Guidelines for the Manual Evacuation of Faeces

Transcription

1 Rationale Guidelines for the Manual Evacuation of Faeces These guidelines are to provide the required information for designated registered nurses, health care assistants and bank support workers to perform the most appropriate bowel care for a specific patient group with spinal cord damage. If patient s have upper motor neurone spinal cord damage, T12 and above, they should have a reflex bowel. A reflex bowel should respond well to the insertion of a glycerine suppository and digital stimulation, followed by a manual evacuation. Some reflex bowels will empty on reflex alone, and will only then require a PR check to ensure the rectum is empty. If it is not empty, and there are stools present, then a manual evacuation should be performed. If patient s have lower motor neurone spinal cord damage below T12, they should have a flaccid bowel. A flaccid bowel should be managed by inserting a glycerine suppository and carrying out a manual evacuation. It is possible to have a mixed bowel, which will require both digital stimulation and manual evacuation. Bowel management should be carried out at regular intervals at the same time daily or alternate days with oral administration of prescribed Lactulose and Senna. This procedure is performed in order to Maintain a patient s normal established bowel regime. It can be harmful and life threatening to deviate from a spinal cord injured (SCI) patient s routine method of bowel care To commence and establish newly SCI patients on an appropriate and necessary bowel regime Patient Group This procedure is appropriate for SCI patients with neurogenic bowel dysfunction Who use this method of bowel evacuation within their normal established personal care routine Patients who have sustained a new injury resulting in neurogenic bowel dysfunction, requiring manual evacuation as part of an individual bowel care programme in order for bowel evacuation to occur It should be noted that all patients should be assessed on an individual basis by a practitioner with appropriate skills in order to determine a patient s medical

2 diagnosis and suitability for this procedure to be necessary as part of their care programme. Staff Group This procedure is to be performed by specifically trained registered nurses, nursing auxiliaries, health care assistants and bank support workers who have completed the specific education, training and assessment session, and have been authorised to perform the procedure Definition Insertion of one finger into the rectum, in order to ascertain the presence of faeces, and to manually remove it. Ethical Considerations It should always be remembered that this is an invasive procedure and should only be performed when required as part of a patient s individual nursing care. It is essential that the patient gives valid consent for this procedure to be carried out. Each patient is assessed on an individual basis and any established bowel regime adhered to where possible following planning of care in consultation with the patient and where appropriate the patient s carer. Circumstances when extra care is required Active inflammatory bowel disease i.e. Crohns Disease or Ulcerative colitis Recent Radiotherapy to Pelvic area Rectal bleeding Haemorroids Any pain in the anal or rectal area Patient has a known history of abuse Spinal cord injured patients due to possibility of Autonomic Dysreflexia Presence of any tissue damage such as anal fissure or anal tear Patient has a history of allergies i.e. latex Contra Indications Where patient does not consent, written, verbal or implied Medical staff request that the procedure is not to be performed The patient has recently undergone rectal/anal surgery or trauma Sphincterotomy. Manual evacuation must not be performed for 5 days following this procedure. Insertion of glycerine suppository only. Surgical Closure of Pressure Sores. Manual evacuation must not be performed for 3 days following this procedure.

3 Equipment Required Disposable receiver Warm water Disposable Gloves x 3 Lubricant Disposable inco pad Paper wipes Waste bag Action 1.Explain the procedure to the patient, especially if this is a new procedure for the patient 2.Gain their consent and ensure this is documented 3.Ensure the procedure is to be carried out in an area where maximum privacy can be gained and where the patient is comfortable 4.Assist or place the patient in the left lateral position with knees flexed Rationale Patient information reduces anxiety Consent is required for any invasive procedure To ensure patient is relaxed and confident that there will be no interruptions To facilitate easy access for removal of faeces and allow rectum to empty downwards 5.Position a pad under the patient to protect the bed 6.Wash hands and put on the disposable gloves 7. Examine the anal/perianal area Before undertaking the procedure abnormalities of the anal and perianal area should be assessed, documented and reported to medical staff 8.Insert one lubricated glycerine suppository into the rectum and leave in place to work for at least 30 minutes. The suppository must be placed so that it is not in contact with the rectal wall and not amidst stools 9.After 30 minutes Insert a single, double gloved, well lubricated finger into the rectum 10.Attempt digital stimulation by rotating the double gloved finger in a circular motion maintaining contact with the rectal wall at all times. Rotate for one minute then remove finger. Repeat this every 3-5 minutes for 1 minute each time. Do not repeat more Lubrication is used to prevent trauma to the mucosa of the structures by reducing friction. For patient with full sensation, anaesthetic gel can be used to reduced discomfort Stimulation of this area may produce reflex emptying of the bowel

4 than five times. 11.Remove the faeces present by inserting and gently rotating the double gloved lubricated finger within the rectum. The finger should be slightly crooked away from the bowel wall and should be used to draw faeces out through the anal sphincter as the finger is withdrawn 12.Repeat to withdraw as much faeces until the rectum is empty. It may be necessary to manually massage the abdomen in a clockwise motion to stimulate the faeces downwards towards the rectum. This can be done by the patient following instruction, or can be done by an assisting nurse. 13.Place the faecal matter into the receiver as it is removed 14.Observe the patient throughout the procedure Stop if the anal area bleeds Stop if pain persists Stop if the patient asks you to stop Stop and reassess if the patient shows any signs of Automonic Dysreflexia 15.When the procedure is complete wash residual lubricating gel and faeces from the anal area 16.Remove the double glove, dispose of equipment, remove remaining gloves and wash hands 17.Document the performed procedure and result referencing the Bristol Stool Score To reduce possible trauma to the bowel wall In order to make sure the bowel is empty and to reduce the possibility of incontinence In order to note any sign of distress or discomfort and act accordingly to prevent any complications To ensure the patient is clean and comfortable To ensure there is evidence of ongoing bowel management and it s effectiveness References Duke of Cornwall Spinal Treatment Centre, Salisbury NHS Trust. Bowel Care. [electronically accessed 7/10/10] MASCIP (2004) National Guidelines for Bowel Management after Spinal Cord Injury. London. MASCIP.

5 National Patient Safety Agency (2004) Bowel care for people with established spinal cord lesions. London, NPSA Powel M, Rigby D (2000) Management of Bowel dysfunction: evacuation difficulties, Nursing Standard. August 9/vol14/no47/p47-51 Royal College of Nursing (2004) Digital Rectal Examination and Manual Removal of Faeces: Guidance for Nurses. London, RCN Spinal Cord Injury Centres (2009) Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. Coloplast. Spinal Injuries Association (2002) Bowel Management Programme for SCI people Factsheet. London. SIA The Walton Centre for Neurology and Neurosurgery NHS Trust. (2005) Guidelines for Manual Evacuation o Faeces.

6 Assessment of Competency for Performing Manual Evacuation of Faeces Name Theoretical Knowledge Element of Knowledge Can competently explain procedure and rationale Can discuss appropriate patient group Demonstrate adequate level of supporting anatomy and physiology knowledge Can discuss relevant contraindications and relevant actions Acceptable level of knowledge Yes/No Assessor s Signature Date Practice Assessment Element of Practice Able to explain the procedure to the patient Can correctly identify that the patient gives consent Positions the patient correctly Demonstrates safe technique following MCSI Guidelines Maintains patient s privacy dignity throughout the procedure Recognises any complications and takes appropriate action Disposes of waste in accordance with Trust Policy Acceptable level of knowledge Yes/No Assessor s Signature Date

7 Assessment of Competency for Performing Manual Evacuation of Faeces Name Activities Completed Successfully Assessor s signature Date Has attended education session Has completed assessment of theoretical knowledge Has completed assessment of practical skills Copy to be retained by Registered Nurse/ Health Care Assistant/Bank Support Worker (as applicable) Copy to be retained by Trust