Q3. If the Trust does not, how is bowel care managed in the above patient groups who present with this care need?

Transcription

1 Response sent by 10 February 2017 St Helier Hospital Wrythe Lane Carshalton Surrey SM5 1AA Tel: Direct dial tel: Re: Freedom of Information request - Ref: FOI 3799 Thank you for your recent request for information under the Freedom of Information (FOI) Act. Set out below is your original request followed by the Trust's response. By way of introduction, I work for the Spinal Injuries Association. Part of my role is to assist the Head of Public Affairs with FOI requests, such as the one that follows. As a request under the Freedom of Information Act, please provide the following information on bowel management for spinal cord injured people and others with neurogenic bowel dysfunction Q1. Does the Trust have a formal written policy for digital rectal examination/check, digital rectal stimulation and the digital removal of faeces (manual bowel evacuation) in spinal cord injured and other patients with neurogenic bowel dysfunction? A1. We do have written guidelines. Q2. If the Trust does, please supply a copy of this document. A2. Please see attached. Q3. If the Trust does not, how is bowel care managed in the above patient groups who present with this care need? Q4. Does the Trust employ a specialist continence nurse(s)? A4. We do employ a specialist continence nurse. Q5. If the Trust employs a specialist continence nurse(s) can they (a) undertake digital rectal checks, digital rectal stimulation and digital removal of faeces (manual bowel evacuation), otherwise known as 'intimate digital bowel care procedures' (b) provide instruction to other nurses to enable them to perform intimate digital bowel care procedures'? A5. Our specialist continence nurse(s) can carry out the actions detailed in your question above. Great care to every patient, every day Patient Advice and Liaison Service (PALS) Main Switchboard Chairman Laurence Newman Chief Executive Daniel Elkeles

2 Q6. If the Trust does not employ a specialist continence nurse, is there another health care professional who undertakes intimate digital bowel care procedures including manual bowel evacuation? If yes, who does this? A6. N/A Q7. Does your Trust have a policy in place that will allow your staff to do trans-anal irrigation (TAI) of the bowel as a method of bowel care management for spinal cord injured patients? Do you train your staff to do TAI/ bowel irrigation? A7. Irrigation is initiated in the outpatient setting, we have no policy to deal with inpatients who are currently using it. Q8. Do you run bowel care courses for your staff that allows them to deliver the full range of bowel care required by spinal cord injured patients or others with a neurogenic bowel? A8. Yes, for manual evacuation. Q9. If yes, please provide details. If no, does the Trust have a policy which allows for the personal care assistants (PAs) of spinal cord injured patients to assist with this element of the patient's care? A9. We have no formal policy on this. If you have any queries about this letter, please contact the Freedom of Information office. Please remember to quote the reference number above in any future communications. If you are unhappy with the way in which your Freedom of Information request has been handled and wish to raise any concerns, please contact Meg Stevens, Head of Governance, at the address above or by (meg.stevens@esth.nhs.uk). Should you still be dissatisfied with the outcome, you are entitled to contact the Information Commissioner at: Information Commissioner s Office (ICO), Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF. Yours sincerely Teresa O Brien Freedom of Information Manager Corporate Affairs Epsom and St Helier University Hospitals NHS Trust T: E: teresa.obrien@esth.nhs.uk W: Great care to every patient, every day Patient Advice and Liaison Service (PALS) Main Switchboard Chairman Laurence Newman Chief Executive Daniel Elkeles

3 Epsom and St Helier University Hospitals NHS Trust Trustwide Guidelines for Digital Rectal Examination and Manual Evacuation of Faeces (Adults) Trustwide Guideline for Digital Rectal Examination and Manual Evacuation of Faeces (Adults)

4 Contents Section Page 1. Introduction 4 2. Purpose 4 3. Objectives 5 4. Scope 5 5 Consent 6 6 Training 6 7 Audit 6 8 Equality 7 9 References 7 Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Assessment 12 Equipment 13 Procedure 14 Bristol Stool Chart 15 Competency assessment and statement 16 2

5 1 Introduction Normal bowel function includes the need for regular defecation without complications such as constipation or diarrhoea. Constipation is a common disorder affecting an individual s normal bowel function and is a common reason for GP consultations (Effective Health Care, 2001). First line treatments include dietary / fluid modification, oral laxatives (bulking agents, stool softeners, osmotic agents, and stimulants), suppositories and enemas. A small number of patients may require further interventions such as DRE, DRS or manual removal of faeces (NICE 2007). More recently, rectal irrigation has been effective for both constipation and faecal incontinence in people with spinal cord injury (Christensen et al 2006). Many nurses are unsure about the professional and legal aspects of undertaking such invasive procedures, and are worried about accusations of abuse following two professional conduct cases reviewed by the UKCC involving inappropriate use of such procedures (Casteldine 2000). Recent medical advances have reduced the need for DRE and manual removal of faeces. However, for certain patients, these procedures are necessary and for other patients/clients they form part of their regular bowel care regime. Nurses need to be reassured that it is legitimate to carry out these procedures safely and competently. Failure to carry out these procedures on patients who require them can lead to severe consequences for the patient and could be a breach of the Nursing and Midwifery Code of Conduct. The National Patients Safety Agency (NPSA 2004) has highlighted that some people with an established spinal cord lesion are dependent on manual evacuation as their routine method of bowel care. Failing to perform the procedure for such individuals can place them at risk of developing autonomic dysreflexia. This is a medical emergency that unresolved may give rise to serious consequences such as cerebral haemorrhage, seizures or cardiac arrest (see complications, Appendix). It is therefore essential that staff providing care to patients with spinal cord injuries can perform manual evacuation of faeces when necessary. 2 Purpose 2.1 The pupose of the guidelines is to assist staff to ensure safe practice and competency for those regsitered nurses who undertake Digital Rectal Examination, Digital Rectal Stimulation and Manual Evacuation of Faeces. 3 Objectives 3

6 3.1 The guidelines outline the procedure which may be undertaken by any registered nurse who can demonstrate professional competence. 3.2 Competence is the ability to demonstrate appropriate knowledge, skills and attitudes. Any registered nurse that can demonstrate competence can delegate the responsibility to a carer or a patient as appropriate. 4 Scope 4.1 These guidelines are applicable to adult patients requiring: Digital Rectal Examination (DRE) Digital Rectal Stimulation (DRS) Manual evacuation of faeces. Digital Rectal Examination DRE can be used as part of a nursing assessment when carried out by a qualified nurse who is deemed competent. DRE should not be used as a first line investigation into the assessment and treatment of constipation (RCN, 2008). DRE is an invasive procedure and should only be performed when necessary and after individual assessment, and with the patient s consent. Cultural and religious beliefs must be respected and it is vital to check for allergies prior to undertaking this procedure (for indications see Appendix A ). Digital Rectal Stimulation Digital rectal stimulation is used to stimulate reflex bowel activity in patients with an upper motor neurone cord lesion (T12 and above). This is achieved by inserting a gloved lubricated finger into the rectum and slowly rotating it whilst maintaining contact with the rectal wall (for indications see Appendix A). Manual evacuation of faeces Manual evacuation is an accepted and routine method of management for people with spinal cord lesions below T12 level. Their bowels will not empty in a reflex response to rectal stimulants or suppositories. People with lesions above T12 are usually capable of achieving good reflex bowel emptying without resorting to manual evacuation. Constipation or impaction of the bowel is a common cause of autonomic dysreflexia (see complications, pg 17) and can be further compounded by additional noxious sensations during attempts to alleviate the cause. Autonomic dysreflexia is a potentially fatal complication for any person living with a spinal cord lesion above T6. It can occur at any time and up to 90% of people with tetraplegia or high paraplegia will experience autonomic dysreflexia at some time in their lives (NPSA 2004). 4

7 Manual evacuation is a distressing experience for the patient and can often be painful. In severe, acute faecal impaction it may be necessary to consider sedating the patient before carrying out the procedure. In these circumstances, the nurse should seek medical advice. 4.2 Prior to a nurse undertaking the procedure a full assessment should be undertaken (see Appendix B) 4.3 Contraindications to performing digital rectal interventions Lack of consent from the patient Specific instructions from the patient s doctor that the procedure should not take place Patient has undergone recent rectal/anal surgery or trauma The patient gains sexual satisfaction from these procedures and the nurse performing them finds this embarrassing. In this case, consultation with a doctor is advised, involving the patient in that consultation. You might consider whether there is a need for a chaperone in such circumstances Presence of abnormalities of the perianal and/or perineal area are observed (See Appendix B) 4.4 Circumstances when extra care is required Particular caution should be exercised with patients who have the following diseases/conditions: Active inflammation of the bowel, including Crohn s disease, ulcerative colitis and diverticulitis Recent radiotherapy to the pelvic area Rectal / anal pain Previous rectal surgery / trauma to the anal/rectal area Tissue fragility due to age, radiation, loss of muscle tone in neurological diseases or malnourishment Obvious rectal bleeding or patient taking anti-clotting medication If the patient has a known or suspected history of abuse In spinal injury patients because of autonomic dysreflexia 5

8 Known allergies to latex, soap (lanolin), phosphate and peanut (present in arachis oil enemas). 5 Consent 5.1 Verbal consent for manual evacuation of faeces should be sought from the patient by the practitioner undertaking the procedure, and recorded in the patient s record. 5.2 For the consent to be valid, the patient must: - be competent to take the decision - have received sufficient information to make the decision - not be acting under duress (Ref Epsom & St. Helier University Hospitals NHS Trust Consent procedure) 6 Training 6.1 The Continence Service will provide inservice training. Practitioners will be asked to complete a pre-course workbook. 6.2 The training will include anatomy and physiology of the rectum and gastrointestinal tract an understanding of the diseases of the rectum and colon the use of medication in bowel dysfunction types of digital rectal interventions indications for digital rectal examinations perianal assessment prior to digital rectal intervention contraindications for digital rectal intervention principles of bowel care in patients with spinal injuries procedure for DRE, DRS and manual evacuation autonomic dysreflexia documentation issues of consent. 6.3 Assessment of practice can be undertaken by a nurse who is a registered practitioner, be at band 6 or above who has undertaken a course that includes the principles of assessment and supervision of practice and is an experienced and competent practitioner in the procedure of digital rectal examination and manual removal of faeces. 6.4 Ward managers need to release staff for training to ensure that there are adequate numbers of experienced staff to undertake this procedure 7 Audit 6

9 7.1 The Continence Service will monitor compliance with this policy. 8 Equality 8.1 This policy has been assessed using an Equality Impact Assessment screening template and has no adverse impact on any particular group, sex, ethnicity, religion, gender or disability. As a result it is considered that a full Equality Impact Assessment is not necessary. 9 References Casteldine (2000) Professional misconduct case studies. Case 34: patient abuse. Nurse who carried out manual evacuations without consent. BJN Vol 9 (17): 1123 Christensen P, Bazzocchi G, Coggrave M, Abel R, Hultling C, Krogh K, et al. (2006) A randomized, controlled trial of transanal irrigation versus conservative bowel management in spin cord-injured patients. Gastroenterology 131: Effective Healthcare Bulletin (2001). Effectiveness of laxatives in adults. NHS Centre for Reviews and Dissemination. University of York Glickman S and Kamm M (1996) Bowel dysfunction in spinal cord injury patients. Lancet 347 (9016): National Institute for Health and Clinical Excellence (2007) Faecal Incontinence: the management of faecal incontinence in adults. NICE London National Patient Safety Agency (2004). Bowel care for people with established spinal injuries. Available on-line at care.pdf Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for Nurses and Midwives. London NMC Powell M and Rigby D (2000). Bowel Dysfunction, Nursing Standard August 9. Vol 14. No Pages

10 Royal College of Nursing (2008) Bowel care, including digital rectal examination and manual removal of faeces. London RCN Spinal Cord Injury Centres of the United Kingdom and Ireland (2009) Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. Available on line at data/assets/pdf_file/0019/253036/cv453n_full _doc.pdf Wiesel P and Bell S (2004) Bowel dysfunction: assessment and mangement in the neurological patient. In Norton C and Chelvanayagam S (eds) Bowel Continence Nursing. Beaconsfield 8

11 Appendices A) Indications for procedures Indications for Digital Rectal Examination (RCN 2006) To assess presence and consistency of stool To assess anal tone / reflex / voluntary contraction To assess anal sensation As part of a prostate assessment To assess for haemorrhoids or rectal polyps/lesions in the presence of rectal bleeding Prior to specialist procedures such as sigmoidoscopy, colonoscopy, anorectal physiology studies, or urodynamics studies Prior to administration of rectal medication Prior to digital stimulation and/or manual evacuation To assess the outcome of rectal/colonic washout/irrigation if appropriate To assess for trauma to anal sphincters and anal canal following vaginal birth Indications for Digital Rectal Stimulation Patients with tetraplegia and paraplegia who have an upper motor neurone cord lesion (T12 and above) generally have reflex bowel activity; this reflex can be triggered to act by the use of suppositories or by digital stimulation, or both (Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury, 2009). Ingestion and passage of liquid or semi-solid material from the stomach stimulates natural waves of peristalsis in a descending pattern towards the sigmoid colon (the gastro-colic reflex). This reflex is generally strongest following the first meal of the day and therefore, bowel care for these patients is best carried out after a meal or hot drink (usually breakfast) ( Powell & Rigby 2000). Indications for Manual Evacuation of faeces Faecal impaction/ loading Incomplete defaecation Inability to defaecate Other bowel emptying techniques have failed In patients with spinal injury Neurogenic bowel dysfunction. 9

12 B) Assessment Assessment prior to undertaking digital examination of the rectum, digital stimulation or manual evacuation of faeces The perianal area should be checked for any of the following abnormalities - the results should be documented and reported. - Rectal prolapse - Haemorrhoids - Anal skin tags - Wounds dressings, discharges - Anal lesions - Gaping anus - Skin conditions, broken areas, pressure sores of any grade - Bleeding and colour of blood - Faecal matter - Infestation - Foreign bodies If examination leads to concerns advice should be sought from the appropriate medical practitioner. 10

13 C) Procedures PROCEDURE: DIGITAL RECTAL EXAMINATION Equipment required: Disposable gloves (2 pairs), Incontinence sheet / pad, Tissues or toilet paper Lubricant(e.g. KY jelly or instillagel), Receptacle for waste (Clinical waste bag) Plastic apron Intervention Rationale Check with patient and hospital notes for To minimize risk of potential problems any contraindications Explain the procedure and obtain verbal consent, documenting consent in the To reduce anxiety and gain consent patient s record. Ensure procedure is carried out in the To maintain patient s privacy and dignity privacy of a cubicle or curtained area* *Where available and appropriate, ME,DRE and DRS should be performed in the patients side room or assisted bathroom to protect the privacy and dignity of the patient, and protect other patients from potential malodour. Wash hands and put on apron and Prevent potential contact with body fluids double gloves and minimize the risk of cross infection Position the patient on their left side with their back next to the edge of the bed, This positioning allows ease of entry into and their knees flexed. Place an the rectum following the natural curve of absorbent pad under the patient and the colon cover the patient with a sheet Examine the perianal area for any abnormalities before proceeding Reassure the patient throughout the procedure Lubricate gloved index finger and insert gently into the rectum. NB nurses nails must be kept short Assess for the presence of faecal matter using the Bristol stool scale(see Appendix ) Slowly withdraw finger from patient s rectum when finished. Check for presence of faeces or blood on glove Remove top glove and dispose of in clinical waste bag Wipe residual lubricating gel from anal area Dispose of gloves, apron and equipment into a yellow bag and wash hands Ensure patient is comfortable and observe for any adverse reactions To ensure that it is safe to proceed. To avoid unnecessary stress or embarrassment and ensure continued consent To minimise patient discomfort and avoid anal mucosal trauma To check for the presence of faecal matter and to establish the consistency of the stool To minimize patient discomfort. To minimize risk of cross infection To ensure the patient s comfort and avoid anal excoriation To prevent cross infection To and minimise embarrassment and note adverse reactions 11

14 Record findings in nursing documentation and communicate findings with medical team if appropriate. Consistency, volume, date and time should all be recorded appropriately To ensure correct care and continuity of care Digital Stimulation of the rectum Equipment Required Disposable gloves (2 pairs) Incontinence sheet / pad Plastic apron Tissues or toilet paper Lubricant (e.g. KY jelly or instillagel) Cleaning wipes / soap and water Receptacle for waste (Clinical Waste bag ) Intervention Rational Check with patient and hospital notes for To minimize risk of potential problems any contraindications Explain the procedure and obtain verbal consent, documenting the consent in the To reduce anxiety and gain consent patient s record. Ensure procedure is carried out in the To maintain patient s privacy and dignity privacy of a cubicle or curtained area* *Where available and appropriate, ME,DRE and DRS should be performed in the patients side room or assisted bathroom to protect the privacy and dignity of the patient, and protect other patients from potential malodour. Wash hands and put on apron and double gloves Position the patient on their left side with their back next to the edge of the bed, and their knees flexed. Place an absorbent pad under the patient and cover the patient with a sheet Examine the perianal area for any abnormalities before proceeding Reassure the patient throughout the procedure Lubricate gloved index finger and insert gently into the rectum to the second joint of finger only. Gently rotate the finger in a clockwise direction for seconds or until internal sphincter relaxes. NB circular motion originates from the wrist, not the finger Do not stimulate for more than one minute Stop if severe spasms of the anal sphincter occur, or if the patient shows signs of autonomic dysreflexia Remove finger Stimulation cycle can be repeated up to 3 times Prevent potential contact with body fluids and minimize the risk of cross infection This positioning allows ease of entry into the rectum following the natural curve of the colon To ensure that it is safe to proceed. To avoid unnecessary stress or embarrassment and ensure continued consent To minimise patient discomfort and avoid anal mucosal trauma To trigger reflex relaxation of internal sphincter and promote emptying of the rectum. The pad of the finger to the first joint stimulates reflex relaxation. To prevent damage to the anal sphincter Patient safety To allow evacuation to occur To facilitate complete evacuation 12

15 Check rectum for presence of faeces. Proceed to manual evacuation if faeces are present, but no faeces has been passed. Remove top glove and clean patient s perianal area. Ensure anal area is clean and dry, and observe skin on completion of procedure. Dispose of gloves, apron and equipment into a yellow bag and wash hands Ensure patient is comfortable and observe for any adverse reactions Record bowel results in nursing documentation and communicate results with patient and medical team if appropriate To ensure complete evacuation Reduces risk of cross infection. Ensures patient comfort To prevent infection, contamination and excoriation of perianal area To prevent cross infection Patient comfort. To note any adverse reactions To establish effectiveness of procedure. To ensure continuity of care. 13

16 Manual Removal of Faeces Equipment required: Disposable gloves (several pairs) Tissues or toilet paper Incontinence sheet / pad Cleaning wipes / soap and water Plastic apron Lubricant (e.g. KY jelly or instillagel) Bed pan/other suitable receptacle for waste and a yellow plastic bag Sphygmomanometer Stethoscope This is a two person procedure to ensure accurate and timely monitoring of observations during the procedure. Whereas automated sphygmomanometers maybe useful in monitoring situations, in this instance manual pulse and blood pressure should be recorded to note rate, rhythm and amplitude. Check with patient and or hospital notes To minimise risk of potential problems for any contraindications Explain the procedure and obtain verbal To reduce anxiety and gain consent consent, documenting the consent in the patient s record. Ensure procedure is carried out in the To maintain patient s privacy and dignity privacy of a cubicle or curtained area* *Where available and appropriate, ME,DRE and DRS should be performed in the patients side room or assisted bathroom to protect the privacy and dignity of the patient, and protect other patients from potential malodour. Take the patient s pulse rate at rest prior To record baseline pulse and monitor for to the procedure changes Take the base line blood pressure in all To record baseline blood pressure and spinal injury patients monitor for changes Wash hands and put on apron and Prevent potential contact with body fluids double gloves Position the patient on their left side with their back next to the edge of the bed, and their knees flexed. Place an absorbent pad under the patient and cover the patient with a sheet Examine the perianal area for any abnormalities before proceeding For patients receiving this treatment regularly use lubricating gel on the gloved index finger As an acute procedure, a local anaesthetic gel (Instillagel) may be applied topically to the anal area. Wait for 5 minutes before proceeding. Do not apply if anal mucosa is damaged Check for contra-indications Reassure the patient throughout the procedure Insert lubricated gloved index finger into the rectum Assess for the presence of faecal matter using the Bristol stool scale(see Appendix ) and minimize the risk of cross infection This positioning allows ease of entry into the rectum following the natural curve of the colon To ensure that it is safe to proceed. To minimise patient discomfort and avoid anal mucosal trauma To make the patient as comfortable and pain free as possible. To ensure that the anaesthetic gel has time to have the required effect To avoid unnecessary stress or embarrassment and ensure continue consent. To minimise patient discomfort and avoid anal mucosal trauma To check for the presence of faecal matter and to establish the consistency of the stool 14

17 In type 1 stool remove a lump at a time until the rectum is empty In type 2 stool, push finger into the middle of the faecal mass and split it. Remove small sections of faeces at a time and place in receptacle. Do not overstretch sphincter by using hooked finger to remove large pieces of stool If top glove becomes very soiled, remove and replace with a new top glove. Lubricate gloved finger with each change of top glove, use extra lubrication as required If faecal mass is too hard or larger than 4cm across or you are unable to break it up, stop and refer to medical team. If patient becomes distressed, check the pulse again and check against the baseline reading; stop if pulse rate has dropped, patient is distressed or if there is pain or bleeding in the anal area. Check blood pressure for patients with spinal injury. When rectum is empty, remove top glove and clean and dry patient s perianal area. Observe skin on completion of procedure Dispose of gloves, apron and equipment into a yellow bag and wash hands Ensure patient is comfortable and check pulse (and blood pressure in spinal patients). Record bowel results in nursing documentation and communicate results with patient and medical team if appropriate. Consistency, volume, date and time should all be recorded. To minimise discomfort and facilitate easier removal of stool To minimise discomfort and facilitate easier removal of stool To avoid trauma to the rectal mucosa and sphincter To avoid soiling of patients skin, and maintain cleanliness. To facilitate easier insertion and minimise friction and discomfort. To minimise risk of autonomic dysreflexia To monitor condition of the patient and to stop if necessary. To maintain cleanliness. To leave patient comfortable To monitor skin condition To prevent cross infection To observe for any adverse reactions To establish effectiveness of procedure. To ensure continuity of care. 15

18 D) Bristol Stool chart 16

19 E) Complications - Autonomic Dysreflexia This is a medical emergency that unresolved may lead to serious consequences such as cerebral haemorrhage, seizures or cardiac arrest. Autonomic dysreflexia can occur in patients with a spinal cord lesion at T6 or above. Any stimuli that would have caused pain, discomfort or physical irritation prior to the spinal cord lesion may cause autonomic dysreflexia (Glickman & Kamm 1996). The condition arises as a result of an autonomic (sympathetic) reflex as a response to pain or discomfort (noxious stimuli) perceived below the level of the lesion. The reflex creates a massive vasoconstriction below the level of the lesion causing a pathological rise in blood pressure that can be life threatening if allowed to continue unchecked. Manifestations of Autonomic dysreflexia Severe hypertension Bradycardia Pounding' headache Flushed or `blotchy' skin above the level of lesion Pallor below the level of lesion Profuse sweating above the level of lesion Shortness of breath. Common causes Any painful or noxious stimuli below the level of injury Distended bladder (usually due to catheter blockage or another form of bladder outlet obstruction) Distended bowel (usually due to a full rectum, constipation, or impaction) Skin problems / in-growing toenail Fracture below the level of lesion Labour/childbirth Ejaculation (Glickman & Kamm 1996, Wiesel & Bell 2004) Actions to take Sit the patient up (where possible) to induce an element of postural hypotension Ensure there is adequate urinary drainage (change the catheter if necessary, do not give a bladder washout/instillation) Empty the rectum by digital removal of faeces (local anaesthetic gel should be used) Blood pressure should be treated until the cause is found and eliminated (administer a proprietary vasodilator e.g. Nifedipine as prescribed) If unable to locate cause, or symptoms persist, get help 17

20 F) Competency Digital Rectal Procedures (Examination /Stimulation/ Removal of faeces) Aim: To ensure Digital Rectal Procedures is performed safely. Outcome: 1. Digital Rectal Procedures are performed & recorded accurately in response to the patients condition. 2. Appropriate action is taken in response to patient before, during & after the procedure. Links to KSF Core: Communication: L3 Health & Safety : L3 Equality & Diversity: L2 Specific : HWB7 / L3 Elements of Competency Performance Criteria Evidence for & Evaluation of competence Further Action if required Signatures and date Demonstrates a knowledge and understanding of key professional issues & professional guidelines ie RCN guidance relating to Digital Rectal Procedures: Accountability Consent Legalities, including duty of care Documentation Health and Safety Communication Demonstrates a knowledge and understanding of: Related anatomy and physiology Indications for Digital Rectal Procedures Factors affecting Digital Rectal Procedures The patient, medical history and reason for Digital Rectal Procedures Clearly explains each issue and states the relationship of each to Digital Rectal Procedures. Discusses all these issues related to Digital Rectal Procedures and stating rationale for actions. 18

21 When Digital Rectal Procedures is contraindicated When to stop the procedure and what action to take The appropriate use of medication, suppositories and enema to support the procedure What can go wrong and problem solving Understands the need to prepare: Patient both physically and psychologically Equipment Records Carries out Digital Rectal Procedures correctly, ensuring patient comfort, privacy and dignity. Observes the patient throughout and recognises signs of deterioration and demonstrates a knowledge of actions to be taken Accurately records Digital Rectal Procedures including any related factors and actions taken Communicates effectively with patient and nursing and medical colleagues as appropriate Acts within own limitations and reports difficulties appropriately Discuss and demonstrate the preparation and state rationale Observe preparation in practice Observed practice follows Trust Policy Observe in practice States signs of deterioration and rationale for actions Observe in practice Observe in practice Observe in practice Competency assessment for Digital Rectal Procedures for: Name of Registered Nurse (RN):.. Ward/Department: Assessment of practice & competence by: Signature of assessor:.. Print name:. 19

22 Position:. Date:. Practitioners' declaration of competence: I. as an accountable RN, feel competent to undertake the responsibility of Digital Rectal Procedures within the limits of my capabilities. I feel I have undertaken the appropriate learning & development required, I also acknowledge the need to maintain & develop my knowledge & skill whilst it remains relevant to my practice. Signature of RN: Date of assessment:.. A photocopy of this document will need to be given to your manager to place in your personal file 20

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