Bowel Assessment and Management (Adults, … · Web viewThe Bowel Assessment and Management Procedure describes practices which will be performed by nurses, midwives, medical officers,

CHHS15/051

Canberra Hospital and Health ServicesClinical ProcedureBowel Assessment and Management (Adults, Adolescents, Children, Infants and Neonates)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Bowel assessment..................................................................................................2

Section 2 – Constipation...........................................................................................................3

Section 3 – Administration of rectal suppository......................................................................5

Section 4 – Administration of enema........................................................................................6

Section 5 – Bowel washout – Adults.........................................................................................7

Section 6 – Bowel washout – Babies (Centre for Newborn Care).............................................9

Section 7 – Flatus tube insertion – Adults...............................................................................11

Section 8 – Manual evacuation of faeces................................................................................12

Section 9 – Bowel management for patients in the community.............................................14

Section 10 – Bowel protocol for enteral and oral fed patients in Intensive Care Unit (ICU). . .15

Section 11 – Instaflo® Bowel Management System – Intensive Care Unit..............................16

Implementation...................................................................................................................... 20

Related Policies, Procedures, Guidelines and Legislation.......................................................20

References.............................................................................................................................. 20

Definition of Terms................................................................................................................. 22

Search Terms.......................................................................................................................... 22

Attachments............................................................................................................................23

Attachment 1: Laxatives and aperients used in adults........................................................24

Attachment 2: Bristol Stool Chart.......................................................................................26

Attachment 3: Neonatal bowel washout............................................................................27

Attachment 4: Instaflo® troubleshooting guide..................................................................29

Attachment 5: Instaflo® Product Features..........................................................................31

Doc Number Version Issued Review Date Area Responsible PageCHHS15/051 1.0 December 2014 December

2019RACC Community Care

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

The purpose of this procedure is to provide clinicians with information on the safe and effective bowel management of patients in the hospital and in the community setting.

This procedure provides clinicians with best practice information for assessment and management of patients with bowel issues and for educating and supporting patients and their carers.

Scope

The Bowel Assessment and Management Procedure describes practices which will be performed by nurses, midwives, medical officers, physiotherapists and dietitians. New staff or students (within their defined scope of practice) will be required to perform these skills under the direct supervision of a competent practitioner.

Nurses, midwives, medical officers, physiotherapists and dietitians providing assessment, education and clinical procedures must have current theoretical and clinical knowledge in bowel management.

Assistants in Nursing (AINs) who have received training and are assessed as competent are able to perform bowel care procedures under the direction of a registered nurse for a designated patient in the community.

The general principle of management in a bowel routine is to provide predictable and effective elimination and reduce evacuation problems and gastrointestinal complications.

Bowel management is multidimensional and requires a multidisciplinary approach. Referrals to dietitians, physiotherapists, occupational therapists and specialist medical services can provide additional advice and interventions to assist in promoting effective bowel management. Consider referral to these services for patients who have poor nutritional status, poor mobility and activity levels or sudden changes in bowel function.

Section 1 – Bowel assessment

Prior to intervention, a detailed bowel assessment is required in order to identify the patient’s history and contributing factors to bowel dysfunction. Bowel assessment tools can be found on the Clinical Record Forms Register.

Physical examinations can include: abdominal examinations - including bowel sounds, distension, masses, tenderness,

rigidity



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Rectal examination- inspection and palpation for masses, anal and perianal fissures, haemorrhoids, bleeding, prolapse, hard stool, anal and sphincter tone

Commence daily bowel record chart (for 14-28 days) to assist with assessment.Document assessment and formulate action plan.

Adverse findings are to be referred to a medical officer for further investigations.

For assessment and management of faecal incontinence see Continence Assessment and Management Clinical Procedure (insert link).

Consider referring patients (adults and children) with constipation, faecal incontinence and other bowel issues to the Community Care Continence Service (via Community Health Intake - ph 62079977) on discharge from hospital.

Back to Table of Contents

Section 2 – Constipation

Constipation refers to difficulty or straining and infrequent bowel movements over an extended period of time. Symptoms associated with constipation include hard/dry stool, bloating and abdominal pain accompanied with a sense of incomplete evacuation.

Initial management of constipation is recommended as a combination of diet, fluids, exercise and good toileting habits.

Diet, fluid and exercise Adults (19 years and over):

o Diet should contain 25-30 g of fibre from a variety of sources. A gradual increase in fibre is recommended. As fibre is increased, fluid intake must also be increased to 2 litres per day.

o Total fluid intake should be between 2.1 L (female) to 2.6 L (male) per day, unless otherwise specified by the patient’s medical officer. Encourage patients to take regular amounts of fluid throughout the day, extra fluid is recommended in summer.

Children:o Adequate intake of dietary fibre for infants, children and adolescents can be found

on the National Health and Medical Research Council website (http://www.nrv.gov.au/nutrients)

o Recommended daily fluid intake is approximately 50-60mL/kg/day (water, juice, cordial) plus fluids from other sources.

Refer to a Dietitian for assessment as appropriate. For patients with spinal cord injury, the amount of fluid needed to promote optimal

stool consistency must be balanced with the amount needed for bladder management. Adult patients with urinary catheters may drink 2 to 3 litres maximum per day. Adult



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patients who do intermittent self-catheterisation may require less fluid to fit with their individual program, normally around 2 to 2.5 litres per day.

Encourage regular exercise. Patients with mobility impairments may benefit from exercises such as pelvic tilt, low trunk rotation and single leg lifts.

Refer to Physiotherapist for mobility assessment and strengthening exercises as appropriate.

Alert: Increasing dietary fibre for the treatment of constipation in end-of-life patients can compound the problem. Use of softeners and/or stimulants should be considered.

Toileting Activities Encourage a prompt response to the call to stool, going to the toilet at a regular time

each day, eating or drinking approximately 30 minutes prior to toileting to stimulate the gastrocolic reflex.

An upright position is recommended during defaecation. Encourage patients to sit with both feet supported, on a footstool, lean forward with straight back and rest elbows on knees. Without straining, relax and widen the back passage, advise patients not to hold their breath. When finished, advise the patients to draw up their back passage firmly.

Where a patient is unable to sit, a left side-lying position while bending the knees and moving the legs toward the abdomen is recommended.

Patients with mobility impairments (and at risk of pressure areas) must have a padded toilet seat or commode, with backrest, footrest and side rails.

Refer to Occupational Therapist and/or Independent Living Centre as required for assistance and advice.

Pharmacological interventions Laxatives/aperients are useful for short-term treatment of acute constipation, and may

only be recommended for long-term management of constipation by medical staff. If organic disease is not the cause of constipation, pharmacological treatment is appropriate on a short-term basis. It should be considered only after non-pharmacological interventions have been unsuccessful (information on laxatives/aperients used in adults can be found in Attachment 1).

When administering rectal medication monitor the patient and check the effectiveness of the medication.

Surgery Usually reserved for severe intractable disease resulting from slow colonic transit, the

most common procedure is a subtotal colectomy and ileo-rectal anastomosis or colectomy resulting in permanent stoma.

Patient /carer education Educate patients/carers about Wide range of normal bowel routines and symptoms related to abnormal bowel

evacuation Diet, fluids, exercise and good toileting habitsDoc Number Version Issued Review Date Area Responsible PageCHHS15/051 1.0 December 2014 December


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Safe and correct use of laxatives - encourage consultation with GP Change in bowel habits - significant or prolonged change in bowel habits should be

reported to the patient’s GP Safe, effective use of aids and equipment.


Section 3 – Administration of rectal suppository

A suppository is inserted into the rectum and dissolves at body temperature. Suppositories assist in the evacuation of faeces from the rectum; or are used to administer medication for absorption through the rectal wall.

Equipment Suppository Water- soluble lubricant (eg KY gel or if patient is at risk of Autonomic Dysreflexia use

lignocaine 2% gel, 5 minutes prior to procedure) or water for glycerin suppository Bedpan, commode or toilet Disposable protective pad - blue sheet Personal protective equipment (PPE), disposable gloves, gown and safety eyewear

Procedure 1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)2. Inform patient of the procedure and obtain consent3. Ensure client has emptied bladder to prevent discomfort4. Ensure privacy and reduce anxiety5. Perform hand hygiene by either hand washing or using alcohol based hand rub (ABHR),

don PPE6. Assemble equipment 7. Assist the patient to adopt the left lateral position (to facilitate contact with rectal

mucosa for effective bowel action) with knees flexed, and blue sheet in place 8. Drape the patient with a sheet or blanket, withdraw sheet to expose the anal area. 9. Don gloves and use generous amount of lubricant 10. Perform Digital Rectal Examination (DRE)11. Remove wrapping and lubricate suppository and insert beyond the anal sphincter and

against the rectal mucosa 12. Encourage patient to retain suppository for 15-20 minutes lying in the left lateral

position 13. Assist patient onto bedpan, commode or toilet if necessary14. Observe the amount and nature of the bowel motions (use Bristol Stool Chart as a

guide) 15. Undertake DRE if in doubt to assess outcome16. Discard waste appropriately 17. Remove gloves and other PPE18. Perform hand hygiene



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19. Document in clinical record


Section 4 – Administration of enema

An enema is introduced into the rectum or lower colon with the purpose of producing a bowel action or instilling medication.

There are two main types of enemas: Evacuant: Used to evacuate the bowel. They may be small or large volume and are

usually commercially prepared Retention: A solution used primarily for local effects, to be retained for a specific period

Equipment Appropriate enema at room temperature Water- soluble lubricant (e.g. KY gel or if at risk of Autonomic Dysreflexia use lignocaine

2% gel, 5 minutes prior to procedure) or water for glycerin suppository Bedpan, commode or toilet Disposable protective pad - blue sheet Protective equipment (PPE)

Procedure 1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)2. Inform patient of the procedure and obtain consent 3. Ensure patient has emptied bladder, to prevent discomfort4. Ensure privacy and reduce anxiety5. Perform hand hygiene, don PPE6. Assemble the equipment7. Assist the patient to adopt the left lateral position (to facilitate contact with rectal

mucosa for effective bowel action) with flexed knees and blue sheet in place 8. Drape the patient with a sheet or blanket, withdraw sheet to expose the anal area9. Don gloves and use generous amount of lubricant 10. Perform Digital Rectal Examination (DRE)11. Remove cap from enema and lubricate nozzle12. Encourage client to relax 13. Part the buttocks. Gently insert the enema tip 5cm into rectum14. Slowly squeeze content into rectum15. Maintain pressure on the enema tube to prevent flow back of liquid returning to the

tube while removing nozzle from rectum16. Encourage patient to retain enema for 15-20 minutes lying in the left lateral position17. Assist patient onto bedpan, commode or toilet if necessary 18. Observe the amount and nature of the bowel motions, use Bristol Stool Chart as a guide

(see Bristol Stool Chart in Attachment 2)19. Undertake DRE if in doubt to assess outcome



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20. Discard waste appropriately 21. Remove gloves and other PPE22. Perform hand hygiene 23. Document in clinical record


Section 5 – Bowel washout – Adults

Bowel washouts are performed with the purpose of: Stimulating peristalsis and remove faeces or flatus Cleanse the colon and rectum in preparation for an examination or a surgical procedure Remove toxins from the large intestine Soften faeces and lubricate the rectum and colon

Equipment Bowel washout solution as ordered Irrigation set (can, rubber tubing, and clamp) or coloplast irrigation set Medium medium connector‐ Disposable rectal catheter or short length, female Foley’s catheter Lubricant Personal protective equipment (PPE) including, clean gloves, gown and protective

glasses, goggles or shield Absorbent underpad Clinical waste receptacle General waste receptacle Bedpan or commode Intravenous (IV) pole/stand

Procedure 1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)2. Explain the procedure and obtain consent3. Ensure Privacy4. Perform hand hygiene, don PPE 5. Assist the patient to assume the left lateral position6. Cover the patient with a sheet7. Attend hand hygiene by either hand washing or using ABHR, don PPE8. Prepare equipment9. Ensure the solution is at body temperature10. Connect the can, rubber tubing and rectal catheter or coloplast irrigation set11. Suspend the can from the IV pole for priming12. Attend hand hygiene by either washing hands or using ABHR 13. Don clean gloves14. Inspect the anus for the presence of haemorrhoids, bleeding or irritation15. Pour approximately 240mL of solution into the can



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16. Expel air from the tubing, then clamp17. Apply lubricant to the catheter (liberally)18. Ask the patient to breathe deeply19. Part the buttocks20. Inform the patient when the catheter is inserted21. Gently introduce the rectal catheter approximately 7-10cm into the rectum22. Allow the solution to flow into the rectum, holding the can 30-45cm above the level of

the patient’s buttocks

Note: If the patient complains of pain, exhaustion or great discomfort during the procedure, cease the flow of solution for a few minutes then slowly recommence. Hold the irrigation can no higher than 44cm above the level of the patient’s buttocks.

23. When the solution has been instilled into the rectum, clamp the tube24. Disconnect the can and hold the tube over the bedpan, unclamp the tube25. When the solution flow ceases, clamp the tubing26. Reattach the can and repeat the procedure with a further 240mL of solution27. Continue the procedure until the return is clear28. When the last of the solution has been siphoned from the rectum, remove the catheter29. Clean the anal area30. The patient may sit on a bed pan31. Discard disposable equipment and gloves into clinical waste receptacle32. Attend hand hygiene by either washing hands or using ABHR33. Disassemble equipment34. Clean appropriately35. Remove safety glasses or goggles and gown36. Perform hand hygiene using either soap and water or ABHR37. Observe amount and nature of return38. Document on the patients medication chart39. Document in clinical record:

Amount of solution instilled Patient’s reaction to the procedure Amount and nature of return




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Section 6 – Bowel washout – Babies (NICU/Special Care Nursery)

NOTE: This is a guide only and will vary between guidelines from Paediatric Surgeons

This procedure is used for rectal or distal stoma washouts:1. To clean the distal portion of the bowel, decompress the bowel and deflate the

abdomen by removing air and faeces. Bowel washouts facilitates surgery and has been shown to prevent or reduce the risk of post operative enterocolitis and as such can be used as a mode of temporary management in proven cases of Hirschsprung’s until definitive surgery – which may be 4 – 12 weeks depending on each case.

2. To relieve low intestinal obstruction due to meconium plug, meconium ileus or intestinal dysmotility of prematurity

Assessment:Physical: Assess and record any signs of bowel obstruction. These include: Vomiting – note the frequency, colour and amount. Is it bile stained?

NOTE: Green bile staining indicates bowel obstruction, if present notify medical team immediately.

Abdominal distension o Is the abdomen tight or shiny?o Determine and record degree of distension of the abdomen prior to performing

bowel washout Bowel action

o Time since last bowel actiono Note – frequency, consistency, colour and +/- blood

Equipment Trolley 60 mL catheter tip syringe Sodium Chloride 0.9% or solution as prescribed – warmed to body temperature Nelaton urine catheters – soft – less likely to damage mucosa (do not use nasogastric

tubes with weighted tips) Lubricating gel Kidney dish Disposable wipes Disposable gloves Disposable sheet Nappies Clinical waste receptacle Alcohol based hand rub

Procedure Medical orders for the bowel washout must be written clearly on the patient’s care plan by the surgical team or Neonatologist. Orders should be clearly documented and include:Doc Number Version Issued Review Date Area Responsible PageCHHS15/051 1.0 December 2014 December


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Frequency Size and length of catheter to be inserted (see table below) Volume of sodium chloride 0.9% to be used – maximum per procedure 20mL/kg Administer acetylcysteine if required, according to medical order

For babies with Hirschsprung’s disease a catheter will be inserted and taped insitu by the Paediatric surgeon. Note length of catheter on return to ward. Do not remove the catheter, notify surgeon if there is any change in the length or if the catheter is dislodged.

Weight Size (Guide only-please refer to Paediatric surgeon notes)

Length to be inserted

Less than 2 kg Size 8 FG Feeding tube or Nelaton

2 – 3 cm

Greater than 2 kg Size 8 FG Feeding tube or Nelaton

5 cm

1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. Explains procedure to parent and gain consent3. Position the infant on back with legs in a frog position on a clean nappy and disposable

sheet4. Prime the catheter with sodium chloride 0.9% or other solution as prescribed5. Lubricate the tip of the catheter with lubricating gel6. Gently insert catheter into rectum or into distal stoma

Do not use excessive force if resistance is felt7. Instil solution in 10 –20 mL aliquots over 1-2 minutes. There should be no resistance

while injecting the sodium chloride 0.9%Do not pull back on syringe to aspirate. Allow the sodium chloride 0.9% to run out naturally

8. Remove syringe and let fluid run into nappy / kidney dish9. Repeat procedure until return is clear10. Remove catheter 11. Ensure infant is left clean and dry12. Discards all waste in bin13. Attend hand hygiene following procedure by either hand washing or using ABHR14. Document the results of bowel washout on fluid balance chart, the bowel washout care-

plan and in the patient’s notes 15. Report abnormal findings immediately16. Watch for signs of increasing abdominal distension, tenderness and any features

suggestive of perforation17. In preterm infants there is a risk of re-absorption of sodium chloride 0.9%, especially if

most of the solution is not expelled

NOTE: Use only sodium chloride 0.9% solution – the use of other solutions or concentrations in this patient group may be dangerous.May need regular monitoring of serum sodium as there is a risk of reabsorption especially in preterm infants.



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Section 7 – Flatus tube insertion – Adults

A flatus tube can be inserted to relieve abdominal distension due to flatus. The insertion of a flatus tube will be prescribed by a Medical Officer. The procedure can be performed by a: Medical Officer. Registered Nurse. Enrolled Nurse. Student under the direct supervision of a Registered Nurse.

Rectal stimulation can cause bradycardia due to vagal nerve stimulation, assess the patient’s heart rate before, during and after the procedure.

Equipment Rectal tube Lubricant Disposable dish Disposable protective pad - blue sheet Draw sheet Protective glasses, safety goggles or shield Tape measure

Procedure 1. Check Medical Officer order 2. Inform patient of the procedure and obtain consent 3. Ensure privacy4. Perform hand hygiene, don PPE5. Prepare equipment6. Measure abdominal girth7. Assist the patient to assume the left lateral position, with underpad in place. Cover the

patient with a drawsheet8. Attend hand hygiene9. Assess the patient’s pulse before examination10. Don gloves and protective glasses11. Expose the anal area and inspect for haemorrhoids, bleeding or irritation12. Lubricate the tip of the rectal tube13. Place the distal end of the tube underwater14. Position the dish near the anal area15. Encourage the patient to breathe deeply16. Part the buttocks and gently insert the rectal tube approximately 5-8cm into the rectum17. Leave the rectal catheter in place for the prescribed time18. Observe for air bubbling and reduction in abdominal distension

NOTE: Cease the procedure if the patient experiences pain. The rectal catheter can be left in place for a maximum of 20 minutes only



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19. Remove the rectal catheter once the air bubbles cease20. Clean the anal area21. Discard equipment, remove gloves, attend hand hygiene22. Measure abdominal girth23. Ensure patient is left comfortable24. Assess the patient’s pulse after examination25. Document in clinical record:

o Record results of flatus tube insertiono Note the patient’s level of comfort/discomfort post procedureo Measure and record decrease in abdominal distension


Section 8 – Manual evacuation of faeces

Manual evacuation may be used for patients with lower motor neurone bowel dysfunction (e.g. spinal cord injury (SCI) below T12) as destruction of the sacral reflex defecation centre results in loss of defecation reflex. In patients with lower motor neurone bowel dysfunction (areflexic bowel) the main goal is to encourage a firm, formed stool that can be retained between bowel care sessions and easily evacuated.

In those patients with a spinal cord injury above T6 manual evacuation may need to be attended if the patient is experiencing an episode of Autonomic Dysreflexia and the cause of Dysreflexia is an overextended rectum/full lower bowel. Extreme caution and specific interventions are required as per the ‘Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crisis) In Spinal Cord Injury’, the algorithm can be accessed via the link: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#zoom=100

Manual Evacuation may need to be attended when impacted stool in the rectum is unable to be removed in any other way. This is sometimes required for patients with neurogenic bowel changes associated with diseases such as Multiple Sclerosis and Parkinson’s disease.

In other patients (patients without neurogenic bowel dysfunction), manual evacuation of faeces is seen as a last resort management where all other methods of bowel evacuation have failed.

Manual removal also may be needed to remove stool prior to the insertion of a suppository or enema for the medication to be effective.

In consultation with the Medical Officer, establish that there are no contraindications that may place patients ‘at risk’. Examples include, but are not limited to: Cardiac conditions with arrhythmias (stimulation of the vagus nerve in the rectal wall

can slow the patient’s heart rate) Bowel perforation, rectal bleeding or anal fissures Distress, pain, discomfort, bleeding or anti clotting medication Recent rectal/anal surgery or trauma



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Equipment Water- soluble lubricant (for patients with spinal cord injury at or above T6 use

lignocaine 2% gel, 3-5 minutes prior to procedure) Personal protective equipment (PPE), disposable gloves, gown and safety eyewear Disposable protective pad - blue sheet Bedpan or collection container

Procedure 1. Inform patient of the procedure and obtain consent 2. Ensure that patient has emptied bladder3. Ensure privacy 4. Perform hand hygiene, don PPE5. Assist the patient to adopt the left lateral position with knees flexed, and blue sheet in

place 6. Drape the patient with a sheet or blanket and withdraw sheet to expose the anal area.

Don gloves.7. Lubricate index finger and anus generously with lubricating gel8. Encourage patient to relax (breathe regularly)9. Part buttocks and insert the gloved finger into the rectum slowly and gently10. If stool is solid mass, push finger into the centre, split it and remove small sections until

none remains. If small hard stool, remove a lump at a time.11. Patients may assist by performing valsalva manoeuvre. Patients with areflexic bowel or

lower motor neurone bowel dysfunction may respond to the Valsalva manoeuvre during manual removal to assist with bowel emptying. (Valsalva manoeuvre is holding the breath and forcibly trying to exhale against a closed glottis, thereby creating raised intra-abdominal pressure and a bearing-down effect)

12. Document in clinical record

NOTE: Valsalva manoeuvre should not be performed on a patient with a full bladder due to risk of vesico-ureteric reflux. It is also contraindicated for individuals with cardiac problems and hypertension.With prolonged straining, valsalva can also predispose to haemorrhoids and rectal prolapse over time.


Section 9 – Bowel management for patients in the community

Routine bowel care is not a clinical service provided by the ACT Health, RACC, Community Care Program (CCP) Nursing Service as it is considered an ‘activity of daily living’. Non Government Organisations provide routine bowel care as part of a personal care package.

An exception to this are Assistants in Nursing (AINs) employed by ACT Health, RACC, who provide personal care for a ventilator dependent patient in the community. AINs in the community attend to bowel care under the direction of a registered nurse.



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CCP nurses offer assessment, advice and review of bowel regimes. CCP nurses will only administer short-term rectal medication if a medical order is in place and will only perform digital rectal examination for the purpose of assessment.

The left lateral position is recommended for most bowel interventions. Where there is a clinical reason why the left lateral position can’t be adopted by the patient, an alternative safe ergonomic recommendation is to be implemented following manager approval. The recommended procedure is to be clearly documented in the care plan and progress notes

CCP nurses should consult with the CCP Continence Clinical Nurse Consultant (CNC) as required.

When caring for patients with a spinal cord injury at or above T6 community nurses will ensure the patient and their carers are educated about the risk factors, signs and symptoms of autonomic dysreflexia. The admitting nurse will ensure that an appropriate management plan is in place for bladder and bowel care, and that medical orders for catheter insertion and medication administration are documented in the patient file. The emergency management plan will be documented in the patient’s file and the patient and their carers are made aware of the plan.

The ‘Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crisis) In Spinal Cord Injury’ is followed in the event of Autonomic Dysreflexia and can be accessed via the link: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#zoom=100

In those patients with a spinal cord injury above T6, manual evacuation may need to be attended to if the patient is experiencing an episode of Autonomic Dysreflexia and the cause of the Dysreflexia is an over distended rectum/full lower bowel. Extreme caution and specific interventions are required to manage this and the ‘Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crisis) In Spinal Cord Injury’ must be followed.


Section 10 – Bowel protocol for enteral and oral fed patients in Intensive Care Unit (ICU)

This protocol does NOT apply to the following patients: Those with signs and symptoms of bowel obstruction (abdominal discomfort and

distention, nausea and vomiting) Those excluded by the ICU medical team Recent gastro intestinal surgery Spinal injury patients



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Procedure 1. Once enteral or oral diet has been started consult doctor to prescribe: Macrogol 3350 (Movicol®) ONCE daily (dissolved in 125 mL water) Docusate/senna 50mg/8mg (Coloxyl® & Senna) TWO tablets TWICE daily 40mL warm water THREE times daily via enteral tubeIf bowels open within 3 days of commencing protocol continue step 1 If bowels NOT open within last 3 days on protocol progress to step 2

2. Rectum Full Continue step 1 and consult doctor to prescribe: ONE bisacodyl and TWO glycerin suppositoriesIf bowels open go back to step 1If bowels NOT open within 24 hrs go to step 3

Rectum emptyContinue step 1Observe for signs & symptoms of bowel obstructionInform doctor regarding unopened bowels & empty rectum

3. Continue step 1 and consult doctor to prescribe phosphate enema (Fleet® Enema)If bowels open return to step 1If bowels NOT open within 24 hrs go to step 4

4. Consult doctor for repeat phosphate enema (Fleet® Enema) and increased aperients +/- manual evacuationIf bowels opened return to step 1If bowels NOT open continue step 4 every 24 hrs until bowels have opened

DiarrhoeaIf diarrhoea occurs (3 large liquid stools within 24 hours) withhold oral aperients for 24 hours then recommence bowel protocol at Step 1.If diarrhoea persists cease macrogol 3350 (Movicol®) and then reduce docusate/senna 50mg/8mg (Coloxyl® & Senna) to 2 tablets ONCE daily.

Record frequency & type of bowel motion in Metavision on the ICU flow chart and the fluid balance chart, using the Bristol Stool Chart (see attachment 2)


Section 11 – Instaflo® Bowel Management System – Intensive Care Unit

The Instaflo® Bowel Management System is used in the Intensive Care Unit when patients are assessed as having Bristol type 7 (watery) stools.

The Instaflo® aims to:



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reduce excoriation from faecal incontinence prevent risk of infecting wounds (e.g. pressure ulcers, burns, grafts) reduce the risk of infection to other patients and health care professionals

A medical officer must prescribe the use of the Instaflo®.

The registered nurse must perform an initial assessment to determine if the patient meets criteria for use of the Instaflo. The following indications and contraindications will be considered:

Indications patients requiring faecal diversion for the protection of wounds, burns, flaps or grafts patients with infectious stool (eg. VRE, MRSA, C. difficile) minimising risk of excoriation from faecal incontinence in diarrhoea not controlled by

medical therapy

Contraindications The bowel management system should not be used for patients who have had previous

colorectal surgery involving an anastomosis, or who have had any rectal surgery or recent anal or sphincter reconstruction

Do not use for the patient with impacted stool Do not use if the patient’s distal rectum cannot accommodate the inflated volume of the

retention cuff or if the distal rectum/anal canal is severely strictured secondary to tumour, inflammatory condition, radiation injury or scarring

Do not use for patients who have a known sensitivity or allergy to the materials used in the device

Before using The Instaflo® The bowel management system should be ordered by a medical officer and documented

in the patient’s medication chart and medical notes The bowel management system is available in 2 catheter sizes either 4cm or 6cm (6cm is

the most frequently used adult size) The colon and rectum should be clear of all stool/faecal matter prior to insertion of the

bowel management system

ALERT:A stool management protocol should be in place for patients who have had insertion of the bowel management system for skin/wound protection. This is to ensure that the stool remains soft enough to ensure flow and prevent blockage until such time that contamination is not longer a risk.The protocol will be ordered by the medical team and reviewed daily.

Tips for inserting the Instaflo® The catheter tip is folded and inserted into the rectum and attached to a large capacity

drainage bag via a wide flexible connector tubing



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The retention cuff (Blue Connector) is inflated with water, after insertion of the catheter, to provide retention of the catheter in the rectum

A flush/sample port is located on the drain tube and provides access for catheter flushing and stool sampling. (see picture below)

If stool is not flowing into the catheter, irrigate the catheter. Fill the Luer syringe with water, connect the syringe to the CLEAR connector (IRRIG), and slowly depress the plunger. WARNING: Verify connection to correct catheter connector

Precautions during use If patients develop rectal bleeding, assess for pressure necrosis from the catheter then

discontinue use Patients with weak sphincter function may expel the catheter or may have increased

leakage of stool Do not insert anything into the anal canal with the catheter such as suppositories or

thermometers Do not allow ointments that contain petroleum (e.g. Vaseline®) to come into contact

with catheter as they may damage the catheter The following adverse events may be associated with the use of any rectal device:

o Infectiono Leakage of faecal contento Perforationo Pressure necrosiso Obstruction or loss of sphincter tone

Equipment Instaflo® bowel management system (Catheter kit which includes silicone catheter,

collection bag, inflation syringe, and lubricant) Personal protective equipment (PPE) gown, gloves, goggles (additional protective

equipment may be required for patients with infective faeces) Extra water soluble lubricant Yellow contamination waste bag Humidified water/sodium chloride 0.9% and plain IV giving set/ enteral feeding set for

irrigation of the rectumProcedure1. Explain the procedure to the patient, where plausible obtain consent, provide pain relief

if necessary2. Attend hand hygiene, put PPE on. It is advisable to double glove for the rectal

examination3. Place patient in left lateral position4. Examine the rectum for faecal impaction and clear any stool present. Feel for any mass,

lesion or stricture which may preclude the use of the device. Check the length of the anal canal during rectal examination, as this will determine catheter size. Typically, most patients will require a 6cm catheter but a short anal canal will necessitate a 4cm catheter (which must be ordered specifically)



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5. Prior to use, verify proper inflation and deflation of catheter cuff and balloon and check patency of the irrigation lumen

6. Connect end of catheter drain tube to collection bag and twist clockwise to lock in place. Clamp and secure collection bag drain tube. Insert drain plug

7. Lubricate the end of the catheter well and fold in half8. Grasp the lubricated catheter directly behind the retention cuff with double lumen

connector tubing oriented anteriorly. At the time of maximum sphincter relaxation, insert the balloon end of the catheter into the distal rectum. Maintain anterior orientation of double lumen connector tubing throughout insertion

9. Fill retention cuff via blue connector with 35-40mL of water. Disconnect the syringe10. Confirm catheter is tension free11. Secure catheter, by anchor straps to the patient’s buttocks (Use hydrocolloid strip to

protect skin then use tape to anchor straps)12. Hang catheter bag so that the catheter drain is not twisted or kinked13. Use sheet clip to secure drain tube14. If patient’s condition permits, tilt the whole bed slightly upward, as this encourages

drainage by gravity

Confirming PlacementTo confirm placement, gently tug and release to seat the cuffIf no noticeable stool is in the fluid draining from the patient, alternately squeeze and release the drain tube to manually douche the patient. This may help break up the large stool piece. Refer to “Insertion of the Instaflo®” to clarify how to irrigate

The Instaflo® should be flushed at least twice a day.1. If tolerated, position the patient’s bed to enable retention of fluid in rectum (i.e. foot end

of bed elevated approx 20-30 degrees. The patient’s head can remain slightly elevated. If using an inflated air mattress, inflate to maximum level. The patient will remain in this position for the duration of the irrigation. Placing the patient in the left lateral position during irrigation may improve fluid retention

2. Verify that the drainage bag can hold another 2 litres of fluid. If not empty bag prior to commencing irrigation

3. Fill irrigation bag with 100mL of luke warm water and hang 1 metre above anus4. Connect irrigation bag administration set (IV giving set) to white capped clear connector5. Open flow control valve on irrigation bag and allow fluid to drain by gravity into the

rectum and colon6. Open flow valve on irrigation bag and allow fluid to drain by gravity into the rectum and

colon. If fluid leaks around the tube, gentle traction on the drain tube may reduce leakage. If leakage persists, check the retention balloon (BLUE connector) volume and add another 10mL of air to the retention. DO NOT EXCEED 40MLS

7. If possible leave the irrigant fluid in situ and patient in position for 5-10 minutes8. Connect syringe to the blue connector and completely aspirate the 20mL of air and allow

irrigant to drain9. After irrigation is complete, disconnect administration set from white capped port and

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10. Return patient to pre procedure position11. Milk all remaining faeces and irrigant from the catheter

Ongoing Maintenance1. Strictly adhere to stool modification plan and irrigation protocol2. Ensure that the tapes are securely attached to patient’s buttocks at all times (White ETT

tape may be tied around the patient’s hips if the buttocks are excoriated)3. Ensure there is no excessive prolonged traction on the catheter or that the catheter is

not occluded due to twisting or patient lying on the tube4. Inspect the catheter near the anus to ensure that stool or irrigation fluids are not sitting

in the catheter. If present milk the drainage tube5. Assess patient’s perineal region for mucous or stool leakage, if present clean6. Excessive leakage may be secondary to catheter occlusion with stool. Catheter removal

and reinsertion may be required7. Flush tubing if required with 50mL of water to prevent faeces building up in the tube8. Verify retention cuff volume every 7 days by aspirating all of the water from the cuff and

perform a digital examination of the rectum9. Document observations on GIT tab on MetaVision to ensure continuity of care (previous

name Zassi)10. Change catheter every 29 days11. Please see attachment 1 for trouble shooting ideas if there are any concerns

Catheter Removal1. Explain the procedure to the patient2. Apply gloves, goggles and gown3. If tolerated, place the patient in a left lateral knee-chest position. Pain relief may be

required prior to position change4. Deflate catheter retention cuff by connecting syringe to (Labelled CUFF) and aspirating all

water from retention cuff. Disconnect syringe. Verify deflated state of retention cuff by confirming pilot balloon collapse

5. Ask the patient to push down gently to expel the catheter6. If catheter does not come out easily, repeat steps after applying water-soluble lubricant

to anal canal7. Perform a visual inspection of the rectum post removal

For Instaflo® troubleshooting guide and product features - see attachment 4 and 5.


Implementation

This procedure will be communicated to relevant staff via team meetings, and will be incorporated into existing education and training programs.




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Related Policies, Procedures, Guidelines and Legislation

Nursing and Midwifery Continuing Competence Policy and Standard Operating Procedure, Document Number DGD12-050

Autonomic Dysreflexia Community Care Program Standard Operating Procedure, Document number CHHS13/250

CHHS Clinical Procedure: Continence Assessment and Management, Document Number CHHS14/033


References

1. Australian and New Zealand Spinal Cord Society (ANZSCOS), September 2010

2. Chew, S. Peer reviewed Clinical Update: Obstructed Defaecation Australian and New Zealand Continence Journal, Volume 13 Number 2. 2007.

3. Clinical Guidelines for Digital Rectal Examination, Manual Removal of Faeces and Insertion of Suppositories /Enemas for Adult Care only. NHS.2012.

4. Coggrave, M. Transanal Irrigation for bowel management, Nursing Times. 2007.

5. Coggrave, M. Norton, C. The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury:

International Spinal Cord Society 48,504-510. 2010.

6. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Neurogenic Bowel Management In Adults with Spinal Cord Injury: Paralysed Veterans of America, Washington. 2010.

7. Emmanuel, A. Review of the efficacy and safety of transanal irrigation for neurogenic bowel dysfunction. International Spinal Cord Society. 48, 664-673. 2010.

8. Furusawa, K. Tokuhiro, A. and Sugiyama, H. Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. International Spinal Cord Society Cord 49, 49-54. 2011.

9. Goetz, L Transanal Irrigation or conservative bowel for clients with spinal-cord injury? Nature Clinical Practice Gastroenterology & Hepatology (4):256-257. 2007.

10. Treatment Algorithm for Autonomic Dysreflexia (Hypersensitive crisis) in Spinal Cord Injury. 2010. http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#zoom=100



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11. Kerr, J (Physiotherapist and Ergonomist). Ergonomic assessment of bowel care management in community setting, 2007.

12. Krassioukov, A. Eng, J. and Claxton, G. Neurogenic bowel management after spinal cord injury. International Spinal Cord Society 48 (10): 718-33. 2010.

13. Management of lower bowel dysfunction, including DRE and DRF Royal Collage of Nursing guidance for nurses 2012.

14. Namirah, J. Zone-En, L. and Olden, K. Diagnostic Approach to Chronic Constipation in Adults. American Family Physician. 2011. www.aafp.org/afp

15. National Guideline Clearinghouse, Practice Guidelines for the Management of Constipation in Adults. 2010.

16. Norton, C and Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield Publishers, Ltd., U.K.

17. Queensland Spinal Cord Injuries Service: Bowel Management Following Spinal Cord Injury. 2012.

18. Rogers, J. How to manage chronic constipation in adults. Nursing Times: 108 (41): 12, 14 16. 2012.

19. St. Mark’s Hospital and Academic Institute Bowel Control. Constipation. 2010.

20. The Joanna Briggs Institute. Management older Constipation for Older Adults. Best practice Vol 12(7):1- 2008.

21. McWilliams D, 2010, Rectal irrigation for patients with functional bowel disorders, Nursing Standard Vol 24, No 26 March.

22. Sutcu, S. The prevention and management of faecal incontinence. (2007). The Journal of Stomal Therapy Australia. (27)4. 10-11. Retrieved from: http://www.stomaltherapy.com/documents/JSTA_December_2007.pdf

23. Zassi Bowel Management System (2003) Instructions for Use, Fernandina Beach, USA.

24. The Royal Children’s Hopital Melbourne Clinical Guidelines: Bowel washout (Rectal). http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220. 17th October 2011.

25. National Health and Medical Research Council – Nutrient Reference Values for Australia and New Zealand (2006).

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http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220

http://www.stomaltherapy.com/documents/JSTA_December_2007.pdf

http://www.aafp.org/afp

CHHS15/051

Definition of Terms

Hirschsprung’s Disease: A rare disorder of the bowel, most commonly of the large bowel (sometimes called megacolon), where there is a lack of nerves, known as ganglion cells in the bowel wall. This prevents effective peristalsis and results in intestinal obstruction. It affects four times as many boys as girls with an increased incidence in infants with Down’s syndrome.

Meconium Plug: This condition is the most common and mildest form of mechanical distal obstruction of the newborn. Inspissated and immobile meconium causes a transient form of distal colonic or rectal obstruction. The aetiology of this disorder is unclear. It is most common in preterm infants.

Meconium ileus: The obstruction is mainly caused by thick tenacious meconium. This stick meconium is unable to be propelled through the intestine, usually the gut is not damaged and continuity is not disrupted. Meconium ileus occurs in 15% of infants with Cystic Fibrosis. In others the condition is associated with volvulus, atresia or perforation.


Search Terms

Bowel Washout, Rectal administration, Enema, Suppository, Flatus tube, Manual evacuation, Instaflo, Intensive Care Unit, Adults, Adolescents, Children, Infants and Neonates




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Attachments

Attachment 1: Laxatives and aperients used in adultsAttachment 2: Bristol Stool ChartAttachment 3: Neonatal Bowel WashoutAttachment 4: Instaflo® Troubleshooting guideAttachment 5: Instaflo® Product Features

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



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Attachment 1: Laxatives and aperients used in adults

Bulk forming laxatives e.g. bran, psyllium (Metamucil®), sterculia (Normacol®)

Act by retaining water and promoting microbial growth in the colon. This increases faecal bulk, which in turn stimulates peristalsis

Takes 48-72 hours to have an effect (due to transit time) so are not suitable for the treatment of acute constipation

Useful to help ensure regular bowel actions and avoid chronic constipation

Start with a small dose taken regularly and wait at least 2 or 3 days for signs of improvement. Increase gradually until an effective dose is reached

Bloating is the most common short-term side effect

Care must be taken when adding fibre to ensure adequate increase in fluids. Patients may develop spurious diarrhoea as a result of constipation and faecal impaction from an increase in fibre, and be misdiagnosed with diarrhoea and thus treated incorrectly, compounding the problem.Patients with actual or suspected intestinal obstruction, low fluid intake or swallowing difficulties should avoid these laxatives.

Stimulant laxativese.g. bisacodyl (Durolax®), (Bisalax®), senna (Senokot®),glycerin

Act on the nerve plexuses in the gut wall causing irritation and increasing peristalsis in the small and large bowel

Abdominal cramping may be increased if the stool is hard and a stool softener may be used in combination with this group

Takes 6 to 12 hours to act after oral administration or 15 to 30 minutes after rectal administration. Neurogenic bowel has a slower transit time so oral medication will often take longer to have an effect

In PR administration, the suppository must come into contact with the mucus membrane to ensure maximal effectiveness

A bisacodyl (Bisalax®) enema acts as a chemical stimulant to the bowel, stimulating reflex action, but may be damaging to the bowel with long-term use

A glycerin suppository acts as a very mild local stimulus and lubricating agent. It forms a gel that lubricates and softens the faeces allowing the stool to be evacuated with minimal side effects



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Faecal softenerse.g. docusate sodium (Coloxyl®), Liquid paraffin (Agarol®), Microlax® enemas

Act by lowering the surface tension of faeces, which allows water to penetrate and soften the stool. They may also have a weak stimulatory effect and are often given in combination with a chemical stimulant

For the drugs to be effective, the patient needs to drink at least 1 to 2 litres of fluid per day

Takes 24 to 48 hours for effect if taken orally or 15-30 minutes after rectal administration

A Microlax® enema liberates the water that is present in faeces. This action causes softening of the stool, resulting in easier elimination

Osmotic laxatives e.g. lactulose, sorbitol (Sorbilax®), macrogol 3350 (Movicol®, Osmolax®, ClearLax®)

Lactulose acts by lowering colonic pH through the generation of fatty acids and fermentation products. Faecal weight, volume and water are significantly increased. Fluid intake is important, as patients may become dehydrated. It is administered orally and may take from 24 to 48 hours to work

Macrogol 3350 (Movicol®, Osmolax® and ClearLax®) has an osmotic effect in the gut, causing a laxative effect. Each sachet should be dissolved in 125mL water

Are effective for the relief of chronic constipation and faecal impactionTolerated by patients with renal disease and impaired cardiac function

Saline laxativese.g. sodium phosphate enemas (Fleet®)

Have an osmotic effect causing an increase in intraluminal volume and also stimulate intestinal motility

Fast acting, resulting in bowel movements in 1 to 3 hours after oral administration

Sodium phosphate products are available for rectal enemas and take 5 to 15 minutes to work generally

Can be used to empty the large bowel prior to surgery or investigationCan cause electrolyte disturbances and dehydration

Sodium phosphate enema should not be used routinely for patient with spinal cord injuries.Any full size enema (Fleet®) used on a regular basis can cause problems with dependency. Patients may not be able to retain the enema for it to be effective, over distension of the bowel may stimulate Autonomic Dysreflexia.



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Attachment 2: Bristol Stool Chart



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Attachment 3: Neonatal bowel washout

NEONATAL BOWEL WASHOUT (rectal or distal stoma)

DATE: ______________________________________________________________

DIAGNOSIS: ________________________________________________________

AIM: To relieve distension and allow regular passing of stools

Recommendations Medical Orders (please fill in blanks or circle appropriate order)

Medical Officers initials

Frequency Daily BD TDS Other: ______

Location – via rectum or distal stoma

rectum distal stoma

Size and depth of soft Nelaton urine catheter< 2 kg 10 FR – 2 – 3 cm> 2 kg 12 FR – 5 cm

(Or 8FR feeding tube if Nelaton urine catheter unavailable)

as per Paediatric surgeon instructions

< 2 kg = 10 FR approx 2-3 cm

> 2 kg = 12 FR approx 5 cm

Other: ________________________

Amount of sodium chloride 0.9% (warmed to body temperature)Total = Maximum of 10 mL/kg

Neonates weight _________ x 10mL/kgAdminister in 5-10 mL aliquots

Other Solution/s: __________________Amount: ________________________

Neonatologist/Surgeon/Medical Officer signature: ________________________



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RESULT:Amount: __________________________________Colour: ___________________________________Consistency: _______________________________Abdominal appearance pre and post procedure:Pre: ________________Post: __________________

Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________


Date: ___________________

Time: ___________________

Signature: ________________



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Attachment 4: Instaflo® troubleshooting guide

PROBLEM POSSIBLE CAUSES INTERVENTIONLeaking around catheterduring irrigation

Poor patient positioning

Poorly inflated retention cuff

Position patient such that gravity and colonic anatomy facilitates the flow of irrigant into the patient, (ie supine with slightly head down and/or slightly tilted to the left) and the drainage of irrigant and faeces out of the patient, (ie supine with slight head up).

Apply gentle traction to “seat” the retention cuff on the rectal floor.

Add additional 10ml water to retention cuff.

Remove added water after irrigation.

Volume of stool in rectum close to defecatory response tripper. Upon initiation of irrigation the defecatory response is triggered resulting in the relaxation of anal sphinchters and rectal contraction

Faeces too firm Deflate intraluminal balloon and aggressively douche to break stool up in the rectum.

Additional irrigant may have to be infused to facilitate douching.

Reactive contraction of the rectum/colon from irrigation that is infused too rapidly, is too voluminous, and/or is too cool. This may or may not be associated with patient cramping

Too cold or too rapid rectal infusion

Optimise rate, volume and temperature of irrigation.

Little or no sphincter Completely deflate retention cuff and re-inflate with 50mL of water (following irrigation, completely deflate retention cuff and re-inflate with 35mL to 40mL of water).

Lack of faecal drainage and/or faecal leakage around catheter

Manage small volume perianal mucous or faeces leakage with routine hygiene and absorbent pads.

Intralumenal balloon is inflated. Transphincteric zone tubing is twisted.

Deflate intralumenal balloon.

Straighten tube and stabilise catheter with anchor straps.

Check for anterior positioning of triple lumen connector tubing.

Proper catheter orientation is required to use anchor straps.

Stool is occluding catheter. Instil 300 – 500mL of lukewarm irrigant with intraluminal balloon



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deflated and douche until significant amounts of stool begin to exit catheter. Additionally irrigation may be required to clear rectum of stool.

Check stool consistently.

More aggressive stool modification plan/irrigation protocol or catheter removal may be required.

Odour Stool may be accumulating in catheter too long.

Rinse catheter more frequently.

Expulsion of catheter Application of too much traction (tube is pulled out of patient).

Verify no external traction is being applied to catheter (eg unsupported weight of collection bag, catheter caught, fit is tension free(1cm or more gap between anchor strap faceplate and anus).

Reduce the amount of traction applied during irrigation.

Little or no sphincter tone. After rinsing catheter, reinsert (per instructions for use) and inflate retention cuff with 40mL of water.

Volume of stool in rectum trigger defactory response resulting in relaxation of sphincters, rectal contraction and catheter expulsion.

Perform rectal exam to verify no impaction or stool is present in the distal rectum.

After rinsing catheter, reinsert (per instructions for use).

Irrigate the rectum with intraluminal balloon deflated and aggressively douche during irrigation to clear rectum.

Check stool consistency.

More aggressive stool modification plan and irrigation may be required.



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Attachment 5: Instaflo® Product Features



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Bowel Assessment and Management (Adults, … · Web viewThe Bowel Assessment and Management Procedure describes practices which will be performed by nurses, midwives, medical officers,

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