e. If unresolved constipation is suspected, a digital rectal examination should be performed with the patient informed consent, in order to assess the contents of the rectum and to identify conditions which could cause discomfort such as haemorrhoids or anal fissure (see section 18.0 on DRE).

f. Management and treatment options include:

Dietary advice, increasing fibre intake;

Advice on appropriate fluid intake, 1.5 - 2 litres daily;

Advice on lifestyle changes;

Laxatives;

Enema or suppositories;

Manual removal of faeces;

Good seating position to defaecate (raise knees higher than hips, lean forward and put elbows on knees, bulge out abdomen and straighten spine); and

Use of Gastro Colic Reflex (See Appendix 12).


g. For further guidance on the recommended management of constipation, see ‘A stepped approach to the management of constipation in primary care flowchart’ (See Appendix 6).

12. Laxatives

a. In general, there is much uncertainty over what constitutes effective management of constipation and laxatives may not be appropriate in all constipated patients. It has been suggested that in mobile people (including the elderly), a change in lifestyle involving changes in diet, increasing fluid intake and increasing physical activity may be sufficient (Effective Health Care, 2001)

b. Although laxatives are not always necessary, they may be needed in the short term to provide rapid initial relief of symptoms (MeReC Bulletin, 1999). Laxatives alter the normal functioning of the alimentary tract and can be grouped as follows:

Bulk-forming agents e.g. bran products, Ispaghula Husk, Normacol.

Available in powder, granule or tablet form. These can help retain water in the stool; it is essential to maintain a fluid intake or symptoms of constipation may worsen. They can also be used to give bulk to loose stools.

Stimulants e.g. Bisacodyl, Dantron, Docusate Sodium, Senna, Glycerol

Will induce a bowel movement within 8-12 hours by increasing peristalsis in the colon. Not to be taken if there is a risk of intestinal obstruction.

Nurses and nurse prescribers should be aware that preparations containing Dantron (Co-Danthramer) are not indicated for general use and should only be used for constipation in palliative care for patients of all ages (BNF, Sept 2012, No 64).

Osmotic laxatives e.g. Lactulose, Macrogols

Retain fluid in the stool and increase bulk by bacterial fermentation. These agents may take up to 48 hours to act, and should be given with plenty of water.

Macrogols e.g. Movicol, Laxido

When mixed with water the solution remains in the colon, achieves an increase in faecal bulk that causes stretching of the circular muscle in the bowel wall, triggering peristalsis. Faecal residue is softened and stools are re-hydrated. Some of these preparations are licensed to treat faecal impaction.

Faecal softeners e.g. Docusate Sodium, Liquid Paraffin, Agarol

Used where it is not possible to successfully promote a soft, formed stool through manipulation of diet and fluids.

c. Some drugs can be both stimulant laxatives and softeners.

13. Suppositories

a. A suppository is a solid pellet introduced into the rectum for medicinal purposes. Once inserted the temperature of the body will dissolve the suppository from its solid form to a liquid.

b. Lubricant suppositories e.g. glycerol, should be inserted directly into the faeces and allowed to dissolve to enable softening of the faecal mass.


c. Stimulant and medicated suppositories e.g. bisacodyl, must come into contact with the mucus membrane of the rectum if they are to be effective and should not therefore be inserted into a faecal mass.

13.1 Indications for use

To relieve acute constipation or to empty the bowel when other treatments for constipation have failed.

To empty the bowel before surgery.

To introduce prescribed medication into the system.

To soothe and treat haemorrhoids or anal pruritis.

As part of a bowel management programme with someone who has a neurogenic bowel or chronic constipation. Suppositories may be combined with other interventions such as oral agents and preventative measures.

a. There has been some controversy over the correct insertion technique with regard to which end of the suppository to insert first – the apex (narrower end) or base (blunt end). In a small sample study (Abd-el-Maeboud et al 1999, cited Higgins 2007) suggested that if suppositories are inserted apex first the circular base distends the anus and the sphincter may not close completely. However, there is as yet insufficient research evidence to be conclusive about which end of a suppository should be inserted first.

Higgins, D. (2007)

13.2 Contraindications for use

Colonic obstruction.

Paralytic ileus.

a. The risks associated with suppository administration is generally considered to be low, but care should be taken when administering suppositories to patients who have undergone rectal or lower colonic surgery or gynaecological surgery or radiotherapy.

13.3 Administering suppositories

a. For full procedure see Appendix 7.

14. Enemas

a. When oral laxatives or suppositories have not produced a bowel movement or when rapid relief from rectal loading is required, an enema may be appropriate. An enema is the introduction of fluid into the rectum or lower colon for the purpose of producing a bowel action or instilling medication.

b. There are two types of enema: retention enemas and evacuant enemas.

c. A retention enema is a solution introduced into the rectum or lower colon with the intention of being retained for a specified period of time. Examples are steroid preparations eg Prednisolone, Arachis oil and olive oil enemas, which soften and lubricate impacted faeces. The latter two contain groundnut and peanut oil, so they should be avoided in people with a nut allergy.

d. Nurses must have a sound knowledge of the use, action, dose and possible ill effects of administering an enema. Volume retention enemas are contraindicated in all spinal injury patients.

Kyle G (2007)


e. An evacuant enema is a solution introduced into the rectum or lower colon with the intention of its being expelled along with faecal matter. Phosphate enemas and sodium citrate micro-enemas come under this group.

f. Phosphate enemas should be used with caution as they can cause mucosal damage and trauma. (Davies 2004)

g. A systematic review of the adverse effects of phosphate enemas (Mendoza 2007) found an absence of conclusive evidence. Those aged under 5 or over 65 appear to be most at risk, especially older people with chronic renal failure and/or diseases that alter intestinal mobility.

14.1 Indications for use

To introduce prescribed medication into the system e.g. Crohn's disease.

Severe constipation or impaction of faeces.

Bowel clearance before investigations or surgery.

14.2 Contraindications for use

Colonic obstruction.

Paralytic ileus.

Where large amounts of fluid into the colon may cause mucosal damage, hypokalaemia, cardiac arrhythmias, necrosis, or haemorrhage.

Proctitis.

Frailty.

Recent radiotherapy to lower pelvis unless medical consent given.

Following gastrointestinal or gynaecological surgery where suture lines could be ruptured (unless medical consent has been given).

The use of micro enemas or hypertonic saline enemas in patients with inflammatory or ulcerative conditions of the large colon.

14.3 Administering enemas

a. For full procedure see Appendix 8.

15. Bowel Care Interventions For Patients With A Colostomy

a. Suppositories and enemas are rarely prescribed for people with a colostomy. However very occasionally the patient may require this type of intervention to relieve unresolved impaction of faeces in the stoma. In these circumstances lubricant suppositories or a micro-enema may be used (Stoma Care Nurses, Worcestershire Acute Hospitals NHS Trust).

b. Factors to consider before administering a suppository or micro-enema into a stoma would be:

The patient should lie in the supine position; and

Use a lubricating gel to assist comfortable passage of suppository/micro-enema through the stoma.

16. Transanal/Rectal Irrigation

a. Rectal Irrigation can be used for clinical conditions such as chronic constipation, faecal incontinence, obstructive defecation secondary to, for example neurogenic bowel dysfunction. Rectal irrigation should only be tried when other less invasive


bowel management has failed to adequately control constipation or faecal incontinence. A full individualised assessment of patient suitability is required before commencing irrigation.

RCN (2012)

b. The Continence Advisory Service should be made aware of all patients performing irrigation or who wish to consider it. The Continence service can also be contacted if more information is required about rectal irrigation.

17. Digital Rectal Examination of Rectum and Manual Removal of Faeces

17.1 Who can perform these procedures?

a. A registered nurse who can demonstrate professional competence to the level determined by the NMC Code of Professional Conduct and the Scope of Professional Practice (NMC 2008) can carry out digital examination of the rectum (DRE) and manual removal of faeces.

b. A registered nurse who can demonstrate competence to this professional level can delegate these procedures to carers or patients as appropriate, ensuring their competence is assessed and reviewed as necessary. The registered nurse remains accountable for the appropriateness of the delegation, for ensuring that the person who does the work is able to do it and that adequate supervision or support is provided.

c. The registered nurse is responsible for informing his/her manager if s/he does not feel competent in these procedures and for identifying any training needs.

(RCN 2012)

d. It may be appropriate for health care assistants to administer suppositories and micro enemas under the delegation from a registered nurse. Registered nurses working within the Trust are reminded that, at all times they are accountable for the actions of the health care assistants working under their direction. The health care assistants should have received approved training, been assessed as competent in carrying out the procedure and undergo regular supervision. Training is available from the Continence service.

e. If these conditions are met, the health care assistant can be expected to carry out laxative suppositories/micro-enemas on named patients who have been prescribed these bowel care interventions as part of their ongoing, pre-planned nursing care. It is not expected that health care assistants would carry out these procedures on patients that have not previously been assessed by a registered nurse.

17.2 Contra-indications to performing DRE and Manual Removal of Faeces

Lack of consent from the patient.

Specific instructions from the patient’s doctor that the procedure should not take place.

17.3 Circumstances when extra care and multidisciplinary discussion is required

a. Particular caution should be exercised when performing DRE and Manual Removal of Faeces with patients who have the following diseases/conditions:

Active inflammation of the bowel, including Crohn’s disease, ulcerative colitis and diverticulitis;

Recent radiotherapy to the pelvic area;


Rectal/anal pain or tumours;

Rectal surgery/trauma to the anal/rectal area (in last 6 weeks);

Tissue fragility due to age, radiation, loss of muscle tone in neurological diseases or malnourishment;

Obvious rectal bleeding or patient taking anti-clotting medication;

If the patient has a known or suspected history of abuse;

In spinal injury patients because of autonomic dysreflexia; and

Known allergies e.g. latex.

17.4 Signs and symptoms to look for in the perineal and perianal area prior to undertaking a DRE or Manual Removal of Faeces

Rectal prolapse – degree and ulceration;

Haemorrhoids – their number, position, grade, prolapse;

Anal fissure;

Anal fistula;

Anal skin tags - number, position, condition;

Wounds, dressings, discharge;

Anal lesions (malignancy);

Gaping anus;

Skin conditions, broken areas, pressure sores of all grades;

Bleeding and colour of blood;

Faecal matter;

Infestation; and

Foreign bodies.

a. The presence of any of the above would indicate that advice should be sought from a specialist nurse or a medical practitioner before undertaken these interventions, unless the practitioner feels confident and is competent to do so.

RCN (2012)

17.5 Digital Rectal Examination (DRE)

a. DRE is an invasive procedure and should only be performed after full assessment. It involves observing the perianal area and inserting a lubricated gloved finger into the rectum. Cultural and religious beliefs must be respected and it is vital to check for allergies prior to undertaking this procedure.

b. DRE is used to establish:

The presence of faecal matter in the rectum, the amount and consistency of stool;

Anal tone and ability to initiate a voluntary contraction, and to what extent anal/rectal sensation;

The need for and effects of rectal medication in certain circumstances;

The need for manual removal of faeces and evaluating of bowel emptiness;


The outcome of rectal/colonic washout/irrigation if appropriate;

The need and outcome of using digital stimulation to trigger defaecation by stimulating the recto-anal reflex; and

Teaching pelvic floor exercises.

(RCN 2012)

17.6 Performing a DRE

a. For full procedure, see Appendix 9

17.7 Manual Removal of Faeces

a. Manual removal of faeces is an invasive procedure and should only be performed when necessary and after individual assessment. Cultural and religious beliefs need to be considered before performing this procedure.

b. Now a wider range of bowel emptying techniques are available, the need to use manual removal of faeces is questioned, however in certain patients it is a necessary part of their bowel care e.g. spinal cord injury.

(RCN 2012)

17.8 When may manual removal of faeces be performed?

Faecal impaction/loading.

Incomplete defaecation.

Inability to defaecate.

Other bowel emptying techniques have failed.

Neurogenic bowel dysfunction.

17.9 Manual Removal of Faeces as an acute or ongoing intervention

a. When performing manual removal of faeces as an acute intervention or part of a regular package of care, it is important to carry out an individualised risk assessment. While undertaking manual removal the following should be performed or observed for:

Blood pressure in spinal cord injury patients who are at risk of autonomic dysreflexia, prior to and at the end of the procedure, a baseline blood pressure is advised for comparison. For such patients where this is a routine intervention and tolerance is well established, the routine recording of blood pressure is not necessary;

Distress, pain, discomfort;

Bleeding;

Collapse; and

Stool consistency.

(RCN 2012)

17.10 Performing a Manual Removal of Faeces

a. For Full Procedure, see Appendix 10.

18. Digital Stimulation

a. This is a type of bowel emptying technique which can enable an individual to evacuate their bowels effectively. It is done by the individual or nurse/carer by inserting a gloved lubricated finger into the anus and slowly rotating the finger in


circular movements, maintaining contact with the rectal mucosa and gently stretching the anal canal. (Coggrave, 2008) This helps to relax the sphincter and stimulates the rectum to contract, and is often used in spinal cord injury and other neurological patients.

b. For Full Procedure see Appendix 11

19. Bowel Care Interventions for Patients with Spinal Cord Injury

a. In September 2004 the NHS Patient Safety Agency that patients with established spinal cord lesions are at risk because their specific bowel care needs are not always met in hospital. Contributing to this situation is a widely held belief that manual evacuation of faeces is abusive and dangerous. In fact it can be harmful, even life-threatening, to deviate from these patients normal bowel routine. This document has been updated to include a section specifically related to individuals with spinal cord lesions. (NPSA 2004.)

20. The Effect of Spinal Cord Injury on Bowel Function

a. After a spinal cord injury the connection between brain and bowel is lost and this gives rise to a number of consequences:

The brain does not feel the urge to defecate or control the anus.

The ability to coordinate what is under voluntary control and influence or mediate reflex activity in the bowel is lost.

The enteric nervous system in the bowel continues to produce peristalsis but because the brain cannot coordinate it this is less effective. As a result stool takes longer to pass through the bowel. (Leduc et al 1997)

Slower transit time through the colon result in greater re-absorption of water and harder more constipated stools.

Constipation causes stretching of the colon, which makes peristalsis less effective.

b. The presenting picture of bowel disorder following spinal cord injury depends upon the level at which damage has occurred and whether the damage to the cord is complete or incomplete. The remaining bowel function is normally described as either reflex or flaccid but may be a mixture of the two in incomplete lesions.

20.1 Bowel Management

a. A bowel management routine or programme is developed by taking account of the area of damage to the cord and making use of any preserved function or reflex systems. It should be tailored to take into account the individuals needs and designed to promote independence.

b. Individuals who have been in a Spinal Injuries Centre will usually be fully aware of the rationale behind their bowel management programme and this should not be changed without careful consideration and consultation.

c. Individuals who present with a partial spinal cord injury, perhaps as a result of spinal cord compression, surgery, or multiple sclerosis may present with a mixed picture of remaining function. As a consequence their bowel management routine will be developed in a more pragmatic manner over time.

d. Failing to recognise the particular needs of these patients and develop an appropriate care plan is clinical neglect that may result in serious costs to the individual’s health and quality of life.


e. The aim of a bowel management routine is:

To open the bowels at a regular and predictable time that fits in to the lifestyle of the individual.

To avoid constipation, accidents and autonomic dysreflexia.

Autonomic Dysreflexia

This is a medical emergency that unresolved may give rise to serious consequences such as cerebral haemorrhage, seizures or cardiac arrest.

This occurs mostly in lesions above T6 but sometimes individuals with lesions between T6-T10 are susceptible. Individuals with injuries below T10 are not susceptible.

The condition arises as a result of an autonomic (Sympathetic) reflex that occurs as a response to pain or discomfort (noxious stimuli) perceived below the level of the lesion.

The reflex creates a massive vaso-constriction below the level of the lesion causing a pathological rise in blood pressure that can be life threatening if allowed to continue unchecked.

Manifestations of Autonomic Dysreflexia

Flushed and blotchy above the level of the injury.

Sweating and goose pimples

Peripheral cyanosis

Pounding headache

Blurred vision and dizziness

Shortness of breath

Slow pulse-high blood pressure

Common Causes

Most common is an over full bladder

Next most common is an overloaded bowel

Skin problems/ in-growing toe nails

Anything that may have given rise to pain previously

Pregnancy, and sometimes ejaculation.

Actions to Take

Identify and remove cause - if a manual evacuation is to be undertaken application of an anaesthetic gel 10 minutes beforehand will reduce the likelihood of exacerbating the situation.

Sit upright as soon as possible.

Give GTN or Nifedipine as prescribed.

If you are unable to locate the cause or the symptoms persist get help.


20.2 Interventions that may be used to manage a Reflex or Upper Motor Neurone Bowel

a. Injury at T12 and above will give rise to upper motor neurone or reflex bowel function.

b. The aim of this programme is to produce a soft-formed stool that is easy to pass by stimulating the reflex activity that is preserved in the rectum to evacuate stool.

c. It would usually consist of these types of interventions:

Stimulate gastro-colic reflex by having a warm drink or something to eat 20-30 minutes before starting the routine. (See Appendix 12.)

Abdominal massage and or use of posture to raise intra-abdominal pressure. (See Appendix 13.)

Use of ano-rectal stimulation - either digital or chemical. (See Appendix 11.)

20.3 Interventions that may be used to manage a Flaccid or Lower Motor Neurone Bowel

a. Spinal cord injury at or below L1 will give rise to lower motor neurone or flaccid bowel function.

b. The aim of this programme is to produce a firmly formed stool that can be removed digitally and will be unlikely to leak out in an unplanned manner.

c. It would usually consist of these types of interventions:

Stimulate gastro-colic reflex by having a warm drink or something to eat 20-30 minutes before starting the routine.

Abdominal massage and or use of posture to raise intra-abdominal pressure.

Use of gentle manual evacuation to remove stool from the rectum.

d. Bowel management is not an exact science and needs to suit the individual and therefore there may be a period of trial and error at the beginning or over time as changes in the individual’s body, lifestyle, or circumstances dictate.

21. Nurse Prescribing

a. Nurses who hold the District Nursing and Health Visiting qualification and who have undertaken nurse prescribing training, and those who are extended nurse prescribers, are now able to prescribe laxatives, enemas and laxative suppositories without prior consultation with a doctor, in accordance with the Trust Nurse Prescribing Policy. Staff who are not nurse prescribers should refer to the simple medications policy.


22. Monitoring Tool

a. The following tool will be used to monitor the implementation of these guidelines.

Aspect % Exceptions

Documentation audit of patient’s notes:

1/ Has valid consent been recorded?

2/ Is there a record of bowel assessment, intervention and evaluation of result?

3/ Is there documented evidence the procedure has been carried out in compliance with Trust policy?

Review of staff education record:

4/ All staff involved in care are trained and updated.

100

None

How will monitoring be carried out? Questionnaire/Data collection tool and education record

When will monitoring be carried out? 12 monthly intervals

Who will monitor compliance with the guideline?

Continence Advisory Team

Clinical Governance


23. References BNF (Sept 2012, No 64). British National Formulary. British Medical Association. London Coggrave, M (2008) Neurogenic Continence: Part 3: Bowel Management Strategies. British Journal of Nursing (2008) Vol 17, 11, p708 - 710 Davies, C (2004) The Use of Phosphate Enemas In The Treatment Of Constipation: Use of laxatives. British Journal of Nursing 12 (19) 1130-6. Dougherty L and Lister S, (2011) Royal Marsden Hospital Manual of Clinical Nursing Procedures 8th edition. Blackwell Publishing Effective Healthcare Bulletin (2001). Effectiveness of laxatives in adults. NHS Centre for Reviews and Dissemination. University of York Fulford, Coggrave and Wright (2004) Bladder and Bowel Management for People With Spinal Cord Injuries. SIA Publishing. Heaton, K (1992). Bristol Stool Form Scale as cited in Constipation: managing a common problem. Prescriber May 19, 31-34 Higgins, D (2007) Bowel Care (Part 6) Administration of Supoository. Nursing Times 103:47 26-27 Kyle, G (2007) Bowel Care Part 4, Administrating an Enema. Nursing Times 103 45 26-27 Leduc BE, Giasson M, Favreau-Ethier M, Lepage Y (1997) Colonic transit time after spinal cord Injury. Journal of Spinal Cord Medicine Vol 20 No 4

Mallett, J (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Blackwell Sciences. Oxford Medoza, J. (2007) Systematic review – Adverse effects of a sodium phosphate enemas. MeReC Bulletin (1999). The Management Of Constipation. National Prescribing Centre, 1999, 10: 33-36. Metcalf (2007) Chronic Diarrhoea: Investigations, Treatments and Nursing Care. Nursing Standard 21 (21) 48-56 National Patient Safety Agency (2004) Improving The Safety of Patients With Established Spinal Injuries In Hospital. London. NPSA NICE (2007) Faecal Incontinence, The Management of Faecal Incontinence In Adults NICE (2011) Referral Guidelines For Suspected Cancer. NICE (2012) Prevention and Control of Healthcare Associated Infections. CG139 Norton, C (2006) Constipation in Older Patents, Effects On Quality Of Life. British Journal of Nursing 15 (4) 188-192


Nursing and Midwifery Council (2004) Professional Conduct: standards for conduct, performance and ethics. London RCN (2011) The principles of accountability and delegation for nurses, students, healthcare assistnats and assistant practitioners. London. Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, includling DRE and DRF Guidance For Nurses. London. Zejdlik, C (1992) Management of Spinal Cord Injury. Boston, Jones and Bartlett Blader and Bowel Fact sheets can be found on www.spinal.co.uk

http://www.spinal.co.uk/


Appendix 1

Glossary of Terms

ANAL PRURITIS: anal itching CONSTIPATION: a delayed movement of intestinal content through the bowel, characterised by infrequent, hard dry stools which are difficult to pass. CLOSTRIDIUM DIFFICILE: an anaerobic bacteria that can occur in the gut DIARRHOEA: an abnormal increase in the quantity, frequency and fluid content of stool and associated with urgency, perianal discomfort and incontinence. DIGITAL RECTAL EXAMINATION (DRE): examination of rectum by insertion of a finger into the rectum. ENEMA: the introduction into the rectum or lower colon of a stream of fluid for the purpose of producing a bowel action or for instilling medication. HYPOKALAEMIA: abnormally low potassium concentration in the blood MANUAL REMOVAL OF FAECES: the use of a finger to remove faeces from the rectum. MELAENA: darkening of the faeces by blood pigments PARALYTIC ILEUS: paralysis of the ileus SALMONELLA: a genus of gram-negative bacteria causing gastro-enteritis, usually caused by the ingestion of food containing salmonelli SUPPOSITORY: a solid or semi-solid pellet introduced into the anal canal for medicinal purposes. STEATORRHOEA: excess fat in the faeces due to malabsorption syndrome TENESMUS - ineffectual and painful straining at stool NEUROGENIC BOWEL: dysfunction of the colon caused by the central neurological disease or damage


Appendix 2

Assessment of Competency for Digital Rectal Examination

Assessment Specification The candidate should be able to demonstrate competence in digital rectal examination using the following knowledge and performance criteria. Competence is achieved through observation, relevant practice and supervision in the classroom and clinical setting by a competent assessor. A competent assessor is defined as practitioners who have undergone training, workplace assessment and who practice the procedure as an integral part of their clinical role. It is recommended an individual observes 2 examinations and is supervised performing 2 examinations to achieve competence. Observed and supervised practice is recorded and countersigned. The action plan can be used to identify learning needs in order to achieve competence.

Performance Criteria

Competency Statement Observation 1

Observation 2

Supervised 1 Supervised 2

Sign/countersign and date




1. Demonstrate knowledge of anatomy and physiology of the bowel including, stool production, normal defaecation and the nervous system including autonomic dysreflexia.

2. Demonstrate knowledge and importance of a full bowel assessment, including risk assessment to identify high risk individuals or factors e.g. bowel cancer, faecal impaction, Clostridium difficile.

3. Demonstrate knowledge of Trust policies in relation to bowel care e.g. infection control, consent, chaperone and respecting patient dignity, privacy, wishes and beliefs.


4. Discuss when digital rectal examination may be performed.

5. Discuss exclusions, contraindications and when extra care is required before performing digital rectal examination.

6. Demonstrate the ability to perform the procedure.

7. Discuss outcomes and provide accurate advice to the individual.

8. Demonstrate accurate contemporaneous record keeping of the procedure.

The candidate has been assessed and achieved the above competence. Name of Candidate (please print) .......................................... Candidate signature ................................ Name of Assessor (please print) ........................................... Assessor signature ................................. Candidate Job Title ....................................... Base/Ward .............................................. Date competence achieved ........................... Completed forms should be sent to the Training and Development department and a copy kept in the staff members portfolio. References: Skills for Health (2008) Continence Care Suite available from www.skillsforhealth.org.uk Royal College of Nursing (2012) Management of lower bowel dysfunction, including DRE and DRF RCN guidance for nurses

Signature log

Assessors Name Initials Designation

http://www.skillsforhealth.org.uk/


Appendix 3

Assessment of Competency for Digital Removal of Faeces

Assessment Specification The candidate should be able to demonstrate competence in digital removal of faeces using the following knowledge and performance criteria. Competence is achieved through observation, relevant practice and supervision in the classroom and clinical setting by a competent assessor. A competent assessor is defined as practitioners who have undergone training, workplace assessment and who practice the procedure as an integral part of their clinical role. It is recommended an individual observes 2 examinations and is supervised performing 2 examinations to achieve competence. Observed and supervised practice is recorded and countersigned. The action plan can be used to identify learning needs in order to achieve competence.

Performance Criteria

Competency Statement Observation 1

Observation 2

Supervised 1 Supervised 2





1. Demonstrate knowledge of anatomy and physiology of the bowel including, stool production, normal defaecation and the nervous system including autonomic dysreflexia.

2. Demonstrate knowledge and importance of a full bowel assessment, including risk assessment to identify high risk individuals or factors e.g. bowel cancer, faecal impaction, autonomic dysreflexia, Clostridium difficile.

3. Demonstrate knowledge of Trust policies in relation to bowel care e.g. infection control, consent, chaperone and respecting patient dignity, privacy, wishes and beliefs.


4. Discuss when digital removal of faeces may be performed.

5. Discuss what you would observe for when performing the procedure.

6. Demonstrate the ability to perform the procedure.

7. Discuss outcomes and provide accurate advice to the individual.

8. Demonstrate accurate contemporaneous record keeping of the procedure.

The candidate has been assessed and achieved the above competence. Name of Candidate (please print) .......................................... Candidate signature ................................ Name of Assessor (please print) ........................................... Assessor signature ................................. Candidate Job Title ....................................... Base/Ward .............................................. Date competence achieved ........................... Completed forms should be sent to the Training and Development department and a copy kept in the staff members portfolio. References: Skills for Health (2008) Continence Care Suite available from www.skillsforhealth.org.uk Royal College of Nursing (2012) Management of lower bowel dysfunction, including DRE and DRF RCN guidance for nurses

Signature log

Assessors Name Initials Designation


Competency Action Plan

Practitioner name: Name of competency framework:

Competency statement e.g. 4, 7

Actions required to achieve competency Review date


Appendix 4 Guidelines for the management of diarrhoea in primary healthcare

Patient presents with diarrhoea

Consider possible causes and identify normal bowel pattern

Sudden onset e.g. infection, recent

travel, food poisoning

Overflow diarrhoea associated with constipation

Overuse of laxatives or medication induced

Pre-existing medical and surgical

condition causing symptoms

Offer education and advice on appropriate laxatives

and diet Review medicines

If constipation suspected, perform DRE to determine faecal loading and treat for

constipation

See stepped management of

constipation (See Appendix 8)

Record and monitor stool type (according to Bristol stool chart), consistency colour, amount, odour and frequency

Obtain stool specimen Consider possible infection control issues and refer to infection control guidelines

Observe temperature and vital signs

Encourage adequate fluid intake Skincare to prevent excoriation/soreness

Consider provision of continence aids

If no improvement in symptoms or

deterioration in condition

Seek medical advice

Continue to monitor and assess patient until symptoms have resolved

Seek medical advice if symptoms persist

Seek medical advice


Appendix 5

The Bristol Stool Form Scale


Appendix 6

A stepped approach to the management of constipation in primary healthcare

No Yes

Yes No

Effective Ineffective

Effective Ineffective

Adjust the dose, choice, combination of laxative according to symptoms, speed of relief required, response to treatment and individual preference. The dose should be titrated up and down to produce

one or two soft stools per day.

Patient presenting with suspected constipation

Advise about normal bowel

function

? Underlying cause e.g. neurological disorder, suspicion of carcinoma, bowel disease, medication

see fig 1 over

Treat underlying cause/Refer to

specialist

Simple constipation

Dietary and lifestyle advice

↑ dietary fibre

ensure adequate fluid intake (1.5 – 2litre) ↑ mobility/exercise

discuss gastro colic reflex (Appendix 4)

good seating position to defaecate

Monitor patient to prevent recurrence

Initiate laxative treatment

Acute/occasional constipation

Add or switch to osmotic laxative if stool remains hard

Chronic/long term constipation

Add stimulant if stool soft but difficult to pass

Substitute low dose Macrogol May require rectal intervention

(suppositories/enema)

Continue advice and review to prevent recurrence

Faecal impaction

For hard stools consider a high dose of Macrogol. For soft stools consider starting/adding oral stimulant/laxative

Refer if not resolved in 3-4 days, abdominal distention and pain, or loss of appetite

Refer to specialist

Bulk forming laxative Bulk forming laxative

Add or switch to osmotic laxative if stool remains hard

Add stimulant if stool soft but difficult to pass

Advise patient that laxatives can be stopped once the stools become soft

and easily passed again

If not sufficient/fast enough consider suppository/mini enema


Appendix 7 : Insertion of suppository Equipment required

Single use disposal gloves

Single use disposable apron

Plastic backed absorbent sheet

Water based lubricating gel If this is not single use ensure technique eliminates contamination risk

Suppositories

commode or bedpan if unable to use toilet.

Action Rationale

Complete bowel assessment and establish need for suppositories

Ensure suppositories are required

Explain and discuss procedure with patient and gain consent. If you are administering a medicated suppository, it is best to do so after the patient has emptied their bowels

To ensure that the patient understand the procedure and gives their valid consent (NMC2008a). To ensure that the active ingredients are not prevented from being absorbed by the rectal mucosa and that the suppository is not expelled before it’s active ingredients have been released (Moppett 2000)

Wash Hands To ensure that the procedure is as clean as possible and for infection control reasons (Fraise and Bradley 2009)

Ensure privacy and dignity To ensure privacy and dignity for the patient (NMC 2008b)

Ensure that a bedpan, commode or toilet is readily available.

In case of premature ejection of the suppositories or rapid bowel evacuation following their administration.

Assist patient to lie on the left side, with the knees flexed, the upper higher than the lower one, with the buttocks near the edge of the bed

This allows ease of passage of the suppository into the rectum by following the natural anatomy of the colon. Flexing the knees will reduce discomfort as the suppository is passed through the anal sphincter (Moppett 2000)

Place a disposable incontinence pad beneath the patient’s hips and buttocks

To avoid unnecessary soiling of linen, leading to potential infection and embarrassment to the patient if the suppositories are ejected prematurely or there is rapid bowel evacuation following their administration.

Wash hands, put on disposable apron and non latex gloves

To minimise cross infection and protect your hands. For infection prevention and control (Fraise and Bradley 2009)

Observe the perineal and perianal area. Document and report any abnormalities

To check for rectal prolapse, haemorroids, anal skin tags, wounds, discharge, anal lesions, gaping anus, bleeding, foreign bodies


Place lubricating gel onto gloved finger Insert finger slowly and gently into the anus

To facilitate easy insertion of finger to avoid trauma

Assess faecal matter against Bristol Stool chart

Assess need for medication To support individual bowel plan

Place some lubricating gel on the topical swab and lubricate the blunt end of the suppository if it is being used to obtain systematic action. Separate the patient’s buttocks and insert the suppository blunt end first, advancing it for about 2-4cm. Repeat this procedure if a second suppository is to be inserted.

Lubricating reduces surface friction and thus eases insertion of the suppository and avoids anal mucosal trauma. Research has shown that the suppository is more readily retained if inserted blunt end first (Abd-el-Maeboud et al. 1991). The anal canal is approximately 2-4 cm long. Inserting the suppository beyond this ensures that it will be retained. (Abd-el-Maeboud et al. 1991)

Once the suppository(ies) has been inserted, clean any excess gel from the patient’s perineal area.

To ensure the patient’s comfort and avoid anal excoriation (Moppett 2000)

Ask the patient to retain the suppository(ies) for 20 minutes, or until they are no longer able to do so. If a medicated suppository is given, remind the patient that its aim is not to stimulate evacuation, and to retain the suppository of at least 20 minutes or as long as possible.

This will allow the suppository to melt and release the active ingredients. Inform patient that there may be some discharge as the medication melts in the rectum (Henry 1999)

Dispose of equipment as per Trust policy. For infection prevention and control (Fraise and Bradley 2009)

Assist patient to use commode/bed pan or safe transfer to toilet

To reduce risk of fall and maintain dignity.

Remove gloves, apron and wash hands To prevent spread of infection

Record that the suppository(ies) have been given, the effect on the patient and the result (amount, colour, consistency and content, using the Bristol Stool Chart) in the appropriate documents.

To monitor the patient’s bowel function (Gill 1999)

Observe patient for any adverse reactions. To monitor for any complications.

Mallett, J (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Blackwell Sciences. Oxford.

Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, including DRE and DRF Guidance For Nurses. London


Appendix 8 Insertion of enema

Equipment required Single use disposal gloves




Enema

Commode or bedpan if unable to use toilet.

Action Rationale

Complete bowel assessment and establish need for enema

Ensure enema is required

Explain and discuss procedure with patient and gain consent

To ensure that patient understands the procedure and gives their valid consent (NMC 2008a)

Ensure privacy and dignity To avoid unnecessary embarrassment and to promote dignified care (NMC 2008b)

Encourage patient to empty bladder first if necessary.

A full bladder may cause discomfort during the procedure (Higgins 2006)

Ensure that a bedpan, commode or toilet is readily available.

In case the patient feels the need to expel the enema before the procedure is completed.

Warm the enema to room temperature by immersing in a jug of hot water.

Heat is an effective stimulant of the nerve plexi in the intestinal mucosa. An enema at room temperature or just above will not damage the intestinal mucosa. The temperature of the environment, the rate of fluid administration and the length of the tubing will all have an effect on the temperature of the fluid in the rectum (Higgins 2006)

Assist patient to adopt left lateral position if possible, on their left side with knees well flexed the upper higher than the lower one and the buttocks near the edge of the bed.

This allows ease of passage into the rectum by following the natural anatomy of the colon. IN this position, gravity will aid the flow of the solution into the colon. Flexing the knees ensures a more comfortable passage of the enema nozzle or rectal tubes (Higgins 2006)

Place protective pad under patient and ensure commode or toilet close to hand

To reduce potential infection caused by soiled linen. To avoid embarrassing the patient if the fluid is ejected prematurely following administration.

Wash hands, put on disposable apron and non latex gloves

To minimise cross infection and protect your hands, for infection prevention and control (Fraise and Bradley 2009)

Observe the perineal and perianal area. Document and report any abnormalities

To check for rectal prolapse, haemorrhoids, anal skin tags, wounds, discharge, anal lesions, gaping anus, bleeding, foreign bodies


Place lubricating gel on gauze, remove cap and lubricate end of nozzle of enema

This prevents trauma to the anal and rectal mucosa which reduced surface friction. (Higgins 2006)

Expel excess air, part buttocks and introduce the nozzle or tube slowly into the anal canal. (A small amount of air may be introduced if bowel evacuation desired)

The introduction of air into the colon causes distention of its walls, resulting in unnecessary discomfort to the patient. The slow introduction of the lubricated tube will minimize spasm of the intestinal wall (Evacuation will be more effectively induced due to the increased peristalsis)

Slowly introduce the tube or nozzle to a depth of 10.0-12.5cm

This will bypass the anal canal (2.5-4.0cm in length) and ensure that the tube of nozzle is in the rectum.

If a retention enema is used, introduce the fluid slowly and leave the patient in bed with the foot of the bed elevated by 45o for as long as prescribed.

To avoid increasing peristalsis. The slower the rate at which the fluid is introduced, the less pressure is exerted on the intestinal wall. Elevating the foot of the bed aids in retention of the enema by the force of gravity.

If an evacuant enema is used, introduce the fluid slowly by rolling the pack from the bottom to the top to prevent backflow until the pack is empty or the solution is completely finished.

The faster the flow of the fluid, the greater the pressure on the rectal walls. Distention and irritation of the bowel wall will produce strong peristalsis, which is sufficient to empty the lower bowel. (Higgins 2006)

If using a funnel and rectal tube, adjust the height of the funnel according to the rate of flow desired.

The forces of gravity will cause the solution to flow from the funnel into the rectum. The greater the elevation of the funnel, the faster the flow of fluid.

Clamp the tubing before all the fluid has run in To avoid air entering the rectum and causing further discomfort

Slowly introduce contents of the enema and slowly withdraw the nozzle

The faster the rate of flow of the fluid, the greater the pressure on the rectal walls. Distension and irritation of the bowel wall will produce strong peristalsis which is sufficient to empty the lower bowel (Higgins 2006)

Remove excess gel by wiping anus clean, dry area with a gauze swab

To leave patient clean and comfortable and avoid excoriation.

Encourage patient to retain enema for up to 10-15 min

To enhance the evacuant effect.

Ensure that the patient has access to the nurse call system is near to the bedpan, commode or toilet, and has adequate toilet paper.

To enhance patient comfort and safety. To minimize the patient’s embarrassment.

The patient may complain of light headedness during the insertion of the enema or during evacuation

This is due to vagal nerve stimulation, which can slow the heart rate and alter its rhythm

Help patient into comfortable position To ensure patient dignity and comfort

Dispose of equipment as per Trust policy To prevent spread of infection

Remove gloves and apron and wash hands To prevent spread of infection and control (Fraise and Bradley 2009)

Record in the appropriate documents that the enema has been given, its effect on the patient and its results (colour, consistency, content and amount of faeces produced) using the Bristol Stool Form chart.

To monitor the patient’s bowel function (Gill 1999)


Mallett, J (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Blackwell Sciences. Oxford

Observe patient for any adverse reactions. To monitor the patient for complications (Peate 2003)


Appendix 9: Performing a Digital Rectal Examination

Equipment required





Action Rationale

1. Collect equipment

To be prepared

2. Ensure the patient has privacy

To avoid unnecessary embarrassment

3. Explain the procedure to the patient and gain their consent and co-operation

To ensure the patient understands and gives valid consent (NMC 2008a)

4. Give patient the opportunity to empty their bladder

To prevent discomfort

5. If the patient has a spinal cord injury above T6 observe the patient throughout the procedure for signs of autonomic dysreflexia

Prevent an emergency situation

6. Ensure that a bedpan, commode or toilet is readily available.

DRE can stimulate the need for bowel movement (Weisner and Bell 2004)

7. Perform hand hygiene and put on apron and gloves

To minimise the risk of cross infection

8. Cover the bed with a protective layer and assist the patient into the left lateral position with knees flexed, the upper knee higher than the lower knee with the buttocks towards the edge of the bed.

To reduce possible infection caused by soiled linen and to avoid embarrassment. The positioning allows ease of digital examination into the rectum by following the natural anatomy of the colon. Flexing the knees reduces discomfort as the examining finger passes the anal sphincter (Kyle et al. 2005b)

9. Observe the perineal/perianal area for any adverse signs and symptoms before proceeding. Examine for skin soreness excoriation, swelling, haemorrhoids, rectal prolapse and infestation. Proceed to insert finger into the anus/rectum.

May indicate incontinence or pruritus. Swelling may be indicative of possible mass or abscess. Abnormalities such as bleeding, discharge or prolapse should be reported to medical staff before any examination is undertaken (RCN 2006)

10. Next palpate the perianal area by starting at the 12 o'clock position moving to 6 o'clock and then returning to 12 o'clock and moving to 6 o'clock anticlockwise, feeling for irregularities, indurations, tenderness or abscess.

To identify any abnormalities

11. Lubricate a gloved finger, part the buttocks and gently insert into the anus, noting tone and any pain or spasm on

To prevent discomfort. Digital insertion with resistance indicates good internal sphincter tone, poor resistance may


insertion. Also work with the anal reflex by putting a finger on the anus gently and wait a few seconds, this will allow the anus to contract and then relax.

indicate the opposite. (Addison 1999b)

12. Sweep clockwise and then anti clockwise, palpate for irregularities internally. Noticing the presence of any tenderness, consistency of stool and any lesions.

To note any irregularities

13. You also assess the external sphincter tone by asking the patient to squeeze and hold. Also ask the patient to push down to assess relaxation on straining.

Assess sphincter control

14 Digital examination may feel faecal matter within the rectum; note consistency of any faecal matter.

May establish loaded rectum and indicate constipation and the need for rectal medication (RCN 2006)

15. Remove finger, wipe the residual lubricating gel from the anal area to prevent soreness or irritation

To ensure the patient’s comfort and avoid anal excoriation. Preserves patient dignity and personal hygiene.

16. Ensure the patient is left feeling as comfortable as possible

To minimise embarrassment and distress

17. Dispose of all equipment according to Trust Policy

To reduce the risk of infection

18. Remove gloves and apron and perform hand hygiene.

To reduce the risk of infection (Fraise and Bradley 2009)

19. Assist the patient to get up or with dressing and offer toilet facilities as appropriate.

To ensure that the patient is composed and comfortable

20. Document the procedure and the granting of consent, the findings and actions taken and report any abnormal findings immediately

To monitor the patient’s bowel function and to provide a record of the procedure and condition of the patient. To ensure continuity of care and ensure appropriate corrective action may be initiated.

Mallett, J (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Blackwell Sciences. Oxford Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, including DRE and DRF Guidance For Nurses. London


Appendix 10: Performing Manual Removal of Faeces

Equipment required Single use disposal gloves




Action Rationale


To be prepared



3. Explain and discuss the procedure with the patient and gain their consent and co-operation

To ensure the patient understands and gives valid consent (NMC 2008)

4. Check patients pulse at least once during the procedure. If the patient has a spinal cord injury, a blood pressure reading should also be taken. If injury above T6 observe the patient throughout the procedure for signs of autonomic dysreflexia

Provides a baseline measurement. Stimulation of the vagus nerve in the rectal wall can lead to a reduction in pulse rate (Powell and Rigby 2000). In spinal cord injury stimulus below the leel of injury may result in symptoms of autonomic dyslexia including hypertension (Kyle et al. 2005)

5. Perform hand hygiene, wash hands with bactericidal soap and water or bactericidal alcohol handrub and put on gloves

For infection prevention and control (Fraise and Bradley 2009)

6. Cover the bed with a protective layer and assist the patient into the left lateral position with knees flexed, the upper knee higher than the lower knee, with the buttocks towards the edge of the bed.

To reduce possible infection caused by soiled linen and to avoid embarrassment. The positioning allows ease of digital insertion into the rectum, by following the natural anatomy of the colon. Flexing the knees reduced discomfort as the finger passes the anal sphincter (Kyle et al 2005)

7. If the patient suffers local discomfort (or symptoms of autonomic dysreflexia) during this procedure local anesthetic gel may be instilled into the rectum prior to to the procedure. (Furasawa, 2008, Cosman, 2005) It should be considered if this is undertaken as an acute intervention. This requires 5-10 mins to take effect and lasts us to 90 mins. Note that long term use should be avoided due to systemic effects (BNF, 2012)

To promote comfort

8. Observe anal area for evidence of skin soreness, excoriation, swelling or prolapse.

To note abnormalities that may need reporting. To prevent discomfort


Inform the patient that you are about to proceed.

Assists with patient co-operation with the procedure (NMC 2008)

9. Lubricate a double gloved finger. To minimize discomfort as lubrication reduces friction and to ease insertion of the finger into the anus/rectum. Lubrication also helps minimize anal mucosal trauma (Kyle et al. 2005)

10. Part the buttocks and gently insert into the rectum. Proceed with caution in those patients with a spinal cord injury.

The majority of spinal cord injury patients will no experience any pain (Kyle et al. 2005)

11. If stool is a solid mass, push finger into centre, split it and remove small sections until none remain. If stool is in small separate lumps remove a lump at a time. Great care should be taken not to use a hooked finger to remove large pieces of hard stool which may graze the mucosa.

To ensure patient comfort, avoid discomfort and mucosal damage

12. Where stool is hard, impacted and difficult to remove other approaches should be employed in combination with manual removal of faeces. If the rectum is full of soft stool continuous gentle circling of the finger may be used to remove stool this is still manual removal of faeces.

To aid defecation

13. During the procedure the person delivering care may carry out abdominal massage.

To aid defecation

14. Check the patient’s pulse at least once during the procedure. In spinal injury patients a blood pressure reading should also be taken at least once during the procedure or at any sign of distress (RCN 2006) If the patient is displaying a reduction in pulse rate or change in rhythm, or in the spinal cord injury patient a raised blood pressure, stop the procedure and if possible, sit the patient up and administer appropriate medications as prescribed (Kyle et al. 2005)

Stimulation of the vagus nerve in the rectal wall can lead to a reduction in pulse rate (Powell and Rigby 2000). In spinal cord injury, stimulus below the level of injury may result in symptoms of autonomic dysreflexia, uncluding hypertension (Kyle et al. 2005)

15. If faecal mass is too hard to break up or more than 4 cm across, stop the procedure and discuss with the multidisciplinary team.

To avoid unnecessary pain and damage to the anal sphincter. The patient may require the procedure to be carried out under anaesthetic (Kyle et al. 2005)

16. Once the rectum is empty on examination, conduct a final digital check of the rectum after 5 mins to ensure the evacuation is complete.

To aid complete evacuation

17. Place faecal matter in a suitable receptacle and dispose of it according to Trust policy

To assist in appropriate disposal and reduce contamination or cross-infection risk.

18. Encourage patients who receive this Patient and nurse education is required


procedure on a regular basis to have a period of rest or, if appropriate to assist using the Valsalva manoeuvre.

to use this technique safely, and so further guidance should be sought before introducing this manoeuvre as it may lead to complications such as haemorrhoids. (Kyle et al. 2005)

19. When the procedure is complete, wash and dry the patient’s buttocks and anal area and leave patient comfortable.

To ensure patient comfort and maintain dignity

20. Remove gloves, apron and dispose of equipment in appropriate clinical waste bin. Wash hands

For prevention and control of infection (Fraise and Bradley 2009)

21. Assist patient into a comfortable position. To promote comfort.

22. Document the procedure and the granting of consent, the outcome using Bristol stool chart and report any abnormal findings immediately

To monitor the patient’s bowel function and to provide a record of the procedure and condition of the patient

Mallett, J (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. Blackwell Sciences. Oxford Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, including DRE and DRF Guidance For Nurses. London


Appendix 11: Digital Stimulation Equipment required





Action Rationale


To be prepared



3. Explain the procedure to the patient and gain their consent and co-operation

To ensure the patient understands and gives valid consent

4. If the patient has a spinal cord injury observe the patient throughout the procedure for signs of autonomic dysreflexia

Prevent an emergency situation

5. Perform hand hygiene and put on apron and gloves

To minimise the risk of cross infection

6. Cover the bed with a protective layer and assist the patient into an appropriate and comfortable position, normally lying in the left, lateral position with the knees well flexed

To reduce possible infection caused by soiled linen and to avoid embarrassment. The positioning allows ease of entry into the rectum following the natural anatomy of the colon

7. If the patient suffers local discomfort (or symptoms of autonomic dysreflexia) during this procedure local anesthetic gel may be instilled into the rectum prior to to the procedure. (Furasawa, 2008, Cosman, 2005) It should be considered if this is undertaken as an acute intervention. This requires 5-10 mins to take effect and lasts us to 90 mins . Note that long term use should be avoided due to systemic effects (BNF, 2012)

To promote comfort

8. Lubricate a double gloved finger, part the buttocks and gently insert into the rectum.


9. Turn the finger so the padded inferior surface is in contact with the bowel wall.

To aid defecation

10. Rotate the finger in a clockwise direction for at least 10 secs maintaining contact with the wall throughout

11. Withdraw finger and await reflex contraction


12. Repeat every5-10 mins until rectum is empty or reflex activity ceases.

To ensure defecation is completed

13. Remove soiled glove and replace, relubricating as necessary between insertions

To ensure patient comfort

14. If no activity occurs during the procedure, do not repeat it more than 3 times. Use manual removal of faeces if stool is present in the rectum.


15. Once the rectum is empty on examination, conduct a final digital check of the rectum after 5 mins to ensure the evacuation is complete.

To aid complete evacuation

16. Place faecal matter in a suitable receptacle and dispose of it according to Trust policy

To reduce risk of infection

17. When the procedure is complete wash and dry the patients buttocks and anal area and leave patient comfortable.

To ensure patient comfort and maintain dignity

18. Remove gloves, apron and wash hands To reduce the risk of infection

19. Dispose of all equipment according to Trust Policy

To reduce the risk of infection

20. Document the procedure and the granting of consent, the outcome using Bristol stool chart and report any abnormal findings immediately

To monitor the patient’s bowel function and to provide a record of the procedure and condition of the patient

Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, including DRE and DRF Guidance For Nurses. London

(NB Procedure not detailed in Royal Marsden, Clinical Nursing Procedures)


Appendix 12: Gastro Colic Reflex The Gastro Colic Reflex, triggered by feeding, produces propulsive peristalsis of the small intestine and colon. For clients to use this reflex and encourage a more regular bowel movement, they should be encouraged to sit on the toilet approx 30 minutes after a meal and a hot drink (breakfast is usually most effective). They should sit for a maximum of 10 minutes and do this every day until they are successful at a particular time and then try not to vary too much from this routine.


Appendix 13: Abdominal Massage Abdominal massage is thought to stimulate the colon to push the stool along towards the rectum. The abdomen is massaged using a half closed fist, of the heel of the hand in a kneading action, or by using a tennis ball (or similar object) in a rolling motion for ten minutes. The massage follows the line of the colon towards the rectum, up the right-hand side of the abdomen, across the abdomen at around the level of the umbilicus, and down the left-hand side of the abdomen. It can be used before and after suppository insertion, and before and between ano-rectal stimulations, or to assist manual evacuation. (Coggrave 2008)

Abdominal massage also has the advantage of no known side effects (Emly, 2001) Medical advice should be sought for patients with cancer of the bowel, herniation of the abdomen, recent surgery or scarring and those on anticoagulation therapy as abdominal massage may be contra-indicated or needs to be used with caution.

Bowel Care Guidelines For Adults

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