Adult Bowel Care Guidelines

Transcription

1 SH CP 205 Version: 1 Summary: Keywords: Target Audience: This guideline defines statements documenting the standards and expectations for the clinical assessment and management of adult bowel dysfunction. The guideline refers to procedures for clinical interventions and their indications. Bowel, constipation, rectal, rectum, DRE, DRF, DRS, stool, digestion, laxative, enema, suppository, stoma, clinical, neurogenic, dysfunction, diet, fluid, evacuation, faecal, incontinence, faeces, rectoanal, anal, impaction, irrigation All SHFT Clinical Staff Next Review Date: July 2019 Approved & Ratified by: Patient Safety Group Date of meeting: 19 th June 2017 Date issued: Author: Director: Virginia Roberts, Clinical Trainer Sarah Constantine, Medical Director 1

2 Version Control Change Record Date Author Version Page Reason for Change Jan 2017 Virginia Roberts 1 All New document Created Reviewers/contributors Name Position Version Reviewed & Date Alison Wileman Continence Service Lead/Advanced Clinical Nurse March 2017 Specialist Continence Steve Coopey Head of Clinical Development March 2017 Sharon Guy Clinical Training Team Lead March 2017 Steve Mennear Senior Clinical Pharmacist April 2017 Katherine Steward Integrated Services Matron April 2017 Janet Brember NHS Portsmouth CCG Catherine Mclean NHS West Hampshire CCG Jason Peett NHS Southeast Hampshire CCG Jackie Hunt Infection Control Patient safety group committee Patient safety group committee 2

3 Quick Reference Guide This guideline defines statements documenting the standards and expectations for the clinical assessment and management of adult bowel dysfunction. The guideline refers to procedures for clinical interventions and their indications. The appendices contain the key documents and evidence supporting practice. 3

4 Contents Section Title Page 1. Introduction 5 2. Purpose and Scope 5 3. Who does this guideline apply to? 5 4. Definitions 5 5. Duties and responsibilities 6 6. Bowel Care Statements 7 7. Training requirements Monitoring compliance Guideline review Associated trust documents Supporting references 13 Appendix 1 Training needs analysis 14 Appendix 2 Equality Impact Assessment Tool 15 Appendix 3 Competencies 16 Appendix 4 Continence Assessment 20 Appendix 5 Bowel Care Pathway 23 Appendix 6a 14 Day Food, Stool and Medication Diary 25 Appendix 6b Bristol Stool Chart 26 Appendix 7 Procedure for Digital Rectal Examination 27 Appendix 8 Procedure for Administration of Enemas and Suppositories 30 Appendix 9 Procedure for Digital Rectal Stimulation 33 Appendix 10 Procedure for Digital Removal of Faeces 35 Appendix 11 Trans-Anal Irrigation Suitability Flowchart / Referral form 38 Appendix 11a NBD Score 40 Appendix 12 Laxative treatment guidelines 41 Appendix 13 Appendix 14 Management of lower bowel dysfunction, including DRE and DRF RCN Guidelines (2012) Guidelines for Management of Neurogenic Bowel dysfunction in individuals with Central Neurological conditions MASCIP (2012)

5 1. Introduction 1.1. Bowel care is a fundamental area of patient care that is frequently overlooked yet it is of paramount importance for the quality of life of service users, many of whom may be reluctant to admit to bowel problems or to discuss such issues. (Royal College of Nursing (RCN) 2012) Robert Francis referred to continence as this most basic of needs, his report highlighting significant concerns in this area of care (Department of Health, 2010) Continence is the ability to voluntarily control emptying the bladder and bowels effectively in a socially acceptable and hygienic way. In the UK half a million people suffer with bowel control problems (Buckley & Lapitan 2009) Bowel care may include assessments and interventions of an intimate nature that are to be carried out when there is a specific and adequate clinical indication It is the policy of Southern Health NHS Foundation Trust (SHFT) that bowel care will be carried out in a safe and consistent manner according to SHFT procedures for bowel care (see Appendices 1-11) When providing bowel care staff must ensure that they follow standard infection prevention precautions (as outlined in SHCP 19 Standard Precautions Procedure, Infection Prevention and Control Policy: Appendix 5) and practice excellent hand hygiene (as outlined in SHCP12 Hand Hygiene Procedure, Infection Prevention and Control Policy: Appendix 6). 2. Purpose and Scope 2.1. To ensure a high standard of bowel care, including assessment, treatment and management including rectal interventions To ensure safe, competent practice by all clinicians undertaking bowel care and reduce risk of complications associated with bowel management To standardise practice across Southern Health Foundation NHS Trust and the wider healthcare community To ensure that all practice is evidence-based, relevant, appropriate and to minimise harm The guideline will apply to all staff undertaking bowel care for adults In order to carry out invasive bowel care all staff must attend relevant training, achieve competency, and be working within their job description. 3. Who does this guideline apply to? 3.1. This guideline applies to all Health Care Professionals employed by SHFT required to undertake bowel care for adults including: healthcare support workers, nurses, doctors and pharmacists. 4. Definitions 4.1 Bowel Care - Activities and interventions provided by health care professionals designed to maintain bowel function including diet, medication, enema and suppository administration, Digital Rectal Examination, Digital Rectal Stimulation and Digital Removal of Faeces. 5

6 4.2 Bowel Dysfunction constipation, faecal incontinence, disordered defaecation. 4.3 Digital Rectal Examination examination of the rectum by inserting a gloved, lubricated finger into the rectum. 4.4 Digital Removal of Faeces removal of stool from the rectum using a gloved, lubricated finger. 4.5 Digital Rectal Stimulation the insertion of a gloved, lubricated finger through the anus into the rectum followed by a gentle circular motion of the finger for seconds to stimulate reflex evacuation of stool. 4.6 Trans-Anal Irrigation the facilitation of faecal evacuation from the bowel by introducing water into the colon via the anus in a quantity sufficient to reach beyond the rectum. 4.7 Neurogenic Bowel Dysfunction dysfunction of the colon due to loss of normal sensory and motor control. 4.8 Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury resulting in acute, uncontrolled hypertension. Acute AD is a reaction of the autonomic nervous system to overstimulation. 5. Duties and responsibilities 5.1. The Quality and Safety Committee 5.2. Southern Health Foundation Trust has a responsibility to provide an effective and appropriate service to their service users and appropriate training to their staff. The Quality and Safety Committee will monitor compliance with this guideline and provide an audit programme for implementation Clinical leads / Managers / Supervisors Will ensure that sufficient priority is given to the successful implementation of the policy both in wards and the community. Will ensure that all staff attend appropriate training Monitor compliance with current standards by all clinical staff Ensure the availability, functioning and maintenance of all appropriate materials plus equipment and that staff have appropriate training to use them. Ensure clinical documentation in line with SHFT guideline Ensuring that any change in practice recommendations are notified to all clinical staff. Reviewing received audit forms relating to the guideline and feedback to staff. Ensure all staff participates in audit process for deficits to be identified and action plans to be developed Clinicians / Staff responsibilities Registered healthcare professionals are accountable for their own practice and will be aware of their legal and professional responsibilities and work within the code of practice of their professional body. Maintaining clinical competency as per competency framework Attending relevant training provided by the Trust and put it into practice 6

7 Bringing to the attention of appropriate senior staff any deficiencies in knowledge, ability or resources that may mediate against safe clinical practice. Participate in audit programmes related to measuring the quality and safety of physical assessment and monitoring. This would include addressing any improvements required and celebration of good practice. Ensuring they are familiar with relevant policies and procedures in their area of practice. All staff that carry out bowel care must be trained and assessed as competent prior to undertaking that skill. 6. Bowel Care Guideline Statements 6.1. Consent Consent is a service user s agreement for a health professional to provide care. Before health care professionals examine, treat or care for any person they must obtain their valid consent. There is a basic assumption that every adult has the capacity to decide whether to consent to, or refuse, proposed medical intervention, unless it is shown that they cannot understand information presented in a clear way. Staff must refer to the Consent for Examination or Treatment Policy (SH CP 16) in relation to this Staff need to be mindful that by attending a consultation it may be assumed that a service user is seeking treatment. However, before proceeding with an examination it is vital that the service user s valid consent is obtained. This means that the service user must have capacity/be competent to make the decision. They must have received sufficient information to take the decision and not be acting under duress When service users do not have the ability to consent for themselves the health care professionals should undertake an assessment of mental capacity and make the decision in the service user s best interests in line with the Mental Capacity Act 2005 and trust policies. This must be documented in the service user s notes 6.2. Privacy, Dignity and Respect In all examinations, procedures and interventions the Privacy, Dignity & Respect Policy (SH CP 144) must be followed Examinations or procedures involving the rectum and any examinations or interventions involving the removal of clothing to a state of undress which may make a service user feel particularly vulnerable constitute Intimate Procedures. Prior to any such examinations, procedures or interventions service users will be offered a chaperone according to the Chaperone Policy (SH CP 184). The ethnic, religious and cultural background of patients must be taken into account and may have particular significance to intimate procedures Bowel Assessment Bowel care concerns intimate parts of the body. All interventions relating to assessment and treatment require discretion and sensitivity Assessment of bowel continence and function will form part of the holistic patient assessment. Bowel assessment includes obtaining a history and carrying out relevant clinical examinations. It also includes carrying out and interpreting relevant baseline physiological observations and tests A structured approach to assessing bowel dysfunction must be adopted according to evidence based guidance (NICE, 2007). Bowel assessment is completed as part of the Continence 7

8 Assessment of Appendix 4. Assessments are to be documented and recorded in accordance with the Clinical Record Keeping Policy (SH IG 01) Where the Continence Assessment identifies bowel dysfunction the Bowel Care Pathway is implemented (see Appendix 5) Investigations Food, Stool and Medication Diary and Fluid Charts A food, stool and medication diary (see Appendix 6) and fluid charts will be completed according to the Bowel Care Pathway The assessing health care professional will have knowledge of when to refer for specialist dietetic assessment Digital Rectal Examination (DRE) DRE is an invasive intimate procedure that can be performed as part of a bowel assessment. DRE can only be performed by a Doctor or Registered Nurse who can demonstrate competence to an appropriate level in accordance with the Nursing and Midwifery Council (NMC) The Code: Professional standards of practice and behaviour (NMC, 2015). Health Care Support Workers (Bands 3 and above) may also carry out this procedure for appropriate named patients where a registered nurse has carried out the initial assessment and providing the care worker has completed the relevant training and demonstrated competence (see Appendix 3) DRE can be performed in the following circumstances: To establish whether faecal matter is present in the rectum and, if so, to assess the amount and consistency. To ascertain anal tone and the ability to initiate a voluntary contraction and to what degree. To assess anal pathology for the presence of foreign objects. Prior to administering rectal medication to establish the state of the rectum. To establish the effects of rectal medication. To administer suppositories or enema. To determine a need for digital removal of faeces (DRF) or digital rectal stimulation (DRS) and evaluating bowel emptiness. To assess a need for rectal medication and to evaluate its efficacy in certain circumstances. E.g. in patients who have diminished anorectal sensation. For digital stimulation to trigger defaecation by stimulating the rectoanal reflex. To establish anal and rectal sensation DRE must not be performed when: No consent has been obtained. The patient s doctor has given specific instructions that an invasive bowel procedure should not take place. The patient has recently undergone rectal/anal surgery or trauma (seek medical advice). The patient gains sexual satisfaction from this procedure (open discussion between health care professional and service user is advised and a chaperone facility made available in accordance with the Chaperone Policy (SH CP 184)). The health care professional does not feel competent to perform the procedure (NMC, 2015). 8

9 DRE is performed according to the procedure in Appendix Interventions Medication Medicines Control, Administration and Prescribing Policy (MCAPP) (SH CP 1) applies to the control, preparation, checking, administration and prescribing of medicines in adult bowel care Medications must only be prepared, checked and administered by the categories of healthcare staff indicated at paragraph 10.2 of the MCAPP (SH CP 1) Medications are to be administered as prescribed. See Laxative Treatment Guidelines for Adults in Appendix Certain medications can be administered at the discretion of nurses and mental health practitioners in accordance with the MCAPP (SH CP 1) (see Appendix C1 of that policy) Enemas and Suppositories The administration of enemas and suppositories is an invasive intimate intervention and can only be performed by a Registered Nurse who can demonstrate competence to an appropriate level in accordance with the Nursing and Midwifery Council (NMC) The Code: Professional standards of practice and behaviour (NMC, 2015). Health Care Support Workers (Bands 3 and above) can carry out this procedure for appropriate named patients where a registered nurse has carried out the initial assessment and providing the care worker has completed the relevant training and demonstrated competence. The task can only be delegated in agreement with and in the best interests of the patient Glycerol suppositories and micro-enemas can be administered at the discretion of nurses in accordance with the Laxative Treatment Guidelines for Adults (see Appendix 12) and the MCAPP (SH CP 1) (see Appendix D of that policy) Enemas and suppositories are administered according to the procedure in Appendix Digital Rectal Stimulation (DRS) DRS is an invasive intimate intervention to increase reflex muscular activity in the rectum to raise rectal pressure and aid stool expulsion. DRS can only be performed by a Registered Nurse who can demonstrate competence to an appropriate level in accordance with the Nursing and Midwifery Council (NMC) The Code: Professional standards of practice and behaviour (NMC, 2015) Health Care Support Workers (Bands 3 and above) can also carry out this procedure for appropriate named patients where a registered nurse has carried out the initial assessment and providing the care worker has completed the relevant training and demonstrated competence (see Appendix 3). The task can only be delegated in agreement with and in the best interests of the patient DRS can be performed in the following circumstances: Faecal impaction/loading. Incomplete defaecation. Inability to defaecate. Other bowel emptying techniques have failed. 9

10 Patients with spinal injury as part of a bowel management programme DRS must not be performed when: No consent has been obtained. The service user s doctor has given specific instructions that an invasive bowel procedure should not take place. The service user has recently undergone rectal/anal surgery or trauma (seek medical advice). The service user gains sexual satisfaction from this procedure (open discussion between health care professional and service user is advised and a chaperone facility made available in accordance with the Chaperone Policy (SH CP 184)). The health care professional does not feel competent to perform the procedure (NMC, 2015) DRS is performed according to the procedure in Appendix Digital Removal of Faeces (DRF) DRF is an invasive intimate intervention for assisted evacuation of the bowel. DRF can only be performed by a Registered Nurse who can demonstrate competence to an appropriate level in accordance with the Nursing and Midwifery Council (NMC) The Code: Professional standards of practice and behaviour (NMC, 2015). Health Care Support Workers (Bands 3 and above) may also carry out this procedure for appropriate named patients where a registered nurse has carried out the initial assessment and providing the care worker has completed the relevant training and demonstrated competence (see Appendix 3) DRF can be performed in the following circumstances: Faecal impaction/loading. Incomplete defaecation. Inability to defaecate. Other bowel emptying techniques have failed. Patients with spinal injury as part of a bowel management programme DRF must not be performed when: No consent has been obtained. The service user s doctor has given specific instructions that an invasive bowel procedure should not take place. The service user has recently undergone rectal/anal surgery or trauma (seek medical advice). The service user gains sexual satisfaction from this procedure (open discussion between health care professional and service user is advised and a chaperone facility made available in accordance with the Chaperone Policy (SH CP 184)). The health care professional does not feel competent to perform the procedure (NMC, 2015) DRF is performed according to the procedure in Appendix Trans-anal Irrigation Trans-anal Irrigation will only be considered when other less invasive methods of bowel management have failed to adequately control constipation and/or faecal incontinence and only 10

11 following DRE examination by a medical practitioner. The flowchart of Appendix 11 provides guidance for the referral of trans-anal irrigation Trans-anal irrigation will be carried out for the first time under the direction of a medical practitioner or a Registered Nurse who can demonstrate competence in trans-anal irrigation to an appropriate level in accordance with the Nursing and Midwifery Council (NMC) The Code: Professional standards of practice and behaviour (NMC, 2015) Subsequent to the first administration of trans-anal irrigation, the procedure is suitable for patient self-administration at the discretion of the medical practitioner Indications for trans-anal irrigation include: Neurogenic bowel dysfunction: e.g. spinal cord injury, spina bifida, multiple sclerosis. Chronic constipation, including both evacuation difficulties and slow transit constipation. Chronic faecal incontinence Trans-anal irrigation may be indicated in the following circumstances with close supervision and monitoring by a medical practitioner or competent Registered Nurse: Spinal cord injury at or above T6, monitor for autonomic dysreflexia, until it is clear that the technique is well tolerated and does not provoke autonomic dysreflexia. Unstable metabolic conditions (frail, known renal disease or liver disease). Inability to perform the procedure independently or comply with the protocol in the absence of close involvement of carers (e.g. due to physical disability, cognitive impairment, major mental/emotional disorder). Anorectal conditions that could cause pain or bleeding during the procedure (e.g. third degree haemorrhoids, anal fissure) The following circumstances are contra-indicated except when specifically directed by a medical practitioner: Pregnant or planning pregnancy. Active perianal sepsis. Diarrhoea. (New onset and no clinical explanation) Anal fissure. Large haemorrhoids that bleed easily. Faecal impaction (clear, if possible before starting irrigation: digital rectal examination if unsure). Past pelvic radiotherapy which has caused bowel symptoms. Known severe diverticular disease. Use of rectal medications for other diseases. Congestive cardiac failure. Anal surgery within the past 6 months. Children under 3 years old The following circumstances are contra-indicated and trans-anal irrigation will not be used: Acute active inflammatory Bowel disease. Known obstructing rectal or colonic mass. Severe cognitive impairments. 11

12 Rectal or colonic surgical anastomosis ( surgical connection of two intestinal structures) within the last six months 6.6. Neurogenic Bowel Dysfunction All staff involved in the management of neurogenic bowel dysfunction must demonstrate competence in the management of autonomic symptoms and acute autonomic dysreflexia. 7. Training requirements 7.1. All practitioners required to undertake bowel care will attend face-to-face foundation training in bowel care and must demonstrate competence in bowel care assessment and interventions (see Appendix 1). Competency assessment will be undertaken by a competent Registered Nurse, who has been deemed competent at level 4 or above All practitioners will have a working knowledge of relevant current legislation, national guidelines, organisational policies and procedures All practitioners will have a working knowledge of working within their sphere of competence and acknowledge when to seek advice All staff must practise their skills regularly to maintain competence. They must refresh their knowledge and skills at least every three years. (Bowel care competencies Appendix 3) 7.5. Staff (practitioners and assessors) must maintain their competence through clinical practice and personal study It is possible that unregistered practitioners (bands 3 and 4) will be involved in carrying out aspects of bowel care. In these cases, the relevant bowel care interventions are delegated by registered practitioners. A registered professional should only delegate bowel care tasks to a person who has had the appropriate training and whom they deem competent to perform the task. The registered healthcare professional will also ensure that the person they have delegated the task to fully understands the nature of the delegated task in relation to what is expected of them. The health care support worker must know their limitations and identify when to seek advice from an appropriate professional. 8. Monitoring compliance Element to be monitored Clinical competency in bowel care Lead Tool Frequency Reporting arrangements Line Bowel Care Annual Appraisal manager Competencies 9. Guideline review 9.1. Guideline should be reviewed in two years 10. Associated trust documents This guideline should be read in conjunction with, and with reference to, the following trust documents: 12

13 10.2. SHFT Care planning Policy SC HP SHFT Clinical Record Keeping Policy SH IG SHFT Medicines Control, Administration and Prescribing Policy SH CP SHFT Chaperone Policy SH CP SHFT Mental Capacity Act Policy and Guidance SH CP SHFT Consent for Examination or Treatment Policy SH CP SHFT Privacy, Dignity & Respect Policy SH CP SHFT Infection Control Policy SH CP SHFT Risk Management Strategy and Policy SH NCP Supporting references National Institute for Health and Care Excellence (2007) Faecal incontinence: the management of faecal incontinence in adults clinical guideline CG49, London: NICE. Royal College of Nursing (2012) Management of lower bowel dysfunction, including DRE and DRF, London: RCN. Royal Marsden NHS Foundation Trust (2015) The Royal Marsden Manual of Clinical Nursing Procedures Ninth Edition, London. Multidisciplinary Association of Spinal Cord Injured Professionals (2012) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions. Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour, London, NMC. Norton, C. (2009) Guidelines for the use of Rectal Irrigation, Kings College, London. 13

14 Appendix 1: Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on ) before the policy goes through the Trust policy approval process. Training Frequency Course Length Delivery Method Facilitators Recording Attendance Programme Foundation in Clinical Bowel Care (Tier Once 1 Day Face to face MLE Educators 1) Directorate Service Target Audience Adult Mental Health All staff required as part of their role to provide bowel care Strategic & Operational Responsibility Director of Nursing / Steve Coopey MH/LD/TQ21 Specialised Services All staff required as part of their role to provide bowel care Learning Disabilities All staff required as part of their role to provide bowel care ISD s Older Persons Mental Health All staff required as part of their role to provide bowel care ISD s Adults All staff required as part of their role to provide bowel care ISD s Children s Services Not applicable Corporate All Not Applicable 14

15 Appendix 2: Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act Stage 1: Screening Date of assessment: 2/04/17 Name of person completing the assessment: Steve Coopey Job title: Head of Clinical Development Responsible department: LEaD Intended equality outcomes: Service users are able to access this service as identified solely by clinical need and therefore this guidance does not discriminate against service users Who was involved in the consultation of this document? Alison Wileman Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: Protected Characteristic Positive impact Negative impact Age x Disability x Gender reassignment x Marriage & civil partnership x Pregnancy & maternity x Race x Religion x Sex x Sexual orientation x Stage 2: Full impact assessment What is the impact? Mitigating actions Monitoring of actions 15

16 Appendix 3: Competencies Bowel Care: Digital Rectal Examination, Digital Removal of Faeces and Digital Rectal Stimulation Clinical Competencies Name: Base: Role: Date initial training completed: Competency Statement: The participant demonstrates clinical knowledge and skill in digital rectal examination and removal of faeces without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Nurse who can demonstrate competence at level 4 or above. Performance Criteria Assessment Method Level achieved Date Assessor/self assessed The Participant will be able to: 1. Demonstrate the knowledge and skill in digital rectal examination (DRE) a) Demonstrate an awareness of professional accountability and guidelines (e.g. RCN) Questioning b) Discuss the rationale for DRE Questioning c) Demonstrate an understanding of the relevant anatomy and physiology of the gastro-intestinal tract d) Discuss the care of a patient with altered bowel function e) Identify when it would be appropriate to carry out DRE f) Identify when it would be necessary to stop procedure and what action to take g) Discuss the use of appropriate medication e.g. Laxatives, suppositories, enemas h) Demonstrate knowledge of appropriate use of equipment i) Demonstrate preparation of the patient and gain informed consent j) Demonstrate the correct procedure to perform DRE k) Demonstrate safe disposal of equipment and waste Questioning Questioning Questioning Questioning Questioning Observation Observation Observation Observation 16

17 Performance Criteria Assessment Method Level achieved Date l) Complete documentation and any recommendations for treatment / follow up m) Recognise symptoms of autonomic dysreflexia in the paralysed patient and take appropriate action 2. Demonstrate the knowledge and skill in digital removal of faeces (DRF) a) Demonstrate an awareness of professional accountability and guidelines (e.g. RCN) b) Identify the indications for digital removal of faeces Observation Observation/Questioning Questioning Questioning Assessor/self assessed c) Demonstrate an understanding of the relevant anatomy and physiology of the gastro-intestinal tract d) Discuss the care of a patient with altered bowel function e) Identify the conditions which contraindicate digital removal of faeces f) Discuss the potential side effects of procedure including stimulation of vagus nerve g) Identify when it would be necessary to stop procedure and what action to take h) Discuss the use of appropriate medication e.g. Laxatives, suppositories, enema i) Demonstrate preparation of the patient and gain informed consent k) Demonstrate the correct procedure to perform digital removal of faeces Questioning Questioning Questioning Questioning Questioning Questioning Observation Observation l) Demonstrate safe disposal of equipment and waste Observation m) Complete documentation and any recommendations for treatment / follow up n) Recognise symptoms of autonomic dysreflexia in the paralysed patient and take appropriate action Observation Questioning/questioning 17

18 Performance Criteria Assessment Method Level achieved Date Assessor/self assessed The Participant will be able to: 3. Demonstrate the knowledge and skill in digital rectal Stimulation (DRS) a) Demonstrate an awareness of professional accountability and guidelines (e.g. RCN) Questioning b) Discuss the rationale for DRS Questioning c) Demonstrate an understanding of the relevant anatomy and physiology of the gastro-intestinal tract d) Discuss the care of a patient with altered bowel function e) Identify when it would be appropriate to carry out DRS f) Identify when it would be necessary to stop procedure and what action to take g) Discuss the use of appropriate medication e.g. Laxatives, suppositories, enemas h) Demonstrate knowledge of appropriate use of equipment i) Demonstrate preparation of the patient and gain informed consent j) Demonstrate the correct procedure to perform DRS k) Demonstrate safe disposal of equipment and waste l) Complete documentation and any recommendations for treatment / follow up m) Recognise symptoms of autonomic dysreflexia in the paralysed patient and take appropriate action Questioning Questioning Questioning Questioning Questioning Observation Observation Observation Observation Observation Observation/Questioning Source: RCN guidelines for the management of lower bowel dysfunction, including DRE and DRF 2012, Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions 2012, Southern Health NHS Foundation Trust Bowel Care Guidelines,

19 Date all elements of Competency Tool completed to level 3 Name Signature Status Date I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency in Bowel care including digital rectal examination, digital removal of faeces and digital rectal stimulation Assessor Signature Status Date Review Competent Signature Assessor Comments Dates: Yes / No signature 19

20 APPENDIX 4 CONTINENCE ASSESSMENT (Level 1) Patient Name (Capitals):... Tel No:... Date:... Time (24hr clock):... Title: Mr Mrs Ms NHS No: Full address: Post Code: Telephone no: Date of birth: GP/Practice: Medications (in capitals): Relevant Medical History (include dates): Number of Back Problems? Parkinson s? pregnancies Difficult deliveries? Constipation? Multiple Sclerosis? Hysterectomy? Dementia? Spinal Injury? Pelvic surgery? Depression? Psychiatric History? Cystoscopy? Diabetes? Weight History? Prostatectomy? Learning Disability? Other Previous Investigations External Vaginal Assessment [Look for: prolapse, sore skin, vaginal atrophic changes]: Rectal Examination: Allergies: Presenting problem and duration: 14 day food and stool diary YES/NO 3 day fluid balance chart: YES/NO Urine Analysis If no give reason: If Leucocytes/Nitrates/Blood present (ie symptoms of UTI), refer to Medical Practitioner (or appropriate Health Care Professional), resume assessment following treatment. Patient Weight: 20

21 How many drinks in 24 hours? Type of drinks If fluid intake is low, advise 6-8 mugs. If caffeine content is high, advise on decaffeinated drinks. Resume assessment when patient has improved fluid intake Bowel habit: Daily... Alternate Days Less Often... Faecal Incontinence. Consistency of faeces Bristol Stool Form Scale If constipated, treat/refer to medical Practitioner, (Or appropriate Health Care Professional) resume assessment following treatment. If recent abnormal changes and altered bowel habit, refer to doctor immediately. Type: Colour of faeces Complete fibre score chart. Score: If patient has any signs of undiagnosed bleeding or black tarry stool and is not taking ferrous sulphate, stop assessment and refer to doctor immediately Use the Fibre Score Chart to establish fibre levels. If scores 12 or less, give and explain fibre advice sheet. Consider fibre SYMPTOM PROFILE Patient Symptoms tick relevant points Do you leak when you laugh/cough/sneeze/exercise? If any box ticked Follow urinary care pathway Do you only ever leak a small amount? Do you know when you have leaked? Do you leak without feeling the need to empty your bladder? Does leaking only wet your underwear (not outer clothes)? Do you feel a strong sudden urge to pass urine and have to go quickly? Do you feel an uncontrollable urge to pass urine prior to leaking? Do you feel that you pass urine frequently? Do you get up at night at least twice to pass urine? Do you leak moderate to large amounts of urine before you reach the toilet? Do you find it hard to start to pass urine? Do you have to strain to pass urine? Refer to Continence Team/Medical Practitioner for further assessment. 21

22 Does your urine flow stop and start? Do you feel that it takes a long time to pass urine? Do you feel the need to pass urine once you have voided? Do you feel as if your bladder is not completely empty? Do you feel that your stream is weaker and slower than it used to be? Do you have difficulty with physical access to a toilet? Do you have difficulty getting on/off the toilet/wiping bottom? Do you experience pain on passing faeces? Prior During After Do you feel strong/sudden urge to pass a stool/have bowels open? Do you have the urge to have bowels open? Refer to Occupational Therapist. Resume treatment following assessment Refer to Medical Practitioner (or appropriate Health care Professional, resume assessment following treatment. Do you soil yourself before reaching the toilet? Follow bowel care pathway Do you have difficulty passing faeces? Do you feel your bowel motions are not frequent/regular enough? Do you only pass small amounts of faeces? Do your bowels still feel full after going to the toilet? Patient unable to answer above questions Patient appears confused Refer to Medical Practitioner for further assessment Resume assessment following consultation. Patient has cognitive impairment Signature.. Date Assessor print name: Designation (e.g. RN) 22

23 Appendix 5 Patient Name:... Date of Birth:... NHS NO... BOWEL CARE PATHWAY (Please initial each box completed) ACTION CONTACT 1 Bothersome rating this visit Onset of Problem When: COMMENTS REGARDING INDIVIDUAL PATIENT CARE DATE/TIME: A lot / moderate / a little / not at all Relation to an event please state: If patient has any signs of undiagnosed bleeding/black runny stool and is not taking ferrous sulphate, stop pathway and refer to Medical Practitioner immediately If not already instigated, commence 14 day Food, Stool and Medication diary, explain to patient and provide stool chart. Modify dietary and fluid intake Review fibre score sheet Address toilet access issues/correct positioning on toilet Review medications CONTACT 2 Bothersome rating this visit Review Food, Stool and Medication diary. DATE/TIME: A lot / moderate / a little / not at all Improvement in symptoms Symptoms reduced to tolerable level Discharge No improvement in symptoms Review medication Discuss with Medical Practitioner re: aperient (constipation) or diarrhoeal (faecal incontinence) medication 23

24 Patient Name... Date of Birth... NHS NO... BOWEL CARE PATHWAY cont... Consider Long Term Management (Please initial each box completed) provision of continence products (faecal incontinence) need for rectal intervention (constipation) CONTACT 3 Bothersome rating this visit DATE/TIME: A lot / moderate / a little / not at all Review Food, Stool and Medication diary. Symptoms resolved/reduced to tolerable level. Discharge Variance: This patient is unable to commence on a Care Pathway because: Inform referring medical practitioner if pathway incomplete at any visit TO BE COMPLETED BY ALL STAFF USING THE PATHWAY Sign to confirm that you have met all standards or recorded variances FULL NAME DESIGNATION INITIALS SIGN DATE Discharge Date: Signature: 24

25 Appendix 6A 14 Day Food, Stool and Medication Diary Patient s Name: DOB: NHS No:.. Address DATE FOOD AND DRINK (Please record everything you eat and drink e.g. Lunch: meat, boiled potatoes, peas, carrots, gravy, apple and yoghurt + 150mls water please do not write normal diet ) STOOL TYPE, FAECAL INCONTINENCE/SOILING IF APPROPRIATE AND TIME OCCURRED (See Bristol Stool Chart) BOWEL MEDICATION Name, amount and times 25

26 APPENDIX 6B By Cabot Health, Bristol Stool Chart [CC BY-SA 3.0 ( via Wikimedia Commons 26

27 Appendix 7 Procedure for Digital Rectal Examination in Adults Action Confirm patient s identity and Obtain careful history from patient prior to examination, including establishing whether patient has any known allergies. Identify patient by surname, first name and date of birth using open questions checking against NHS number. Rationale To avoid error in patient identification. To assess symptoms, and reduce the risk of allergic reaction. Ensure Patient is introduced to staff involved in the procedure Explain each step of the procedure to the patient, including potential risks and complications, and also the benefits. Obtain valid and informed consent and document in patient s health records. If necessary refer to the Mental Capacity Act 2005, and consider if the examination is in patient s best interest. Follow the SHFT consent for examination or treatment policy. Clarify if the patient requires a formal chaperone. Follow SHFT Chaperone policy. Decontaminate hands as per Southern Health Hand Hygiene Procedure, and apply gloves and apron (single use non sterile disposable) Ensure a bedpan/commode or toilet is readily available. Perform physical 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 patients. If at any time the heart rate drops, rhythm changes or signs of Autonomic Dysreflexia STOP the procedure Helps reduce anxiety by improving communication. To ensure patient is informed and understands the procedure. Patient information can help to reduce anxiety. To ensure patient is happy for the procedure to take place. It is the patient s choice to have a chaperone if required. Refer to Chaperone policy. To reduce the risk of infection, and to protect clothing or uniform from contamination and potential transfer of micro-organisms. Protect hands from contamination with organic matter. DRE can stimulate the need for a bowel movement. (need up to date reference) To facilitate easy access for defecation ensuring privacy and dignity. To provide a baseline measurement to assess any changes in the pulse/blood pressure during or after the procedure (RCN 2012) Spinal cord injured patients have frequently been observed for changes in blood pressure without signs and symptoms of Autonomic dysreflexia. Monitoring blood pressure as part of an ongoing 27

28 intervention is thought to be of little benefit. The Practitioner should observe for signs of potential shock/autonomic Dysreflexia (Coggrave et al 2009) Assist the patient to lie on the left side, with knees drawn to the abdomen, and buttocks near the edge of the bed. Place a disposable protective pad underneath the patient s hips and buttocks and cover area to be. exposed Inform the patient that you are about to begin the procedure and that you will be examining the outer and internal area. Observe the perianal area prior to procedure for evidence of skin soreness, excoriation, swelling, haemorrhoids, lesions, such as skin tags, rectal prolapse, fistulas, foreign bodies, faecal matter, mucus, blood or infestation. Palpate the perianal area by starting at the 12 o clock position moving clockwise to 6 o clock and then returning to 12 o clock and moving to 6 o clock anticlockwise. Lubricate gloved finger with lubricant gel. Prior to insertion, encourage the patient to breathe out or talk and place gloved finger on the anus for a few seconds. On insertion, assess anal sphincter control. With the finger inserted in the anus, sweep clockwise, then anticlockwise. Note any irregularities. To promote the stability of the patient and to allow ease of digital rectal examination by following the natural anatomy of the colon. (RCN 2012) To reduce potential infection risk caused by soiled linen. To promote dignity of the patient and avoid embarrassment if faecal staining occurs during or after the procedure. To ensure the patient is aware the examination is about to begin. To assess for abnormalities such as bleeding, discharge or prolapse, all of which should be reported to medical staff before examination is undertaken. (RCN 2012) Swelling may be indicative of possible mass or abscess. To assess for any irregularities, indurations, tenderness or abscess formation. To prevent trauma to rectal mucosa and minimize discomfort as lubrication reduces friction. To ease finger into anus/rectum. To prevent the anal sphincter from spasm on insertion. Gently placing a finger on the anus initiates the anal reflex, causing the anus to contract and then relax (RCN 2012) If there is resistance on insertion, this indicates good internal sphincter tone, it is only during defecation that the sphincter should relax. (RCN 2012). Palpating around the anus at 360 degrees allows to establish any tenderness or swelling in the rectum (steggall 2008) Assess for faecal matter in the rectum. Note consistency, amount and type using the Bristol stool chart. To assess if rectum is loaded, for constipation and/or the need for further intervention. Observe the patient throughout the procedure: To note signs of distress, pain, bleeding and general discomfort. 28

29 STOP If anal area is bleeding If the patient asks you to If patient is showing signs of Autonomic Dysreflexia Or Autonomic Dysreflexia (Refer to section/page in policy not written yet) When procedure is completed, clean residual lubricating gel from the perianal area. Make the patient comfortable and offer toilet, commode, bedpan or other equipment as appropriate and assist as required. To promote comfort and prevent skin excoriation. Examination may have stimulated the anorectal reflex and the urge to defecate. Dispose of all equipment and PPE as per SHFT Handling and Disposal of waste policy, remove gloves and apron and decontaminate hands as per the SHFT Hand Hygiene Procedure. Document procedure in the patient s health records including the reason for DRE, the outcome and review date to assess the need for repeat DRE. If any abnormality is found ensure an appropriate referral is made in line with SHFT policy To prevent cross infection and environmental contamination and to ensure staff and patient safety. To comply with NMC Code and SHFT guidelines on documentation. To monitor effects and improve communication and enhance delivery of care. To promote continuity of care and patient safety. References Higgins, D. (2006) How to administer an enema. Nursing Times, 102(20), Kyle, G (2007) Bowel care part 4. Administering an enema. Nursing Times; 103(45), Kyle, G (2009) Should a suppository be inserted with the blunt end or the pointed end first, or does it not matter? Nursing times, 105(2), 16. Royal College of Nursing (2012) Management of Lower Bowel Dysfunction including DRE &DRF guidance for nurses. Steggall, M.J (2008) digital rectal examination. Nursing standard, 22(47), Cggrave et al (2009) Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord injury. 29

30 Appendix 8 Procedure for Administering Suppositories and Enemas Action Rationale Obtain careful history from patient prior to examination, including establishing whether patient has any known allergies. Establish indications for use and eliminate any contra-indications or allergies prior to proceeding. Ensure Patient is introduced to staff involved in the procedure Explain each step of the procedure to the patient, including potential risks and complications, and also the benefits. Obtain valid and informed consent and document in patient s health records. If necessary refer to the Mental Capacity Act 2005, and consider if the examination is in patient s best interest. Follow the SHFT consent for examination or treatment policy. Identify patient by surname, first name and date of birth using open questions checking against NHS number. Establish that the patient has no known allergies. To assess symptoms, and reduce the risk of allergic reaction. To ensure appropriateness, suitability and safety of administration. Helps reduce anxiety by improving communication. To ensure patient is informed and understands the procedure. Patient information can help to reduce anxiety. To ensure patient is happy for the procedure to take place. To ensure correct identification of the patient. To reduce the risk of allergic reactions. Clarify if the patient requires a formal chaperone. Follow SHFT Chaperone policy. Check Suppository/Enema to be administered against Medicines Administration chart or, if at nurses discretion according to policy, document the administration appropriately. Ensure Medicines Administration chart specifies: 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. It is the patient s choice to have a chaperone if required. Refer to Chaperone policy. To protect patient from harm and ensure effective record keeping. To maintain patient safety. To ensure the enema or suppository is 30

31 prepared and administered in accordance with manufacturer s instructions. Allow patient to empty bladder first if required. To reduce the feeling of discomfort during the procedure (Higgins 2006). Ensure a bedpan, commode or toilet is readily available. In case the patient feels the need to expel the enema or suppository before the procedure is completed. Decontaminate hands as per Southern Health Hand Hygiene Procedure, and apply gloves and apron (single use non sterile disposable) Administration of Enemas: Prepare the enema by warming to body temperature in accordance with manufacturer s instructions. Assist the patient to lie on the left side, with knees drawn to the abdomen, and buttocks near the edge of the bed. Place some lubricating gel on nozzle of enema Expel excessive air from enema prior to administration Inform the patient that you are about to commence the procedure, slowly introduce the nozzle to the depth recommended by the manufacturer Introduce the fluid slowly as recommended by the manufacturer Once instilled, slowly withdraw the nozzle Ask the patient to retain the enema for minutes before evacuating the bowel Administration of suppository: Open the packet/suppository and lubricate the suppository with lubricating gel or water according to the manufacturer s instructions Insert the suppository into the rectum, ensuring that it is placed against the bowel wall. To reduce the risk of infection, and to protect clothing or uniform from contamination and potential transfer of micro-organisms. Protect hands from contamination with organic matter. Warming the enema solution to body temperature may be beneficial as heat is an effective stimulant to the intestinal mucosa. Cold solutions should be avoided as they may cause cramping. (Higgins 2006) If water is used to warm the enema, care must be taken not to overwarm. To allow ease of passage and flow of fluid into rectum. The anatomical structure of the sigmoid colon assists enema distribution and retention To prevent trauma to the anal and rectal mucosa, reducing surface friction (Higgins 2006) Excessive air may cause abdominal discomfort or pain (kyle 2007) To ensure the nozzle is in the rectum To promote comfort (will find a better answer when completed my research. To avoid reflex emptying of the rectum To enhance the evacuant effect Lubrication reduces surface friction, avoiding anal mucosa trauma. Aids ease of suppository insertion. Suppositories need body heat in order to dissolve and become effective. If they are placed in faecal matter they will remain intact and be ineffective. (Kyle 2009) There is inconclusive evidence regarding whether suppositories should be inserted blunt 31

32 end first (Higgins 2007). Please refer to individual manufacturer s instructions for use. Observe the patient throughout the procedure: STOP If anal area is bleeding If the patient asks you to If patient is showing signs of Autonomic Dysreflexia When completed procedure, clean residual lubricating gel from the perineal area. Ensure patient is comfortable and ask them to retain the suppository for 20 minutes, or until they are no longer able to do so. Ensure patient has access to commode/bedpan/toilet Dispose of all equipment and PPE as per SHFT Handling and Disposal of waste policy, remove gloves and apron and decontaminate hands as per the SHFT Hand Hygiene Procedure. Document the procedure carried out, and the outcome of the procedure in the patient s health records If any abnormality is found ensure an appropriate referral is made in line with local policy To note signs of distress, pain, bleeding and general discomfort. Or Autonomic Dysreflexia (Refer to section/page in policy not written yet) To prevent skin excoriation and promote comfort. To allow the suppository to melt and release the active ingredients. In case rapid bowel evacuation following procedure. To prevent cross infection and environmental contamination and to ensure staff and patient safety. To comply with NMC Code and SHFT guidelines on documentation. To monitor effects and improve communication and enhance delivery of care. To promote continuity of care and patient safety. References Higgins, D. (2006) How to administer an enema. Nursing Times, 102(20), Kyle, G (2007) Bowel care part 4. Administering an enema. Nursing Times; 103(45), Kyle, G (2009) Should a suppository be inserted with the blunt end or the pointed end first, or does it not matter? Nursing times, 105(2),

33 Appendix 9 Procedure for Digital Rectal Stimulation in Adults Action Rationale Obtain careful history from patient prior to examination, including establishing whether patient has any known allergies. Ensure Patient is introduced to staff involved in the procedure Explain each step of the procedure to the patient, including potential risks and complications, and also the benefits. Obtain valid and informed consent and document in patient s health records. If necessary refer to the Mental Capacity Act 2005, and consider if the examination is in patient s best interest. Follow the SHFT consent for examination or treatment policy. Identify patient by surname, first name and date of birth using open questions checking against NHS number. Clarify if the patient requires a formal chaperone. Follow SHFT Chaperone policy. Ask the patient if they wish to use the toilet prior to undertaking the procedure. Ensure the bedpan/commode/toilet is readily available. Perform physical observations required according to whether an acute intervention or regular ongoing intervention and observe for signs and symptoms of Autonomic Dysreflexia in Spinal cord injured patients. If at any time the heart rate drops, rhythm changes or signs of Autonomic Dysreflexia STOP the procedure Assist the patient to lie on the left side, with knees drawn to the abdomen, and buttocks near the edge of the bed To assess symptoms, and reduce the risk of allergic reaction. Helps reduce anxiety by improving communication. To ensure patient is informed and understands the procedure. Patient information can help to reduce anxiety. To ensure patient is happy for the procedure to take place. To ensure correct identification of the patient. It is the patient s choice to have a chaperone if required. Refer to Chaperone policy. For comfort of the patient. To facilitate easy access for defecation ensuring privacy and dignity To provide a baseline measurement to assess any changes in the pulse/blood pressure during or after the procedure (RCN 2012). Spinal cord injured patients have frequently been observed for changes in blood pressure without signs and symptoms of Autonomic dysreflexia. Monitoring blood pressure as part of an ongoing intervention is thought to be of little benefit. The Practitioner should observe for signs of potential shock/autonomic Dysreflexia. (Coggrave et al 2009) To promote the stability of the patient and to allow ease of digital rectal stimulation by following the natural anatomy of the colon. (RCN 2012) 33

34 Place a disposable protective pad underneath the patient s hips and buttocks and cover area to be exposed. Place lubricating gel onto gloved finger and anus. Inform the patient of imminent procedure 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 throughout. (Coggrave et al 2009) Gently rotate in a clockwise direction 6-8 times for approximately 10 seconds, or until relaxation of the sphincter felt. Observe the patient throughout the procedure: STOP If in discomfort If perianal area bleeding If patient asks 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) If reflex activity does not occur, repeat every 5-10 minutes until rectum is empty or activity ceases. Do not repeat more than three times if reflex activity does not occur (Coggrave et al 2009) When completed procedure, clean the perianal area. Dispose of all equipment as per Handling and Disposal of waste policy, remove gloves and apron and decontaminate hands as per the SHFT Hand Hygiene Procedure. Document all actions and outcomes in patient s health records. If any abnormality is found ensure an appropriate referral is made in line with local policy To reduce potential infection risk caused by soiled linen. To promote dignity of the patient and avoid embarrassment if faecal staining occurs during or after the procedure. To prevent trauma to the anal and rectal mucosa, reducing surface friction (Higgins 2006) To ensure the patient is aware that the procedure is about to begin. To prevent trauma to the To minimize discomfort and 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 promote comfort of the patient Digital removal of faeces may be required if faeces felt in the rectum (Coggrave et al) To promote comfort and prevent skin excoriation. To ensure staff and patient safety and to prevent infection. To comply with NMC Code and SHFT guidelines on documentation To promote continuity of care and patient safety. References Higgins, D. (2006) How to administer an enema. Nursing Times, 102(20), Kyle, G (2007) Bowel care part 4. Administering an enema. Nursing Times; 103(45), Royal College of Nursing (2012) Management of Lower Bowel Dysfunction including DRE &DRF guidance for nurses. Coggrave et al (2009) Guidelines for the management of Neurogenic Bowel Dysfunction after Spinal Cord injury. 34

35 Appendix 10 Procedure for Digital Removal of Faeces Action Rationale Obtain careful history from patient prior to examination, including establishing whether patient has any known allergies. To assess symptoms, and reduce the risk of allergic reaction. Ensure Patient is introduced to staff involved in the procedure Helps reduce anxiety by improving communication. Explain each step of the procedure to the patient, including potential risks and complications, and also the benefits. Obtain valid and informed consent and document in patient s health records. If necessary refer to the Mental Capacity Act 2005, and consider if the examination is in patient s best interest. Follow the SHFT consent for examination or treatment policy. Identify patient by surname, first name and date of birth using open questions checking against NHS number. Clarify if the patient requires a formal chaperone. Follow SHFT Chaperone policy. Ask the patient if they wish to use the toilet prior to undertaking the procedure. Ensure the bedpan/commode/toilet is readily available. Perform physical observations required according to whether an acute intervention or regular ongoing intervention and observe for signs and symptoms of Autonomic Dysreflexia in Spinal cord injured patients. If at any time the heart rate drops, rhythm changes or signs of Autonomic Dysreflexia STOP the procedure Decontaminate hands prior to the procedure according to SHFT policy Apply single use apron and single use disposable non-sterile gloves To ensure patient is informed and understands the procedure. Patient information can help to reduce anxiety. To ensure patient is happy for the procedure to take place. To ensure correct identification of the patient. It is the patient s choice to have a chaperone if required. Refer to Chaperone policy. For comfort of the patient. To facilitate easy access for defecation ensuring privacy and dignity To provide a baseline measurement to assess any changes in the pulse/blood pressure during or after the procedure (RCN 2012). Spinal cord injured patients have frequently been observed for changes in blood pressure without signs and symptoms of Autonomic dysreflexia. Monitoring blood pressure as part of an ongoing intervention is thought to be of little benefit. The Practitioner should observe for signs of potential shock/autonomic Dysreflexia. (Coggrave et al 2009) To reduce the risk of transfer of transient micro organisms on the healthworkers hands and to protect the clothing or uniform from contamination 35

36 Gather and prepare all required equipment for the procedure ensuring patients dignity Assist the patient to lie on the left side, with knees drawn to the abdomen, and buttocks near the edge of the bed Place a disposable protective pad underneath the patient s hips and buttocks and cover area to be exposed. Place lubricating gel onto gloved finger and anus. Inform the patient of imminent procedure Prior to insertion of gloved finger into the anus, observe area for evidence of skin excoriation, swelling, haemorrhoids, rectal prolapse 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. Avoid using a hooked finger to remove faeces. 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 in discomfort If perianal area bleeding If patient asks you to If there are signs and symptoms of Autonomic Dysreflexia. If faecal matter is too hard to break up, or is more than 4cm wide, stop the procedure and discuss with the multidisciplinary team When the procedure is complete, cleanse the anal area Dispose of all equipment as per Handling and Disposal of waste policy, remove gloves and apron and decontaminate hands as per the SHFT Hand Hygiene Procedure. To facilitate easier insertion of the finger and reduce sensation and discomfort for the removal of faecal matter (RCN 2012) To promote the stability of the patient and to allow ease of digital rectal stimulation by following the natural anatomy of the colon. (RCN 2012) To reduce potential infection risk caused by soiled linen. To promote dignity of the patient and avoid embarrassment if faecal staining occurs during or after the procedure. To prevent trauma to the anal and rectal mucosa, reducing surface friction (Higgins 2006) To ensure the patient is aware that the procedure is about to begin. May indicate incontinence or pruritus. Swelling may indicate possible mass or abscess. Any abnormalities such as bleeding, discharge or prolapse should be reported to medical staff before any medical examination is undertaken.(rcn2012) To minimize discomfort and reduce risk of trauma Use of a hooked finger may cause damage to the rectal mucosa and anal sphincter(rcn2012) To dispose of appropriately. To note signs of distress, pain, bleeding and general discomfort or Autonomic Dysreflexia. To avoid unnecessary pain and damage to the anal sphincter. To make the patient comfortable, prevent irritation, soreness and skin excoriation. To ensure staff and patient safety and to prevent infection. 36

37 Document all actions and outcomes in patient s health records. If any abnormality is found ensure an appropriate referral is made in line with local policy To comply with NMC Code and SHFT guidelines on documentation To promote continuity of care and patient safety. References Higgins, D. (2006) How to administer an enema. Nursing Times, 102(20), Kyle, G (2007) Bowel care part 4. Administering an enema. Nursing Times; 103(45), Royal College of Nursing (2012) Management of Lower Bowel Dysfunction including DRE &DRF guidance for nurses. Coggrave et al (2009) Guidelines for the management of Neurogenic Bowel Dysfunction after Spinal Cord injury. 37

38 38