BOWEL CARE PROCEDURES

Transcription

1 First Issued Issue Version Purpose of Issue/Description of Change Planned Review Date One To promote safe and effective care when carrying out bowel care procedures in a 2013 community setting Named Responsible Officer:- Approved by Date Continence Nurse Specialist Nursing Policy Group February 2010 Section :- Continence C N o 05 Impact Assessment Screening Complete Date: January 2010 Full Impact Assessment Required Y/N UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM NHS WIRRAL WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 INDEX Contents Page Number Introduction 3 Procedure aim 3 Procedure outcomes 3 Target group 4 Training 4 Related policies 4 Risk Assessment 4 Medication Review 5 Circumstances where extra care is required 5 Exclusions and contra-indications 5 Patients who lack capacity 6 Sensitivities 6 Observation of the perianal and perineal area 6 PROCEDURES Digital Rectal Examination 7-8 Insertion of Suppositories and Enemas 9-11 Digital Removal of Faeces Digital Rectal Stimulation Care & Management of Autonomic Dysreflexia Further Reading 20 References 21 Appendix 22 2/22

3 INTRODUCTION This procedure will outline the professional and legal aspects of Digital Rectal Examination, Insertion of Suppositories and Enemas, Digital Removal of Faeces, and Digital Rectal Stimulation. The procedure is based upon standards from the Royal College of Nursing (2006 & 2008). With advances in oral, rectal and surgical treatments, the need for these procedures have been reduced (Kyle et al 2005). However, they may still be required as an acute intervention or as part of a regular bowel management programme for patients with neurological conditions or Spinal cord Injury (Powell & Rigby 2000). Nurses commonly encounter patients on their caseload with acute bowel dysfunction including constipation and faecal incontinence and it is not uncommon for the nurse to be the key person who will assess, treat and manage these conditions. If patients with constipation or faecal impaction are referred by a General practitioner but are not currently on the District Nurses caseload or present with severe pain, nausea, vomiting or fever, they should be seen by their General Practitioner to exclude other conditions such as bowel obstruction. A Bowel Management Programme may incorporate a combination of the above procedures, which are performed in a particular order to achieve a predictable evacuation of the bowel. Its aims are to avoid constipation or faecal incontinence and reduce the risk of long term complications (Coggrave 2008). Loss of bowel function can have a significant effect on quality of life, with implications for independence, and long term health (Coggrave et al 2009). For the Spinal Cord injured patient, developing such a programme is a specialist field and results in a highly individualised bowel management programme (Coggrave et al 2009) alterations to management should only be undertaken following discussion with the patient s Spinal Injury Unit (RCN 2008). Failure to support patients in their bowel management programme can place them at risk of autonomic Dysreflexia (National Patient Safety Agency 2004). PROCEDURE AIM This procedure aims to ensure that patients in the community setting who require any of the above bowel interventions have the procedure carried out in a safe and timely manner. PROCEDURE OUTCOMES This will enable nurses to:- Comply with evidence based NHS Wirral Procedures for Bowel Care Recognise the signs, symptoms and management of Autonomic Dysreflexia Be aware of the varying issues of consent for performing this procedure Consider the cultural and religious beliefs prior to performing this procedure. Assess which group of patients are suitable for this type of intervention TARGET GROUP 3/22

4 This procedure applies to all clinical staff directly employed by NHS Wirral, who are required to carry out this role and have attended the in-house Continence Care Course. TRAINING All registered nurses will attend the in house Continence Care Course within six months of joining organisation and thereafter every three years. This is a two day in house course provided by the Continence Service. RELATED POLICIES NHS Wirral Record Keeping Procedure for Community Nursing NHS Wirral Health Records Policy Nursing and Midwifery Council (NMC 2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives NHS Wirral Consent Policy Chaperone and Intimate Care Policy Health and Safety Policies Infection Control Policies Disposal of clinical waste policy Incident Reporting policy Essence of Care Privacy and Dignity (2003) NB Always use most current versions of NHS Wirral and NMC policies as may be superseded at any time BOWEL ASSESSMENT Nurses need to complete a bowel assessment by completing a Wirral Integrated Continence Service Bowel Pathway Documentation, forms available from the Continence Service. RISK ASSESSMENT In some circumstances, differences of opinions occur between the patient, carer and nurse over the need for these interventions. Full consultation between the patient, the carer will help clarify why the procedure is required (RCN 2008). Wider consultation with the General Practitioner, the injured patient and their spinal injury unit, may be required in the patient s best interests. Potential Risks Include: Damage to the anal and rectal mucosa Stretching of the anal sphincter, potentially resulting in faecal incontinence Allergies including latex, soap (Lanolin), phosphate and peanuts (present in arachis oil enemas). Autonomic Dysreflexia (see page 20) Complete a separate risk assessment prior to carrying out bowel procedures for these patients. 4/22

5 MEDICATION REVIEW Following an episode of constipation, faecal impaction or faecal incontinence the patient s medications should be reviewed as many drugs may have possible side effects on gut motility and stool consistency. The main groups are: Broad spectrum antibiotics Opiods Laxatives Anti Diarrhoeals Obesity Medication Anti Depressants Antimuscarinics Anti Histamines Iron Preparations Antacids Consider requesting a medication review if the patient is taking four or more medications, which may be contributing to bowel dysfunction, by referring to the Medicines Management Team, using the referral form available on the NHS Wirral Intranet site under Medicines Management/documents. Check patients understand potential side effects of their medications and how to manage symptoms. Refer to General Practitioner if required. CIRCUMSTANCES WHERE EXTRA CARE IS REQUIRED In the following circumstances, nurses should fully document the clinical rationale for performing the procedures including any advice or recommendations from the General Practitioner or Continence Service. Active inflammation of the bowel e.g. Crohn s Disease, Ulcerative Colitis, Diverticulitis etc. Recent radiotherapy to the pelvic area Rectal/anal pain Obvious Rectal Bleeding Tissue fragility due to age/radiation, loss of muscle tone in neurological diseases or malnourishment If the patient has a known history of abuse If the patient has a history of allergies i.e. Latex, Lanolin, Peanuts, Phosphate The patient gains sexual satisfaction from the procedure in these circumstances consultation with other members of the team, including the team leader is advised, involving the patient in that consultation. Fully document outcome in patient s health records EXCLUSIONS AND CONTRA-INDICATIONS Where there is a lack of valid consent from a patient with capacity The patient s doctor has given specific instructions that these procedures are not to take place The patient has recently undergone rectal/anal surgery or trauma Rectal bleeding of unknown cause Malignancy of the perianal area 5/22

6 PATIENTS WHO LACK CAPACITY Situations may arise where the need for these procedures has been deemed in the patients best interests. This would need full consultation with carers/family close to the patient including the General Practitioner and the Specialist Continence Nurse if required, with the outcome fully documented in the patient s health records. Complete Consent Form Four. If the patient has a Lasting Power of Attorney for Personal Welfare, they should be involved in the discussion to determine the patients best interests. SENSITIVITIES Patients should be informed that they have the right to request a chaperone when undergoing this procedure. If a chaperone cannot be provided, the patient must be informed and asked if they wish to continue with the procedure. Their decision should be recorded in the patient s records. Where intimate procedures or examinations are required, be aware of any cultural and religious beliefs or restrictions the patient may have which prohibit this procedure being done by a member of the opposite sex. Comply with NHS Wirral Consent Policy if translators are required, use only NHS Wirral recommended translators. OBSERVATION OF THE PERIANAL AND PERINEAL AREA Before performing these procedures, check for abnormalities, document and report if required: Rectal prolapse Haemorrhoids Anal skin tags Infestation Bleeding and the colour of the blood Pressure ulcers of all grades (complete incident form if level 2 or above) Wounds, dressings, discharge Anal lesions (malignancy) Gaping anus Foreign bodies Skin conditions, broken areas Faecal matter/ stool consistency (refer to Bristol Stool Chart Appendix 1) 6/22

7 PROCEDURE FOR DIGITAL RECTAL EXAMINATION IN ADULTS INDICATIONS FOR DIGITAL RECTAL EXAMINATION (DRE): To assess presence of stool in the rectum, amount and consistency To assess the need for rectal medication To evaluate the efficacy of interventions/medication To assess anal tone and contraction and to what degree (RCN 2008) Digital Rectal Examination (DRE) may be used as part of a nursing assessment to establish the presence of stool in the rectum; a care plan will outline the intervention required for the patient. EQUIPMENT single use disposable non sterile gloves Single use disposable apron Disposable under pad to protect the bed Lubrication Gel single use only Tissues/wipes Receptacle Waste bag Access to toilet/commode/bedpan Hand washing facilities (Alcohol Gel does not kill Clostridium Difficile spores) Medicines Administrations Chart, for patients at risk of Autonomic Dysreflexia in case they need their prescribed medication ACTION Confirm patient s identity, by asking for name and date of birth, clarify with family or carers if patient not able to do so Ensure patient is introduced to staff involved in the procedure by name Establish patient has no known allergies, check in patients records and also ask patient/family of any known history For Spinal Injury Patients contact Wirral Integrated Continence Service for advice prior to carrying out this procedure Explain procedure (including an explanation of the investigations to be undertaken and the risks and benefits of the procedure) Obtain valid consent and document in patients health records Follow NHS Consent Policy if unable to gain valid consent, may need to be in discussion with other members of team, carers and G.P. Ask if the patient has any allergies RATIONALE To avoid error in patient identification Improves communication and helps reduce anxiety To reduce allergic reactions Refer to page 20 for the care and management of Autonomic Dysreflexia To ensure the patient understands the procedure Patient information will help patient to understand the procedure and reduce anxiety To gain co-operation and patients agreement to care Complete Consent Form 4 to demonstrate treatment is in patients best interests To reduce risk of allergic reaction. 7/22

8 Clarify if patients require formal chaperone Decontaminate hands prior to procedure Apply single use disposable apron Apply single use disposable non-sterile gloves Position the patient; left lateral side with knees flexed if possible, ensuring privacy at all times. Protect the bed with a disposable underpad Observe and examine the anal/perineal area Inform patient of imminent examination when finger to be inserted and ask patient to relax Lubricate the index finger with gel. Inform the patient you are about to perform the procedure. Insert the index finger into the anus and on into the rectum slowly and encourage patient to relax use one finger only. Assess for faecal matter, the amount and consistency using Bristol Stool Scale When the procedure is complete wipe residual lubricating gel from anal area Make the patient comfortable and offer toilet, commode, bedpan or other equipment as appropriate and assist in the use of such equipment. On completion of procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Record information in patients health records, this should include:- Valid consent If a chaperone was required Reason for digital rectal examination Date and time Record any anaesthetic gel used Problems negotiated during the procedure Review date to assess the need for repeat digital rectal examination Report any comments/concerns made by the patient Report to G.P. any findings on the same day It is the patients choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To protect hands from contamination with organic matter and transfer of micro-organisms To facilitate examination To minimise any soiling To detect any visible abnormalities that may require medical intervention To ensure the patient is aware the examination is about to begin To minimise discomfort and resistance. Resistance should be felt; this indicates the tone of the internal anal sphincter. It is only during defecation that is sphincter should relax. Appendix 1 Best practice guidelines To make the patient comfortable and prevent irritation and soreness Examination may have stimulated the anorectal reflex and the urge to defecate To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE To comply with NHS Wirral Health Records Policy. To provide a point of reference or comparison in the event of later queries. 8/22

9 PROCEDURE FOR THE INSERTION OF ENEMAS & SUPPOSITORIES *INDICATIONS FOR INSERTION OF SUPPOSITORIES OR ENEMAS Evacuation of faecal matter from the bowel Treatment of inflammatory bowel conditions Neurogenic bowel dysfunction as part of regular bowel management program Spinal Cord Injuries as part of regular bowel management program Drug administration as an alternative to the oral route, to be absorbed for systemic effect. (Kyle 2008) INTRODUCTION An enema is a solution introduced into the rectum to either promote the evacuation of faeces or administer medication. They may be used to treat faecal impaction, to clear the bowel prior to surgery, to treat inflammatory bowel conditions, as an alternative to the oral route where the patient is experiencing nausea and vomiting or as a regular part of a patient s ongoing bowel management programme (Kyle 2007 & Coggrave et al 2009). Prior to administrating an enema or suppository, the peri-anal region should be checked for abnormalities (Heywood-Jones, 1994; Addison 1999, Marsden 2008). A Digital Rectal examination should be carried out to assess for faecal loading and for abnormalities including blood, pain and obstruction. Non-medical prescriber s, if required, will need to use a formulary which reflects their level of prescribing and their area of medical expertise. CONSIDERATIONS Large volume enemas are not suitable for use in patients with neurogenic bowel and spinal cord injury as part of their regular bowel management programme. This is because the patient may not be able to retain the enema for it to be effective, over distension of the bowel may stimulate Autonomic Dysreflexia or cause trauma (Coggrave 2008 & Coggrave et al 2009) Phosphate can be absorbed systemically and accumulate (Addison et al 2000). o They should not generally be administered to patients with severely impaired renal function, and conditions where there is likely to be increased colonic absorption (Martindale, 1999). Phosphate enemas should not be used in: o Compromised clients, such as those who are elderly or debilitated or have advanced malignancy (Sweeney et al 1986 & Norton 2006) They must be avoided in clients with: o colitis, proctitis, inflammatory bowel conditions, o inflamed haemorrhoids or skin tags, o acute gastrointestinal conditions o rectal surgical wounds/trauma o Radiotherapy to the lower pelvic area. 9/22

10 EQUIPMENT Single use non sterile disposable gloves Single use disposable apron Disposable under pad to protect the bed Lubrication Gel single use only Tissues/wipes Receptacle Waste bag Access to toilet/commode/bedpan Hand washing facilities Medicines Administrations Chart Prescribed Suppository/Enema ACTION Confirm patients identity by asking for full name and date of birth, clarify with family/carer if patient unable to do so. Ensure patient is introduced to staff involved in the procedure by name Explain procedure (including reasons for the procedure to be undertaken and the risks and benefits) Obtain valid and informed consent and document in patients health records Follow NHS Wirral Consent Policy if unable to gain valid consent, may need to be in discussion with other members of team, carers and G.P. Establish that the patient has no known allergies, check in patients health records and also ask patient/family of known allergies Clarify if the patient requires a formal chaperone Check Suppository/Enema to be administered against Medicines Administration Chart Ensure Medicines Administration Chart specifies the following: Patients Full Name Patients Date of Birth Prescriber s Signature and Date Prescribed Name of Suppository/Enema to be administered Dose to be Administered Route of Administration Patients Allergy Status Read manufacturer s instructions for use Give the client an opportunity to urinate (Mallet & Bailey 1996) Ensure a bedpan, commode or toilet is readily available Decontaminate hands prior to procedure 10/22 RATIONALE To ensure correct patient and avoid error in administration Improves communication and helps reduce anxiety To ensure the patient understands the procedure Patient information will help patient to understand the procedure and reduce anxiety To gain co-operation and patients agreement to care Complete consent form 4 to demonstrate treatment is in patients best interests To reduce risk of allergic reactions It is the patients choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment To protect patient from harm To maintain patient safety To ensure the enema or suppository is prepared and administered in accordance with manufacturer s instructions To promote comfort during procedure In case the patient feels the need to expel the enema/suppository before the procedure is completed To reduce the risk of transfer of transient micro-

11 Apply single use disposable apron Apply single use disposable non-sterile gloves Administration of Enemas: Prepare the enema in accordance with manufacturer s instructions Place some lubricating gel on nozzle of enema Expel excessive air from enema prior to administration Informing the patient first that you are about to commence the procedure, Slowly introduce the nozzle to the depth recommended by the manufacturer Introduce the fluid slowly using gravity, not force. Once instilled, slowly withdraw the nozzle Administration of Suppository: Lubricate the end of the suppository with lubricating gel according to the manufacturer s instructions Insert the suppository via the anus into the rectum as per manufacturer s instructions Some patients may wish to insert suppository themselves. If so the nurse should explain the procedure and be available to offer assistance if necessary Observe the patient throughout the procedure: STOP If anal area bleeding If patients ask you to If there are signs and symptoms of Autonomic Dysreflexia When the procedure is complete, wipe residual lubricating gel from anal area Make the patient comfortable and ask them to retain the enema or suppository for the time suggested by manufacturer s if possible Ensure patient has access to commode/bedpan/toilet On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Wait with patient to monitor the effects of treatment administered using the Bristol stool scale(see related procedure for Digital Rectal Examination), unless prior agreement has been made to telephone patient later that day organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To protect hands from contamination with organic matter and transfer of micro-organisms To minimise shock and prevent bowel spasm (Mallet and Bailey 1996) To prevent trauma to the anal and rectal mucosa Excessive air may cause abdominal discomfort or pain (Kyle 2007) To ensure the nozzle is in the rectum Forcing an enema into the rectum could result in, bowel spasm, leakage and shock.(mallet & Bailey 1996) To avoid reflex emptying of the rectum (Kyle 2007) Lubrication reduces surface friction, avoiding anal mucosa trauma. Aids ease of suppository insertion There is some contention regarding whether suppositories should be inserted blunt end first or pointed end first depending upon their desired action, available evidence is inconclusive (Higgins 2007). Please refer to individual manufacturer s instructions for use To note signs of distress, pain, bleeding and general discomfort or autonomic Dysreflexia (page 20). To prevent skin excoriation and promote comfort (Mallet & Doherty 2000) To maintain dignity and comfort and ensure maximum effectiveness In case of rapid bowel evacuation following treatment To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE To monitor the patients bowel function 11/22

12 Document outcome of procedure in the patients To improve communication and enhance care health records. delivery PROCEDURE FOR DIGITAL REMOVAL OF FAECES IN ADULTS Indications for Digital Removal of Faeces (DRF) Where other bowel emptying techniques have failed or are inappropriate Faecal loading/impaction Incomplete Defaecation Inability to Defaecate Neurogenic Bowel Dysfunction as part of regular bowel management program Spinal Cord Injuries as part of regular bowel management program (RCN 2008) Digital Removal of Faeces (DRF) may be used as an acute intervention following DRE where other methods have failed, or as part of the patient s regular bowel management program (Kyle et al 2005, Powell & Rigby 2000 & Coggrave et al 2009). DRF is defined as the insertion of a finger into the patient s rectum to evacuate the contents. It is a last resort procedure and should be avoided if at all possible since it is distressing to the patient. Cultural and religious beliefs should be considered prior to performing this procedure (Powell & Rigby 2000, RCN 2008). However, in some patients with flaccid neurogenic bowel dysfunction following spinal cord injury, Digital Removal of Faeces may be the only method of evacuating the bowels effectively; it must however, be incorporated into a planned, well structured bowel management programme (Coggrave et al 2009). OBSERVATIONS REQURIED PRIOR TO DIGITAL REMOVAL OF FAECES DIGITAL REMOVAL OF FAECES AS AN ACUTE INTERVENTION As an acute intervention or new patient, the following observations and risk factors should be considered and documented:- Pulse should be recorded before, during and after the procedure In spinal injured patients Pulse and BP should be recorded before, during and after the procedure. Signs and symptoms of Autonomic Dysreflexia in spinal injured patients (page 20) Distress, Pain, Discomfort Collapse The procedure should be discontinued/not commenced if any of the above factors are identified and medical advice should be sought. DIGITAL REMOVAL OF FAECES AS A REGULAR INTERVENTION Observations/risk factors to consider include: Pulse at rest Distress, pain or discomfort Bleeding Signs and symptoms of Autonomic Dysreflexia Collapse 12/22

13 If the patient has a history of Autonomic Dysreflexia, do not attempt to carry out this procedure and contact the continence service immediately for guidance and advice EQUIPMENT Single use Disposable non sterile gloves (latex free) Lubricating gel single use only Disposable underpad to protect bed Tissues/wipes Receptacle Waste bag Single use Disposable apron Access to toilet/commode/bedpan Hand washing facilitates (alcohol based had rub/gel does not kill Clostridium Difficile spores) ACTION Confirm the patients identity by asking for full name and date of birth, clarify with family or carers if patient not able to do so Establish the a patient has no known allergies, check in patients health records and also ask patient/family of known allergies For spinal injuries patients contact Wirral Integrated continence Service for advice prior to carrying out this procedure Patients are at risk of Autonomic Dysreflexia Ensure the patient is introduced to staff involved in the procedure by name Explain risks and benefits of the procedure to the patient (including an explanation of the investigations to be undertaken. Obtain valid consent and document in patients health records Follow NHS Wirral Consent Policy if unable to gain consent, complete consent form 4 to demonstrate treatment is in patients best interests Clarify if the patient requires a formal chaperone Ask the patient if they wish to use the toilet prior to undertaking the procedure. Prepare the environment i.e. commode, bedpan, toilet RATIONALE To avoid error in patient identification To reduce risk of allergic reactions To manage the patient s condition safely (NSPA 2004) Refer to page (20) for the care and maintenance of autonomic dysreflexia Improves communication and helps reduce anxiety To ensure the patient understands the procedure and can give consent. Patient information helps reduce anxiety To gain co-operation and patients agreement to care Needs to be in discussion with other members of the team, carers, G.P. and in spinal cord injured patients, their spinal injury centre It is the patients choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment For comfort of the patient To facilitate easy access for defaecation ensuring privacy and dignity 13/22

14 *Perform observations required according to whether it is an acute intervention or regular ongoing intervention and observe for signs of Autonomic Dysreflexia in Spinal cord injured (SCI) patients. If at any time the heart rate drops, rhythm changes or signs of Autonomic Dysreflexia STOP the procedure Decontaminate hands prior to procedure Apply single use disposable apron Apply single use disposable non-sterile gloves Protect the bed with a disposable underpad Maintaining patients dignity, gather all equipment and prepare for the procedure Lubricate the finger and anus with lubricant gel Inform the patient of imminent examination when finger to be inserted If Scybala type stool felt (Bristol Stool type 1), remove one lump at a time. In a solid mass, gently push finger into middle of the mass, split it and remove small pieces at a time. A period of rest may allow further faecal matter to descend into the rectum. Use extra lubrication as required Place faecal matter into receptacle as it is removed. Observe the patient throughout the procedure: STOP If anal area bleeding If patients ask you to If there are signs and symptoms of Autonomic Dysreflexia When the procedure is complete, wipe residual lubricating gel from anal area and cleanse the area Gently wash & dry the area if required To provide a baseline measurement to assess any changes in the pulse/blood pressure during or after the procedure (RCN 2008). In the SCI patient, changes in blood pressure have frequently been observed without signs and symptoms of Autonomic Dysreflexia, monitoring blood pressure as part of a regular ongoing intervention is thought to be of little benefit. Rather the nurse should observe for signs of potential Autonomic Dysreflexia (Ash 2005 & Coggrave et al 2009). To reduce the risk of transfer of transient microorganisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To protect hands from contamination with organic matter and transfer of micro-organisms To avoid embarrassing the patient if faecal staining occurs during or after the procedure To facilitate easier insertion of the finger and reduce sensation and discomfort for the removal of faecal matter (RCN 2008) To prevent trauma to anal and rectal mucosa by reducing the surface friction (Mallet & Dougherty 2000) To ensure the patient is aware the examination is about to begin As per training provided by Wirral integrated Continence Service. To dispose of appropriately. To note signs of distress, pain, bleeding and general discomfort or autonomic Dysreflexia. To make the patient comfortable and prevent irritation and soreness To prevent skin excoriation and promote comfort (Mallet & Doherty 2000) 14/22

15 On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Document all actions and outcomes in patient s health records. To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE To record patient care given, provide seamless care and comply with health records policy. Inform the General practitioner of any abnormalities e.g. rectal bleeding 15/22

16 PROCEDURE FOR DIGITAL RECTAL STIMULATION IN ADULTS INDICATIONS FOR DIGITAL RECTAL STIMULATION (DRS): Neurogenic bowel as part of regular bowel management programme Spinal Cord Injured patients with reflex bowel dysfunction as part of regular bowel management programme (Coggrave et al 2009) Digital Rectal Stimulation (DRS) may be used in patients with neurological conditions with reflex bowel dysfunction, the technique involves inserting a gloved finger into the anus and circling in a clockwise direction; it increases reflex activity, thus stimulating movement of stool into the rectum and promoting evacuation (RCN 2008, Coggrave 2008 & Coggrave et al 2009). OBSERVATIONS ARE REQURIED PRIOR TO DIGITAL RECTAL STIMULATION DIGITAL RECTAL STIMULATION AS AN ACUTE INTERVENTION In an acute situation, do not attempt to carry out this procedure before firstly contacting the continence service for guidance and advice. After obtaining advice from the Continence Service, the following observations and risk factors should be considered and documented:- Pulse and Blood pressure should be recorded before, during and after the procedure Signs or symptoms of Autonomic Dysreflexia in spinal injured patients Distress, Pain, Discomfort Collapse DIGITAL RECTAL STIMULATION AS A REGULAR INTERVENTION Observations/risk factors to consider include: Pulse at rest Distress, pain or discomfort Bleeding Signs and symptoms of Autonomic Dysreflexia Collapse The procedure should be discontinued/not commenced if any of the above factors are identified and medical advice should be sought. EQUIPMENT Single use disposable non sterile gloves Single use disposable apron Lubricating gel single use only Disposable underpad to protect bed Tissues/wipes Receptacle Waste bag Access to toilet/commode/bedpan Hand washing facilitates 16/22

17 ACTION Confirm the patients identity by asking for full name and date of birth, clarify with family or carers if patient not able to do so Ensure the patient is introduced to staff involved in the procedure by name Establish that the a patient has no known allergies, check in patients health records and also ask patient/family of known allergies Explain the procedure (including reasons for the procedure, the risks and benefits). Obtain valid consent and document in patients health records Follow NHS Wirral Consent Policy if unable to gain consent, complete consent form 4 to demonstrate treatment is in patients best interests Clarify if the patient requires a formal chaperone Ask the patient if they wish to use the toilet prior to undertaking the procedure. Prepare the environment i.e. commode, bedpan, toilet Perform observations required according to whether an acute intervention or regular ongoing intervention and observe for signs of Autonomic Dysreflexia in Spinal cord injured(sci) patients If at any time the heart rate drops, rhythm changes or signs of Autonomic Dysreflexia STOP the procedure RATIONALE To avoid error in patient identification Improves communication and helps reduce anxiety To reduce risk of allergic reactions To ensure the patient understands the procedure and can give consent. Patient information helps reduce anxiety To gain co-operation and patients agreement to care Needs to be in discussion with other members of the team, carers, G.P and in spinal cord injured patients, their spinal injury centre It is the patients choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment For comfort of the patient To facilitate easy access for defaecation ensuring privacy and dignity To provide a baseline measurement to assess any changes in the pulse/blood pressure during or after the procedure (RCN 2008). In the SCI patient, changes in blood pressure have frequently been observed without signs and symptoms of Autonomic Dysreflexia, monitoring blood pressure as part of a regular ongoing intervention is thought to be of little benefit. Rather the nurse should observe for signs of potential shock/ Autonomic Dysreflexia (Ash 2005 &Coggrave et al 2009). Decontaminate hands prior to procedure Apply single use disposable apron To reduce the risk of transfer of transient microorganisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of micro-organisms Apply single use disposable non-sterile gloves Protect the bed with a disposable underpad To protect hands from contamination with organic matter and transfer of micro-organisms To avoid embarrassing the patient if faecal staining occurs during or after the procedure 17/22

18 Maintaining patients dignity, gather all equipment and prepare for the procedure Lubricate the finger and anus with lubricant gel Inform the patient of imminent examination when finger to be inserted Gently insert single gloved finger into the rectum up to the 2 nd joint only. Turn the finger so that the padded area is in contact with the bowel wall.(coggrave et al 2009) Gently rotate in a clockwise direction 6-8 times for approximately 10 seconds, or until relaxation of the sphincter felt or flatus passed. Maintain contact with the bowel wall throughout (RCN 2006, Coggrave et al 2009) Observe the patient throughout the procedure: STOP If discomfort felt If anal area bleeding If patients ask you to If there are signs and symptoms of Autonomic Dysreflexia Gently remove finger and await reflex evacuation of the stool (Coggrave et al 2009) Place faecal matter into a receptacle as it is evacuated If reflex activity does not occur, repeat every 5-10 minutes until rectum is empty or activity ceases. To facilitate easier insertion of the finger and reduce sensation and discomfort for the removal of faecal matter (RCN 2008) To prevent trauma to anal and rectal mucosa by reducing the surface friction (Mallet & Dougherty 2000) If the patient suffers from discomfort during this intervention, or autonomic Dysreflexia, local anaesthetic gel may be required. This takes approximately 5 minutes to take effect and lasts for 90 minutes. Long term use should be avoided due to systemic side effects (Coggrave et al 2009 & BNF 2009) To ensure the patient is aware the examination is about to begin As per training provided by Wirral integrated Continence Service. To stimulate peristalsis and promote movement of the stool into the rectum. To note signs of distress, pain, bleeding and general discomfort or autonomic Dysreflexia. To dispose of appropriately Digital Removal of Faeces may be required if faeces felt in the rectum (Coggrave et al 2009) Do not repeat more than three times if reflex activity does not occur (Coggrave et al 2009) When the procedure is complete, wipe residual lubricating gel from anal area and cleanse the area Gently wash & dry the area if required On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE To make the patient comfortable and prevent irritation and soreness To prevent skin excoriation and promote comfort (Mallet & Doherty 2000) To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following 18/22

19 removal of PPE Document all actions and outcomes in patient s health records. To record patient care given, provide seamless care and comply with health records policy. Inform the General practitioner of any abnormalities e.g. rectal bleeding CARE AND MANAGEMENT OF AUTONOMIC DYSREFLEXIA Autonomic Dysreflexia (ADR) is a syndrome unique to patients with spinal cord injury at the level of the 6 th thoracic vertebrae or above. It is a sudden, potentially lethal rise in blood pressure and is often triggered by acute pain or a harmful stimulus, below the level of the injury. It should always be treated as a medical emergency; if left untreated it can be fatal due to the risk of cerebral haemorrhage, seizures or cardiac arrest. Patients who have been discharged from a spinal injury unit should never have their bowel management programme altered without first consulting with their spinal injury unit, that other methods of evacuation are suitable (NPSA 2004). The risk assessment is part of a bowel dysfunction assessment and a full medical history should be considered prior to any bowel related procedures COMMON CAUSES Distended bladder (usually due to catheter blockage or some form of bladder outlet obstruction) Distended bowel (usually due to a full rectum, constipation or impaction) Ingrown toenail Fracture below level of the lesion Pressure ulcer, contact burn, scald or sunburn Urinary tract infections or bladder spasms Renal or bladder calculi Pain or trauma Deep vein thrombosis Over stimulation during sexual activity Sever anxiety (eliminate all physiological factors first) SIGNS AND SYMPTOMS Pounding usually frontal headache is always present Severe hypertension (note spinal cord injured patients have a lower resting blood pressure) Slow pulse One or more of the following Flushed appearance of the skin above the level of the injury Profuse sweating above the level of the injury Pallor above the level of the injury Nasal congestion 19/22

20 TREATMENT Identify, remove or treat the most common cause for example non-drainage of urine, check for kinking in tubing, drainage bag full, blocked catheter. If catheter blocked, change catheter never attempt a washout in this situation. If catheter is not the problem check for constipation, anal haemorrhoids or an infection. If constipation carry out usual bowel management. under normal circumstances a tetraplegic person may have a low blood pressure (e.g. 60/90.hg). a rise to normal levels 80/120.hg may represent a significant elevation. Regular monitoring of blood pressure is essential as changes can occur quickly; monitor blood pressure every five minutes until blood pressure control is achieved. Each spinal unit has its own protocol; therefore the nurse must familiarise themselves with the protocol for that patient, ensure it is the most up-to-date protocol and that the patient has telephone numbers for their spinal injury unit. Autonomic Dysreflexia is considered a medical emergency and nurses need to ensure that the patient has medication prescribed on Medicines Administration Chart, that they are aware of location the medication is stored in the patient s house and that it is within date in case they need to administer the prescribed medication for autonomic Dysreflexia. Administer the prescribed medication, monitor the patient s blood pressure, if no response and blood pressure not responding, telephone for an ambulance to take patient to Accident & Emergency Department or contact spinal unit for advice. CLINICAL INCIDENTS Any related incidents arising from carrying out these procedures which may involve clinical error or near miss must be reported following the NHS Wirral incident reporting policy. SPECIALIST ADVICE In the event of any complications or difficulties in carrying out these procedures, contact the Continence Specialist Nurse, General practitioner or in the case of spinal injured patients, their spinal injury unit. FURTHER READING Fact sheet 25 Autonomic Dysrefelxia, Sheets/sheets21-25fact25.html Northeast Rehabilitation Health Network. Autonomic Dysreflexia, Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. 0SCI.pdf 20/22

21 REFERENCES Abd-el-Maebound, K.H. et al (1991) Rectal Suppository: Common Sense and Mode of Insertion. The Lancet. 338(8870) Addison R. (2999) Digital Rectal Examination 1 Practical Procedure for Nurses. Nursing Times. 95(40) Insert. Addison, R., Ness, W. Swift, I. Robinson, M. (2000) How to Administer Enemas and Suppositories. Nursing Times, ACA Supplement 96(6), 3-4. Ash, D. (2005) Sustaining safe and acceptable bowel care in spinal cord injured patients. Nursing Standard. 20(8), Coggrave et al (2009) Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. [online] Available at: Guidelines%20for%20bowel%20management%20after%20SCI.pdf Coggrave, M. (2008). Neurogenic Continence. Part 3: Bowel Management Strategies. British Journal of Nursing. 17(15), Heywood-Jones, I ) Skills Update: Administration of Enemas. Community Outlook. 4(5)18-19 Higgins, D. (2007) Bowel care Part 6 Administration of a suppository. Nursing Times; 103(47), 26 Kyle et al. (2005). A procedure for the Digital Removal of Faeces. Nursing Standard. 19(20), Kyle, G. (2007) Bowel care part 4. Administering an enema. Nursing Times; 103(45), Mallet, J. & Doherty, L. (2000) Bowel Care in: Royal Marsden Hospital Manual of Clinical Nursing Procedures, Fourth edition. Pg Blackwell Scientific Publications. London Moppett, S. (2000) Which Way is it Up for a Suppository? ACA Supplement. Nursing Times. 96(19) Norton, C. (2006) Constipation in Older Adults: Effects on Quality of Life. British Journal of Nursing. 15(4) Powell, M. & Rigby, D. (2000) Management of Bowel Dysfunction: Evacuation Difficulties. Nursing Standard. 14(47) Royal College of Nursing (2008) Bowel Care Including Digital Rectal Examination and Manual Evacuation of Faeces guidance for nurses. RCN, London Royal College of Nursing Continence Care Forum (2006) Digital Rectal Examination and Manual Removal Faeces guidance for nurses. Sweeney, J.L. et al (1986) Rectal Gangrene: A Complication of Phosphate Enemas. The Medical Journal of Australia. 144(7) The Essence of Care: Patient focused benchmarking for healthcare practitioners (2001). London, Department of Health. 21/22

22 22/22 Appendix 1