NHS GRAMPIAN RESOURCE PACK BOWEL MANAGEMENT

Transcription

1 NHS GRAMPIAN RESOURCE PACK ON BOWEL MANAGEMENT Continence Advisory Service NHS Grampian January 2006 Date of review January 2008

2 NHS GRAMPIAN RESOURCE PACK ON BOWEL MANAGEMENT CONTENTS SECTION 1 - (Pages 1-2) INTRODUCTION TO RESOURCE PACK SECTION 2 - ASSESSMENT (Pages 3-4) (a) Planning a Bowel Programme (Pages 5-15) (b) Guidelines to Completion of Bowel Assessment Form Bowel Assessment Form Code No. ZOY894 (not included) Bowel Chart ZOY892 (not included) Three Day Food/Fluid Chart ZOY893 (not included) Above three forms available from Central Stores SECTION 3 - MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES (Page 16) (a) Flowchart Nursing Actions for a Patient with Constipation (Page 17) (b) Flowchart Nursing Actions for a Patient with Faecal Impaction (Pages 18 24) (c) Bowel Policy for Neurogenic Bowel Maidencraig Rehabilitation Unit, Woodend Hospital SECTION 4 - (Pages 25 32) SECTION 5 - (Pages 33 36) PHARMACEUTICAL Pharmaceutical Aspects of Bowel Management DIETARY ASPECTS OF BOWEL MANAGEMENT Dietary Aspects of Bowel Management SECTION 6 - PROCEDURES (Pages 37 39) (a) Administration of Suppositories (Pages 40 43) (b) Administration of Enemas (Pages 44 46) (c) Digital Rectal Examination (Pages 47 50) (d) Manual Evacuation of Faeces SECTION 7 - APPENDICES (Page 51) Appendix 1 - Group Members (Pages 52 54) Appendix 2 - Anatomy and Physiology of the Normal Bowel (Page 55) Appendix 3 - Definitions in Bowel Management (Pages 56 62) Appendices 4 to 9 - Dietary Information (Page 63) Appendix 10 - Fibre Scoring Sheet (Page 64) Appendix 11 - MSQ Chart (Page 65) Appendix 12 - Bristol Stool Chart (Page 66) Appendix 13 - Position Chart (Page 67) Appendix 14 - Guidelines for the Use of Phosphate Enemas (Page 68) Appendix 15 - Sign Guideline 67 SECTION 8 - (Pages 69 70) BIBLIOGRAPHY AND FURTHER READING

3 SECTION 1 INTRODUCTION TO RESOURCE PACK PAGES 1-2

4 NHS GRAMPIAN INTRODUCTION TO RESOURCE PACK BACKGROUND Recently there has been increasing professional interest in the neglected area of bowel and anorectal function. It is often not appreciated by health professionals how common bowel dysfunction s such as constipation and faecal incontinence are and that patients are reluctant to seek help. Control of continence is a basic human need. Any disorder or abnormality will affect the person s quality of life and could lead to or be an indicator of other underlying conditions. Constipation is a common problem for many people. It can cause discomfort and if not treated can lead to faecal impaction and bowel obstruction. A consistent approach to Bowel Management is pertinent in all clinical areas in NHS Grampian. BOWEL GUIDELINES The Bowel Assessment Guidelines have been updated and developed from the previous Grampian Healthcare Guidelines to Good Practice Bowel Management (July 1995). This Resource pack can be used by any health care professional with an interest in this area (although it will be mainly nurses that will be undertaking the assessment). The resource pack is divided into different sections and will act as a reference document. The AIM of these Guidelines is to outline good practice in bowel management and provide a resource that will be updated according to new research and developments. The assessment forms have been developed following audits in care homes, surgical/medical wards, community bases and community hospitals. NHS GRAMPIAN ASSESSMENT FORM The NHS Grampian Assessment bowel assessment, bowel chart and three-day food and fluid form should be adopted as standard practice. This assessment should be undertaken by a registered nurse but non-registered nurses can be allocated appropriate duties relevant to their experience under the guidance of the registered nurse. The Guidelines that are included in the Resource pack will also give practical advice, which will ensure consistency in approach for patient care, based on evidence-based research where possible

5 BOWEL PROCEDURES If a patient requires to have any bowel procedures this section provides the information that is required to undertake them safely. The Bowel procedures have been set out by the Royal College of Nursing, Digital Rectal Examination and manual removal of faeces (2004) and the Royal Marsden hospital manual of Clinical Nursing Procedures 5 th Edition. These procedures will also be on the Intranet site TRAINING SESSIONS Staff should keep themselves up-to-date and attend relevant training sessions (which would be linked to the NHS Grampian learning and development plan) to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems. INFORMED CONSENT Patients must give informed consent as per the NHS Grampian Informed Consent Policy before any investigation; treatment or procedure is undertaken. Any treatment provided or refused should be documented in the patient's notes either in the home, ward or care home setting. STAFF SHOULD ADHERE TO The Nursing and Midwifery Council Code of Professional Code April 2002 Nursing and Midwifery Council Guidelines for Records and Record keeping (2002) Royal College of Nursing, Digital Rectal Examination and Manual removal of Faeces (2004). BIBLIOGRAPHY AND FURTHER READING LIST (SECTION 8) At the rear of the Resource pack is a Bibliography and Further Reading list (Section 8) that can be used for client assessment and background reading - 2 -

6 SECTION 2 (a) ASSESSMENT Planning a Bowel Programme PAGES 3-4

7 Planning a Bowel Programme Following assessment and careful planning, a bowel programme should result in achieving bowel continence and adequate evacuation. This should be undertaken as a package of care rather than a single intervention. Prior to commencing a routine bowel programme it is essential that any constipation or impaction be resolved otherwise it may be difficult to establish a predictable pattern. Flowcharts for Constipation and Faecal Impaction can be found under Section 3 and may assist with clinical decision making. This is intended as a guide only and clinical judgement still applies. Included in Section 3 is the Bowel Policy for people with a Neurogenic Bowel as used in Maidencraig Rehabilitation Unit. This is intended as a guide only and clinical judgement still applies. The following should be considered as part of the programme: Diet and fluid intake Current and previous bowel habit Exercise/Mobility Medication which may cause constipation or aperients being used Evacuation techniques Toileting Facilities/Ability to sit on the toilet Is gastro-colic reflex being utilized? (See last paragraph of this section) Is there a package of care in place, will this need to be reviewed as a result of intervention. If the above aspects have been reviewed and there are still difficulties other interventions may be necessary: Timed oral aperients may be used in conjunction with rectal medication such as suppositories or micro enemas. Trial and error is often required to find the best approach for individuals. It is important to be consistent with approach, meal times, sitting on the toilet, privacy, timing of medication etc to allow the programme to work. It is also important not to make too many changes at once. Where there is known nerve damage, long term interventions may require to be implemented e.g. in conditions such as Multiple Sclerosis and Spinal Cord Injury

8 The aims of the programme would be:- Regular planned bowel movements (At least 3x weekly) Appropriate techniques will be used following assessment Minimise episodes of faecal incontinence It may be useful to continue charting timing of oral, rectal medicines, consistency of stool, timing of bowel movements and any accidents when establishing the bowel programme. This allows careful adjustments to medication, or timing of interventions. It will also demonstrate the effectiveness of the programme. Gastro-Colic Reflex Peristalsis in the gut is normally continuous through out the day but is further stimulated by the taste, smell of food, or eating and drinking. This increase in peristalsis in the gut aids propulsion of stool through the bowel. The best time to take advantage of this as part of a bowel programme is thought to be minutes after a meal. Literature suggests it may be stronger after the first meal of the day

9 SECTION 2 (b) ASSESSMENT Guidelines on Completion of Bowel Assessment Form PAGES 5-15

10 GUIDELINES TO COMPLETION OF BOWEL ASSESSMENT FORM SEPTEMBER 2005 The AIM of guidelines is that all patients in NHS Grampian with bowel problems are assessed and treated on an individual basis according to the Charter for Incontinence. This would provide a quality service ensuring effective delivery of care. INTRODUCTION TO ASSESSMENT The purpose of the assessment is to help identify the many different causes and contributing factors resulting in bowel problems. In the majority of cases these symptoms can be improved or cured by identifying and treating the underlying causes. From a full assessment treatment/management of the patients problem can be implemented. THE PATIENT/CLIENT MUST BE ASSESSED BY A TRAINED NURSE USING THE BOWEL ASSESSMENT FORM AND GUIDELINES - 5 -

11 PLEASE TICK ( ) THE APPROPRIATE BOXES AND ADD ANY COMMENTS AS NECESSARY. IF YOU OR THE PATIENT/CARER ARE UNABLE TO ANSWER ANY OF THE QUESTIONS PLEASE INDICATE THIS ON THE ASSESSMENT FORM. PLEASE SIGN AND DATE EACH PAGE OF THE ASSESSMENT FORM WHEN THE ASSESSMENT FORM IS COMPLETED A BOWEL MANAGEMENT PLAN SHOULD BE IMPLEMENTED SECTION ONE - PATIENT DETAILS Please complete all relevant details paying particular attention to Unit Number/CHI and Postcode SECTION TWO FACTORS AFFECTING INDIVIDUALS ABILITY TO COPE A - Using the MSQ (Mental Status see Appendix 11) questions please record the patients score in the space provided. Each correct answer scores one point A low score may result in poor compliance with treatment. B - PLEASE RECORD THE (PATIENT S) HOME CIRCUMSTANCES This will give a full picture of the patient s home circumstances. This information will be important in treatment implementation. C - COMMUNICATION SPEECH e.g. Does the patient have any speech difficulties? Does the patient have swallowing difficulties? Does the patient have dentures do they fit properly? SIGHT e.g. Can the patient see to access the toilet? Does the patient wear spectacles? Does the patient have problems with their visual fields When did they last have an optician s assessment? HEARING e.g. Is the patient hard of hearing? Is the patient deaf? Does the patient wear a hearing aid? - 6 -

12 D - MANUAL DEXTERITY e.g. Can the patient hold their cutlery/cup/glass? Can the patient dress/undress themselves? Can the patient undo zips/buttons/fastenings? E - MOBILITY e.g. Is the patient independent? Can the patient get out of the chair/bed unaided? Does the patient use a walking aid/wheelchair? Does the patient require to use a hoist? F - USING THE TOILET e.g. Is the patient able to access the toilet/commode unaided? Can the patient get to the toilet in time? Can the patient get on/off the toilet unassisted and clean him or herself? Are the patient s feet supported whilst on the toilet? (Appendix 13) Would the patient benefit from an O.T./Physiotherapy assessment? G - OTHER AGENCIES INVOLVED Do they have a Care Manager, Home Care, Community Psychiatric Nurse Support Worker or Private Agency? SECTION THREE - PAST MEDICAL HISTORY This section is made up of a series of boxes to tick in order to detail medical or surgical conditions. These may affect the client s ability to maintain continence or contribute to constipation. For further information on these conditions details can be obtained from e.g. Library, Internet and liaison with other health professionals i.e. Specialist Nurses, GP, etc

13 SECTION FOUR - SEXUAL HEALTH/LIFESTYLE ISSUES Is the bowel problem having an effect on relationships or lifestyle? Is the person avoiding having a sexual relationship for fear of having an episode of incontinence? Refer to RCN Guidelines Sexuality and Sexual Health in Nursing Practice. SECTION FIVE - CURRENT GENERAL HEALTH ISSUES Please indicate the patient s current general health status e.g. anxious, coping, tired. Is there a medical condition, which is currently causing problems? SECTION SIX OBSTETRIC HISTORY The following may contribute to nerve or tissue damage to pelvic floor or sphincters:- Type of delivery e.g. Spontaneous, Forceps, Ventouse, Caesarean Section Episiotomy/Tear/3 degree Tear was the patient cut or did they tear? Did the patient have any follow-up or treatment? e.g. Physiotherapy Any other comments e.g. Infections Rapid Delivery Wound Infections/Re-suturing SECTION SEVEN MEDICATION Refer to B.N.F./Mim s/intranet for more detailed information. Can current medication be modified to reduce side effects? - discuss with GP or Consultant Computer printouts if available can be attached to Assessment form. Is the patient taking any alternative remedies? - 8 -

14 SECTION EIGHT- ALLERGIES Please document any known allergies/sensitivities or known anaphylactic reaction e.g. latex lanolin peanut allergy (arachis oil enema) SECTION NINE DESCRIBE YOUR PRESENT PROBLEMS What for you is the worst thing about your bowel problem? Embarrassment Don t go out Odour When did the problem start? Was it related to a specific event? Following surgery Following childbirth Due to medication Due to injury/illness/stressful time in life Have you had any investigations for this problem? Any recent or previous bowel investigations such as rectal examination, barium meal, sigmoidoscopy

15 Has any medication been tried? This should include any over the counter medication or alternative therapies. Has it been effective or not? Check if doses were therapeutic. What helps or aggravates the problem? What makes your problem worse/better? Any coping mechanisms being used at the moment which are helpful. Do you use pads or protective clothing?/are they effective? Are they used for faecal/urinary incontinence? Is it actual incontinence or fear of being incontinent? What type of pad is used? How often are they changed? Is the pad always soiled when changed? Is there any leakage onto their clothes/bed etc.? Does patient buy them or are they provided by a Health Professional? Has your bowel pattern changed recently? If there are significant changes such as a change in normal pattern, rectal bleeding or mucus, +ve FOB, abdominal bloating or discomfort inform GP (Sign Guideline No. 67) - Appendix 15 Could there be other identifiable causes for this: Change in toilet facilities e.g. bedpan/commode Change in diet Change in home circumstances Change in medication

16 SECTION TEN PRESENTING BOWEL SYMPTOMS (Patients with difficulties in the following areas may require further specialist assessment or advice.) How often do your bowels move? Is there frequency or constipation? Anything between 3 x daily or 3 x weekly is considered normal. What is the consistency of your stool? Use of the Bristol Stool Form Scale Chart (Appendix 12) will identify stool consistency and will ensure consistent reporting of bowel habit. Patients find it easier to look at a chart than trying to describe their stool. Ideally this should be between 3 or 4. 1 > 2 are hard dry stool so could indicate constipation. 5 > 7 are loose and for some patients bulking the stool may lessen risk of incontinence. Loose stool may be indicative of e.g. inflammatory bowel disease, tumour or overflow impaction, or due to rectal prolapse, fistulas or after pelvic radiotherapy. Do you get a desire to open your bowels? Is the patient aware of the pressure to pass stool? This may be absent or reduced in neurological damage/disease or in chronic constipation. Ignoring the urge to defecate may lead to faecal loading and impaction. In conditions such as dementia the desire to defecate may be absent but the patient may have automatic emptying at the same time each day i.e. after breakfast, so initiating toileting at this time could reduce the risk of incontinence. Are you able to delay? /How long for? If there is external sphincter weakness ability to delay defecation may be considerably reduced. Patient may not have enough voluntary squeeze to stop stool from leaving rectum. This can be worse if stool is loose or if Irritable Bowel Syndrome or Inflammatory Bowel Disease is present. Is there urgency? Is it because they have frequent episodes of incontinence or because they have had some episodes and are fearful of it happening again?

17 Do you lose control of stool or flatus? Identify if incontinence of stool or flatus is a feature. How often does this happen? Can they tell the difference between flatus or needing a bowel movement? May be as a result of e.g. Neurological damage, Obstetric trauma, Congenital conditions such as imperforate anus, following haemorroidectomy. If inflammatory disease is present, high pressures in the bowel and diarrhoea can make maintenance of continence impossible. What quantity/consistency? Is it soiling of underwear or do they lose an entire stool? Does the consistency vary? Do you feel you empty your bowels completely/strain or use manual assistance? Evacuation difficulties may be as a result of e.g. weakened sphincters or obstructive defecation. Does passive soiling occur after a bowel movement Internal sphincter may not close anal canal and stool will leak out. Incomplete emptying may be as a result of e.g. a rectocele following childbirth or due to excessive straining. Some female patients will describe inserting a finger into their vagina to aid expulsion of stool, this expels faeces trapped in rectocele. Do you have pain or bloating? Is this associated with opening their bowels? If it is with an urge to defecate and is relieved by opening bowels, it may be due to Irritable Bowel Syndrome or Inflammatory Bowel Disease Pain as stool is passed is likely to be due to haemorrhoids or fissure. Do you pass blood or mucus? If blood or mucus is a feature this should be reported to medical staff in case the cause is Inflammatory Bowel Disease, malignancy, or caused by haemorrhoids, fissures etc. Fresh blood is more likely to be haemorrhoids/fissures; darker blood could be malignancy. Excessive mucus may be caused by e.g. villious adenoma or Inflammatory Bowel Disease

18 SECTION ELEVEN INFORMATION FROM BOWEL AND DIETARY FIBRE SCORING SHEET Information from these charts should be recorded in Section 11 and 13 on the Bowel Assessment Form. Is the patient on Gastrostomy feeding? If so refer to dietician for further assessment. Is there enough fibre in diet? This can be calculated by using the fibre-scoring sheet Appendix 10 Is eating pattern regular throughout the day e.g. eating three meals a day? The patient s functional ability to feed must be considered as this may lead to inadequate fibre or fluid intake, which can exacerbate constipation. Is the intake of fibre spread evenly throughout the day or is it consumed at one meal? Fluid intake should be between mls. SECTION TWELVE- EXAMINATION AND INVESTIGATION See RCN document on Digital Rectal Examination and Manual Removal of Faeces Remember to gain consent from the patient before undertaking any examination or procedure nurse must be trained and competent before undertaking any procedure or examination. Provide the reason as to why it is necessary. Patient should be offered opportunity to have a chaperone present during examination. 12B If stool specimen is sent, document the reason why SECTION THIRTEEN PROBLEMS IDENTIFIED FROM ASSESSMENT Please record information on main problems identified from assessment e.g. - Poor Oral Intake - Assisted Evacuation - Constipation/Diarrhoea - Irritable Bowel Syndrome - Faecal Incontinence - Post-delivery Laceration etc

19 SECTION FOURTEEN PLAN OF ACTION Fluid intake/dietary advice refer back to Section 11 MEDICATION REVIEW It is important that the patient s medication is reviewed regularly to determine if they still need to be on that drug/dose etc. Refer to BNF/MIMS as some medication may cause side-effects that may contribute to constipation. The Community Pharmacist/Hospital Pharmacist will also provide advice/information. Information on positioning refer to Appendix 13 REFERRAL TO OTHER SPECIALISTS Following assessment of the patient s needs and for on-going management, referral to other agencies may be necessary e.g. Dietician, following Consultant assessment - Physiotherapist, Speech Therapist. (In the community this would be done through the GP.) STRESS/EMOTIONAL MANAGEMENT If a patient has incontinence it is important to determine how this has affected their lifestyle. It may be necessary to help patients cope with any aspects of stress or emotion that may be affecting them. Some patients report e.g. feeling restricted and plan journeys around toilet facilities. Methods of helping may be the use of relaxation tapes, counselling, good communication, explanation of treatment. Referral to GP, Continence Adviser, Stoma Nurse, Colorectal Nurse may also be required. The Continence Foundation (Tel. No ) may also help. Ensure patients are provided with correct products for managing faecal incontinence and are aware of how to receive them e.g. home delivery service from the companies. Information on environment refer to Section 2 Aperient advice refer to Pharmaceutical aspects of bowel management refer to Section 4 Bowel Programme/Gastro Colic Reflex refer to planning a bowel programme refer to Section

20 SECTION FIFTEEN - MANAGEMENT PLAN Please record the information of selected product, size, and daily amount, code numbers. If patient has been referred to other agencies write date in box COMMODE Available from Central Stores or to buy PADS Refer to Bowel Assessment Form and Chart for correct type and quantity of pad to be issued N.B. Washable pants are not suitable for patients who have faecal incontinence ANAL PLUGS These are available from Coloplast on Prescription in two sizes. These patients must be assessed to determine which size is most appropriate and given the appropriate literature. FAECAL COLLECTOR This is available from Hollister on Prescription. Samples are available from the Continence Advisors. STRETCH FIT PANTS To be worn with Pad size 6, 7 and 8 but patient should be encouraged to wear their own close fitting underwear. 3 pairs issued every 8 weeks. REFERRAL TO PHYSIOTHERAPIST Referral via GP for pelvic floor exercises or advice on perineal support etc. Ensure before referral the patient gives consent to ensure compliance with treatment

21 SECTION 3 (a) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES Flowchart Nursing Actions for a Patient with Constipation PAGE 16

22 NURSING ACTIONS FOR A PATIENT WITH CONSTIPATION Patient with Constipation Assess diet and lifestyle for predisposing factors (Use bowel diary to establish patterns) Introduce changes if required. Provide health education i.e. diet/fluids/exercise Yes Effective? No Hard Assess Stool Consistency Soft Select Oral Laxative (faecal softener) Select Oral Laxative (faecal stimulator ) Continue Yes Effective? No Re-assess stool consistency And review regimes accordingly

23 SECTION 3 (b) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES Flowchart Nursing Actions for a Patient with Faecal Impaction PAGE 17

24 NURSING ACTIONS FOR A PATIENT WITH FAECAL IMPACTION Patient with Faecal Impaction Yes Discomfort? i.e. Immediate action required No HARD Assess Stool Assess Stool Consistency SOFT HARD Consistency SOFT Administer stool softening suppository/enema Administer stool stimulating suppository/enema Select Oral Laxative (faecal softener) Select Oral Laxative (faecal stimulant) Effective? Yes Effective? No No Select Oral Laxative (faecal softener) Select Oral Laxative (faecal stimulant) Effective? Yes Effective? Yes Re-assess stool consistency and review regimes No Effective? No Yes Manual Evacuation 1. Assess for predisposing factors 2. Address diet and lifestyle changes 3. Follow constipation pathway if required

25 SECTION 3 (c) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES Bowel Policy for People with Neurogenic Bowel as Implemented in Maidencraig Rehabilitation Unit Woodend Hospital PAGE 18-24

26 Upper and Lower Motor Neuron Bowels Explanations A Neurogenic Bowel can be defined in two ways Upper Motor Neuron Bowel and Lower Motor Neuron Bowel depending on which part of the nervous system is affected by injury or disease. Upper Motor Neuron Bowel An upper motor neuron bowel problem occurs in injury or disease in the brain or spinal cord above T12 level e.g. after Head Injury, in Multiple Sclerosis, Parkinson s Disease or Spinal Injury. On examination anal sphincter tone is maintained and there may be some sensation and voluntary contraction of anal sphincter. The bowel reflexes are all preserved, therefore the bowel contracts and should empty when stimulated. Often patients in this group can be managed with alternate day bowel movements but this also depends on their previous bowel pattern. Even though the bowel contracts and should empty when stimulated, often other impairments and disabilities (e.g. immobility, poor fluid intake, drugs for bladder dysfunction) make people prone to constipation. Cognitive impairments with reduced awareness or understanding can also result in faecal incontinence and as well as the bowel management guidelines, behavioural strategies can also be tried. Lower Motor Neuron Bowel A lower motor neuron bowel problem occurs due to damage to the lower spinal cord (T12 or below) or from damage or disease of the peripheral nerves. Diseases which may affect the lower cord are Multiple Sclerosis, after injury, Disc disease, infection or tumours. Diseases that can affect the peripheral nerves are Diabetes or injury during abdominal operations. On examination the anal sphincter is flaccid with little resting tone or active contraction. Although there is some intrinsic peristalsis, it is not usually effective in propelling bowel contents distally. Constipation, impaction, overflow and incontinence often result. Most patients will require at least daily bowel care in order to keep the rectum empty to avoid incontinence later in the day. Some patients will not respond to stimulant suppositories and may require enemas or manual evacuation to completely empty the rectum. Rigorous management is required in order to prevent constipation

27 Faecal Incontinence Management Guidelines For Upper Motor Neuron Bowel Disorders Bowel Policy Maidencraig Rehab Unit

28 Faecal Incontinence Management Guidelines For Lower Motor Neuron Bowel Disorders Bowel Policy Maidencraig Rehab Unit

29 Faecal Incontinence Management Guidelines Explanation Sheet (to be used in conjunction with flowchart) Management options differ slightly for Upper Motor Neuron Bowel than for Lower Motor Neuron Bowel problems Education and Support Considerations: Bowel symptoms can be distressing and embarrassing for patients. Empathy and support is essential. Give adequate time and privacy for assessment and discussing management. Education for the patient is also important to ensure an understanding of the bowel symptoms, the possible complications and the role of diet, fluids, medications and bowel care. Advice and Support Skin Care Odour Control Emotional Support Pads Clothing Storage of soiled clothes Change/clean clothes Set Goals of Management Considerations: Depends on assessment and diagnosis of bowel problem. Aim to continue premorbid bowel pattern if possible e.g. daily/alternate day. Patient s wishes important. Patient s ongoing care package/placement are important to consider early. Upper Motor Neuron Bowel can often manage with alternate day bowel opening. Lower Motor Neuron Bowel almost always will require daily emptying. Bowel Health Measures Optimise diet and fluids: Aim for regular routine - Use gastrocolic / This will usually be in the morning before/after breakfast but will depend on premorbid experience, patient preference as well as the care package

30 Use gastrocolic Peristalsis, the wave movement that propels bowel contents reflex where through the digestive tract, occurs all day, but is further possible - stimulated by the smell/taste of food and by eating particularly food with a hot drink. The bowel routine can take advantage of this reflex at breakfast with a hot drink/ warm food bolus. Consider positioning on toilet, bed/ commode - Is faeces the right consistency? Impaction? Is faeces in the right place? Is there a right trigger? When possible if the patient has adequate sitting balance, they should get up onto the toilet or commode for bowel care. Otherwise, ensuring a comfortable position in bed this is usually on the left, foetal position, exerting some abdominal pressure. The Bristol Stool Chart is now recognised as a standard for describing stool consistency and is a useful tool. Ideal results are 3, 4 or 5. The stool consistency is influenced by fluid intake and dietary fibre as well as by some medications which, by relaxing the bowel, can lead to excessive reabsorption of water from the stool leading to hard, constipated stools e.g. codeine and other opiods, as well as Oxybutinin, inflammatory bowel disease or other bowel pathology, as well as overuse of laxatives or loose stool due to overflow incontinence. If bowel management gives no results over 3-4 treatments/ days, consider impaction. Impaction is a mass of compressed faeces in the rectum/sigmoid colon. This is not always due to hard stool. Initial management involves rehydration and stimulation of the bowel using fluids, fibre and if necessary, Movicol. i.e. Is the faeces in or near the rectum ready for expulsion? This is influenced by a regular routine and making use of the gastrocolic reflex. If required, stimulant laxatives will assist in the propulsion of bowel contents into the rectum. Is there a reliable trigger to stimulate rectal emptying? - This is mainly for Upper Motor Neuron bowels although some Lower Motor Neuron bowels may still have some weak reflex activity to utilise triggers. Triggers may be abdominal pressure/massage, digital rectal stimulation or pharmacological

31 Is expulsion at the right time? / Is expulsion at the right time? Is the result right? Liaise with Community Staff Because sensation is usually impaired, patients need a predictable time for bowel opening. This results from having a regular routine that fits in with their individual daily schedule or care package. If bowels are additionally, regularly moving between scheduled times either stimulant laxatives can be reduced or bowel care frequency may need increased e.g. to daily instead of alternate day. If bowel care results are taking a long time or are moving later in the day, the timing of stimulant laxatives could be changed to earlier in the day, to allow longer to work before the morning bowel routine. i.e. Does the rectum empty fully (need check rectal examination after bowels move). This can be helped by using the gastrocolic reflex, increasing oral or rectal stimulant in some patients the frequency of bowel care may need to be increased. Necessary again prior to discharge to update them on progress, explain bowel routine and reasons for it, and to ensure bowel routine is manageable

32 Constipation Management Guidelines Bowel Policy Maidencraig Rehab Unit

33 SECTION 4 PHARMACEUTICAL ASPECTS OF BOWEL MANAGEMENT PAGES 25 32

34 Pharmaceutical Aspects of Bowel Management Laxatives are important adjuncts to the management of constipation, but they are not innocuous and should only be given when other measures are inadequate. Laxative abuse may lead to hypokalaemia and an atonic non-functioning colon. It is important to be sure that the patient is constipated before prescribing laxatives and that the constipation is not secondary to an underlying undiagnosed complaint. Ideally a full bowel assessment should be completed before laxatives are prescribed. Constipation can be defined as, the passage of hard stools less frequently than the patient s own normal pattern. This may be difficult to define in practice as the perception of normal bowel habit varies from person to person. What one patient may regard as constipation another may regard as normal bowel activity and misconceptions about bowel habits can lead to excessive laxative use. Many elderly people incorrectly assume that they are constipated if they do not have a daily bowel movement. Non-pharmacological methods to address bowel management problems should always be the first step. Drug treatment of constipation should only be considered where it cannot be addressed by: Increasing the fibre intake of the normal diet. Increasing fluid intake. Increasing the mobility of the patient. Selecting dietary products/fruit juices with a laxative effect as appropriate. Reviewing patient s current medication to alleviate constipation caused as a side effect of medication for another condition. In general laxatives should only be used: Where straining may exacerbate conditions such as angina, cerebral and/or cardiovascular disease. To reduce the risk of rectal bleeding & straining e.g. hemorrhoids, anal fissures. Where bowel motility has been reduced by drugs such as opiates or anticholinergics. (Where possible contributing drug therapy should be discontinued, including over-the-counter medicines). In elderly patients who may have weak abdominal and perineal muscles. Where dietary interventions have persistently failed. To clear the bowel before surgery or a diagnostic procedure, or to expel parasites after anthelmintic treatment. Immobilised patients threatened with constipation. In-patients with motor neurone problems, either resulting from an accident or through disease. Ideally laxatives should be prescribed for short-term use only i.e. the lowest effective dose for the shortest possible time. Over-dosage of any preparation is accompanied by looseness, abdominal pain and increased frequency of bowel action. An acute episode of constipation needs to be treated and it may be necessary to consider maintenance therapy for some patients. Prolonged treatment is not usually required, except occasionally in the elderly or some patients with neurological disease or injury. The patient s medication (including over-the-counter medicines) should be reviewed for potentially constipating drugs and where possible stopped or changed. The use of laxatives in children should be discouraged unless absolutely necessary (refer to Tough going Childhood Idiopathic Constipation Management Pathway)

35 General Points Each patient should be assessed individually and their need for laxatives determined by their bowel function, stool type and their ability to make the necessary changes to their lifestyle e.g.: fluid & fibre intake and exercise. The choice of laxative should relate to the individual patient s needs and relative risk. Laxative choice should also follow the recommendations contained in the Grampian Nursing Formulary, Symptomatic Relief Policy and the Grampian Joint Formulary. The latter be accessed on the Grampian intranet: The latest edition of the BNF should always be used to determine current availability, cautions, contraindications and doses of laxatives. Special indications Palliative Care Where bowel management issues are a consequence of opioid drug use for palliative care refer to the Grampian Palliative Care guidelines on the Grampian Intranet: Pregnancy and breastfeeding Constipation in pregnancy should preferably be managed by increased dietary fibre, fluid intake and exercise wherever possible. Where pharmacological therapy is required, bulking agents are safer, however, other laxatives may be appropriate in specific individuals. Caution should be exercised in using stimulant laxatives near to term or if pregnancy is unstable. Constipation in breastfeeding mothers should be treated as for normal patients. However, it is important that co-danthramer is not used in these patients. Management of impaction or overflow Evacuation may be necessary when the rectum is full and there is impaction or overflow. Use a step-wise approach until the bowel is evacuated using a minimum number of steps. Step 1: Micro-enema Or Bisacodyl suppositories Step 2: If stool is hard If stool is soft Step 3: Arachis oil enema sodium citrate microenema 10mg* in the morning Fletchers phosphate enema Bisacodyl suppositories 10mg* in the morning Check for peanut allergy. Warm before use. *adult dose

36 MAIN LAXATIVE GROUPS PHARMACOLOGY, DOSAGE AND USE BULK FORMING DRUGS Bulk forming drugs relieve constipation by increasing faecal mass, which stimulates peristalsis. The full effect may take some days to develop and so they are of limited use when rapid relief is desired and are therefore best for long term use. They are of particular value in ambulatory patients with small hard stools, but should not be required unless fibre cannot be increased in the diet. They are useful in the management of patients with colostomy, ileostomy, haemorrhoids, anal fissure, chronic diarrhoea associated with diverticular disease, irritable bowel syndrome and ulcerative colitis. Adequate fluid intake must be maintained to avoid intestinal obstruction (approximately 1 glass of fluid per average dose). Bulk forming drugs are the only laxatives acceptable for long-term use and they may be useful for weaning patients off long term use of stimulant laxatives. They should not normally be used in the elderly with atonic bowels as obstruction may ensue and should only be used with great caution in non-ambulatory patients. Patients with slow-transit constipation and those with a functional outlet obstruction may have their symptoms aggravated by the use of bulk forming drugs as the patient will have to move and expel more stool which may magnify their symptoms. Bulk forming laxatives may be appropriate for longterm use only in-patients with normal gut motility and otherwise uncomplicated constipation where good fluid intake can be assured. a) Ispaghula Husk The normal adult dose is one sachet in water, twice daily, preferably after meals, but an evening dose should not be taken immediately before going to bed. Ispaghula Husk is indicated for treating mild or moderate chronic constipation. (Note: - in the elderly one sachet daily may be sufficient along with adequate fluid intake) STIMULANT LAXATIVES They act directly on the myenteric plexus and stimulate colonic peristalsis, but their mechanisms of action may be diverse and more complex. They increase intestinal motility and often cause abdominal cramp. They should not be used in intestinal obstruction and prolonged use can precipitate the onset of atonic non-functioning colon and hypokalaemia. They are potent laxatives and the agents most often implicated in the cathartic bowel syndrome i.e. poorly functioning bowel. Stimulant laxatives may be used when rapid relief of constipation is desired, but are recommended for short-term use only. Improved mobility and the provision of time and privacy for going to the toilet may be all that is required. They should not be used for faecal impaction, which should be first cleared manually or with the use of enemas. Patients with neurological constipation and those taking opiates may require the continuous use of stimulant laxatives

37 a) Senna This is an anthraquinone. It increases the patient s sensitivity to the stimuli, which normally promote defaecation. The correct dose is the smallest required to produce a comfortable, soft, formed motion. It varies between individuals but the laxative effect takes between 8-12 hours. The usual adult dose is 2 tablets at bedtime (up to 4 on medical advice). If no bowel action has occurred after 3 days progressively increased dosage, a medical examination should be considered. Once regularity has been achieved, dosage should be reduced and can usually be stopped. Senna is thus indicated for the short-term treatment of acute constipation. Senna is also available as a syrup (5mL syrup = 1 tablet). Senna is included in the NHS Grampian symptomatic relief policy. b) Bisacodyl Bisacodyl is a diphenylmethane used for the treatment of constipation and for bowel evacuation in oral doses of 5-10mg at night. The night before radiological procedures and surgery, 10-20mg. A 10mg dose is used in adults when given by suppository. It is usually effective within 10 to 12 hours following oral administration and within 20 to 60 minutes following rectal administration. Rectal administration may be associated with local irritation. b) Sodium Picosulphate This is given by mouth as a solution once daily in a dose of 5-10mg at night for adults. It is effective within 6 12 hours. It is also available, in combination with magnesium citrate, as Picolax sachets for bowel evacuation prior to abdominal radiological procedures, endoscopy and surgery. It should be used with caution in-patients with active inflammatory bowel disease. c) Docusate Sodium This acts as a stimulant and softening agent, effective within 1-2 days. The usual adult dose is up to 500mg daily in divided doses. This can be used in doses up to 600mg in palliative care but this dose is outside the licence for the product. Initial doses should be large and gradually reduced. Adverse effects rarely occur. It is useful in-patients, when given orally, with hemorrhoids who are constipated, for the elderly and to treat opioid - induced constipation. Docusate is usually considered to be comparatively ineffective on its own and is usually used in combination with a stimulant laxative. (Rectal preparations of Docusate should not be used if there are hemorrhoids or anal fissures) Docusate sodium is available as 100mg capsules or as an adult oral solution containing 50mg/5mL. d) Danthron Danthron is an anthraquinone laxative that now has limited indications because rodent studies indicate potential carcinogenic risk. It is now only indicated for constipation in terminally ill patients of all ages. Danthron acts within 6-12 hours and may colour the urine red. Prolonged contact with the skin (as in incontinent patients) should be avoided as irritation and excoriation may occur. Danthron is available combined with a stool softener as Co-Danthrusate capsules (danthron 50mg,docusate sodium 60mg). The usual dose is 1-3 capsules at bedtime

38 Co-danthramer or co-danthramer strong (Danthron with poloxamer 188 (a wetting agent)) is available as capsules or suspension. The usual dose is 1-2 capsules or 5-10mL at night. (NB: 5mL for the strong suspension) e) Glycerol (Glycerin) suppositories act as a rectal stimulant due to the mildly irritant action of glycerol, an osmotic agent with lubricating properties. It is absorbed when given orally and is therefore only effective when given by suppository. Glycerol suppositories are available in 4g size for adult use. They should be moistened with water before use. Glycerol suppositories are included in both the symptomatic relief policy and the Patient Group Direction for the Grampian Formulary of Nursing Care Products. FAECAL SOFTENERS Faecal softeners have a detergent action that reduces surface tension and promotes the admixture of water and fat, allowing their penetration into the faeces and thus softening the stool. They may also act directly on the intestine, stimulating the secretion of water and electrolytes. Rectally administered suppositories and enemas lubricate and soften impacted faeces and promote a bowel movement. Arachis Oil enemas are used to lubricate and soften faeces, which are impacted higher than the rectum. The enemas should be warmed before use. They are expensive and should only be used where other measures have failed. Contra-indicated in patients with peanut allergy. OSMOTIC LAXATIVES Osmotic laxatives are poorly absorbed and act by drawing water into the intestine, increasing the bulk and water content of the stool and promoting peristalsis by mechanical distension. Most have a rapid onset of action (except lactulose) and are useful when rapid relief is desired. a) Lactulose is a semi-synthetic disaccharide, which is not absorbed from the gastrointestinal tract. It is broken down by colonic bacteria into simple organic acids, which exert a local osmotic effect in the colon resulting in increased faecal bulk and stimulation of peristalsis. It may take up to 48 hours before an effect is obtained. Lactulose should not be used routinely as a laxative. It can be unpalatable, causes abdominal discomfort, flatulence and cramps, has a slow onset of action, requires large doses for effect and is expensive. It should be used with caution in patients with lactose intolerance. Lactulose should be reserved for situations where other laxatives are unsuitable or for patients with hepatic encephalopathy. For hepatic encephalopathy larger than normal doses are used, the ph in the colon is reduced significantly by this acid production and the absorption of ammonium ions and other toxic nitrogenous compounds is decreased, leading to a fall in bloodammonia concentration. Lactulose is available as a solution containing 3.35g/5mL. For constipation the initial dose is 15mL twice daily, gradually reducing according to patient s needs

39 b) Saline Laxatives The osmotically active ions are sulphate, magnesium, phosphate and citrate in order of decreasing potency. They are indicated when rapid relief of constipation is desired. Sodium citrate micro-enemas are available for rectal use in constipation. Sodium citrate microenemas are included in the Patient Group Direction for the Grampian Formulary of Nursing Care Products. In susceptible individual sodium salts may give rise to sodium and water retention. Phosphate enemas are used in bowel clearance before radiology, endoscopy and surgery. They may also occasionally be required for the treatment of impacted faeces, where the rectum and lower colon contain soft faeces or for in-patients where dehydration is a problem. MACROGOLS Macrogols are inert polymers of ethylene glycol which sequester fluid in the bowel. Giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives. Macrogol 3350 or 4000 are high molecular weight polymers that are virtually unabsorbed by the gut. The polymer exerts an osmotic pressure when dissolved in water, thus retaining water in the gut. This fluid load lubricates the faeces stimulating peristalsis and facilitating the easy passage of stools. Movicol is a combination of macrogol (polyethylene glycol) 3350 and electrolytes (sodium, potassium, chloride, bicarbonate). The inclusion of electrolytes in Movicol may help prevent electrolyte depletion sometimes experienced in long term use of laxatives. If patients develop any symptoms indicating shifts of fluid/electrolytes (e.g. oedema, shortness of breath, increasing fatigue, dehydration, cardiac failure) macrogols should be stopped immediately. Abdominal distension, pain and nausea due to the expansion of the contents of the intestinal tract can also occur. Movicol is available in two sachet sizes Movicol and Movicol-Half (13.8g & 6.9g respectively) for reconstitution with 125mL and 62.5mL of water respectively to an oral solution. Movicol (Macrogols) is included within the Grampian Joint Formulary for restricted use only. It should be reserved only for the treatment of acute faecal impaction when other therapies have failed to be effective. Usual duration of 3 days in adults. Macrogrols (Movicol ) can also be used in the treatment of chronic severe constipation, with faecal loading, only in patients with neurological disorders (eg: multiple sclerosis, spinal injury) when other therapies have failed to be effective. A course of treatment should not normally exceed two weeks. The recommended oral dose for chronic constipation is 1-3 Movicol sachets (or 2-6 of Movicol-Half ) daily in divided doses, reducing according to individual response. A course of Movicol should not normally exceed 2 weeks. Movicol is also licensed for faecal impaction in adults, adolescents and the elderly where the dose is 8 sachets dissolved in 1 litre of water and consumed within 6 hours, for a maximum of 3 days. Movicol is not licensed for use in children under

40 All laxatives can be prescribed by nurse prescribers except magnesium sulphate mixture which can only be prescribed by extended nurses prescribers. Nurse prescribers are reminded that they need to prescribe these medicines generically (see BNF for correct names). Drugs with the Potential to cause constipation Antacids containing Aluminium or Calcium e.g. Aludrox Anti-diarrhoeals e.g. Loperamide Antihistamines e.g. Chlorpheniramine Anticholinergics e.g. Benzhexol Calcium-channel blockers e.g. Verapamil Cough suppressants e.g. Codeine Diuretics (if dehydration occurs) Opioid analgesics e.g. codeine, dihydrocodeine, morphine Tricyclic antidepressants e.g. Amitriptyline Phenothiazine anti-psychotics e.g. Chlorpromazine Iron preparations This list is not exhaustive see the BNF for more information

41 MAIN LAXATIVE GROUPS SUMMARY TABLE Group Bulk Forming Drugs Stimulant laxatives Faecal Softners Osmotic laxatives DRUG & ADULT DOSE Ispaghula Husk (Fybogel, Regulan ) Senna Bisacodyl Oral & rectal Dantron (codanthramer, codanthrusate) Docusate sodium Sodium picosulfate Glycerol (Glycerin) suppositories Arachis Oil Enema Lactulose Phosphate Enemas Sodium citrate (rectal) (eg: Micolette Magnesium Sulphate Mixture Macrogrols (Movicol Movicol-Half ) INDICATION Valuable in patients producing small hard stools where an increase in fibre in the diet cannot be achieved. Useful in the management of patients with colostomies, ileostomies, haemorrhoids and anal fissures. Useful in patients who cannot tolerate bran. Suitable for long term use. May worsen problem in immobile patients who have slow transit times. Short term treatment of acute constipation. Senna may be used long term in patients with opioid induced constipation. Used only for treatment of constipation in terminally ill patients. Acts both as a weak stimulant and as a softening agent so useful for softening hard stools. Useful for patients with anal fissures or haemorrhoids and in the elderly. Large doses used in constipation induced by opioids in palliative care. Useful for bowel evacuation before surgery or radiological/endoscopic procedure. Effective for acute constipation. Lubricates and softens impacted faeces to cause a bowel movement. Only to be used when other methods have failed. Not suitable for acute relief of symptoms. Used for hepatic encephalopathy and situations where other laxatives are unsuitable. Not indicated as first line choice. Useful for bowel clearance before surgery or radiological/ endoscopic procedures. Suitable where large volume enemas are contra-indicated. Used for rapid bowel evacuation. Useful before radiological procedures. Not for long term use. Reserved for the treatment of acute faecal impaction when other therapies have failed to be effective. GENERAL INFORMATION Patients MUST be able to maintain a good fluid intake in order to avoid intestinal obstruction. The full effect may take some days to develop. Abdominal distension can occur. Orally takes 8 to 12 hours to act. Bisacodyl suppositories act within minutes, tablets within hours Dantron takes 6 to 12 hours to work Oral preparation takes 1 to 2 days to work. Acts within 6-12 hours. Moisten with water before use. Contra-indicated in peanut allergy. Warm before use. Can take up to 48 hours to work. Caution in lactose intolerant patients. Good fluid intake is essential. Indicated when rapid relief of constipation needed. Acts in 2-4 hours. Usual duration of treatment 3 days in adults. May also be used in the treatment of chronic severe constipation, with faecal loading, in patients with neurological disorders (eg: multiple sclerosis, spinal injury) when other therapies have failed to be effective. A course of Movicol should not normally exceed 2 weeks

42 SECTION 5 DIETARY ASPECTS OF BOWEL MANAGEMENT PAGES 33 36

43 DIETARY ASPECTS OF BOWEL MANAGEMENT Inadequate intake of food, dietary fibre and fluid may all contribute to the development of constipation. Intake of Food A poor intake of food results in an inadequate volume of colonic contents and this may lead to constipation. When dietary intake is considered as insufficient try encouraging with small, well presented meals and nourishing snacks between meals (Appendix 4 Snack Ideas). Suggestions regarding suitable snack foods can be given to carers/relatives who may be able to provide these and encourage intake. If dietary intake food remains consistently poor the Dietician should be contacted. Dietary Fibre (Non Starch Polysaccharides) Non Starch Polysaccharides (NSP) comprise the major proportion of what is commonly called dietary fibre. These include the parts of cereals, fruit and vegetables, which are not digested and absorbed in the small intestine. Dietary fibre is important in preventing constipation. It increases stool weight and reduces bowel transit time and has the ability to absorb water which results in the formation of a soft more easily passed stool. Wholegrain cereals, pulses and some vegetables and fruit are high in dietary fibre and are recommended in particular because they are also valuable sources of several other nutrients. High fibre diets have also been used effectively to improve blood glucose control and may help to reduce blood cholesterol. Dietary fibre intake needs to be increased gradually in an attempt to avoid problems such as flatulence and abdominal discomfort. Carers/relatives of the patients can be given suggestions of suitable high fibre snack foods to bring in (Appendix 5 High Fibre Snacks). Most people enjoy foods which are high in dietary fibre but those with ill fitting dentures or those who do not wear their dentures may have difficulty chewing several of the foods rich in fibre and therefore may avoid them. Those requiring the consistency of their diet altered due to dysphagia may also be avoiding high fibre foods. However, there are high fibre foods of suitable consistency available (Appendix 6 High Fibre Foods suitable for those with Chewing/Swallowing Difficulties). A high fibre intake results in a feeling of fullness. Care should, therefore, be taken with the frail or chronically sick with small appetites to ensure the amount of fibre rich foods in the diet does not reduce their intake of foods providing other important nutrients

44 The use of unprocessed bran/natural bran is not advised as a way of increasing fibre intake. In order to increase the quantity of fibre taken in the diet, it is more favoured to eat a variety of foods, which are naturally high in fibre. Unprocessed bran is tasteless and unpalatable and if added in large quantities to a previously low fibre diet it can result in stomach pains, diarrhoea and flatulence. It may also reduce the absorption of some minerals e.g. calcium and zinc. It should only be used under medical/dietetic supervision. In order for patients to achieve higher fibre intakes, certain measures can be taken:- If porridge and wholegrain cereals are liked, patients should be encouraged to choose them. Stewed fruits (prunes/apple) or grapefruit segments can be offered at breakfast. An increased intake of wholemeal toast, if liked, should be encouraged it can be offered at breakfast and it makes an ideal mid-morning and evening snack. If wholemeal bread is particularly disliked offer a white bread that has been fortified with fibre or contains multigrains. Offer wholemeal bread or wholemeal rolls along with soup. Encourage fruit daily fresh, tinned, stewed or dried. Encourage vegetables daily hot or in salad. (Appendix 7 High Fibre Foods Available from the Catering Department and Appendix 8 Fibre Content of Everyday Foods) Fluid An inadequate fluid intake is often forgotten as a cause of constipation. If fluid intake is poor dietary fibre cannot expand (absorb enough water) and soften sufficiently to pass through the digestive tract. Faeces can become hard and compacted. An adequate fluid intake is essential for health. Aim for a fluid intake of 8-10 cups (1.5 2 litres) per day

45 The 8-10 cups of fluid can be taken as water, tea, coffee, milky drinks, fruit juices or squashes. To achieve the desired intake, fluids should be offered both with and between meals (Appendix 9 Fluids). Some individuals may have a fading sense of thirst and they will require prompting to consume some fluids at regular intervals even if they are not thirsty. Fear of incontinence may also lead to an insufficient quantity of fluids being consumed. For those concerned about nocturnal incontinence, sufficient fluids should continue to be encouraged throughout the day. Ways to achieve adequate fluid intakes of 8-10 cups per day:- Regular fluid rounds Offering drinks the patient likes Assist fluid intake through use of feeder cups or straws if required For individuals who are able to take drinks independently the cup/glass should be placed within easy reach. Encourage carers/relatives to offer drinks to the individual. Additional information and leaflets available from Dietetics Department

46 DIETARY ASPECTS OF BOWEL MANAGEMENT SUMMARY An adequate intake of food, dietary fibre and fluid is important to help prevent and also to treat constipation. Intake of food: If dietary intake is poor try encouraging small frequent meals. If intake does not improve contact the Dietician. Dietary fibre has an important role in the prevention of constipation. Encourage porridge, wholegrain cereals, pulses, wholemeal bread, fruit and vegetables. It is important to increase intake of dietary fibre gradually to avoid abdominal discomfort. The use of unprocessed bran is not advised. Fluid: An inadequate intake of fluid can cause constipation. Aim for a fluid intake of 8 10 cups (1.5 2 litres) per day. Appendices: Appendix 4 Snack Ideas Appendix 5 High Fibre Snacks Appendix 6 High Fibre Foods Suitable for those with chewing / swallowing difficulties Appendix 7 High fibre foods available from the Catering Department Appendix 8 Fibre Content of Everyday Foods Appendix 9 - Fluids

47 SECTION 6 (a) PROCEDURES Administration of Suppositories Staff should keep themselves up-to-date and attend relevant training sessions to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems. Staff should adhere to:- THE NURSING AND MIDWIFERY COUNCIL CODE OF PROFESSIONAL CONDUCT APRIL 2002 ROYAL COLLEGE OF NURSING, DIGITAL RECTAL EXAMINATION AND MANUAL REMOVAL OF FAECES (2004) PAGES 37 39

48 ADMINISTRATION OF SUPPOSITORIES Refer to Pharmaceutical Section for details of suppositories Pages DEFINITION A semi-solid pellet introduced into the anal canal INDICATIONS 1. To evacuate the lower bowel/rectum before certain types of surgery 2. To empty the bowel to relieve acute constipation or when other treatments for constipation have failed 3. To empty the bowel before endoscopic examination 4. To soothe and treat haemorrhoids 5. To administer certain systemic medicine CONTRA-INDICATIONS 1. Chronic constipation which would require repetitive use 2. Paralytic ileus 3. Colonic obstruction 4. Following gastrointestinal or gynaecological operations, unless specified by a Doctor REQUIREMENTS Prescription and drug recording sheet Prescribed suppository Non-sterile disposable gloves as per Glove Guidelines Policy Disposable apron Paper tissue Lubricating jelly/water for glycerine suppository Scissors if required Disposal bag as per Clinical Waste Guidelines Bed protection NB Check for latex, lanolin, peanut allergy

49 PROCEDURE Explain and discuss procedure to patient. If a medicated suppository is being prescribed it is best to do so after the patient has emptied their bowels Allow patient to empty bladder if necessary Provide privacy to patient Ensure that a bedpan/commode or a toilet is readily available Assist patient to remove clothing from the waist down and lie the patient in the left lateral position with the knees flexed. Ensuring they are covered at all times Place bed protection under patient hips and buttocks Wash and dry hands thoroughly Put on disposable apron and apply gloves Remove suppository from packaging use scissors if required Place some lubricating jelly on swab/tissue on the blunt end of the suppository Glycerine suppositories should be moistened with water Separate the patient s buttocks, insert the suppository using the index finger into the rectum for about 4cm. a) Medication that is to be absorbed from the rectum should be inserted with the blunt end first. b) For bowel evacuation the suppository should be inserted pointed end first Repeat this procedure if a second suppository is to be inserted Dry the peri-anal area with tissue and place in Disposal bag RATIONALE Ensure patient understands procedure and gives valid consent A full bladder may cause discomfort during procedure Ensure patient comfort and dignity and to avoid embarrassment to the patient In case of premature ejection of the suppositories or rapid bowel evacuation following their administration This allows ease of passage of the suppository into the rectum by following the natural anatomy of the colon. Flexing the knees will reduce discomfort as the suppository is passed through the sphincter To reduce potential of soiled linen Prevent risk of cross-infection Prevent risk of cross-infection Prevent risk of cross-infection Lubricating reduces surface friction and avoid anal mucosal trauma Stimulates dissolving of suppository To ensure suppository is retained To ensure patient comfort and prevent anal excoriation

50 PROCEDURE Ask the patient to retain the suppository(s) for 20 minutes or until he or she is no longer able to do so. If the patient has had a medicated suppository given remind patient that its aim is not to stimulate evacuation and to retain suppository for at least 20 minutes or for as long as possible. Ensure the patient is near the bedpan, commode or toilet and has adequate toilet paper Remove apron and gloves and dispose of equipment as per Clinical Waste Guidelines Wash and dry hands thoroughly Record details of procedure in patients notes Type of suppository Result (colour, amount, consistency and content) Related to Bristol Stool Chart RATIONALE To allow the suppository to melt and release the active ingredients To enhance patient comfort Prevent risk of cross-infection Prevent risk of cross-infection Provide a legal record and monitor patients bowel function RECTAL MEDICATION Rectal medication avoids liver metabolism and can have a greater and faster effect than oral medication

51 SECTION 6 (b) PROCEDURES Administration of Enemas Staff should keep themselves up-to-date and attend relevant training sessions to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems. Staff should adhere to:- THE NURSING AND MIDWIFERY COUNCIL CODE OF PROFESSIONAL CONDUCT APRIL 2002 ROYAL COLLEGE OF NURSING, DIGITAL RECTAL EXAMINATION AND MANUAL REMOVAL OF FAECES (2004) PAGES 40 43

52 ADMINISTRATION OF ENEMAS Refer to Pharmaceutical Section for details of enemas Pages DEFINITION An enema is the introduction into the rectum or lower colon of fluid for the purpose of producing a bowel action or instilling medication. INDICATIONS 1. To evacuate the bowel 2. To prepare the lower bowel prior to surgery or X-ray examination 3. To introduce medication and fluids into the body for absorption 4. To soothe and treat bowel mucosa 5. To decrease body temperature 6. To stop local haemorrhage 7. To reduce hyperkalaemia (calcium resonium) 8. To reduce portal systemic encephalopathy(phosphate enema) CONTRAINDICATIONS 1. Paralytic ileus 2. Colonic obstruction 3. Where the administration of tap water or soap and water enemas may cause circulatory overload, water intoxication, mucosal damage and necrosis, hyperkalaemia and cardiac arrhythmias. 4. When the administration of large amounts of fluid may cause perforation and haemorrhage 5. Following gastrointestinal or gynaecological surgery, where suture lines may be ruptured (unless medical consent has been given) 6. The use of micro-enemas and hypertonic saline enemas in patients with inflammatory or ulcerative conditions of the large colon TYPES OF ENEMAS 1. EVACUANT Is a solution introduced into the rectum or lower colon with the intention of it being expelled, along with faecal matter and flatus, within a few minutes. 2. RETENTION Is a solution introduced into the rectum or lower colon with the intention of being retained for a specified length of time

53 REQUIREMENTS Prescription and Drug Recording Sheet Prescribed enema Non sterile gloves as per Glove Guidelines Disposable apron Paper Tissue Lubricating jelly Jug Disposal bag as per Clinical Waste Guidelines Bed protection NB Check for Latex, Lanolin. Peanut Allergy PROCEDURE Explain and discuss procedure to patient Allow patient to empty bladder if necessary Ensure patient privacy Ensure that a bedpan, commode or toilet is readily available Warm the enema to the required temperature by immersing in a jug of hot water Assist the patient to remove clothing from the waist down and lie the patient in the left lateral position with knees flexed ensuring they are covered at all times. Place bed protection under the patients hips and buttocks Wash and dry hands thoroughly Apply apron and put on gloves RATIONALE Ensure patient understands procedure and gives consent A full bladder may cause discomfort during the procedure Provide patient comfort and dignity Incase the patient feels the need to expel the enema before the procedure is complete Heat is an effective stimulant of the nerve plexi in the intestinal mucosa. An enema heated to body temperature or just above will not damage the intestinal mucosa. To minimise shock and prevent bowel spasms This allows ease of passage into the rectum by following the natural anatomy of the colon. In this position, gravity will aid the flow of the solution onto the colon. Flexing the knees ensures a more comfortable passage of the enema nozzle or rectal tube To prevent risk of cross-infection. Reduce potential of soiled linen Prevent risk of cross-infection Prevent risk of cross-infection

54 PROCEDURE Place some lubricating jelly on a swab/tissue. Remove cap from enema and lubricate the nozzle of the enema or the rectal tube Expel excessive air from enema tube. Separate buttocks and introduce the nozzle or tube slowly into the anal canal (to a depth of cm, if long tube used) while separating the buttocks RETENTION ENEMA Introduce the fluid slowly by rolling the pack from the bottom to the top to prevent backflow, until the pack is empty or the solution is completely finished. Slowly withdraw the nozzle. Leave the patient in bed with the foot of the bed elevated (if possible) for as long as prescribed before evacuating the bowel EVACUANT ENEMA Introduce the fluid slowly by rolling the pack from the bottom to the top to prevent backflow until the pack is empty or the solution is completely finished. Slowly withdraw the rube or nozzle, request patient to retain enema according to manufacturers instructions Dry the patient s perineal area with tissue and place in disposal bag RATIONALE To prevent trauma to the anal and rectal mucosa by reducing surface friction To prevent distension of colon and minimise spasm of the intestinal wall. To avoid increasing peristalsis and to reduce pressure on rectal walls. Elevating the foot of the bed aids in retention of the enema by force of gravity Avoid reflex emptying of the rectum To enhance the evacuant effect Avoid pressure on rectal walls and encourage retention of enema Avoid reflex emptying of the rectum Promote patient comfort and prevent excoriation Ensure the patient is near the bedpan, commode or toilet and has adequate toilet paper Remove gloves, apron and dispose of equipment as per clinical waste guidelines Wash and dry hands thoroughly To enhance patient comfort and prevent excoriation Prevent risk of cross-infection Prevent risk of cross-infection

55 PROCEDURE Record details of procedure in patients notes Type of enema Expiry date Amount of enema instilled Result (colour, consistency, content and amount of faeces produced). Related to Bristol stool chart RATIONALE Provide a legal record and monitor patients bowel function NOTES STEROID ENEMA Should be given after defecation, preferably at bedtime COMPLICATIONS OF PHOSPHATE ENEMA Trauma to anal/rectal mucosa caused by the enema nozzle Topical activity in the local tissue caused by the phosphate Some people have a greater risk of localised and systemic complications and are therefore more at risk when other complications occur They should not be used in patient s who are elderly, debilitated or have advanced malignancy. If there is bleeding after a phosphate enema a surgical opinion should be sought Avoid in patient s who have colitis, procitis, inflammatory bowel conditions, inflamed haemorrhoids, skin tags acute, gastrointestinal conditions, anal or rectal surgical wounds, trauma, recent radiotherapy to lower pelvic area

56 SECTION 6 (c) PROCEDURES Digital Rectal Examination Staff should keep themselves up-to-date and attend relevant training sessions to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems. Staff should adhere to:- THE NURSING AND MIDWIFERY COUNCIL CODE OF PROFESSIONAL CONDUCT APRIL 2002 ROYAL COLLEGE OF NURSING, DIGITAL RECTAL EXAMINATION AND MANUAL REMOVAL OF FAECES (2004) PAGES 44 46

57 DIGITAL RECTAL EXAMINATION Refer to Royal College of Nursing Digital Rectal Examination and Manual Removal of Faeces (2004) A nursing assessment should be undertaken before this procedure is performed. THIS SHOULD NOT BE PERFORMED ON A CHILD DEFINITION Insertion of a finger into a patient s rectum to perform an examination INDICATIONS 1. To assess anal tone and the ability to initiate a voluntary contraction and to what degree 2. Anal/rectal sensation 3. To assess if faecal matter is present, amount and consistency 4. The need and outcome of using digital stimulation to trigger defecation by stimulating the recto-anal reflex 5. The need for manual removal of faeces and evaluating bowel emptiness 6. To assess the need for and effects of rectal medication and/or to evaluate its outcome in patients who are unable to communicate or who have diminished anal/rectal sensation 7. The outcome of rectal/colonic washout/irrigation if appropriate PRECAUTIONS 1. Active inflammation of the bowel 2. Recent radiotherapy to the pelvic area 3. Rectal/anal pain 4. Rectal surgery or trauma to the anal/rectal area 5. Patients with tissue fragility and obvious rectal bleeding 6. Patients with a history of abuse 7. Spinal patients with known autonomic dysreflexia 8. Patients with known allergies e.g. latex/soap/phosphate and peanut (present in arachis oil enema)

58 OBSERVATIONS WHILE UNDERTAKING PROCEDURE 1. Rectal prolapse 2. Haemorrhoids, position, grade, prolapse 3. Anal skin tags 4. Wounds, dressings, discharge 5. Anal lesions 6. Gaping anus 7. Skin conditions, broken areas, pressure sores of all grades 8. Bleeding and colour 9. Faecal matter 10. Infestation 11. Foreign bodies REQUIREMENTS Disposable apron Non-sterile disposable gloves as per Glove Guidelines Bed protection Paper tissue Lubricating jelly Disposable bag as per Clinical Waste Guidelines PROCEDURE Explain and discuss procedure to patient Allow the patient to empty bladder if necessary Ensure patient privacy Assist the patient to remove clothing from the waist down and lie them in the left lateral position with knees flexed. Place bed protection under the patient s hips and buttocks Wash and dry hands thoroughly Apply apron and put on disposable gloves RATIONALE Ensure patient understands procedure and gives consent. Document that consent has been given A full bladder may cause discomfort during procedure Provide patient comfort and dignity To expose the anus and allow for insertion of finger for examination Prevent risk of cross-infection and reduce potential of soiled linen Prevent risk of cross-infection Prevent risk of cross-infection

59 PROCEDURE Examine the anal area as in the list above Apply lubricating gel to the gloved index finger Inform the patient that you are going to perform the procedure Insert one gloved finger slowly into the patient s rectum and undertake examination for presence of faecal matter, amount and consistency (using the Bristol Stool Chart) N.B. This may also be required to assess the need for or outcome of rectal medication, and for assessment of size, consistency of prostate gland (if trained for this) Slowly withdraw finger from patient s rectum when finished N.B. At this point rectal medication can be administered Dry the patient s peri-anal area with tissue and place is disposal bag Make patient comfortable and offer the toilet, commode, bedpan if required Remove apron and gloves and dispose of equipment as per Clinical Waste Guidelines Wash and dry hands thoroughly Record results of examination in patient s notes and communicate with patient/carer/doctor as necessary Record observations Findings Action taken What information was given to patient written/verbal RATIONALE To facilitate easier insertion and minimise patient discomfort To ensure the patient is relaxed To minimise discomfort To ensure nurse only examines within criteria. To minimise patient discomfort Prevent skin irritation or soreness Leave patient comfortable and minimise risk of cross-infection Examination may stimulate the patient to defecate Prevent risk of cross-infection Prevent risk of cross-infection Provide a legal record and ensure correct care is provided

60 SECTION 6 (d) PROCEDURES Manual Evacuation of Faeces Staff should keep themselves up-to-date and attend relevant training sessions to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems. Staff should adhere to:- THE NURSING AND MIDWIFERY COUNCIL CODE OF PROFESSIONAL CONDUCT APRIL 2002 ROYAL COLLEGE OF NURSING, DIGITAL RECTAL EXAMINATION AND MANUAL REMOVAL OF FAECES (2004) PAGES 47 50

61 MANUAL EVACUATION OF FAECES Refer to Royal College of Nursing Digital Rectal Examination and Manual Removal of Faeces (2004) A nursing assessment should be undertaken including a DIGITAL RECTAL EXAMINATION before this procedure is undertaken THIS SHOULD ONLY BE PERFORMED IN THE FOLLOWING SITUATIONS It has been identified as an acceptable bowel management method Faecal impaction/loading Incomplete defecation Inability to defecate All other bowel emptying techniques have failed Neurogenic bowel dysfunction In patients with spinal injury EXCLUSIONS There is lack of consent from the patient The patient s Doctor has given specific instructions that these procedures are not to take place The patient has recently undergone rectal/anal surgery or trauma The patient gains sexual satisfaction from these procedures and the nurse involved find them embarrassing. In this instance consultation with a Doctor is advised. CAUTION WHEN PERFORMING THIS PROCEDURE IN THE FOLLOWING Acute inflammation of the bowel, including Crohns Disease, Ulcerative Colitis and Diverticulitis Recent radiotherapy to the pelvic area Rectal/anal pain 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 If patient has known history of abuse In spinal injured patients because of autonomic dysreflexia If patient has known history of allergies e.g. latex, soap, phosphate and peanut (present in an arachis oil enema)

62 OBSERVATIONS AND RISK FACTORS Pulse at rest during procedure Pulse during procedure Blood pressure in spinal injuries prior to, during and at the end of procedure. A baseline blood pressure is advised for comparison Signs and symptoms of autonomic dysreflexia headache, flushing, sweating, hypertension Distress, pain, discomfort Bleeding Collapse Stool consistency/amount REQUIREMENTS Disposable apron 1-2 pairs of Gloves as per Glove Guidelines Lubricating jelly/anaesthetic gel Bed protection Paper tissue Bedpan/commode 1. A nurse should NOT undertake the manual removal of faeces from a child as it is viewed as being traumatic and disturbing. 2. Manual removal of faeces is viewed as a last resort and should only be used if all other treatments have been tried. 3. If the manual removal of faeces is an established aspect of care, prior examination by a Doctor is not required

63 PROCEDURE Explain the procedure to the patient. The patient must agree/consent to the procedure Allow patient to empty bladder if necessary Ensure patient privacy Assist the patient to remove clothing from the waist down and lie the patient in the left lateral position with knees flexed in order to expose the anus Place bed protection under the patients hips and buttocks Take the patient s pulse rate Wash and dry hands thoroughly Apply disposable apron and put on gloves A) If a patient has manual removal of faeces performed on a regular basis then lubricate gloved finger with gel B) If a patient has not had a manual removal of faeces performed before then apply anaesthetic gel to anus and rectum liberally, adhere to manufacturers instructions for length of time to leave in situ for it to take effect Inform the patient you are about to start the procedure Inert gloved finger into the patient s rectum slowly and: A) In scybala-type stool(hard rocks), remove one lump at a time until no more faecal matter can be felt B) In a solid mass, push finger into the middle of the faecal mass and split, i.e. remove small sections until no more faecal matter can be felt As the faecal matter is removed it should be placed in the bedpan or another acceptable receptacle RATIONALE Ensure the patient understands the procedure, gives consent A full bladder may cause discomfort during procedure Provide patient comfort and dignity and will help the patient to relax To expose the anus and allow easy insertion of a finger for removal of faecal material To prevent risk of cross-infection. Reduce potential of soiled linen To form a baseline to assess changes in pulse during the procedure Prevent risk of cross-infection Prevent risk of cross-infection A) To facilitate easier insertion of the finger and removal of faecal matter B) To facilitate easier insertion of the finger, reduced sensation and discomfort and removal of faecal matter To ensure the patient is ready and relaxed A) To minimise discomfort and make it easy to remove faecal mater B) To minimise discomfort and make it easy to remove faecal matter To facilitate appropriate disposal of faecal material at the end of the procedure

64 PROCEDURE Monitor observations and risk factors When all the faecal matter has been removed, wash and dry the patient s buttocks and anal area Make the patient comfortable and offer the toilet, commode or bedpan if needed Remove the bedpan or receptacle and its contents and dispose of in an appropriate manner Remove apron, gloves and dispose of as per Clinical Waste Guidelines Wash and dry hands thoroughly Take the patient s pulse to check with the baseline recording Record the findings in the nursing documentation and communicate the results to the patient and doctor if appropriate. Result (colour, consistency, content and amount of faeces as per Bristol Stool Chart) RATIONALE Vagal stimulation can slow the heart rate. The patient can also become shocked. Review patient s condition in particular signs & symptoms of autonomic dysreflexia, observe and record any reaction to the anaesthetic gel To leave the patient in a comfortable and clean state Manual removal may stimulate a patient to defecate To reduce risk of cross-infection and ensure correct disposal of body waste Prevent risk of cross-infection Prevent risk of cross-infection To monitor pulse changes and take appropriate action To ensure the correct care is provided and to provide a legal record

65 SECTION 7 APPENDICES PAGES 51-68

66 CONTACTS APPENDIX 1 NAME TITLE TELEPHONE ADDRESS BASE Caroline Hind Pharmacist Extn Caroline.Hind@gpct.grampian.scot.nhs.uk Pharmacy Department Woodend Hospital Eday Road Aberdeen, AB15 6XS Effie Jamieson Community Rehabilitation Nurse Extn Effie.Jamieson@nhs.net Horizons Rehabilitation Centre 2 Eday Walk Aberdeen, AB15 6LN Isobel MacDonald Senior Dietitian Extn Isobel.Macdonald@nhs.net Dept of Nutrition and Dietetics Woodend Hospital Eday Road Aberdeen, AB15 6XS Susan May Development Nurse for the Promotion of Continence Extn Susan.May@arh.grampian.scot.nhs.uk Staff Home Woodend Hospital Eday Road Aberdeen, AB15 6XS Wilma Nicolson Community Continence Advisor Extn Wilma.Nicolson@gpct.grampian.scot.nhs.uk Continence Advisory Service Inverurie Hospital Upperboat Road Inverurie, AB51 3UL Wendy Robertson Pharmacist Extn Wendy.Robertson@arh.grampian.scot.nhs.uk Pharmacy Department Woodend Hospital Eday Road Aberdeen, AB15 6XS Sheila Shearer Continence Advisor Extn Sheila.Shearer@nhs.net Continence Service Spynie Hospital Elgin, IV30 5PW Sandra Whyte Senior 1 Physiotherapist Extn Sandra.Whyte@arh.grampian.scot.nhs.uk Aberdeen Maternity Hospital Foresterhill Site Aberdeen, AB25 2ZL

67 APPENDIX 2 ANATOMY AND PHYSIOLOGY OF THE NORMAL BOWEL The main functions of the bowel are Storage of unabsorbed food residue Absorption Secretion of mucus Elimination of waste For the purposes bowel management we will focus on the LARGE BOWEL A Mouth B Oesophagus C Stomach D Small Bowel E Large Bowel F Rectum The large bowel is about 5 feet long and extends from the ILEO-CAECAL VALVE to the ANUS It consists of the ASCENDING, TRANSVERSE, DECENDING and SIGMOID COLON, the RECTUM and the ANUS. The muscle in the rectum contains sensory nerves, which are thought to detect the presence of faeces

68 APPENDIX 2 ANAL SPHINCTERS 2 MUSCULAR SPHINCTERS, the INTERNAL and EXTERNAL SPHINCTERS, surround the anal canal. The INTERNAL anal sphincter is composed of SMOOTH MUSCLE (involuntary) The EXTERNAL sphincter is composed of SKELETAL MUSCLE (voluntary) Another important factor in maintaining continence is the role of the pelvic floor muscles, in particular the PUBORECTALIS portion of the LEVATOR ANI MUSCLE, this forms a sling around the rectum and forms an angle known as the ANORECTAL ANGLE

69 THE PROCESS OF DEFECATION APPENDIX 2 Within the colon lies thick bands of muscle, which contract and relax to form peristaltic waves along the bowel. These strong surges propel waste products along the length of the bowel. These surges often occur after a meal and are known as the GASTRO COLIC REFLEX. External influences such as exercise, emotion, medication etc can affect this process. These mass movements propel the faecal mass into the rectum. Sensory nerve endings are stimulated which triggers the SPINAL REFLEX, the rectum contracts, the internal sphincter relaxes and we experience the desire to defecate If it is appropriate to defecate the external sphincter relaxes, peristaltic waves increase, the internal sphincter and pelvic floor relaxes the levator ani muscle lifts the rectum and the faeces is expelled through the anus. Evacuation is assisted by an increase in ABDOMINAL PRESSURE and an increase in thoracic pressure (VALSALVA MANOUVRE), this is also known as BRACE AND BULGE. If defecation is not appropriate the external sphincter contracts inhibiting the defecation reflex, the walls of the sigmoid colon and rectum relax, as the reflex abates the faecal mass is pushed back up into the colon leaving the rectum in the normal state that of empty

70 APPENDIX 3 DEFINITIONS IN BOWEL MANAGEMENT Constipation (1) "The state in which an individual experiences or is at risk of experiencing a delay in the passage of food residue resulting in dry, hard stool". Constipation (2) "A condition in which bowel evacuation occurs infrequently or in which the faeces are hard and small or where passage of faeces causes difficulty or pain". (National agreed definition) Faecal Incontinence "A state in which an individual experiences a change in normal bowel habits characterized by involuntary passage of stool". Diarrhoea Presence of loose, watery stool. Faecal Impaction Mass of compressed faeces in rectum and/or sigmoid colon. - Faecal loading - Not always caused by hard stool (Ref. "Rehabilitation Nursing Practice" 1998 Chin, Finocchiaro, Rosebrough P , Chapter 19) Incomplete Emptying Reflex and voluntary defecation process only partially empties rectum. May result in sensation of fullness or further defecation. Urgency Reduced times from awareness of desire to defecate to actual defecation process. Frequency Different for individuals but more than three motions daily is considered frequent

71 APPENDIX 4 Snack Ideas Yoghurts/Fromage Frais Tubs of Desserts e.g. Custard, Trifle, Rice Pudding Fruit based puddings e.g. Fruit crumble, Bread & Butter pudding, Individual Apple Pies / Jam Tarts. Ice Cream Malt Loaf/Fruit Loaf/Sponge Cake Scones/Pancakes/Muffins Biscuits e.g. Crackers, Digestives, Oatcakes, Butter Biscuits Individual Cheese Portions/Spreading Cheese Pate/Meat Paste Sandwiches variety of fillings e.g. Cold Meat, Egg Mayonnaise, Tuna, Cheese Fresh Fruit Fruit Salad (ready made) Tinned Fruit Bowl of Breakfast Cereal Milk Based Drinks e.g. Malted Drinks, Hot Chocolate For those who are Diabetic:- Sugar-free varieties of foods e.g. Yoghurts, Fromage Frais, Breakfast Cereal should be used. Tinned Fruit should be in natural juice. Fruit pies/tarts and sweet biscuits should be avoided

72 APPENDIX 5 High Fibre Snacks Fresh Fruit Juice small individual cartons are ideal Fresh Fruit Fruit Salad (ready made) Tinned Fruit Biscuits e.g. Digestives, Oatcakes, Wholegrain Crackers, Crispbread Cereal Bars Scones Fruit/Wholemeal Pancakes Wholemeal Fruit Loaf Wholegrain Breakfast Cereals e.g. Bran Flakes, Sultana Bran, Fruit & Fibre Dried Fruit and Nuts

73 APPENDIX 6 High Fibre Foods Suitable for those with Chewing/Swallowing Difficulties Wholegrain Breakfast Cereals e.g. Porridge, Weetabix Stewed Fresh Fruit e.g. Apples, Rhubarb Pureed Fresh Fruit/Tinned Fruit This can be added to milk and blended together to make a tasty drink. Fresh Fruit Juice small individual cartons are ideal Soups which contain pulses and vegetables Baked Beans Vegetables which have been cooked until soft

74 High Fibre Foods Available from the Catering Department APPENDIX 7 These following foods are available from the Catering Department:- Porridge Wholegrain Breakfast Cereal e.g. Weetabix, Bran Flakes Grapefruit Segments Stewed Fruit e.g. Prunes, Apple Wholemeal Rolls Wholemeal Bread Soft Grain Bread Digestive Biscuits Oatcakes Soups which contain pulses and vegetables Potatoes Vegetables hot at meal times or in salad Baked Beans Tinned Fruit Fresh Fruit NOTE The Catering Department liase with the Dietitians when designing the hospital menu and aim to ensure that all patients receive a nutritionally balanced diet in hospital

75 APPENDIX 8 FIBRE CONTENT OF EVERYDAY FOODS BREAD: Wholemeal 1 medium slice 2g per serving Brown 1 medium slice 1g per serving White 1 medium slice 0.5g per serving Wholemeal softie 2g per serving BREAKFAST CEREAL: All bran 1 medium bowl 12g per serving Branflakes 1 medium bowl 5g per serving Cornflakes 1 medium bowl 0.4g per serving Porridge 1 medium bowl 1.5g per serving Shredded Wheat 2 biscuits 4g per serving Weetabix 2 biscuits 4g per serving ROOT VEGETABLES: Beetroot 4 slices 1g per serving Carrots medium portion 1.5g per portion Potatoes 3 medium boiled 2g per portion Jacket 5g per serving Turnip medium portion 0.5g per serving LEAF VEGETABLES: Broccoli 2 florets 2g per serving Cabbage medium portion 2g per serving Celery raw 2 sticks 0.5g per serving Leeks medium portion 1g per serving Lettuce 6 leaves 0.2g per Pepper 2 rings 0.5g per serving Spinach medium portion 2g per serving

76 APPENDIX 8 FIBRE CONTENT OF EVERYDAY FOODS OTHER VEGETABLES: Cucumber 5 slices Trace Lentils(brown) 1 tablespoon 1g per serving Mushrooms 3 cooked 0.5g per serving Peas 2 tablespoons 3g per serving Sweetcorn 1 tablespoon 0.5g per serving Tomatoes 1 medium 1g per serving Baked beans 1 small can 8g per serving Kidney beans 1 tablespoon 2g per serving FRUIT: Apple medium with skin 2g per serving Banana medium 1g per serving Figs 1 dried 1.5g each Grapefruit ½ fruit 1g per serving Grapes small bunch 1g per serving Melon 1 slice 1.5g per serving Pear 1 medium 4g per serving Pineapple canned, 1 ring 0.5g per serving Strawberries 6 average 1.0g per serving NUTS: Peanuts roasted and salted 1.5g per serving (small bag) BISCUITS: Digestive Rich Tea Cream Cracker Wholewheat cracker Oatcakes 0.5g per biscuit 0.1g per biscuit 0.1g per biscuit 0.5g per biscuit 0.75g per biscuit

77 APPENDIX 9 FLUIDS Water preferably with ice added Tea Coffee Refresh this provides Vitamin C which is an important nutrient Fresh Fruit Juice small individual cartons are ideal Milk Milk based drinks e.g. Malted Drinks, Drinking Chocolate Squashes Fizzy Drinks Bovril For those who are Diabetic:- Sugar-free varieties of juice should be used

78 APPENDIX 10 Pick the foods you eat a home and find your score: FIBRE SCORING SHEET Rate your Diet for Fibre SCORE TYPE OF FOOD: BREAD White Brown Variety of breads e.g Wholemeal/ Granary BREAKFAST CEREAL POTATOES, PASTA, RICE PULSES, BEANS, NUTS VEGETABLES ALL KINDS OTHER THAN PULES, POTATOES AND BEANS FRUIT ALL KINDS OATCAKES, WHOLEWHEAT CRACKERS, WHOLEMEAL/FRUIT SCONES, CRISPBREADS SCORE GUIDE Rarely or never eat. Or eat sugar coated cereal e.g. Frosties Rarely or never eat Rarely or never eat Less than once a week Less than once per week Rarely or never Cornflakes Rice Crispies Cheerios Special K Eat potatoes, white rice or pasta most days 1-2 times per week 1-3 times per week 1-3 times per week 1-3 times per week Bran Flakes Weetabix Shredded Wheat Muesli Shreddies Porridge Eat potatoes in jackets, brown rice or pasta most days Three times per week or more Daily Daily Daily YOUR TOTAL SCORE - Write your score here 0 12 Increase your fibre Good 18+ Excellent

79 MSQ Name.. Address. Date of Birth.. Unit No. APPENDIX 11 INSTRUCTIONS: Ask questions 1 10 in this list and record all errors. Ask question 4A only if the patient does not have a telephone. Record the total number of errors based on 10 questions. Fully date and sign each entry. 1. What is the date today? (d-m-y) DATE DATE DATE DATE DATE 2. What day of the week is it? 3. What is the name of this place? 4. What is your telephone number? 4a What is your street address? (ask only if no telephone) 5. How old are you? 6. When were you born? 7. Who is the Prime Minister? 8. Who was the previous Prime Minister? 9. What was your mother s maiden name? 10 Take 3 away from 20 and keep taking 3 from each new number you get, all the way down. TOTAL ERRORS: Administered by:. 0-2 errors intact intellectual function 3-4 errors mild intellectual impairment 5-7 errors moderate intellectual impairment 8-10 errors severe intellectual impairment

80

81 APPENDIX 12