GUIDELINES FOR BOWEL MANAGEMENT (NCHT Version)

Transcription

1 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

2 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

3 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

4 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

5 See General Principles for All Procedures. RATIFIED 2004 FOR REVIEW 2006 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. 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). RATIONALE 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. 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

6 ACTION 1 Advise/educate the patient/carer regarding healthy eating and fluid intake. A combined daily intake of grams of fibre is recommended and approximately 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). 2 Advise/inform the patient/carer regarding bowel anatomy and function. 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. RATIONALE Appropriate diet plus fluid intake stimulates gastric distension necessary for gastrointestinal activity (MeReC,1994; Winney,1998). Knowledge empowers and enables the patient to make informed choices. 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) Bowel Guidelines, May

7 ACTION RATIONALE 4 Encourage exercise wherever possible within the patient s own limitations. Exercise increases peristalsis and bowel motility (Chiarelli & Markwell, 1992). 5 Wherever possible, ensure that the patient's To aid defecation. usual bowel rituals are followed. 6 Review medication. To reduce the predisposition for future constipation. 7 Appropriate laxatives should be prescribed if necessary depending on the consistency, volume and frequency of the stools passed. (see appendix 4) 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. To aid effective management. Facilitates effective evaluation of care. Best Practice 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

8 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 Kamm M (1994) Constipation. Internal Medicine Journal Vol. 22, No. 8, pp 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 Reynolds J E F, Martindale W (1994) The Extra Pharmacopoeia 30 th Edition London: Pharmaceutical Press Winney J (1998) Constipation. Nursing Standard. Vol. 13, No. 1, pp 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

9 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

10 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. However, it is important that the nurse records the result. EQUIPMENT Prescribed suppository Lubricating jelly Non-sterile glove & apron Tissues PRINCIPLES OF CARE See General Principles for All Procedures. ACTION 1 Check the patient's case notes for any anal or rectal surgery or abnormalities and / or check with General Practitioner before proceeding if necessary. 2 Explain the purpose of the suppository i.e. evacuant, anti-biotic, analgesic. RATIONALE To maintain patient safety and to prevent undue trauma. To ensure the patient is aware of the expected/desired effect of the suppository and to obtain informed consent. 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. Bowel Guidelines, May

11 ACTION 5 Wherever possible, position the patient on their left side with knees flexed. Place a disposable procedure sheet under the patients hips and bottom. 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. 7 Lubricate the suppository and insert blunt end foremost into the anal canal. RATIONALE 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. To prevent undue trauma to the patient. 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. 10 Ensure access to nurse call bell and / or toilet, bedpan or commode. 11 Ask the patient to retain the suppository for as long as possible (for at least 20 minutes) 12 If an evacuant suppository was used, the effect must be monitored and documented Reduce the risk of cross infection Ensure the patient has safe and appropriate access to the toilet facilities To allow the suppository to dissolve and the active ingredients to be absorbed (Addison, 2000). 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

12 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 3-7. Gruen J (2000) Neurosurgical Terms in Plain English Vasovagal Available at [Accessed 31 st 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 pp 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

13 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

14 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

15 ACTION 1 Check the patient's case notes for any anal or rectal surgery or abnormalities and / or check with medical staff before proceeding. RATIONALE 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. 5 Wherever possible, position the patient on their left side with knees flexed. Place an absorbent pad under the patients hips and bottom. 6 Examine the perianal region and perform digital examination of the rectum if appropriate. If any abnormalities are noted, seek medical advice before continuing. 6 Lubricate the nozzle of the enema, remove cap and gently introduce its entire length into the patient's rectum. 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. To identify any pre-existing perianal pathology. To prevent trauma to anal and rectal mucosa by reducing surface friction and to ensure the fluid is not immediately expelled. Best Practice 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 7 Instil the contents of the enema into the rectum and ask the patient to retain the enema solution for as long as possible. RATIONALE To maximise the evacuant affect. 8 Slowly withdraw the nozzle. To avoid reflex emptying of the rectum. Bowel Guidelines, May

16 ACTION RATIONALE 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 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). 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 Reduce the risk of cross infection Ensure the patient has safe and appropriate access to the toilet facilities This aids the retention of the enema by force of gravity. 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 3-7. Gruen J (2000) Neurosurgical Terms in Plain English Vasovagal Available at [Accessed 31 st 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, pp FURTHER READING Heywood Jones I (1994) Skills Update: Administration of enemas. Community Outlook. Vol.4, No. 5, pp 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

17 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 RATIONALE To determine cause and ensure appropriate management. Bowel Guidelines, May

18 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. 5. Teach specific individualised external anal sphincter exercises. 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. 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. 8 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. 9 If infection is identified follow appropriate infection control guidelines. Do not use stool firming agents Knowledge empowers and enables the patient to make informed decisions. To strengthen the pelvic floor muscles and increase the ano-rectal angle. 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. To effectively contain the faecal incontinence and preserve dignity. To remove harmful faecal enzymes. To protect skin from faecal contamination. To ensure effective treatment is given and to prevent the spread of infection Fast elimination of infected diarrhoea should be encouraged. Bowel Guidelines, May

19 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 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? Bowel Guidelines, May

20 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? 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 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 Bowel Guidelines, May

21 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

22 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 Bowel Guidelines, May

23 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 Bowel Guidelines, May

24 ACTION 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 2 Explain the purpose and the technique of the procedure Obtain informed consent RATIONALE To determine the problem, the cause and ensure appropriate, effective and safe management. To ensure the patient is aware of the proceedings and the rationale. Facilitate an informed consent Legal and ethical requirement 3 Give the patient the opportunity to urinate A full bladder may cause discomfort during the procedure 4 Wash and dry hands thoroughly and put on To reduce the risk of cross infection apron 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. 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 6 Examine the perianal region. If any abnormalities are noted seek medical advise before continuing. 7 Continually inform the patient of your actions and what to expect. 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. 9 Once necessary information is obtained, gently remove the finger and wipe the anus clean. 10 Wash and dry hands thoroughly, dispose of the gloves and apron appropriately. To maintain dignity To identify any pre-existing perianal pathology. To maintain patient safety. To reduce anxiety and keep the patient informed The anal canal has extremely sensitive nerves. A misdirected finger will cause pain and trauma. Ensure the perineal area is left clean and dry. To reduce the risk of cross infection Bowel Guidelines, May

25 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

26 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 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 RATIONALE 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 4 Administer prescribed sedative and / or analgesia as per doctors / pharmaceutical instructions before the procedure. Assess effectiveness of the drugs To assist easier removal. To relax and calm the patient, provide effective pain control based on individual needs. Bowel Guidelines, May

27 ACTION 5 Assess the patients blood pressure, pulse, temperature and respiratory rate prior to the procedure. 6 Wherever possible, position the patient on their left side with knees flexed. 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. 7 Place protective sheet under the patient s hips and bottom. 8 Wash and dry hands thoroughly, apply gloves and apron. 9 Continually inform the patient of your actions and what to expect. 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). 11 Advise patient to take slow deep breaths during the procedure. 12 Remove smaller particles and break larger pieces up by inserting the finger into the stool, collect in an appropriate receptacle. 13 Where possible advise patient to bear down whilst exhaling to assist with valsalva manoeuvre if possible 14 Pause frequently during procedure and apply more lubrication if necessary. RATIONALE Assess a baseline for future comparison. 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. To maintain dignity. The recto-anal reflex may be stimulated and to collect any leaked rectal contents. To reduce the risk of cross infection. To reduce anxiety and keep the patient informed of all proceedings. The anal canal has extremely sensitive nerves, a misdirected finger will cause pain and trauma. To promote relaxation. Reduce the trauma of the procedure, facilitate easier removal of faeces. 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). Allow the patient a rest from the discomfort and re-lubricate as required. Bowel Guidelines, May

28 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. 16 If abnormal signs become evident or severe rectal bleeding or pain is evident stop the procedure and seek medical advice. 17 After removal of faecal matter gently remove the finger and clean the anus and offer commode / toilet if necessary. 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. RATIONALE 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). Rectal trauma may be evident, the patient is experiencing severe adverse reactions. Ensure the perianal area is left clean and dry. Ano-rectal reflex may be stimulated and further bowel actions may follow. 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 Mohammed, J. et. al. (1978) Rectal bleeding secondary to faecal disimpaction; Angiographic diagnosis and treatment. Diagnostic Radiology No. 126; pp Nursing and Midwifery Council (2002) The Code of Professional Conduct London: NMC Bowel Guidelines, May

29 O Connor, E.M. (1994) How to identify and remove faecal impactions, Geriatric Nursing, May/June pp 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 FURTHER READING Cefalu C.A. et. al. (1981) Treating Impaction A Practical Approach Geriatrics, Vol. 38, No. 5, pp 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, 2 nd Edition, St. Louis, USA: CV Mosby Company Vaidyanathan, S. (2000) Autonomic dysreflexia in spinal cord injury patients, Urology Vol. 4, No. 6, pp Author Elaine Cathcart, Continence Advisor Tel. (0115) 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

30 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

31 Continence Assessment Form APPENDIX First name: Family name: DOB: Assessment date: Assessing nurse: Urinary symptoms Y N Comments Patient s Main Problem Onset of problem Extent of wetting Dry 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: Behaviour prior to micturition Aggressive Agitated Wandering Pacing Not observed Other, please state Labour Caesarean section Episiotomy Tear Forceps Ventouse Long second stage Short second stage Breech Normal delivery Epidural N/A Frequency How often are they passing urine Urgency How long can they hold following desire to pass urine Urge Incontinence Do they wet before reaching toilet Dysuria Is it painful to pass urine 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 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... Vaginal Examination Normal Redness Dryness Discharge Cystocele Rectocele Fistula Caruncle Refused Not done Reason Pelvic Floor Tone No contraction Flicker Weak Moderate Good Strong Sustains for seconds No of repetitions Fast Twitch Urinalysis Leucocytes Nitrite Protein PH Blood SG Ketone Glucose MSU sent Post Void Residual Bowel Guidelines, May

32 Fluids Number of drinks Laxatives (Past and Present) Behaviour associated with defaecation Cups/mugs Aggressive Pacing Type of fluid Agitated Other, please state: Wandering Bowel Symptoms Y N Y N Type 1 Pebbles Constipation Type 2 Hard stool Faecal incontinence Type 3 Formed stool Sensation of rectal fullness Type 4 - Formed smooth stool Reduced sensation Type 5 Semi formed Pain on defecation Type 6 fluffy pieces Blood Type 7 - Liquid stool Mucus Colour of stool Pale Black Brown Urgency Haemorrhoids Usual bowel pattern/habits Penis/Scrotum Retraction Abnormalities Hydrocele NAD Not examined General comments 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? Have you had to make changes to your life because of your problem? Unhappy Terrible None (0) A few (1) Many (2) Delighted Pleased Mostly satisfied Mixed about equally satisfied and dissatisfied Stress Detrusor instability/mixed Nocturnal polyuria Outflow obstruction Functional Atonic bladder No residual No residual No residual Residual Poor mobility Wetting on exertion Frequency 33% of urine output during Hesitancy wetting and exertion Poor dexterity hours of sleep Poor pelvic floor tone Urgency, urge incontinence May have frequency urgency Clothing Nocturia Nocturia Environment Small wetting episodes Quite large voids Large voids Dribbling or large voids Can be large voids Recurrent UTI s Bowel Guidelines, May

33 Constipation Risk Assessment Tool APPENDIX 2 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: Hosp. No. FLUIDS MOBILITY DIET MENTAL STATE Drinks mls per day 1 Drinks less than 1000 mls 2 Drinks less than 700 mls 3 Fully mobile Active 1 Mobile but sedentary Use of aids 2 Immobile 4 Eats full meals 1 Takes small unvaried diet 2 Poor diet? Eats very little 3 Normal & appropriate 1 Confused or memory impaired 2 Very confused, unable to ask for toilet 3 Date: Assessor: Total PREDISPOSITION Takes predisposing medication Takes Opioids 4 Has history of constipation Predisposing medical condition 3 3 SCORE 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

34 Constipation Re-assessment Tool (continuation) Patient Name: DOB: Hosp. No. FLUIDS MOBILITY DIET MENTAL STATE PREDISPOSITION SCORE Drinks mls per day 1 Fully mobile Active 1 Eats full meals 1 Normal & appropriate 1 Takes predisposing medication 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 4 Poor diet? Eats very little 3 Very confused, unable to ask for toilet 3 Predisposing medical condition 3 Date: Assessor: Total FLUIDS MOBILITY DIET MENTAL STATE PREDISPOSITION SCORE Drinks mls per day Fully mobile Active 1 Eats full meals 1 Normal & appropriate 1 Takes predisposing medication 3 Takes Opiods 4 Drinks less than 1000 mls Mobile but sedentary of aids 2 Use Takes small unvaried diet 2 Confused or memory impaired 2 Has history of constipation 3 Drinks less than 700 mls Immobile 4 Poor diet? Eats very little 3 Very confused, unable to ask for toilet 3 Predisposing medical condition 3 Date: Assessor: Total FLUIDS Drinks mls per day 1 Drinks less than 1000 mls 2 Drinks less than 700 mls 3 MOBILITY Fully mobile Active 1 Mobile but sedentary Use of aids 2 Immobile 4 DIET Eats full meals 1 Takes small unvaried diet 2 Poor diet? Eats very little 3 MENTAL STATE Normal & appropriate 1 Confused or memory impaired 2 Very confused, unable to ask for toilet 3 PREDISPOSITION Takes predisposing medication 3 Takes Opiods 4 Has history of constipation 3 Predisposing medical condition 3 SCORE Date: Assessor: Total Bowel Guidelines, May

35 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

36 APPENDIX 4 Name Start working Fybogel Up to 48 hours How it works Imitates natural action of fibre. Increases faecal mass, which stimulates peristalsis. Laxatives Bulk forming Side effects Cautions Dose Flatulence, abdominal distension, intestinal obstruction/ impaction Must have adequate fluid intake 1 sachet in 150mls of water twice daily after meals. Name Start working Lactulose Up to 48 hours How it works Retains fluid in the bowel by osmosis which softens the stool Osmotic Laxatives Side effects Cautions Dose Flatulence, abdominal discomfort and cramps Contraindicated in galactosaemia 10 or 20mls B.D. Fletchers phosphate enema Approx mins. 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 mins. Softens and lubricates to promote a bowel movement. Local irritation. Contraindicated in flammatory bowel disease. Avoid prolonged use. 1x5mls Faecal Softeners Name Arachis oil Start working Liquid to be installed and retained. How it works Lubricates and softens the stool to promote a bowel move. Side effects Cautions Dose Avoid use if allergic to nuts. 130mls. Bowel Guidelines, May

37 Name Start working Bisacodyl Tablets: hrs. Suppository: 20-60mins Codanthram er 6-12hrs Docusate Capsules 1-2 days RATIFIED 2004 FOR REVIEW 2006 Stimulant Laxatives How it works Side effects Cautions Dose Increases intestinal mobility Soften and stimulates to promote a bowel movement Increases intestinal mobility, also softens. Senna 8-12 hrs Increased intestinal mobility. Sodium Picosulphate (Picolax) Glycerine suppository Sachets: within 3 hours. Approx mins Stimulates bowel clearance. Rectal stimulant. Abdominal cramps. Atonic non functioning colon, hypocalcaemia. Abdominal cramps, urine discoloured pink. Abdominal cramps. Abdominal cramps, Atonic non functioning colon, hypocalcaemia. Can be very severe. Avoid prolonged use. Avoid taking antacids at the same time as tablets. Only to be used in the terminally ill potential carcinogenic risk. Tablets: 5-10mgs at night, Suppository 10mgs. Capsules: 1-2 at night. Suspension 5-10mls at night. Avoid prolonged use. Capsules: mg daily in divided doses. Avoid prolonged use. Avoid prolonged use. Usually used preoperatively. Blunt end first ensures better retention. Moisten before use. Tablets: 2-4 at night. Syrup: 10-20mls at night. As directed 1x4g Iso- Osmotic Laxative Name Movicol Start working Up to 30 hrs depending on dosage. How it works Side effects Cautions Dose 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 5-6 hrs for 1-3 days only. Bowel Guidelines, May

38 Nottingham Community Nutrition & Dietetic Service APPENDIX 5 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 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

39 STOOL CHART Name...Hospital Number..Ward... Normal Bowel Habit Frequency: Consistency: Date & Time Amount small/ moderate/large Consistency see Bristol Stool Chart Colour Blood Amount/ Colour Mucous Amount Specimen Sent See reverse for guide and indicate what test for Recorded by Please sign Bowel Guidelines, May

40 Stool Specimen Guide for patients with diarrhoea Please send 1 SAMPLE, if result is negative and diarrhoea persists please repeat Microbiology investigation Culture & Sensitive Clostridium Difficile Toxin Virology (Please send separate sample) Parasites & Ova 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) -hospital acquired diarrhoea (develops diarrhoea whilst an inpatient) -antibiotics within the last four weeks -inpatient within last 3 months -immunosuppressed -outbreak 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