Community Health Services
Guidance for Bowel Care in Adults
Title:
Bowel Care in Adults
Procedural Document Type:
Guideline
Reference:
OP-CON-G01
Version:
V 1.0
Approved by:
Practice Professional Forum
Ratified by:
Clinical Quality Safety Committee
Date ratified:
30th March 2015
Freedom of Information:
This document can be released
Name of originator/author:
Sharon Eustice
Name of responsible team:
Bladder & Bowel Specialist Service
Review Frequency:
Yearly
Review date:
30th March 2016
Target audience:
Healthcare Professionals
Executive Signature (hard copy only):
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Contents
1
Introduction ........................................................................................................ 4
2
Definitions .......................................................................................................... 4
3
Equality Impact Assessment .............................................................................. 5
4
Good Corporate Citizen ..................................................................................... 5
5
Duties................................................................................................................. 5
6
Bowel Care ........................................................................................................ 6
6.1 Assessment ....................................................................................................... 6
6.2 Laxatives ............................................................................................................ 7
6.3 Bulking Agents ................................................................................................... 7
6.4 Stimulant laxatives ............................................................................................. 7
6.5 Osmotic agents .................................................................................................. 8
6.6 Suppositories ..................................................................................................... 8
6.7 Indications for use .............................................................................................. 8
6.8 Contraindications for use ................................................................................... 8
6.9 Administering suppositories ............................................................................... 9
6.10 Enemas.............................................................................................................. 9
6.11 Indications for use .............................................................................................. 9
6.12 Contraindications for use ..................................................................................10
6.13 Administering enemas ......................................................................................10
6.14 Rectal irrigation .................................................................................................10
6.15 Colostomy .........................................................................................................11
6.16 Digital Rectal Examination of Rectum (DRE) and Digital Removal of
Faeces (DRF) ...........................................................................................................11
6.17 Digital Rectal Examination (DRE) .....................................................................12
6.18 Contra-indications to performing DRE and Digital Removal of Faeces .............12
6.19 Circumstances when extra care is required ......................................................12
6.20 Signs and symptoms to look for in the perineal and perianal area prior to
undertaking a DRE or Digital Removal of Faeces (RCN, 2008) ................................13
6.21 Factors to be aware of when performing DRE ..................................................13
6.22 Performing DRE ................................................................................................13
6.23 Digital Removal of Faeces ................................................................................13
6.24 When should digital removal of faeces be performed? .....................................14
6.25 Contra-indications to carrying out digital removal of faeces ..............................14
6.26 Factors to be aware of when performing digital removal of faeces ...................14
6.27 Performing Digital Removal of Faeces ..............................................................14
6.28 Bowel Care for Patients with Spinal Cord Injury (SCI) ......................................15
6.29 Effect of SCI on Bowel Function .......................................................................15
6.30 Bowel Management in Spinal Cord Injured Patients .........................................15
Autonomic Dysreflexia ..............................................................................................16
Manifestations of Autonomic Dysreflexia ..................................................................16
Common Causes ......................................................................................................16
Actions to Take .........................................................................................................16
6.33 Referral onwards...............................................................................................17
6.34 Infection Control ................................................................................................17
6.35 Adverse Events .................................................................................................17
6.36 Bladder and Bowel Specilaist Service...............................................................18
7
Risk Management Strategy Implementation .....................................................18
7.1 Implementation .................................................................................................18
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7.2 Training and Support ........................................................................................18
7.3 Dissemination ...................................................................................................19
7.4 Storing the Procedural Document .....................................................................19
8
Process for Monitoring Effective Implementation ..............................................19
9
Associated Documentation ...............................................................................19
10 References .......................................................................................................19
Appendix 1 ................................................................................................................21
Appendix 2 ................................................................................................................22
Appendix 3: Performing DRE (Digital Rectal Examination) .......................................23
Appendix 4: Performing DRF (Digital Removal of Faeces) .......................................24
Appendix 5: Digital Stimulation .................................................................................26
Please Note the Intention of this Document
To inform healthcare professionals (HCP) within Peninsula Community Health of best
practice in bowel care for adults. This guideline applies to all staff, including
unqualified staff, locums, bank staff and students who provide bowel care under the
supervision of qualified staff.
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1 Introduction
To inform healthcare professionals (HCP) within Peninsula Community Health of best
practice in bowel care for adults. This guideline applies to all staff, including
unqualified staff, locums, bank staff and students who provide bowel care under the
supervision of qualified staff.
The Mental Capacity Act 2005 came into force on the 1st October 2007. Staff reading
this policy, guidance or strategy document should refer to the principles of the MCA
2005 when interpreting or applying the principles of this document.
In addition, the HCP should refer to guidance for the management of patients who
lack capacity and require health and social service interventions.
Normal bowel function includes the need for regular defaecation without
complications such as constipation or faecal incontinence. Constipation and faecal
incontinence are common disorders affecting an individual’s normal bowel function
and is a common reason for GP consultations (MeReC 2011; NICE 2007).
Expenditure on laxatives is around £104 million per year in England and costs have
increased by nearly 30% (Health & Social Care Information Centre 2014). HCP have
a crucial contribution to make in providing effective advice and care to patients
suffering from common bowel disorders.
Additionally, clarity is required with regard to digital rectal examination (DRE) and
digital removal of faeces. Because of the invasive nature of these procedures and
fears of accusations of abuse, some HCP are uncertain over whether they should go
ahead with these procedures (RCN, 2012).
Recent advances in oral, rectal and surgical treatments for bowel care has reduced
the need for DRE and digital removal of faeces. However, for some patients in
certain circumstances, these procedures are necessary and for other patients they
form part of their regular bowel care regime. In these circumstances nurses need to
be reassured that it is legitimate to carry out these procedures safely and
competently.
The purpose of the guideline is to:

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Establish a framework for bowel care management
Establish a framework for the management of constipation and faecal
incontinence
Provide nurses with the support, knowledge and evidence of good practice
necessary to enable them to manage bowel care safely and competently
Clarify the use and procedure of Digital Rectal Examination (DRE) and Digital
Removal of Faeces
2 Definitions
Constipation is defined in the British National Formulary, March 2014, No 66 as – the
passage of hard stools less frequently than the patient’s own normal pattern”. People
may normally have anything between 3 bowel movements a day to only 3 bowel
movements a week. Therefore constipation is more easily confirmed in a patient
when there has been a significant change in normal bowel habit.
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Faecal Incontinence is a sign or a symptom, not a diagnosis. It is the involuntary loss
of liquid or solid stool (NICE 2007). Anal incontinence includes the above and also
flatus.
3 Equality Impact Assessment
As part of its development, this document and its impact on equality have been
reviewed in line with the Equality and Diversity Policy. The Equality Impact
Assessment Tool has been used to help consider the needs and assess the impact
of this policy and has been completed alongside this document and no detriment was
identified
4 Good Corporate Citizen
As part of its development, this policy was reviewed in line with the CIOSCHS Good
Corporate Citizen Action Plan. The implementation of this strategy promotes good
governance.
5 Duties
All HCP who offer/perform bowel care for patients should be aware of the contents of
these guidelines. HCP carrying out bowel care interventions are reminded that they
should at all times adhere to:
 The code of conduct from their professional body
 Guidelines for records and record keeping
 Relevant organisational policies and procedures
HCP who delegate bowel care interventions to healthcare support workers (HCSW)
under specific direction, are reminded that they are at all times accountable for the
delegated task.
 the HCSW has received training and assessment of competence in the
care of the adult with bowel care needs and insertion of rectal
interventions.
 the HCSW undergoes regular supervision to ensure their competence to
carry out this care.
 the HCSW will only administer rectal intervention to a previously identified
patient (those with routine, uncomplicated bowel care) under direct
delegation from a registered nurse who is prepared to be accountable for
the delegated task.
Valid consent must be obtained from the patient where possible and with approval
from the person with continuing medical responsibility for the patient. This consent
should be recorded in the patient notes or other appropriate documentation.
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6 Bowel Care
6.1 Assessment
Assessment and the identification of the underlying cause of constipation or faecal
incontinence is therefore important in achieving successful treatment and
management. HCP are expected to use locally agreed assessment tools, including
stool diaries.
Many factors may affect normal bowel functioning, these may include:

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Change in diet
Change in fluid intake
Lack of exercise
Use of drugs e.g. analgesics, iron preparations, use of over the counter products
Lack of privacy e.g. use of shared toilet facilities especially in hospital
Change in persons normal routine
Disease process e.g. neoplasm
X-ray investigation of bowel involving use of barium
A careful history of a patient’s bowel habits should be taken with particular note taken
of any red flags (MeReC 2011):
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Persistent unexplained change in bowel habits
Palpable mass in the lower right abdomen or the pelvis
Persistent rectal bleeding without anal symptoms
Narrowing of stool calibre
Family history of colon cancer, or inflammatory bowel disease
Unexplained weight loss, iron deficiency anaemia, fever, or nocturnal symptoms
Severe, persistent constipation that is unresponsive to treatment
Use of laxatives or other bowel medication (including over the counter products)
The frequency, volume, consistency and colour of stool (Bristol Stool Form
Scale, Heaton, K, 1992)
If unresolved constipation is suspected, a digital rectal examination may need to be
performed with valid consent from the patient, in order to assess the contents of the
rectum and to identify conditions which could cause discomfort such as
haemorrhoids or anal fissure. Patients should be offered a chaperone where
necessary.
Management and treatment options include:
 Dietary advice, increasing fibre intake (caution in the older person and frail
patients)
 Advice on appropriate fluid intake
 Advice on lifestyle changes
 Regular toileting (maximising the gastro-colic reflex)
 Good seating position to defaecate (raise knees higher than hips, lean
forward and put elbows on knees, bulge out abdomen and straighten spine)
 Laxatives
 Enema or suppositories
 Digital removal of faeces
 Rectal irrigation
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
Specialist referral
For further guidance on the recommended management of constipation, see
‘Guidance for the Management of Constipation and Use of Laxatives in Adults’
(Appendix 1). For further guidance on the recommended management of faecal
incontinence, see ‘Guidance for the management of faecal incontinence in adults’
(Appendix 2)
6.2 Laxatives
In general, there is much uncertainty over what constitutes effective management of
constipation and laxatives may not be appropriate in all patients with constipation. It
has been suggested that in mobile people (including the older person), a change in
lifestyle involving changes in diet, increasing fluid intake and increasing physical
activity may be sufficient.
Although laxatives are not always necessary, they may be needed in the short term
to provide rapid initial relief of symptoms (MeReC Bulletin, 2011). Laxatives alter the
normal functioning of the alimentary tract and can be grouped in to three types
according to their action:
 Bulking agents
 Osmotic agents
 Stimulants
This section refers to some of the laxatives available in three groups. HCP are
reminded that they will normally administer or prescribe (if they are nurse
prescribers) those laxatives that are recommended by local prescribing formularies.
All medicines should be used only according to their licensed indications. For further
information please refer to the latest edition of the British National Formulary (BNF).
6.3 Bulking Agents (Bran products / Ispaghula Husk)
Bulk laxatives are of particular value for people complaining of small, hard stools but
should not be required unless fibre cannot be increased in the diet. A person should
aim to eat at least one fibre-rich food at each meal. A fluid intake of 1.5–2 litres a
day if possible should also be taken (unless specified otherwise).
These agents supplement dietary fibre intake to increase the weight and water
absorbency of the stool. This increases faecal mass production and increases
peristalsis. These agents need an increased fluid intake in order to work and should
be taken with at least one glass of water. They take 2-3 days to exert their effect and
so are not suitable for acute relief (MeReC Bulletin, 2011). Adequate fluid intake
must be maintained to avoid intestinal obstruction and therefore they are contraindicated in patients with faecal impaction, existing bowel obstruction and should be
used with caution in debilitated patients. Bulking agents may cause transient
bloating and flatulence.
6.4 Stimulant laxatives (Bisacodyl / Danthron / Docusate Sodium/ Senna)
Stimulant laxatives increase intestinal motility with a laxative effect seen in 6-12
hours. They can cause abdominal cramping and should be avoided in cases of
intestinal obstruction. An osmostic laxative may be used in combination with this
group of laxatives. Prolonged use of stimulant laxatives may precipitate the onset of
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an atonic, non-functioning colon and hypokalaemia. However, long-term use may be
justified for those people taking long-term opiates.
HCP should be aware that preparations containing Danthron (Co-Danthramer) are
not indicated for general use and should only be used for analgesic-induced
constipation in palliative care for patients of all ages (BNF, March 2014, No 66).
Some drugs may be both stimulant laxatives and softeners (Refer to BNF).
6.5 Osmotic agents (Lactulose / Macrogols)
These act by retaining fluid in the bowel by osmosis or by changing the pattern of
water distribution in the faeces. They can cause bloating, flatulence and cramping
and must be taken regularly for up to three days before an effect is seen. Therefore
they are unsuitable for rapid relief of constipation (MeReC, 2011).
Lactulose is a synthetic disaccharide which exerts an osmotic effect in the small
bowel. Distension in the small bowel induces propulsion which in turn reduces transit
time.
Macrogols include Movicol and Laxido, which are preparations containing
polyethylene glycol and various electrolytes. According to a Cochrane Review,
macrogols have some advantage over Lactulose (Lee-Robichaud et al 2010). It has
a license for the treatment of faecal impaction and chronic constipation.
Bowel cleansing products such as Picolax, Citrafleet, Fleet Phospho-Soda, Klean
Prep, Moviprep should not be used for the treatment of constipation (NPSA 2009).
6.6 Suppositories
When oral laxatives have not produced a bowel movement, or when rapid relief from
rectal loading is required or there is difficulty with emptying, a suppository may be
appropriate.
Lubricant suppositories e.g. glycerin, should be inserted directly into the faeces and
allowed to dissolve to enable softening of the faecal mass.
Stimulant suppositories e.g. bisacodyl, must come into contact with the mucus
membrane of the rectum if they are to be effective and should not therefore be
inserted into a faecal mass.
6.7 Indications for use
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To relieve acute constipation or to empty the bowel when other treatments for
constipation have failed
To empty the bowel before surgery
To introduce prescribed medication into the system
To soothe and treat haemorrhoids or anal pruritis
As part of a bowel management programme with someone who has a neurogenic
bowel
6.8 Contraindications for use


Colonic obstruction
Paralytic ileus
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6.9 Administering suppositories
Before administering suppositories nurses should be aware of:
 In the case of suspected rectal loading, nurses should perform a DRE prior to
administering suppositories to determine the presence of faeces in the rectum.
 A suppository usually takes 20 minutes to dissolve
 Medicated suppositories which need to be absorbed should be inserted with the
blunt end first
 Lubricant suppositories can be inserted pointed end first, but maybe better
retained if administered blunt end first
 Glycerine suppositories can be moistened with water before administering but
other types of suppository should be lubricated before inserting
 Advance the suppository about 4cms into the rectum, using the index finger
 Do not insert a medicated suppository into a faecal mass as its effect will be
minimal (except for lubricant suppositories which can be inserted into the faecal
mass, in order to dissolve and soften the faecal mass)
For further guidance on the correct procedure for the administration of suppositories
refer to: Dougherty L and Lister S, (2011) Royal Marsden Hospital Manual of Clinical
Nursing Procedures 8th edition.
6.10 Enemas
When laxatives or suppositories have not produced a bowel movement or when
rapid relief from rectal loading is required, an enema may be appropriate. An enema
is the introduction of fluid into the rectum or lower colon for the purpose of producing
a bowel action or instilling medication.
There are two types of enema: retention enemas and evacuant enemas.
A retention enema is a solution introduced into the rectum or lower colon with the
intention of being retained for a specified period of time. Arachis oil and olive oil
enemas come under this group and have been used for softening and lubricating
impacted faeces. Medicated retention enemas e.g. Prednisolone enemas are
prescribed by a doctor and must be checked against the prescription before
administration.
An evacuant enema is a solution introduced into the rectum or lower colon with the
intention of its being expelled along with faecal matter. Phosphate enemas (large
volume) and sodium citrate micro-enemas (small volume) come under this group.
Phosphate enemas should be used with caution as they can cause mucosal damage
and trauma (Davies 2004). Prolonged use of sodium phosphate enema is not
recommended and may lead to dependence. Unless otherwise directed, sodium
phosphate enema should not be used for more than 2 weeks. Caution should be
applied for the older and frail person (BNF 2014).
6.11
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Indications for use
To introduce prescribed medication into the system
Severe constipation or impaction of faeces
To clean lower bowel before surgery
Neurogenic bowel
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6.12
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Contraindications for use
Colonic obstruction
Paralytic ileus
Where large amounts of fluid into the colon may cause perforation or
haemorrhage
Following gastrointestinal or gynaecological surgery where suture lines could be
ruptured (unless medical consent has been given)
In patients with a known cardiac condition where intervention could cause
possible collapse
6.13
Administering enemas
Before an enema is administered nurses should be aware of:
 In the case of suspected rectal loading, the HCP should perform a DRE prior to
administering an enema to determine the presence of faeces in the rectum.
 HCP should have knowledge of the relevant anatomy before administering
enemas into the rectum or lower bowel
 Position the patient lying in the left lateral position
 Enemas should be administered at room temperature
 Use gravity and not force to administer an enema. Forcing an enema into the
rectum can result in bowel spasm, leakage or adverse events
 Steroid enemas should be administered after defaecation, preferably at bed time
For further guidance on the correct procedure for the administration of enemas refer
to: Dougherty L and Lister S, (2011) Royal Marsden Hospital Manual of Clinical
Nursing Procedures 8th edition
6.14 Other drugs used in constipation
Linaclotide is licensed for the use of irritable bowel syndrome associated with
constipation. Lubiprostone is licenced for chronic idiopathic constipation in adults
where there has little or no response to conservative measures. Prucalopride is a
NICE approved medication, which is licensed for chronic constipation in women
where laxatives have failed to provide adequate response
(http://www.nice.org.uk/TA211). All of these medications should only be prescribed
by HCP experienced with treating chronic constipation.
6.15 Rectal irrigation
If first-line methods of managing constipation and faecal incontinence have failed or
do not adequately control the symptoms, rectal irrigation may be considered. It is
important that introduction of this procedure is discussed with the patient’s GP and
that the HCP is competent.
Patient information can be found at:
http://www.stmarkshospital.org.uk/patient-information-leaflets. Please consult with
the Bladder and Bowel Specialist Service.
The risk of bowel perforation is rare with the use of rectal irrigation. However, it is
important to ensure that patients, carers and HCP have received comprehensive
training, are aware of the risk of bowel perforation, how to recognise the symptoms
and actions to be taken (MHRA 2011).
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6.16
Colostomy
Suppositories and enemas are rarely prescribed for people with a colostomy.
However very occasionally the patient may require this type of intervention to relieve
unresolved impaction of faeces in the stoma. In these circumstances lubricant
suppositories or a micro-enema may be used.
Factors to consider before administering a suppository or micro-enema into a stoma
would be:
 The patient should lie in the supine position
 Use a lubricating gel to assist comfortable passage of suppository/microenema through the stoma
6.17 Anal Plugs
Anal plugs may offer some comfort and dignity to people where faecal leakage is
passive. They are foam, cup-shaped devices, made from medical grade foam, which
sits inside the rectum in order to prevent bowel leakage. Individual plugs are covered
in a dissolvable film which keeps the plug in a size and shape similar to a suppository
or small tampon for easy insertion. Once in the rectum, moisture from the lining of
the rectum dissolves the film and the anal plug expands to a cup or mushroom
shape. The plugs can stay in place for a maximum of 12 hours but must be removed
(by the attached string) in order to pass stool.
They are most suited for:
 Preventing leakage for a specific period e.g. during exercise
 Leakage is associated with spina bifida, anorectal malformation, rectal
sphincter damage / tear
They shouldn’t be used in cases of:
 disease of the bowel or rectum
 spinal cord injury and are at risk from autonomic dysreflexia
 unacceptability by the patient
 an anal plug disrupting a successful, established routine
For more information, please visit
http://www.continenceproductadvisor.org/products/faecaldevices/analplugs
6.18 Digital Rectal Examination of Rectum (DRE) and Digital Removal
of Faeces (DRF)
HCP who can demonstrate professional competence can perform these procedures.
They can delegate these procedures to carers or patients as appropriate, ensuring
their competence is assessed and reviewed as necessary (RCN 2012). The HCP is
responsible for informing their manager if s/he does not feel competent in these
procedures and for identifying any training needs.
It may be appropriate for HCSW carrying out bowel interventions under delegation
from a HCP, to carry out DRE (digital rectal examination) prior to administration of
laxative suppositories/micro-enemas or DRF (digital removal of faeces). HCP are
reminded that, at all times they are accountable for the actions of the HCSW working
under their direction. They should have received approved training and been
assessed as competent in carrying out DRE and DRF.
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If these conditions are met, the HCSW can be expected to carry out these
procedures on patients who have been prescribed these bowel care interventions as
part of their ongoing, pre-planned nursing care. It is not expected that HCSWs would
carry out these procedures on patients that have not previously been assessed by a
HCP.
6.19 Digital Rectal Examination (DRE)
DRE can be used as part of a clinical assessment when carried out by a HCP who
can demonstrate professional competence (NMC 2008) or as delegated by such a
professional providing competence of carer or patient is assessed and reviewed, as
required (RCN 2012). DRE should not be used as a first line investigation into the
assessment and treatment of constipation (RCN 2012).
DRE is an invasive procedure and should only be performed when necessary and
after individual assessment (Kyle et al 2004). Cultural and religious beliefs must be
respected and it is vital to check for allergies prior to undertaking this procedure.
DRE is used to establish (RCN 2012)

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
The presence of faecal matter in the rectum, the amount and consistency of
stool
Anal tone and ability to initiate a voluntary contraction, and to what extent
anal/rectal sensation
The need for and effects of rectal medication in certain circumstances
The need for digital removal of faeces and evaluating of rectal emptiness
The outcome of rectal / colonic washout/ irrigation if appropriate
The need and outcome of using digital stimulation to trigger defaecation by
stimulating the recto-anal reflex
6.20 Contra-indications to performing DRE and Digital Removal of
Faeces
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Lack of consent from the patient
Specific instructions from the patient’s doctor that the procedure should not
take place
Patient has undergone recent rectal/anal surgery or trauma
The patient gains sexual satisfaction from these procedures and the HCP
performing them finds this embarrassing. In this case, consultation with a
doctor is advised, involving the patient in that consultation.
Presence of abnormalities of the perianal and/or perineal area are observed
6.21
Circumstances when extra care is required
Particular caution should be exercised when performing DRE and Digital Removal of
Faeces with patients who have the following diseases/conditions:

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Active inflammation of the bowel, including Crohn’s disease, ulcerative colitis
and diverticulitis
Recent radiotherapy to the pelvic area
Rectal / anal pain
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
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Rectal surgery / trauma to the anal/rectal area
Tissue fragility due to age, radiation, loss of muscle tone in neurological
diseases or malnourishment
Obvious rectal bleeding or patient taking anti-clotting medication
If the patient has a known or suspected history of abuse
In spinal injury patients because of autonomic dysreflexia
Known allergies
6.22 Signs and symptoms to look for in the perineal and perianal area
prior to undertaking a DRE or Digital Removal of Faeces (RCN 2012)
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Rectal prolapse – ulceration
Haemorrhoids – number, prolapse
Anal skin tags – number, condition
Wounds, dressings, discharge
Anal lesions (malignancy)
Gaping anus
Skin conditions, broken areas, pressure sores of all grades
Bleeding and colour of blood
Faecal matter
Infestation
Foreign bodies
The presence of any of the above would indicate that advice should be sought from a
specialist nurse or a medical practitioner before undertaken these interventions,
unless the practitioner feels confident and is competent to do so.
6.23




Factors to be aware of when performing DRE
Ensure the patient understands and consents to the procedure
Ensure the patient is lying in the left, lateral position with the knees well flexed
Ensure the gloved, index finger is well lubricated with gel
Ensure the examination is performed gently, using one finger only
6.24
Performing DRE
See Appendix 3 for details of how to perform a DRE.
6.25
Digital Removal of Faeces
Digital removal of faeces from the rectum should be avoided if possible and should
only be performed if all other methods of relieving constipation have failed or as part
of a patient’s routine care management e.g. a person with a spinal injury or a person
suffering from loss of bowel tone or in the case of advanced Multiple Sclerosis (RCN,
2012).
The procedure can be a distressing experience for the patient and may be
uncomfortable. In severe, acute faecal impaction it may be necessary to consider
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sedating the patient before carrying out the procedure. In these circumstances, the
HCP should seek medical advice.
When digital removal of faeces is performed as an acute intervention, the procedure
and approach differ from when used as part of routine care management and special
consideration should be given to:
 The possible need for sedation
 The possibility of patient collapse
 The possibility that it will cause pain and distress to the patient
Managing constipation and bowel evacuation in patients who are unable to evacuate
their bowel without intervention, as in the case of patients with spinal injury, loss of
bowel tone or neurogenic bowel requires a multimodality approach.
6.26 When should digital removal of faeces be performed?




Faecal impaction/ loading
Incomplete defaecation
Inability to defaecate
Other bowel emptying techniques have failed
6.27 Contra-indications to carrying out digital removal of faeces
Extra care should be taken when:
 The patient is experiencing severe abdominal/rectal/anal pain
 Active inflammation of the bowel
 Recent radiotherapy to the pelvic area
 If patient has a known or suspected history of sexual abuse
6.28 Factors to be aware of when performing digital removal of faeces








Ensure the patient understands and gives valid consent to the procedure
Ensure the patient is lying in the left lateral position with knees well flexed
Take the patients pulse to use as a baseline
Ensure the gloved finger is well lubricated with gel
Ensure the procedure is performed gently using one finger only
Remove the faecal matter slowly in small amounts
If the patient becomes distressed during the procedure, check the patient’s pulse
again and check against baseline recording and STOP if the pulse rate has
dropped or the patient is clearly distressed.
Anaphylaxis
6.29 Performing Digital Removal of Faeces
See Appendix 4 for details of how to perform a digital removal of faeces (Kyle et al
2008).
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6.30
Bowel Care for Patients with Spinal Cord Injury (SCI)
In September 2004 the NHS Patient Safety Agency identified that patient’s with
established spinal cord lesions are at risk because their specific bowel care needs
are not always met in hospital. Contributing to this situation is a widely held belief
that manual evacuation of faeces is abusive and dangerous. However, it can be
harmful, even life-threatening, to deviate from these patients normal bowel routine
(NPSA 2004).
6.31
Effect of SCI on Bowel Function
After a spinal cord injury the connection between brain and bowel is lost and this
gives rise to a number of consequences:
 The brain does not feel the urge to defecate or control the anus.
 The ability to coordinate what is under voluntary control and influence or
mediate reflex activity in the bowel is lost.
 The enteric nervous system in the bowel continues to produce peristalsis but
because the brain cannot coordinate it this is less effective. As a result stool
takes longer to pass through the bowel.
 Slower transit time through the colon result in greater re-absorption of water
and harder more constipated stools.
 Constipation causes stretching of the colon, which makes peristalsis less
effective.
The presenting picture of bowel disorder following spinal cord injury depends upon
the level at which damage has occurred and whether the damage to the cord is
complete or incomplete. The remaining bowel function is normally described as either
reflex or flaccid but may be a mixture of the two in incomplete lesions.
6.32 Bowel Management in Spinal Cord Injured Patients
A bowel management programme is developed by taking account of the area of
damage to the spinal cord and making use of any preserved function or reflex
systems. It should be tailored to take into account the individuals needs and
designed to promote independence (Spinal Cord Injury Centres 2012).
Individuals who have been in a Spinal Injuries Centre will usually be fully aware of
the rationale behind their bowel management programme and this should not be
changed without careful consideration and consultation.
Individuals who present with a partial spinal cord injury, perhaps as a result of spinal
cord compression, surgery, or multiple sclerosis may present with a mixed picture of
remaining function. As a consequence their bowel management routine will be
developed in a more pragmatic manner over time.
Failing to recognise the particular needs of these patients and develop an
appropriate care plan is clinical neglect that may result in harm to the individual’s
health and quality of life.
The aim of a bowel management routine is:
 To empty the rectum at a regular and predictable time that fits in to the
lifestyle of the individual.
 To avoid constipation and faecal soiling.
 To avoid autonomic dysreflexia (Essat 2003).
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Autonomic Dysreflexia
This is a medical emergency that unresolved may give rise to serious
consequences such as cerebral haemorrhage, seizures or cardiac arrest.
This occurs mostly in lesions above T6. Individuals with injuries below T6 are not
susceptible.
The condition arises as a result of an autonomic (sympathetic) reflex that occurs as a
response to pain or discomfort (noxious stimuli) perceived below the level of the
lesion.
The reflex creates a massive vaso-constriction below the level of the lesion causing a
pathological rise in blood pressure that can be life threatening if allowed to continue
unchecked.







Manifestations of Autonomic Dysreflexia
Flushed and blotchy above the level of the injury.
Sweating and goose pimples
Peripheral cyanosis
Pounding headache
Blurred vision and dizziness
Shortness of breath
Slow pulse





Common Causes
Most common is an over full bladder
Next most common is an overloaded bowel
Skin problems/ in-growing toe nails
Anything that may have given rise to pain previously
Pregnancy, and sometimes ejaculation.
Actions to Take




Identify and remove cause - if a manual evacuation is to be undertaken
application of an anaesthetic gel, e.g. 2% lignocaine, 10 minutes beforehand
will reduce the likelihood of exacerbating the situation.
Sit upright as soon as possible.
Give GTN or Nifedipine as prescribed.
If you are unable to locate the cause or the symptoms persist get help.
6.33 Interventions that may be used to manage a Reflex or Upper Motor
Neurone Bowel
Injury at T12 and above will give rise to upper motor neurone or reflex bowel function.
The aim is to produce a soft-formed stool that is easy to pass by stimulating the
reflex activity that is preserved in the rectum to evacuate stool.
It would usually consist of these types of interventions:

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

30 minutes before starting the routine.
Abdominal massage and or use of posture to raise intra-abdominal pressure.
Use of ano-rectal stimulation (Appendix 5) - either digital or chemical.
6.34 Interventions that may be used to manage a Flaccid or Lower Motor
Neurone Bowel
Spinal cord injury at or below L1 will give rise to lower motor neurone or flaccid bowel
function.
The aim is to produce a firmly formed stool that can be removed digitally and will be
unlikely to leak out in an unplanned manner. It would usually consist of types of
interventions:



Stimulate gastro-colic reflex by having a warm drink or something to eat 2030 minutes before starting the routine.
Abdominal massage and or use of posture to raise intra-abdominal pressure.
Use of gentle digital evacuation to remove stool from the rectum.
Bowel management needs to suit the individual and therefore there may be a period
of trial and evaluation at the beginning or over time as changes in the individual’s
body, lifestyle, or circumstances determine.
6.35
Referral onwards
In certain circumstances the HCP should always refer to a doctor before carrying out
any intervention. These may be:
 If any alarm symptoms are present – constipation alternating with diarrhoea,
rectal bleeding, unresolved abdominal pain, weight loss, anorexia, tenesmus
(painful and ineffectual straining) (MeReC 2011).
 If the HCP observes trauma to the perianal area.
 In the case of a frail/older patient where the HCP is of the opinion that an
intervention could cause the patient harm.
 If digital removal of faeces is necessary but the HCP considers that sedation
may be necessary before the procedure.
6.36
Infection Control
As detailed in the Infection Control Policies and Procedures, safe working practices
must be adopted when carrying out bowel care interventions on patients. These
include:
 Hand-washing, before and after any procedures.
 Education of the patient, where applicable, on the importance of hand washing.
 The use of protective clothing, including the wearing of non sterile, single use
non-latex/vinyl gloves and single use, disposable plastic aprons to minimise the
risk of cross infection/contamination during care interventions.
 The disposal of waste should be in line with the Infection Control Policies and
Procedures.
6.37
Adverse Events
Consideration should be given to user sensitisation to latex products, especially in
those patients with spina bifida as they are at high risk due to repeated exposure
http://www.shinecharity.org.uk/
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6.38
Bladder & Bowel Specialist Service
The Bladder & Bowel Specialist Service for Cornwall offers professional advice,
guidance and information on the promotion and management of continence; and
facilitates best practice in continence care for faecal and urinary incontinence,
including enuresis, and related bladder and bowel problems for children and adults.
For any further information or feedback on the contents of this guideline, please
make contact via:
Bladder & Bowel Specialist Service
St Austell Community Hospital
Porthpean Road
St Austell
PL26 6AA
Tel: 01726 873095
Fax: 01726 291249
7 Risk Management Strategy Implementation
7.1 Implementation
Local organisations will take responsibility to ensure quality of service for
indwelling urinary catheterisation.
7.2 Training and Support
Through self-regulation, the HCP who is learning this skill will remain
accountable for his or her competency in bowel care, as in the spirit of
their professional code. Informal learning pathways, such as teaching
from a team colleague who is competent in the skill, should be
documented to provide evidence of the learning experience. HCPs
should inform their manager if they feel they are not competent and
identify their training needs relating to this area of practice.
Continence care will be supported by an educational framework that
describes several levels of knowledge acquisition. Before undertaking
bowel care in patients, all HCPs should possess an understanding of the
male and female anatomy and physiology.
Workforce competences can be viewed at
http://www.skillsforhealth.org.uk/
Assess bladder and bowel dysfunction (CC01)
HWB6: Assessment and treatment planning
Level 4: Assess physiological and/or psychological functioning when
there are complex and/or undifferentiated abnormalities, diseases and
disorders and develop, monitor and review related treatment plans
Enable individuals to effectively evacuate their bowels (CC09)
HWB5: Provision of care to meet health and wellbeing needs
Level 4: Plan, deliver and evaluate care to address people’s complex
health and wellbeing needs
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7.3 Dissemination
Once ratified this policy will be loaded to the intranet (read only)
Staff will be made aware of its existence through the appropriate
communications mechanisms in local organisations.
Confirmation of receipt is not required for this procedural document.
7.4 Storing the Procedural Document
The signed procedural document will be stored (hard copy) centrally, as
will the digital (soft copy) version.
8 Process for Monitoring Effective Implementation
The effective implementation of this policy will be monitored by the local organisation.
Key performance indicators:

Educational take-up of bowel dysfunction in adults learning events.

Guidelines will be updated every 2 years to reflect changing practice.

Nursing Matrices
9 Associated Documentation
This document references the following supporting documents which should
be referred to in conjunction with the document being developed.
Infection, Protection and Control Policies
Standard Operational Procedures
Chaperoning Guidelines
Management of medical devices
10 References
BNF (March 2014, No 66). British National Formulary. British Medical Association.
London
Davies C (2004) The use of phosphate enemas in the treatment of constipation
Nursing Times Vol 100 No 18
Dougherty L and Lister S, (2008) Royal Marsden Hospital Manual of Clinical Nursing
Procedures 7th edition. Blackwell Publishing
Effective Healthcare Bulletin (2001). Effectiveness of laxatives in adults. NHS Centre
for Reviews and Dissemination. University of York
Essat Z (2003) Management of autonomic dysreflexia Nursing Standard Vol 17 No 3
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Bowel Care in Adults
Health & Social Care Information Centre (2014) Prescriptions dispensed in the
community; July
Heaton, K (1992). Bristol Stool Form Scale as cited in Constipation: managing a
common problem. Prescriber May 19, 31-34
Kyle G, Prynn P & Oliver H (2004) An evidence-based procedure for the digital
removal of faeces Nursing Times Vol 100 No 48
Kyle G, Prynn P & Dunbar T (2008) The procedure for the digital removal of faeces
guidelines (supported by Association for Continence Advice; Royal College of
Nursing and Spinal Injuries Association). NHS, Thames Valley University & Norgine
Pharmaceuticals Limited
Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus Polyethylene
Glycol for Chronic Constipation. Cochrane Database of Systematic Reviews 2010,
Issue 7. Art. No.: CD007570. DOI: 10.1002/14651858.CD007570.pub2.
MeRec Bulletin (2011) The Management of Constipation. National Prescribing
Centre, Vol 21 No 2
MHRA (2011) Medical Device Alert: Peristeen Anal Irrigation System manufactured
by Coloplast Limited MDA/2011/002
NICE (2007) Feacal incontinence: the management of faecal incontinence in adults
National Institute for Health and Clinical Evidence: Clinical Guideline 49
NMC (2008) The Code: Standards of conduct, performance and ethics for nurses
and midwives Nursing & Midwifery Council, 1 May 2008
NPSA (2004) National Patient Safety Information 15 September 2004
www.npsa.nhs.uk/advice
NPSA (2009) http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/reducing-riskof-harm-from-oral-bowel-cleansing-solutions/
Royal College of Nursing (2012). Management of lower bowel dysfunction, including
DRE and DRF Publication code 003 226 September 3rd Edition
Spinal Cord Injury Centres (2012) Guidelines for management of neurogenic bowel
dysfunction in individuals with central neurogenic conditions. Initiated by
Multidisciplinary Association of Spinal Cord Injured Professionals
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Appendix 1
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Appendix 2
Guidance for the Management of Faecal Incontinence in Adults
Patient presents
with history of
faecal
incontinence
Abdominal palpation;
perineal/anal
observation; skin
integrity; DRE is
clinically required
Faecal incontinence is a sign or
symptom and is involuntary leakage
of stool
Use bowel assessment tool, stool
chart, fluid matrix, bowel diary,
laxatives and other medications,
review fibre
Assess and
identify cause
Worrying symptoms:
Rectal bleeding with a change in
bowel habit; undiagnosed rectal
bleeding; abdominal or rectal mass;
anorexia and unintentional weight
loss; passing mucus
Yes
Refer for
medical
opinion
No
General advice:
Skin care (hygiene; barrier agents)
Containment (pads, plugs, collectors)
Toilet substitutes (commode)
Nutrition (fibre; fliuds; calories)
Specific treatments :
Faecal impaction (see box A)
Infection: specimen, antibiotics, then probiotics
Medication: change, review, prescribe
Box A
Faecal impaction:
Treat with 8
sachets Macrogol
3350 for max of 3
days or by enema
If no improvement
Specialist Referral:
Gynaecologist during pregnancy and up to 16 weeks
post-partum
Colorectal surgeon (prolapse, cancer)
Gastroenterologist for disease/condition related
Continence Promotion Service
Tissue Viability Service
Infection Control
Dietician
Dietry Fibre: Aim to increase to 18-30 gms daily with adequate fluid intake
For older patients, fibre should be introduced gradually (may cause bloating and discomfort)
Must be used with caution in older immobile people as it can increase risk of faecal incontinence
Adapted from: Addison & Ness (2003) Management of faecal incontinence in adults (male & female) Croydon Integrated Continence Services
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Appendix 3: Performing DRE (Digital Rectal Examination)
Procedure
Rationale
1)
Explain the procedure to the patient and Patient information reduces anxiety.
ensure that it is carried out in privacy.
Privacy/relaxed secure environment protect
Gain valid consent from the patient.
dignity and increases co-operation. Consent
Check for latex sensitivity/allergy.
ensures compliance with legal procedures and
local policy.
2)
Assist the patient to lie on his/her left
This allows ease of passage into the rectum by
lateral side with knees flexed so as to
following the natural anatomy of the colon.
expose the anus. The upper knee
Flexing the knees ensures a more comfortable
higher that the lower knee.
passage of a gloved finger for examination.
Recognise that there may be a need to
protect the bed from soiling.
3)
4)
5)
6)
Wash hands with soap and water; and
apply disposable gloves/apron.
Examine/observe the perineal area for
skin soreness, excoriation, swelling,
haemorrhoids, rectal prolapse and
infestation.
Place lubricating gel on gloved index
finger.
Inform patient of imminent examination
and slowly insert gloved finger into the
patient’s rectum.
7)
Examine for:
Presence of faecal matter, amount and
consistency
Anal tone at rest and with voluntary
contraction
8)
Slowly withdraw finger.
9)
Wipe the perineal area with
tissues/wipes and dispose in the clinical
waste bag.
Assist the patient into a comfortable
position. Ensure the patient has access
to the toilet or commode if necessary.
Remove and dispose of equipment.
Wash hands.
Record in patient records that valid
consent obtained, the findings of the
examination, treatment given/suggested
and implications for care planning.
Communicate findings with
patient/carer, nurse and/or doctor.
10)
11)
12)
Protection of the bed reduces potential
infection caused by soiled linen. It also avoids
embarrassing the patient if there is faecal
soiling as a result of the procedure.
To minimise risk of cross infection.
Visual inspection of the anus could highlight
evidence of a divided sphincter, gaping of the
anus and may indicate sphincter injury, or
neurological impairment.
To prevent trauma to anal and rectal mucosa
by reducing surface friction.
Ensure the patient is informed and prepared.
The anal canal is 2.5-4cms in length and the
nurse needs to insert the finger this far to
perform an examination.
To assess for faecal loading
To evaluate sphincter contractility and check
for defects. Normal sphincter complex is in a
state of contraction at rest. In the patient with
deficient sphincter function, it may be lax at
rest, and when the patient is instructed to
contract the sphincter voluntarily, the examiner
may detect little or no contraction.
To minimise discomfort and avoid reflex
emptying of the rectum.
To promote patient comfort, avoid excoriation
and infection.
To promote comfort. Examination may
stimulate the patient to defaecate.
To minimise cross-contamination.
To ensure that the correct care is provided.
Enhance continuity and communication.
Ensure that the patient understand the results
of the examination and associated care.
Practical Procedures: Bowel Care (April 2008) Nursing Times & Norgine Pharmaceuticals Ltd http://www.nursingtimes.net/nursingpractice-clinical-research/practical-procedures/1561899.article
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Appendix 4: Performing DRF (Digital Removal of Faeces)
1)
Procedure
Explain the procedure to the patient and
ensure that it is carried out in privacy.
Gain valid consent from the patient.
Check for latex sensitivity/allergy.
2)
Take the patient’s pulse at rest prior to
the procedure.
3)
Assess the risk for autonomic
dysreflexia. For those spinal injury
patients (SCI) with injury at T6 or
above, record BP
Place protective pad under the patient
and ensure a suitable receiver to hand.
Assist patient to adopt, if possible, the
left lateral position with knees flexed. A
sitting position should be avoided.
However, individual assessment of
each patient’s regime as required.
4)
5)
6)
Observe the perineal and perianal area.
Document and report any abnormalities.
7)
Wash hands and put on disposable and
non-latex gloves of suitable thickness.
For patients receiving this procedure on
a regular basis, place water based
lubricating gel on gloved index finger.
As an acute procedure, a local
anaesthetic gel may be applied topically
to the anal area.
8)
9)
10)
11)
12)
13)
V2.0
Rationale
Patient information reduces anxiety.
Privacy/relaxed secure environment protect
dignity and increases co-operation. Consent
ensures compliance with legal procedures and
local policy.
To obtain a baseline of the patient’s condition
prior to the procedure as vagal stimulation can
slow the heartrate.
To obtain baseline BP.
To protect bedding from faecal matter.
To expose anus and allow easy insertion of the
finger. To prevent overstretching of the anal
sphincter and discomfort to the patient.
Independent SCI patients may prefer to
conduct the manual removal of faeces over a
toilet.
To check for rectal prolapse, haemorroids, skin
tags, wounds, discharge, anal lesions, gaping
anus, bleeding, infestation or foreign bodies.
To minimise cross-infection and to protect
hands.
To facilitate easy insertion of finger.
To reduce sensation and discomfort to the
patient.
Read contra-indications, warnings,
precautions and interactions of
anaesthetic gel.
Lignocaine is a topical anaesthesia and is
absorbed via the anal mucous membrane.
Do not apply if documented evidence of
anal damage or bleeding.
Lignocaine may cause anaphylaxis,
hypotension, bradycardia or convulsions if
applied to damaged mucosa.
To ensure patient is ready and relaxed.
To avoid trauma to the anal mucosa and
prevent forced over dilation of the sphincter.
Inform patient of imminent examination.
Insert non-latex gloved, lubricated index
finger slowly and gently, encouraging
the patient to relax. Use one finger
only.
In scybala type stool (Bristol stool scale
Type 1) remove one lump at a time until
no more faecal matter can be felt.
In a solid faecal mass, push finger into
the middle of the mass, split it and
remove small pieces with a hooked
finger until no more faecal matter can
To relieve patient’s discomfort.
To relieve patient’s discomfort.
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be felt.
14)
15)
If the faecal mass is too hard or larger
than 4cm across and you are unable to
break it up, STOP and refer to medical
team for digital removal of faeces under
general anaesthetic.
To avoid considerable pain and trauma to the
patient.
Proceed with caution with the SCI
patient; those with a reflex bowel may
require further rectal stimulant.
As faecal matter is removed it should be
placed in a suitable receiver.
Encourage patients who receive this
procedure on a regular basis to have a
period of rest or to assist, if appropriate,
with Valsalva manoeuvre.
Most SCI patients will not experience any pain.
Extra lubrication may be required.
To facilitate appropriate disposal of faecal
matter.
To allow further faecal matter to descend into
the rectum. Correct breathing technique will
prevent raised intra-cranial pressure.
Use of valsalva manoeuvre in an upright
position may result in increased hydrostatic
pressure in the perirectal blood vessels,
therefore increasing likelihood of haemorroids.
SCI patients may assist with evacuation by
using the valsalva manoeuvre – however
excessive straining should be discouraged.
Please note that for some SCI patient raising
intra-abdominal pressure does not result in
relaxation of the sphincter or excessive
pressures may be required. Therefore the
valsalva manoeuvre should be used with
caution and its effects evaluated for each
patient.
16)
17)
18)
19)
20)
21)
Observe the patient throughout the
procedure – STOP is anal area
bleeding or patient asks to stop.
Check patient’s pulse – STOP if heart
rate drops or rhythm changes.
STOP at first sign of autonomic
dysreflexia.
When procedure is completed wash
and dry the buttocks and anal area.
Inform the patient of outcome and
document procedure and outcome.
If concerned contact the GP,
Continence Promotion Service or Spinal
Cord Injury Centre.
Valsalva is not recommended for use in with
patient with intrathecal baclofen pumps.
To note signs of distress, pain, bleeding and
general discomfort.
Vagal stimulation can slow heart rate and alter
heart rhythm.
BP is always raised during an autonomic
episode.
To leave the patient comfortable and clean.
Documentation should provide clear evidence
of care planned, decisions made and care
delivered.
Duke of Cornwall Spinal Injury Centre contact
number is 01722 336262
http://www.spinalinjurycentre.org.uk/
Kyle G, Prynn P & Dunbar T (2008) The procedure for the digital removal of faeces guidelines (supported by Association for
Continence Advice; Royal College of Nursing and Spinal Injuries Association). NHS, Thames Valley University & Norgine
Pharmaceuticals Limited
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Appendix 5: Digital Stimulation
Stimulation of the anus or anal sphincter can aid some patients to improve
defaecation. This procedure can be effective when used together with techniques to
enhance defaecation, such as adopting the correct position on the lavatory and
taking hot drinks and food 20 – 30 minutes prior to instigating bowel care. This takes
advantage of the gastric colonic reflex, which is strongest after first meal of the day
but can be stimulated at other times of the day. In patients with a spinal cord lesion
at or above T12, it is usually possible to stimulate a defaecation reflex using digital
stimulation. This stimulated reflex may be insufficient to completely empty the bowel
but a digital removal of faeces may still be required.
Action
Rationale
1.
A patient using digital self-stimulation
should be in a comfortable lying or
sitting position
Gravity will aid evacuation
2.
Individual assessment is required
with regard to the optimum position
for the patient
Some patients with spinal cord injury
may need assistance with digital
stimulation may find a sitting position
more effective and quicker than lying
down
3.
Assist the patient to adopt the left
lateral position with knees flexed
To expose anus and to avoid damage
to the anal canal
4.
Insert a gloved (non-latex) lubricated
To facilitate easier insertion and
index finder through the anal
rotation of finger also to prevent
sphincter to second joint of finger only trauma to the anal and rectal mucosa
5.
Gently rotate the finger 6-8 times in a
clockwise motion and withdraw. This
may be repeated up to 3 times
allowing between 5-10 minutes
between each stimulation
To minimise discomfort and to
stimulate ano-rectal reflex
6.
Results should be noted and
documented
To establish effectiveness of
procedure
Kyle G, Prynn P & Dunbar T (2008) The procedure for the digital removal of faeces guidelines (supported by
Association for Continence Advice; Royal College of Nursing and Spinal Injuries Association). NHS, Thames Valley
University & Norgine Pharmaceuticals Limited
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