1. health and fitness
2. disease
3. ibs and crohn's disease

RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
GUIDELINES FOR BOWEL MANAGEMENT
(NCHT Version)
CONTENTS
PAGE NO
Guidelines for Bowel Management
1
Management of Constipation
2
Procedure for Administration of Suppositories
8
Procedure for the Administration of Enemas
12
Guidelines for the Management of Faecal Incontinence
16
Digital Rectal Examination and the Manual Removal of Faeces
19
Manual Removal of Faeces – Acute and Regular Intervention
25
Appendix 1 – Continence Assessment Form
30
Appendix 2 – Continence Risk Assessment Tool
32
Appendix 3 – The Bristol Stool Form Scale
34
Appendix 4 – Laxatives
35
Appendix 5 – How to Eat More Fibre
36
Appendix 6 – Example of a Stool Chart
38
RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
GUIDELINES FOR BOWEL MANAGEMENT
(NCHT Version)
INTRODUCTION
Effective bowel management is the maintenance of the individual's normal bowel function using
research-based interventions as required. Normal bowel actions may vary from three times per day to
three times per week (Kamm, 1994; Nazarko, 1996).
ASSESSMENT
Effective bowel management is dependent on comprehensive assessment. This can be achieved by
using a constipation risk assessment tool and continence assessment form, examples of which can be
found in appendices 1 and 2. These assessments focus on the following:
•
•
•
•
•
•
•
History of present bowel complaint
Holistic assessment to include diet, fluids, mobility, dexterity, cognitive function and
environment
Usual bowel pattern
Medication (past and present)
Examination (rectal and abdominal)
Stool Formation using Bristol Stool Classification (appendix 3)
Accurate recording of bowel actions
It is recommended that a constipation risk assessment tool be used on all patients within 48 hours of
admission. The continence assessment tool is used if bowel problems are identified by initial nursing
assessment. When constipation is highlighted, the assessment needs to identify if it is an acute or
chronic constipation, as the management differs.
Best Practice
ASSESSMENT
Patients who have constipation must receive a thorough assessment in order to devise an effective,
individualised and evidence - based plan of care. The doctor does not necessarily have to see or
examine the patient first, unless the assessment indicates that a medical opinion is required.
As a Registered Nurse you remain accountable for both your actions and omissions. If a Registered
Nurse feels unable to assess or treat constipation because of a lack of knowledge and / or clinical
skills, this is a training need and the appropriate training / study must be accessed in order to gain
clinical competency. Patient care must never be compromised.
Bowel Guidelines, May 2004
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GUIDELINES FOR THE MANAGEMENT OF CONSTIPATION
INTRODUCTION
Drossman (1982) defines constipation as “the infrequent passage of stools – that is less than every
three days or – excessive straining when having the bowels open”.
There are many factors that may interrupt normal bowel actions and lead to constipation. The most
common are listed below, but this list is not exhaustive.
•
Reduced Appetite and Food Intake
may reduce colonic propulsive motility
•
Reduced Fluids
•
•
Poor Mobility and/or Unfamiliar Surroundings
may cause people to postpone defaecation
Psychological Factors
•
Surgery
•
Age
Decreased ano-rectal motor function
Decreased upper oesophageal sphincter pressure
•
Endocrine Disorders
Hypothyroidism
Hormonal changes during pregnancy & childbirth
Addison's disease
Diabetes
•
Medications
Opiates including codeine
Anticholinergics
Diuretics
Antidepressants
Tricyclics
Phenothiazines
Calcium antagonists i.e. Verapamil & Nifedipine
Iron
Antihistamines
Anti-diarrhoea drugs
Antacids
•
Psychiatric Disorders
Depression
Dementia
Anxiety
Bowel Guidelines, May 2004
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•
Metabolic Disorders
Hypercalcaemia
Hypokalaemia
•
Bowel disorders
Tumours
Inflammatory bowel disorders
Diverticular disease
Hirschsprung's disease
Congenital abnormalities
Irritable Bowel Syndrome
Idiopathic megacolon & megarectum
•
Neurological Disorders
Stroke
Parkinson's disease
Multiple Sclerosis
Spinal or pelvic nerve injury
Scleroderma
SIGNS AND SYMPTOMS
Abdominal distension and discomfort
Halitosis
Loss of appetite
Nausea and vomiting
Agitation and confusion
Diarrhoea - seeping of faecal fluid (overflow)
Hard, dry stool or soft stool difficult to pass
Urinary retention and/or urinary incontinence
Constipation can be an acute or chronic problem and should be managed accordingly
ACUTE CONSTIPATION
Best Practice
ASSESSMENT
A diagnosis must be made to exclude underlying pathology. Medical involvement is recommended if the
clinical judgement, based on information gained from an assessment, indicates this is necessary.
Patients who may require a medical opinion include:
♦ Those who have an unexplained acute change in bowel pattern
♦ Absolute constipation – (no flatus or stool)
♦ Additional significant unintentional weight loss
♦ General appearance and feeling of being unwell
♦ Rectal pain
♦ Rectal bleeding
♦ Malaena stools
♦ Significant amount of rectal mucus
♦ Known cancer of the bowel or rectum
♦ Recent rectal surgery
This list is not exhaustive – it is a general guide only
Bowel Guidelines, May 2004
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See General Principles for All Procedures.
RATIONALE
ACTION
1
Complete a holistic individualised assessment
and a bowel assessment.
If appropriate a digital rectal examination and /
or abdominal examination may be necessary to
discover whether the bowel is impacted higher
up in the colon or lower down in the rectum.
To direct management or treatment decisions
(Kamm, 1994).
A digital rectal examination will identify rectal
contents – amountand consistency. If the rectum
appears ballooned this may indicate the
constipation is higher up in the colon.
2
Implement treatment plan i.e. administration of
suppositories, enemas and /or oral medication
according to stool consistency, position of stool
and ability to defecate (see appendix 4 for table
of laxatives).
For effective management.
3
Document results.
To evaluate treatment.
4
Following initial treatment of acute constipation,
a plan of care should be devised.
To prevent or manage further constipation.
CHRONIC CONSTIPATION
Best Practice
ASSESSMENT
A diagnosis must be made to exclude underlying pathology. Medical involvement is recommended if the
clinical judgement, based on information gained from an assessment, indicates this is necessary.
Patients who may require a medical opinion include:
♦ Those who have an unexplained acute change in bowel pattern
♦ Absolute constipation – (no flatus or stool)
♦ Additional significant unintentional weight loss
♦ General appearance and feeling of being unwell
♦ Rectal pain
♦ Rectal bleeding
♦ Malaena stools
♦ Significant amount of rectal mucus
♦ Known cancer of the bowel or rectum
♦ Recent rectal surgery
This list is not exhaustive – it is a general guide only
Bowel Guidelines, May 2004
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RATIONALE
ACTION
1
Advise/educate the patient/carer regarding
healthy eating and fluid intake. A combined
daily intake of 18 -24 grams of fibre is
recommended and approximately 1.5 - 2 litres
of fluid where the patient's condition allows.
(See appendix 5 for information on fibre).
Natural juices including prune juice are
recommended (Reynolds, 1994).
Appropriate diet plus fluid intake stimulates
gastric distension necessary for gastrointestinal
activity (MeReC,1994; Winney,1998).
2
Advise/inform the patient/carer regarding
bowel anatomy and function.
Knowledge empowers and enables the patient to
make informed choices.
3
Patient should be advised and enabled to
assume an effective posture to aid defecation.
Some patients may find a squatting position,
feet on the floor with heels raised and resting
the elbows on the knees (see below), or have
feet raised on a small foot stool.
The posture will raise the intra-abdominal
pressure. A relaxed pelvic floor will help
straighten the ano-rectal angle. Together effective
bowel emptying will be encouraged (Chiarelli &
Markwell, 1992).
Adapted from Chiarelli & Markwell (1992)
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RATIONALE
ACTION
4
Encourage exercise wherever possible within
the patient’s own limitations.
Wherever possible, ensure that the patient's
usual bowel rituals are followed.
Review medication.
Exercise increases peristalsis and bowel motility
(Chiarelli & Markwell, 1992).
To aid defecation.
7
Appropriate laxatives should be prescribed if
necessary depending on the consistency,
volume and frequency of the stools passed.
(see appendix 4)
To aid effective management.
8
Bowel actions should be recorded within
nursing records using the Bristol Stool Chart
(see appendix 3).
The aim for the majority of patients would be
a type 3, 4 or 5 stool.
Facilitates effective evaluation of care.
5
6
Best Practice
To reduce the predisposition for future
constipation.
OPIOIDS
Patients commencing on regular opioid -based medication may benefit from the introduction of an
appropriate laxative at the same time in order to avoid constipation
Best Practice
PRIVACY AND HYGIENE
Wherever possible, patients should be offered the use of the toilet in preference to a commode.
Where a commode is necessary, consideration of privacy is paramount. The toilet or commode
should be at a position that is comfortable for the patient, allowing the patient to place feet on the
floor and raise their heels, or have access to a foot stool.
If using a bedpan consider hoisting the patient over it. This helps achieve the correct positioning for
effective defaecation and maintains safety.
Patient hygiene is vital for the patient as well as the nurse to reduce cross-infection.
Bowel Guidelines, May 2004
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REFERENCES
Chiarelli P, Markwell S (1992) Lets get things moving New South Wales, Australia: Gore &
Osment,.
Drossman D A, Sandler R S, Mckee D C, Lovitz J (1982) Bowel patterns among subjects not seeking
health care Gastroenterology. Vol. 83 pp 529-534.
Kamm M (1994) Constipation. Internal Medicine Journal Vol. 22, No. 8, pp 305-385.
Medicines Resource Centre (MeReC) (1994) Bulletin 5 June 1994
Nazarko L (1996) Prevention of constipation in older people. Professional Nurse. Vol. 11, No 12, pp
816-818.
Reynolds J E F, Martindale W
Pharmaceutical Press
(1994)
The Extra Pharmacopoeia
30th Edition London:
Winney J (1998) Constipation. Nursing Standard. Vol. 13, No. 1, pp 49-56.
FURTHER READING
Barrett J A (1993) Faecal Incontinence and related problems. London:Edward Arnold
Authors:
Elaine Cathcart, Continence Advisor
Sue Brown, Senior Continence Advisor
Sharon Lane, Ward Manager, B48 (QMC)
Angela Saunders, Ward Manager, Linby Ward, Rushcliffe PCT
Review Date: Three years from ratification.
SUGGESTED AUDIT POINTS:
1.
Was a continence assessment form used ?
2.
Was a constipation risk assessment form used?
3.
Was there evidence or discussion with, or assessment by medical staff?
4.
Was there an appropriate care plan written, including rationale?
5.
Was there evidence of appropriate evaluation for the planned care?
6.
Were appropriate review dates documented?
Bowel Guidelines, May 2004
7
RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
PROCEDURE FOR ADMINISTRATION OF SUPPOSITORIES
INTRODUCTION
A suppository is a medicated solid substance prepared for insertion into the rectum and which
dissolves at body temperature. Rectal medications avoid liver metabolism and can have a predictable
greater and faster effect than oral medication.
Best Practice
ADMINISRATION WITHOUT MEDICAL ASSESSMENT
Nurses can administer a prescribed suppository without the doctor’s prior assessment as long as an
assessment of the patients bowel problems has been undertaken prior to the administration of the
suppository. This will enable the nurse to identify any issues which may contra-indicate the
administration of the suppository.
If the nurse feels unable to perform the assessment and / or the procedure, this is a training need and
the nurse has a responsibility to access the necessary training as soon as possible, in order to become
competent. Patient care must never be compromised.
INDICATIONS
Include:
• To empty the lower bowel prior to a surgical procedure or endoscopic examination
• As treatment for constipation
• To introduce medication into the system
• As treatment for haemorrhoids or anal pruritus
CONTRA-INDICATIONS
Include:
• Low platelet count
• Malignancy (or other pathology) of the perianal region
• Recent lower gastrointestinal or gynaecological surgery
• Related allergies i.e. Latex
• Neutropenia
Bowel Guidelines, May 2004
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HAZARDS
Collapse
Administration of a suppository may precipitate a vasovagal attack. The vagus is one of the nerves
that control heart rate and blood pressure. When the nerve is stimulated, it decreases heart rate and
lowers blood pressure which may result in inadequate perfusion of the brain which results in
collapse or faint. The vagus nerve can be stimulated by a number of physiologic and psychologic
reasons including sight of blood, fear etc. (Gruen, 2000) Collapse is a serious complication, which
may be expected in patient groups that are at particular risk, such as frail elderly people (Addison,
2000). A complete and in date shock box should be available for use if necessary. The nurse must
be competent with how to use it.
Best Practice
PATIENT CHOICE
Patients should be given the option of administering their own suppositories.
important that the nurse records the result.
However, it is
EQUIPMENT
Prescribed suppository
Lubricating jelly
Non-sterile glove & apron
Tissues
PRINCIPLES OF CARE
See General Principles for All Procedures.
ACTION
RATIONALE
Check the patient's case notes for any anal or
rectal surgery or abnormalities and / or check
with General Practitioner before proceeding if
necessary.
Explain the purpose of the suppository i.e.
evacuant, anti-biotic, analgesic.
To maintain patient safety and to prevent
undue trauma.
3
Give the patient the opportunity to urinate.
A full bladder may cause discomfort during
procedure.
4.
Wash hands and put on disposable gloves and
apron.
To reduce risk of cross- infection.
1
2
Bowel Guidelines, May 2004
To ensure the patient is aware of the
expected/desired effect of the suppository and
to obtain informed consent.
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ACTION
RATIONALE
5
Wherever possible, position the patient on
their left side with knees flexed. Place a
disposable procedure sheet under the patients
hips and bottom.
This position allows ease of access, reduces the
risk of possible trauma by following the natural
anatomy of the anal canal and rectum. Flexing
the knees reduces discomfort.
6
Examine the perianal area and perform a
digital examination of the rectum (if
appropriate). If any abnormalities are noted,
seek medical advice before continuing.
To prevent undue trauma to the patient.
7
Lubricate the suppository and insert blunt end
foremost into the anal canal.
To aid retention and prevent expulsion. Pressure
in the anal canal assists the progression of the
suppository. When the blunt end is inserted
foremost, the lower edge of the contracting
external sphincter can provide a tight closure of
the anus.(Abd-El-Maebound et al, 1991).
8
Clean the patient's perianal area with tissues
For the patient's dignity and comfort.
9
Wash and dry hands thoroughly. Dispose of
gloves and apron appropriately.
Reduce the risk of cross infection
10 Ensure access to nurse call bell and / or toilet,
bedpan or commode.
Ensure the patient has safe and appropriate
access to the toilet facilities
11 Ask the patient to retain the suppository for as
long as possible (for at least 20 minutes)
To allow the suppository to dissolve and the
active ingredients to be absorbed (Addison,
2000).
12 If an evacuant suppository was used, the
effect must be monitored and documented
To monitor the patient's bowel function and
effectiveness of the suppository.
13 Document all assessment findings, care plan,
.
rationale and outcomes in the patients notes
Effective record keeping.
Best Practice
Lubricant suppositories e.g. glycerine, should be moistened with water and inserted directly into
the faeces to enable softening of the faecal mass. Medicinal suppositories e.g. Bisacodyl, must
come into contact with the mucous membrane of the rectum to be effective (Mallett & Bailey,
1999).
Bowel Guidelines, May 2004
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REFERENCES
Abd-El-Maeboud K H, El-Nagger T, El-Hawi EMM , Mahmoud SAR, Abd-El-Hay S (1991) Rectal
Suppository: Common sense and mode of insertion. The Lancet. Vol. 338 pp798.
Addison R, (2000) How to administer enemas and suppositories. Nursing Times Vol. 96, No. 6 pp 37.
Gruen J (2000) Neurosurgical Terms in Plain English – Vasovagal
Available at http://uscneurosurgery.com/glossary/v/vasovagal.htm [Accessed 31st July 2003]
Mallet J, Bailey C (1999) Fifth Edition, Manual of Clinical Nursing Procedures. Oxford:Blackwell
Science Limited
FURTHER READING
Cambell J. (1993) Skills Update: Suppositories. Community Outlook. Vol. 3, No 7 pp22-23.
Authors:
Elaine Cathcart, Continence Advisor
Sue Brown, Senior Continence Advisor
Sharon Lane, Ward Manager, B48 (QMC)
Angela Saunders, Ward Manager, Linby Ward, Rushcliffe PCT
Review Date: Three years from ratification.
SUGGESTED AUDIT POINTS:
1.
Was there an appropriate care plan written, including rationale?
2.
Was there evidence of appropriate evaluation for the planned care?
3.
Were appropriate review dates documented?
Bowel Guidelines, May 2004
11
RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
PROCEDURE FOR THE ADMINISTRATION OF ENEMAS
INTRODUCTION
An enema is the introduction into the rectum or lower colon of a liquid for producing a bowel action
or instilling medication.
Best Practice
ADMINISRATION WITHOUT MEDICAL ASSESSMENT
Nurses can administer a prescribed suppository without the doctor’s prior assessment as long as an
assessment of the patients bowel problems has been undertaken prior to the administration of the
suppository. This will enable the nurse to identify any issues which may contra-indicate the
administration of the suppository.
If the nurse feels unable to perform the assessment and / or the procedure, this is a training need and
the nurse has a responsibility to access the necessary training as soon as possible, in order to become
competent. Patient care must never be compromised.
There are two main types of enemas:
Evacuant:
Used to evacuate the bowel. They may be small or large volume and are usually commercially
prepared
Retention:
A solution used primarily for local effects, to be retained for a specific period.
INDICATIONS
Enemas may be prescribed for the following reasons:
•
•
•
•
•
To clean the lower bowel prior to surgery or endoscopy
To introduce medication
To treat irritated bowel mucosa
To reduce hyperkalaemia
To relieve constipation
Bowel Guidelines, May 2004
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CONTRA-INDICATIONS
Include:
• Low platelet count
• Malignancy (or other pathology) of the perianal region
• Recent lower gastrointestinal or gynaecological surgery
• Allergies i.e. Latex, phosphate, nuts.
• Neutropenia
• Inflammatory bowel disorders
HAZARDS
Collapse
Administration of a suppository may precipitate a vasovagal attack. The vagus is one of the nerves
that control heart rate and blood pressure. When the nerve is stimulated, it decreases heart rate and
lowers blood pressure which may result in inadequate perfusion of the brain which results in
collapse or faint. The vagus nerve can be stimulated by a number of physiologic and psychologic
reasons including sight of blood, fear etc. (Gruen, 2000) Collapse is a serious complication, which
may be expected in patient groups that are at particular risk, such as frail elderly people (Addison,
2000). A complete and in date shock box should be available for use if necessary. The nurse must
be competent with how to use it.
Best Practice
PAIN ON INSERTION
If the patient complains of pain on insertion of the enema nozzle or during administration,
discontinue the procedure and inform medical staff. Pain may indicate ano-rectal trauma (Saltzstein,
Quebbeman & Melvin 1988).
EQUIPMENT
Non sterile gloves & apron
Lubricating gel
Prescribed enema
Tissues/wipes
Absorbent pad/sheet
PRINCIPLES OF CARE
See General Principles for All Procedures.
Best Practice
PATIENT CHOICE
Patients should be given the option of administering their own enema. However, it is important that
the nurse records the result.
Bowel Guidelines, May 2004
13
RATIFIED 2004 – FOR REVIEW 2006
RATIONALE
ACTION
1
Check the patient's case notes for any anal or
rectal surgery or abnormalities and / or check
with medical staff before proceeding.
To maintain patient's safety and to prevent
undue trauma.
2
Explain the purpose of the enema.
So that the patient is aware of the
expected/desired effect of the enema and to
obtain informed consent.
3
Give the patient the opportunity to urinate.
A full bladder may cause discomfort during the
procedure.
4.
Wash and dry hands thoroughly, put on the
gloves and apron.
Reduce the risk of cross infection
5
Wherever possible, position the patient on
their left side with knees flexed. Place an
absorbent pad under the patients hips and
bottom.
This position allows ease of access reduces risk
of possible trauma by following natural
anatomy of anal canal and rectum. Flexing the
knees reduces discomfort.
6
Examine the perianal region and perform
digital examination of the rectum if
appropriate. If any abnormalities are noted,
seek medical advice before continuing.
To maintain patient safety.
Lubricate the nozzle of the enema, remove
cap and gently introduce its entire length into
the patient's rectum.
To prevent trauma to anal and rectal mucosa
by reducing surface friction and to ensure the
fluid is not immediately expelled.
6
Best Practice
To identify any pre-existing perianal
pathology.
ENEMAS
Enemas must be at room temperature or should be warmed to minimise shock and prevent bowel
spasm. If an enema is to be retained it should not be more than 200ml. Steroid enemas should be
given after defecation, preferably at bedtime.
ACTION
RATIONALE
7
Instil the contents of the enema into the
rectum and ask the patient to retain the enema
solution for as long as possible.
To maximise the evacuant affect.
8
Slowly withdraw the nozzle.
To avoid reflex emptying of the rectum.
Bowel Guidelines, May 2004
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RATIONALE
ACTION
9
Clean the patient's perianal area with tissues.
For the patient's dignity and comfort.
10 Wash and dry hands thoroughly. Dispose of
gloves and apron appropriately
Reduce the risk of cross infection
11 Ensure access to nurse call bell and / or toilet,
bedpan or commode.
12 If large volume enema leave the patient in bed
with the foot of the bed elevated (if the
patient's condition allows).
Ensure the patient has safe and appropriate
access to the toilet facilities
This aids the retention of the enema by force
of gravity.
13 If an evacuant enema was used the effect
must be monitored and documented.
14 Document all assessment findings, care plan,
rationale and outcomes in the patients notes
To monitor patient's bowel function and
effectiveness of enema.
Effective record keeping.
REFERENCES
Addison R (2000) How to administer enemas and suppositories. Nursing Times Vol. 96, No. 6 pp 37.
Gruen J (2000) Neurosurgical Terms in Plain English – Vasovagal
Available at http://uscneurosurgery.com/glossary/v/vasovagal.htm [Accessed 31st July 2003]
Saltzstein R.J, Quebbeman E, Melvin J L (1988) Anorectal injuries incident to enema administration
American Journal of Physical Medicine & Rehabilitation. Vol. 67, No. 4, pp186-188.
FURTHER READING
Heywood–Jones I (1994) Skills Update: Administration of enemas. Community Outlook. Vol.4, No.
5, pp18-19.
Authors:
Elaine Cathcart, Continence Advisor
Sue Brown, Senior Continence Advisor
Sharon Lane, Ward Manager, B48 (QMC)
Angela Saunders, Ward Manager, Linby Ward, Rushcliffe PCT
Review Date: Three years from ratification.
SUGGESTED AUDIT POINTS:
1.
Was there an appropriate care plan written, including rationale?
2.
Was there evidence of appropriate evaluation for the planned care?
3.
Were appropriate review dates documented?
Bowel Guidelines, May 2004
15
RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
GUIDELINES FOR THE MANAGEMENT OF FAECAL INCONTINENCE
INTRODUCTION
Faecal incontinence can be defined as the involuntary or inappropriate passing of liquid or solid stool
(Royal College of Physicians, 1995). Faecal incontinence remains a taboo subject and patients
frequently conceal their symptoms because of fear and embarrassment (Chelvanayagam & Norton,
1999).
FACTORS THAT MAY CONTRIBUTE TO FAECAL INCONTINENCE
•
•
•
•
•
•
•
•
•
•
•
•
Constipation
Infection
Medication
Radiotherapy to pelvis or abdomen
Colo-rectal disease e.g. Diverticular disease, Crohns disease, Irritable bowel syndrome,
Carcinomas.
Weakness /damage of the external and / or internal anal sphincters and pelvic floor muscles.
Immobility
Neuropathic disorders e.g. Spinal cord involvement, Dementia, Multiple Sclerosis, Cerebral
Vascular disease.
Rectal Trauma
Childbirth
Surgery
Diarrhoea
PRINCIPLES OF CARE
See General Principles for All Procedures.
ACTION
1
Complete a thorough continence assessment
using the continence assessment tool. (see
appendix 1)
A medical assessment and opinion is
recommended
Bowel Guidelines, May 2004
RATIONALE
To determine cause and ensure appropriate
management.
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ACTION
2
Obtain a stool specimen and request
microscopy, culture and sensitivity, if
appropriate.
RATIONALE
To identify any pathogenic organisms
responsible.
A routine microscopy, culture and sensitivity
does not include screening for clostridium.
Please also request Clostridium Difficile
Toxins on the microbiology card.
3
Review medication.
To identify any pharmacological causes.
4
Advice/educate the patient/carer regarding
bowel anatomy and function.
Knowledge empowers and enables the patient to
make informed decisions.
5.
Teach specific individualised external anal
sphincter exercises.
To strengthen the pelvic floor muscles and
increase the ano-rectal angle.
6
In the absence of infection where stools are
soft, discuss dietary requirements with
dietician.
Stool-firming medication can be used with
functional loose stool i.e. loperamide.
Firmer, more formed stools are easier to control
and may enable the patient to hold on for longer,
until a toilet, commode or bedpan is accessible.
To keep interventions basic but effective
wherever possible.
7
Identify appropriate aids or pads to contain
incontinence.
Seek advice if necessary from Continence
Advisory Service regarding specialist
products such as faecal collectors, anal plugs
etc.
To effectively contain the faecal incontinence
and preserve dignity.
At each pad change, wash skin with mild
soap and water or cleansing foam. Pat skin
dry. If skin is at risk of excoriation, apply a
thin layer of barrier cream (e.g. Cavilon or
zinc & castor oil) using a stroking action.
To remove harmful faecal enzymes.
If infection is identified follow appropriate
infection control guidelines.
To ensure effective treatment is given and to
prevent the spread of infection
Do not use stool firming agents
Fast elimination of infected diarrhoea should be
encouraged.
8
9
Bowel Guidelines, May 2004
To protect skin from faecal contamination.
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Best Practice
USE OF CLEANSING FOAMS AND BARRIER CREAMS
The use of cleansing foams and wash mousses are recommended as soap can alter the pH of the skin
making it more permeable and enhances the faecal enzyme activity.
The use of barrier creams should be kept to a minimum wherever possible as the most effective
method of preserving skin integrity is keeping it clean and dry.
The use of barrier creams are contraindicated if incontinence pads are to absorb urine as well as
faeces, as the barrier cream will effect the pads ability to absorb urine. Cavilon spray/cream/
applicator creates a protective film over the skin that does not affect the effectiveness of the pad.
REFERENCES
Chelvanayagam, S. & Norton, C. (1999) Causes and assessment of faecal incontinence, British
Journal of Community Nursing, Vol. 4, No. 1
Royal College of Physicians (1995) Incontinence: Causes, management and provision of services. A
working party of the Royal College of Physicians. Journal of the Royal College of Physicians,
London: RCP pp. 272 - 274
Authors:
Elaine Cathcart, Continence Advisor
Sue Brown, Senior Continence Advisor
Sharon Lane, Ward Manager, B48 (QMC)
Angela Saunders, Ward Manager, Linby Ward, Rushcliffe PCT
Review Date: Three years from ratification.
SUGGESTED AUDIT POINTS:
1.
Was a continence assessment form used ?
2.
Was a constipation risk assessment form used?
3.
Was there evidence or discussion with, or assessment by medical staff?
4.
Was there an appropriate care plan written, including rationale?
5.
Is the condition of the patient’s skin documented?
6.
Was an appropriate plan devised for the use of pads/appliances/ aids etc?
7.
Was there evidence of appropriate evaluation for the planned care?
8.
Were appropriate review dates documented?
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NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
GUIDELINES FOR DIGITAL RECTAL EXAMINATION AND MANUAL
REMOVAL EVACUATION OF FAECES
INTRODUCTION
Faecal impaction is one of the potential consequences of unresolved constipation, in all age groups. A
variety of factors predispose individuals to become constipated (See Guidelines for the Management
of Constipation). If impaction is not detected and treated, there may be an acute progression of
associated cardiac and respiratory symptoms which may result in death (Wright, 1986).
Manual removal of faeces is occasionally required to empty the rectal faecal contents.
Many nurses are confused about the professional, ethical and legal aspects of digital rectal
examination (DRE) and manual removal of faeces because of the invasive nature of the procedures,
the physical and psychological risks involved and fears of potential accusations of abuse.
With advances in oral, rectal and surgical treatments the need to perform DRE and especially manual
removal of faeces has reduced. For certain patients these procedures are still part of their bowel
management routine. (RCN, 2000)
WHO CAN CARRY OUT DIGITAL RECTAL EXAMINATION AND MANUAL REMOVAL OF
FAECES?
3
Any registered nurse who can demonstrate professional competence to the level
determined by the Nursing and Midwifery Council (NMC) in the Code of Professional
Conduct (2002).
This requires registered nurses to maintain and improve their professional knowledge and
competence, to acknowledge any limitations in their knowledge and competence and to decline any
duties or responsibilities unless they are able to perform them in a safe and skilled manner
3
A registered nurse who can demonstrate competence to this professional level can
delegate these procedures to carers, patients and students as appropriate, ensuring their
competence is assessed and reviewed as necessary.
Accountability lies with the individual practitioner. Failure to carry out tasks competently could
result in practitioners being asked to account for their actions by the NMC even if the patient
concerned doesn’t suffer harm and legal negligence cannot be established.
Practitioners who feel unable to carry out these procedures have a responsibility to inform their
managers and take steps towards accessing appropriate training to become competent.
General Practitioners or medical practitioners do not necessarily have to examine the patient before
a registered nurse assesses or treats a patient for constipation. Medical involvement is dependant on
the clinical findings gleaned from a thorough assessment
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WHEN SHOULD NURSES PERFORM A DIGITAL RECTAL EXAMINATION?
You can use Digital Rectal Examination to establish the following:
•
•
•
•
•
•
•
The presence of faecal matter in the rectum – the amount and consistency
Anal tone - the ability to initiate a voluntary contraction, and to what degree
Anal / rectal sensation
The need for and effects of, rectal medication in certain circumstances
The outcome of rectal / colonic washout / irrigation if appropriate
The need and outcome of using digital stimulation to trigger defecation by stimulating the
recto-anal reflex
The need for manual removal of faeces and evaluating bowel emptiness
Best Practice
PERFORMING A DIGITAL RECTAL EXAMINATION
Nurses can perform a digital rectal examination without the doctor’s prior assessment as long as a
thorough assessment has taken place. The doctor does not necessarily have to see or examine the
patient first, unless the assessment indicates that a medical opinion is required.
As a Registered Nurse you remain accountable for both your actions and omissions. If a Registered
Nurse feels unable to perform a digital rectal examination because of a lack of knowledge and / or
clinical skills, this is a training need and the appropriate training / study must be accessed in order to
gain clinical competency. Patient care must never be compromised.
WHEN SHOULD NURSES UNDERTAKE MANUAL REMOVAL OF FAECES?
•
•
•
•
Faecal impaction / loading
Incomplete defaecation
Inability to defaecate
Neurogenic bowel dysfunction
Manual removal of faeces is invasive and should only be performed as a last resort following
comprehensive assessment (holistic and continence assessments) and when all other appropriate
treatments have been tried and evaluated as ineffective. Nursing and medical consultation / assessment
is advised
Best Practice
SENSITIVITY ANND CAUTION
Sensitivity and caution are required when the patient has:
• active inflammation of the bowel e.g. Crohns Disease, Ulcerative colitis, and Diverticulitis;
• had recent radiotherapy to the pelvic area;
• tissue fragility due to age, radiation, loss of muscle tone in neurological diseases or
malnourishment;
• a known history of abuse;
• a spinal injury because of autonomic dysreflexia (see page 24);
• known allergies (see best practice box on page 22);
• a known cardiac condition
• pancytopenia and / or neutropenia
Bowel Guidelines, May 2004
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Best Practice
CULTURAL ISSUES
Cultural and religious beliefs need to be considered before performing any of these procedures if
there is any risk of the procedure being misunderstood. If indicated, the use of an interpreter is
strongly recommended.
SIGNS AND SYMPTOMS OF FAECAL IMPACTION
Primary Symptoms:
• Faecal leakage (overflow) – often mistaken for diarrhoea
• Abdominal cramps
• Malaise
• Anorexia
• Nausea and vomiting
• Confusion and agitation (exacerbation of existing chronic confusion and agitation).
• Hypotension, dizziness and falls due to vaso-vagal response caused by pressure of faeces on
the vagus nerve
• Back pain due to pressure on the sacral nerve
• Urinary retention / urinary incontinence
Other indications
•
•
•
•
•
•
•
•
•
•
Low grade pyrexia
Tachycardia
Leucocytosis
Angina
Scaling dry skin
Poor turgor (tenting of skin over forehead and sternum)
Dry, cracked mucus membranes
Eyes that appear sunken in the sockets
Shortness of breath (pressure on the diaphragm resulting in impaired pulmonary ventilation,
hypoaemia and left ventricular dysfunction)
Hyperventilation
PERINEAL AND PERIANAL OBSERVATION
Before a digital rectal examination or manual removal of faeces is carried out, abnormalities of the
perineal and perianal area should be observed, documented and reported. The visual assessment aims
to identify:
•
•
•
•
•
•
•
Rectal prolapse
Haemorrhoids – their number, position, grade and prolapse
Anal skin tags – number, position and condition
Wounds, dressings and discharge
Anal lesions (?malignancy)
Gaping anus
Anal fissure
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•
•
•
•
•
Skin conditions, broken areas, pressure sores of all grades
Bleeding and colour of the blood
Faecal matter
Infestation (warts, threadworm)
Foreign bodies
Digital rectal examination is part of the overall assessment process and should not be seen as a
primary investigation in the assessment and treatment of constipation. After assessment, a doctor’s
assessment and advice / opinion is required to provide a diagnosis and to decide jointly on appropriate
intervention.
Best Practice
ALLERGIES
It is important to assess for allergies including latex, soap (lanolin), phosphate (present in phosphate
enemas ) and peanuts (present in arachis oil enemas) before going ahead with any rectal procedures.
Assessing for latex allergy is important for the nurse as well as the patient.
CONSENT
Any nursing care or treatment, which involves physical contact with the patient’s body, cannot be
undertaken unless informed consent has been given. If informed consent is not given, touching the
patient’s body is unlawful. The patient could sue the individual practitioner and / or the employer for
compensation even if no harm occurred.
Please refer to the Trust’s informed consent policy.
DIGITAL RECTAL EXAMINATION
PRINCIPLES OF CARE
See General Principles for All Procedures.
EQUIPMENT
Non sterile gloves & apron
Lubricating gel – water based
Tissues/wipes
Absorbent pad/sheet
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RATIFIED 2004 – FOR REVIEW 2006
ACTION
RATIONALE
1
Assess patient to include a holistic assessment,
continence assessment (reverse side of the
continence assessment form is specific to
bowels and perineal / perianal visual
assessment) See appendix 1 – continence
assessment form
To determine the problem, the cause and
ensure appropriate, effective and safe
management.
2
Explain the purpose and the technique of the
procedure
To ensure the patient is aware of the
proceedings and the rationale. Facilitate an
informed consent
Legal and ethical requirement
Obtain informed consent
3
Give the patient the opportunity to urinate
4
Wash and dry hands thoroughly and put on
apron
Wherever possible, position the patient on their
left side with knees flexed.
5
Place an absorbent pad under the patients hips
and bottom.
A full bladder may cause discomfort during the
procedure
To reduce the risk of cross infection
This position allows ease of access reduces risk
of possible trauma by following natural
anatomy of anal canal and rectum. Flexing the
knees reduces discomfort. To maintain patient
safety.
The recto-anal reflex may be stimulated and
there may be faecal loss
Cover the exposed area of the patient as much
as possible with a sheet
To maintain dignity
6
Examine the perianal region. If any
abnormalities are noted seek medical advise
before continuing.
To identify any pre-existing perianal
pathology.
To maintain patient safety.
7
Continually inform the patient of your actions
and what to expect.
To reduce anxiety and keep the patient
informed
8
Insert a lubricated and gloved index finger
gently into the anal orifice following the
natural curve of the anal canal. Once inside the
rectum assess for rectal contents and rectal
distension.
Fingernails should be short and smooth.
The anal canal has extremely sensitive nerves.
A misdirected finger will cause pain and
trauma.
9
Once necessary information is obtained, gently
remove the finger and wipe the anus clean.
Ensure the perineal area is left clean and dry.
10 Wash and dry hands thoroughly, dispose of the
gloves and apron appropriately.
Bowel Guidelines, May 2004
To reduce the risk of cross infection
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ACTION
11 Document all care planned including rationale,
and record the results. A specific date for
review should be documented.
RATIONALE
To record and evaluate treatment
implemented.
Promote a high standard of nursing care
EXCLUSIONS AND CONTRA-INDICATIONS
Nurses should not undertake a digital rectal examination or manual removal of faeces in situations if:
•
•
•
•
•
•
•
•
there is lack of consent;
the medical staff have given instructions not to do so;
the patient has recently undergone rectal / anal surgery or trauma;
the patient appears to gain sexual satisfaction from these procedures – inform the doctor
there is obvious rectal bleeding;
the patient has rectal / anal pain
the patient has a low platelet count or clotting disorder;
the nurse has any concerns regarding the safety of carrying out a digital rectal examination or
manual evacuation of faeces
AUTONOMIC DYSREFLEXIA IN SPINAL CORD INJURY
Autonomic dysreflexia is a condition that develops after spinal cord injury (usually above T6) in
which potentially life threatening episodic hypertension is triggered by stimulation of the sensory
nerves in the body below the site of injury. The clinical incident has a rapid onset: the symptoms
include:
•
Headache
•
Blurring vision
•
Shivering
•
Nasal obstruction
•
Flushing
•
Sweating
•
Hypertension
•
Feeling unwell and nauseous
The acute increase in arterial blood pressure can also result in serious conditions such as subarachnoid
haemorrhage, seizures, intra-cerebral haemorrhage or even death in severe cases
If symptoms become apparent stop any procedures, place the patient in an upright sitting position and
seek medical advice immediately. Continue to monitor the patient’s blood pressure and pulse every 5
minutes until the condition stabilises.
Bowel Guidelines, May 2004
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RATIFIED 2004 – FOR REVIEW 2006
NOTTINGHAM CITY HOSPITAL/ QUEEN’S MEDICAL CENTRE/ RUSHCLIFFE PCT
NURSING PRACTICE GUIDELINES
MANUAL REMOVAL OF FAECES – ACUTE AND REGULAR INTERVENTION
Best Practice
The decision to carry out a manual evacuation must be based on nursing and medical assessments.
EQUIPMENT
Stool softeners (oral / rectal)
Mild sedative if prescribed
Non sterile gloves & apron
Lubricating gel – water based
Tissues/wipes
Absorbent pad/sheet
Sphygmomanometer
Thermometer
Bed pan or receptacle
PRINCIPLES OF CARE
See General Principles for All Procedures.
ACTION
RATIONALE
1
Assess patient to include a holistic
assessment, continence assessment (reverse
side of the assessment form is specific to
bowels and perineal / perianal visual
assessment
To determine the problem, the cause and ensure
appropriate, effective and safe management.
2
Obtain informed consent
Legal and ethical requirement
3
Administer appropriate stool softener if
prescribed
To assist easier removal.
4
Administer prescribed sedative and / or
analgesia as per doctors / pharmaceutical
instructions before the procedure. Assess
effectiveness of the drugs
To relax and calm the patient, provide effective
pain control based on individual needs.
Bowel Guidelines, May 2004
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RATIFIED 2004 – FOR REVIEW 2006
ACTION
RATIONALE
5
Assess the patients blood pressure, pulse,
temperature and respiratory rate prior to the
procedure.
Assess a baseline for future comparison.
6
Wherever possible, position the patient on
their left side with knees flexed.
This position allows ease of access reduces risk
of possible trauma by following natural anatomy
of anal canal and rectum. Flexing the knees
reduces discomfort. To maintain patient safety.
Place an absorbent pad under the patients hips
and bottom and cover the exposed area of the
patient as much as possible with a sheet.
To maintain dignity.
7
Place protective sheet under the patient’s hips
and bottom.
The recto-anal reflex may be stimulated and to
collect any leaked rectal contents.
8
Wash and dry hands thoroughly, apply gloves
and apron.
To reduce the risk of cross infection.
9
Continually inform the patient of your actions
and what to expect.
To reduce anxiety and keep the patient
informed of all proceedings.
10 Apply water based lubricant to gloved index
finger and gently insert into the anal orifice
following the canal as it curves (ensure
fingernails are short and smooth).
The anal canal has extremely sensitive nerves, a
misdirected finger will cause pain and trauma.
11 Advise patient to take slow deep breaths
during the procedure.
To promote relaxation.
12 Remove smaller particles and break larger
pieces up by inserting the finger into the stool,
collect in an appropriate receptacle.
Reduce the trauma of the procedure, facilitate
easier removal of faeces.
13 Where possible advise patient to bear down
whilst exhaling – to assist with valsalva
manoeuvre if possible
Bearing down releases the anal sphincter.
Exhaling whilst bearing down reduces
unnecessary straining that can raise intrathoracic
pressure and significantly impede coronary blood
flow (Earnest D.L. et. al. 1982).
14 Pause frequently during procedure and apply
more lubrication if necessary.
Allow the patient a rest from the discomfort and
re-lubricate as required.
Bowel Guidelines, May 2004
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RATIONALE
ACTION
15 Check the patient’s blood pressure, pulse and
respiration rate once during the procedure.
The frequency of these observations during
the procedure is dependant on the results of
the patients previous observations and their
clinical condition. Continually check for
dizziness, chest pains and cramps.
Vagal stimulation can slow the heart rate (Perri
and Potter, 1990) removal of large quantities of
stool may lower intra-abdominal pressure and
induce shock (O’Connor, 1994).
16 If abnormal signs become evident or severe
rectal bleeding or pain is evident – stop the
procedure and seek medical advice.
Rectal trauma may be evident, the patient is
experiencing severe adverse reactions.
17 After removal of faecal matter gently remove
the finger and clean the anus and offer
commode / toilet if necessary.
Ensure the perianal area is left clean and dry.
Ano-rectal reflex may be stimulated and further
bowel actions may follow.
18 Monitor the patient’s temperature, blood
pressure and respirations post procedure. The
patient’s condition must be monitored for up
to one week post procedure and the frequency
of the observations is dependant on the
patients progress and clinical condition.
Cases of rectal bleeding have been reported as
occurring up to 7 days following manual
removal. Initial minor erosions caused during the
procedure may become infected (Mohammed
1978).
Best Practice
USE OF ORAL; FAECAL SOFTENERS
Oral faecal softeners may take longer to be effective, and may cause severe cramping which could
rupture the colon (O’Connor, 1994). Consider their use with caution.
Best practice
STAGED APPROACH TO MANUAL REMOVAL
Removal of a large amount of impacted faeces can and should take place in stages. The sudden
removal of a large amount of stool can lower intra-abdominal pressure and can cause transient
hypotension, dizziness and falls
REFERENCES
Earnest, D.L. et. al. (1982) Therapy for gastrointestinal disease IN Conrad K and Bressler R (Eds)
Drug therapy for the Elderly St. LouisUSA: C.V. Mosby Co. pp 189 – 196
Mohammed, J. et. al. (1978) Rectal bleeding secondary to faecal disimpaction; Angiographic
diagnosis and treatment. Diagnostic Radiology No. 126; pp 387 – 389.
Nursing and Midwifery Council (2002) The Code of Professional Conduct London: NMC
Bowel Guidelines, May 2004
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RATIFIED 2004 – FOR REVIEW 2006
O’Connor, E.M. (1994) How to identify and remove faecal impactions, Geriatric Nursing, May/June
pp 158 – 161.
Royal College of Nursing (2000) Digital Rectal Examination and Manual Removal of Faeces,
London: RCN
Wright, B.A. (1986) The Geriatric Implications of Faecal Impaction, Nurse Practitioner, October, pp
53 – 66.
FURTHER READING
Cefalu C.A. et. al. (1981) Treating Impaction – A Practical Approach Geriatrics, Vol. 38, No. 5, pp
143 – 146.
Coloplast Foundation (1988) Objective Continence Teaching Resource, Peterborough: Coloplast
Norton, C (1986) Nursing For Continence, Beaconsfield: Town Beaconsfield Publishers
Perri, A.G. & Potter, P.A. (1990) Pocket Guide To Basic Skills and Procedures, 2nd Edition, St.
Louis, USA: CV Mosby Company
Vaidyanathan, S. (2000) Autonomic dysreflexia in spinal cord injury patients, Urology Vol. 4, No. 6,
pp 12 – 14.
Author
Elaine Cathcart, Continence Advisor Tel. (0115) 9845511 Nottingham City PCT
NNPDG Link Members
Sharon Lane, Ward Manager, B48 (QMC)
Angela Saunders, Ward Manager, Linby Ward, Rushcliffe PCT
Review Date: Three years from ratification.
SUGGESTED AUDIT POINTS
1.
Was the reason for the digital rectal examination / manual removal of faeces documented?
2.
Is there evidence of a medical assessment?
3.
Is there evidence of informed consent from the patient?
4.
Is there evidence that other appropriate methods of relieving the constipation / impaction
had been implemented and evaluated before a manual removal was used?
5.
Are there baseline observations of blood pressure, pulse, temperature and respirations
recorded prior to a manual removal of faeces?
Bowel Guidelines, May 2004
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RATIFIED 2004 – FOR REVIEW 2006
6.
Was a pre-procedure analgesia and stool softener prescribed and given to the patient?
7.
Is the care planned adequately evaluated including documented review dates?
8.
Are the observations of blood pressure, pulse, temperature and respirations recorded
during and after a manual removal of faeces?
9.
Has appropriate care been planned to prevent faecal impaction and constipation if possible?
Bowel Guidelines, May 2004
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Continence Assessment Form
First name:
Patient’s Main Problem
APPENDIX
Family name:
DOB:
Urinary symptoms
Assessment date:
Y N Comments
Frequency How often are they
passing urine
Onset of problem
Extent of wetting
Dry
Urgency
How long can they hold
following desire to pass urine
Urge Incontinence
Do they wet before reaching toilet
Damp
Volume ____
Wet - pads, pants, clothes, furniture, bedding
Aids or pads used – Type___________________
Panty liner
Sanitary towel
Buys own
All in one
2 piece pads
Sheath
Menstrual Cycle
Menopause
Pill
Date____________
Normal cycle ___
Flushes
Irregular cycle
Vaginal dryness
Menorrhagia
HRT
Worse before period
Hysterectomy
N/A
N/A
Parity
Number of pregnancies
_____
Number of live births _____ Weights:
Labour
Behaviour prior to
Caesarean section
micturition
Episiotomy
Tear
Forceps
Ventouse
Long second stage
Short second stage
Breech
Normal delivery
Epidural
N/A
Bowel Guidelines, May 2004
Aggressive
Agitated
Wandering
Pacing
Not observed
Other, please state
Dysuria
Is it painful to pass urine
Assessing nurse:
Vaginal Examination
Normal
Redness
Dryness
Discharge
Cystocele
Rectocele
Fistula
Caruncle
Refused
Not done
Reason
Nocturia Are they woken by the urge to
pass urine
Nocturnal Enuresis
Do they wet the bed
Straining
Do you have to strain
Poor Stream
Is it a gush or a trickle
Post Micturitional Dribbling
Do you leak as soon as you have finished
Hesitancy
Do you have to wait before
Pelvic Floor Tone
No contraction
___
Flicker
___
Weak
___
Moderate
___
Good
___
Strong
___
Sustains for __ seconds
No of repetitions
___
Fast Twitch
___
starting
Manual Expressing
Do you have to press over your bladder to
pass urine
Lack of Sensation
Does your bladder empty without warning
Voiding Difficulties
Do you feel you haven’t emptied your
bladder
Stress Incontinence
When coughing, exertion, etc...
Urinalysis
Leucocytes ____
Nitrite
____
Protein
____
PH
____
Blood
____
SG
____
Ketone
____
Glucose
___
MSU sent ___
Post Void Residual
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Laxatives (Past and
Present)
Behaviour associated with
defaecation
Aggressive
Pacing
Agitated
Other, please state:
Wandering
Y N
Constipation
Usual bowel pattern/habits
Type 2 – Hard stool
Type 3 – Formed stool
Faecal incontinence
General comments
Type 4 - Formed smooth stool
Reduced sensation
Type 5 – Semi formed
Type 6 – fluffy pieces
Pain on defecation
Blood
Type 7 - Liquid stool
Mucus
Fluids
Number of drinks
Cups/mugs
Type of fluid
Bowel Symptoms
Y
Type 1 – Pebbles
Black
Pleased
Mostly satisfied
Mixed about equally satisfied
and dissatisfied
Unhappy
Detrusor instability/mixed
Nocturnal polyuria
No residual
No residual
No residual
Wetting on exertion
Frequency
33% of urine output during
hours of sleep
Poor pelvic floor tone
Urgency, urge incontinence
Nocturia
Quite large voids
Large voids
Bowel Guidelines, May 2004
Abnormalities
Not examined
Haemorrhoids
Stress
Small wetting episodes
Retraction
NAD
Urgency
Brown
If you were to spend the rest of your life with your urinary condition just the way it is now, how
would you feel about it?
Delighted
Penis/Scrotum
Hydrocele
Sensation of rectal fullness
Colour of stool
Pale
N
Terrible
Have you had to make changes to your life because of
your problem?
None (0)
A few (1)
Many (2)
Outflow obstruction
Atonic bladder
Residual
Functional
Hesitancy wetting and exertion
Poor dexterity
May have frequency urgency
Nocturia
Dribbling or large voids
Recurrent UTI’s
Clothing
Poor mobility
Environment
Can be large voids
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APPENDIX 2
Constipation Risk Assessment Tool
1) Each patient should have a constipation risk assessment on admission within the first 48 hours and
reassessment on a weekly basis or sooner if condition or treatment changes. This risk assessment will be
recorded in the care plan.
Patient Name:
DOB:
FLUIDS
MOBILITY
DIET
Drinks
1500-2000
mls per day
Fully mobile
Active
Eats full
meals
1
1
Drinks less
than 1000
mls
2
Hosp. No.
MENTAL
STATE
Normal &
appropriate
1
1
Mobile but
sedentary
Use of aids
2
Takes small
unvaried
diet
2
Confused
or memory
impaired
Drinks less
than 700
mls
3
Immobile
Poor diet?
Eats very
little
3
Very confused,
unable to
ask for toilet
3
Date:
Assessor:
4
PREDISPOSITION
SCORE
Takes predisposing
medication
3
-------------Takes Opioids
4
Has history of
constipation
2
3
Predisposing medical
condition
3
Total
All nursing actions will be documented in the care plan.
Scoring 5 points or less = minimal risk
Patients should be advised of importance of diet, exercise and fluid intake and should be encouraged
to report any changes in bowel habit.
Scoring up to 7 points = at medium risk
Complete bowel assessment.
a. Encourage mobility within own capabilities
b. Increase fluid intake to two litres in 24 hours, unless contraindicated.
c. Encourage foods rich in fibre unless stool is soft and mushy.
d. Introduce prune juice half cup daily (this may need to be increased to be effective) if the patient is
not having their normal bowel movement. If not tolerated then substitute with other fruit juices.
The patient will be asked about bowels on a daily basis and this will be documented clearly in the
evaluation of the care plan.
Scoring 8+ above points = high risk
(If bowel action normal for patient, follow medium risk assessing daily.)
Complete bowel assessment.
Keep bowel chart with document including : action, type of stool, frequency. amount and problems
with defaecation
Intervention as for medium risk plus :e. Discuss with doctor the appropriate laxative to be used for the individual. This should be
evaluated and revised if problems occur or are not resolved.
Discuss with medical staff, the necessity for rectal, abdominal or radiological examination.
The Continence Advisor should be contacted for advice with patients with persistent constipation.
Bowel Guidelines, May 2004
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Constipation Re-assessment Tool (continuation)
Patient Name:
DOB:
Hosp. No.
FLUIDS
MOBILITY
DIET
MENTAL STATE
PREDISPOSITION
Drinks 1500-2000
mls per day
Fully mobile
Active
Eats full
meals
Normal &
appropriate
Takes predisposing
medication
3
-------------4
Takes Opiods
1
1
1
1
Drinks less than
1000 mls
2
Mobile but
sedentary Use
of aids
2
Takes small
unvaried diet
Drinks less than
700 mls
3
Immobile
Poor diet?
Eats very
little
3
Date:
4
2
Assessor:
Confused
or memory
impaired
Has history of
constipation
2
3
Very confused,
unable to
ask for toilet 3
Predisposing medical
condition
3
Total
FLUIDS
MOBILITY
DIET
MENTAL
STATE
PREDISPOSITION
Drinks 1500-2000
mls per day
Fully mobile
Active
Eats full
meals
Normal &
appropriate
Takes predisposing
medication
3
Takes Opiods 4
1
1
1
Drinks less than
1000 mls
Mobile but
sedentary Use
of aids 2
Takes small
unvaried diet
2
Confused
or memory
impaired
2
Has history of
constipation
Drinks less than
700 mls
Immobile
Poor diet?
Eats very
little 3
Very confused,
unable to
ask for toilet 3
Predisposing medical
condition
3
Date:
4
Assessor:
Total
MOBILITY
DIET
MENTAL
STATE
PREDISPOSITION
Drinks 1500-2000
mls per day
1
Fully mobile
Active
1
Eats full
meals
1
Normal &
appropriate
1
Takes predisposing
medication 3
Takes Opiods 4
Drinks less than
1000 mls
2
Mobile but
sedentary Use
of aids 2
Takes small
unvaried diet
2
Confused
or memory
impaired
2
Has history of
constipation
3
Drinks less than
700 mls
3
Immobile
Poor diet?
Eats very
little
3
Very confused,
unable to
ask for toilet 3
Predisposing medical
condition
3
4
Assessor:
Bowel Guidelines, May 2004
SCORE
3
FLUIDS
Date:
SCORE
SCORE
Total
33
RATIFIED 2004 – FOR REVIEW 2006
APPENDIX 3
THE BRISTOL STOOL FORM SCALE
Type 1
Separate hard lumps like nuts (hard to pass)
Type 2
Sausage-shaped, but lumpy
Type 3
Like a sausage, but with cracks on its surface
Type 4
Like a sausage or snake, smooth and soft
Type 5
Soft blobs with clear-cut edges (passed
easily)
Type 6
Fluffy pieces with ragged edges, a mushy
stool
Type 7
Watery, no solid pieces ENTIRELY LIQUID
Bowel Guidelines, May 2004
34
RATIFIED 2004 – FOR REVIEW 2006
APPENDIX 4
Laxatives
Bulk forming
Name
Start
working
How it
works
Side effects
Cautions
Dose
Fybogel
Up to 48
hours
Imitates
natural action
of fibre.
Increases
faecal mass,
which
stimulates
peristalsis.
Flatulence,
abdominal
distension,
intestinal
obstruction/
impaction
Must have adequate
fluid intake
1 sachet in 150mls of
water twice daily after
meals.
Osmotic Laxatives
Name
Start
working
How it
works
Side effects
Cautions
Dose
Lactulose
Up to 48
hours
Retains fluid
in the bowel
by osmosis
which softens
the stool
Flatulence,
abdominal
discomfort and
cramps
Contraindicated in
galactosaemia
10 or 20mls B.D.
Fletchers
phosphate
enema
Approx.
2030mins.
Softens and
lubricates to
promote a
bowel
movement.
Local irritation.
Contraindicated in
Hirschsprung's
disease. Avoid
prolonged use. Used
with caution in
patients with renal
impairment: risk of
phosphate.
1 x 128mls standard or
long tube.
Micro
enema
Approx.
2030mins.
Softens and
lubricates to
promote a
bowel
movement.
Local irritation.
Contraindicated in
flammatory bowel
disease. Avoid
prolonged use.
1x5mls
Cautions
Dose
Avoid use if allergic
to nuts.
130mls.
Faecal Softeners
Name
Start
working
How it
works
Arachis
oil
Liquid to
be
installed
and
retained.
Lubricates and
softens the
stool to
promote a
bowel move.
Bowel Guidelines, May 2004
Side effects
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RATIFIED 2004 – FOR REVIEW 2006
Stimulant Laxatives
Name
Start
working
How it works
Side effects
Cautions
Dose
Bisacodyl
Tablets: 1012 hrs.
Suppository:
20-60mins
Increases intestinal
mobility
Avoid prolonged use.
Avoid taking antacids
at the same time as
tablets.
Tablets: 5-10mgs
at night,
Suppository
10mgs.
Codanthram
er
6-12hrs
Capsules 1-2
days
Only to be used in the
terminally ill –
potential
carcinogenic risk.
Avoid prolonged use.
Capsules: 1-2 at
night. Suspension
5-10mls at night.
Docusate
Senna
8-12 hrs
Soften and
stimulates to
promote a bowel
movement
Increases intestinal
mobility, also
softens.
Increased intestinal
mobility.
Abdominal
cramps. Atonic
non functioning
colon,
hypocalcaemia.
Abdominal
cramps, urine
discoloured pink.
Sodium
Picosulphate
(Picolax)
Glycerine
suppository
Sachets:
within 3
hours.
Approx. 2030mins
Stimulates bowel
clearance.
Abdominal
cramps.
Abdominal
cramps, Atonic
non functioning
colon,
hypocalcaemia.
Can be very
severe.
Rectal stimulant.
Avoid prolonged use.
Capsules: 100500mg daily in
divided doses.
Tablets: 2-4 at
night. Syrup: 1020mls at night.
Avoid prolonged use.
Usually used preoperatively.
Blunt end first
ensures better
retention. Moisten
before use.
As directed
1x4g
Iso- Osmotic Laxative
Name
Start
working
How it works
Side effects
Cautions
Dose
Movicol
Up to 30 hrs
depending on
dosage.
Water retention by
PEG (polyethyleneglycol)
Abdominal
distension and
discomfort if on
the maximum
dose.
Avoid use pregnancy,
known bowel
inflammation or
obstruction.
Initially 2-3
sachets per day
but dosage can
very according to
individual needs.
To remove
impaction – 8
sachets within 56 hrs for 1-3 days
only.
Bowel Guidelines, May 2004
36
RATIFIED 2004 – FOR REVIEW 2006
APPENDIX 5
Nottingham Community Nutrition & Dietetic Service
HOW TO EAT MORE FIBRE
FIBRE is a mixture of plant substances providing bulk in the diet and encouraging the correct
functioning of the bowel.
•
When eating more fibre in your diet it is important to introduce high fibre foods
gradually.
•
Drink extra fluid, make sure you take at least 8 cups each day in the form of water,
tea, coffee or fruit juice.
•
Eat regular meals.
The following suggestions will help to increase the fibre content of your diet:
•
Choose wholemeal, granary, multigrain or high fibre white bread.
•
Use wholegrain breakfast cereals – try Weetabix, Shredded Wheat, Shreddies, Bran
Flakes, All Bran, Porridge, unsweetened Muesli.
•
Try wholemeal flour instead of white flour in cooking
- or try a combination of half and half.
•
Choose wholewheat pasta shapes, spaghetti, macaroni, lasagne.
•
Chapattis can be made with a coarser grain flour (number 2 or 3).
•
Try brown rice for a change – this is available various types including basmati.
•
Include pulses such as lentils, chick peas, butter beans, red kidney beans just to
name a few. These are ideal in soups, casseroles and stews and can be used to
substitute for some of the meat.
•
Eat more fruit, vegetables and salads. Aim for at least five portions of fruit and
vegetables per day.
Each of the following count as one portion:
Vegetables - 2 tablespoons, raw, cooked, frozen or canned
Salad - 1 desert bowlful
Small fruit (eg plums, apricots, satsumas) 2 fruit
Medium size fruit ( eg apple, orange, banana) 1 fruit
Very large fruit (melon, pineapple) 1 large slice
Raspberries, strawberries, grapes - 1 cup full
Fresh fruit salad, cooked or canned fruit - 2-3 tablespoons
Dried fruit - 1/2 - 1 tablespoon
Fruit or vegetable juice - 1 glass (150mls)
•
Leave the skins on potatoes or have jacket potatoes.
Bowel Guidelines, May 2004
37
RATIFIED 2004 – FOR REVIEW 2006
STOOL CHART
Name…..…………………….Hospital Number………………………..Ward…………………...
Normal Bowel Habit
Date
&
Time
Frequency:
Amount
Consistency
small/
moderate/large
see Bristol Stool
Chart
Bowel Guidelines, May 2004
Colour
Consistency:
Blood
Mucous
Amount/
Colour
Amount
Specimen
Sent
See reverse for
guide and indicate
what test for
Recorded
by
Please sign
38
RATIFIED 2004 – FOR REVIEW 2006
Stool Specimen Guide for patients with diarrhoea
Please send 1 SAMPLE, if result is negative and diarrhoea persists please repeat
Microbiology investigation
Culture & Sensitive
Criteria
-admitted with diarrhoea
-recent travel abroad
-inpatient for less than 72hours
-immunosuppressed
-outbreak within the ward/hospital (more
than one existing inpatient person with
symptoms)
Clostridium Difficile Toxin
-hospital acquired diarrhoea (develops
diarrhoea whilst an inpatient)
-antibiotics within the last four weeks
-inpatient within last 3 months
-immunosuppressed
Virology
-outbreak
(Please send separate sample)
Parasites & Ova
within the ward/hospital (more
than one existing inpatient with symptoms
with diarrhoea and vomiting)
-onset within 24 hrs of admission
-recent
travel abroad
Diarrhoea: If stools between type 6 & 7 on Bristol Stool Chart (check patient is not on laxatives).
Note: Patients who develop diarrhoea whilst an inpatient should be referred to Gastro Nurse Practitioner. If
there is a suspected outbreak, inform infection.
Constipation: Constipation is a common problem. If allowed to continue it may cause serious medical; problems.
Bowel Guidelines, May 2004
39