NHS GRAMPIAN

RESOURCE PACK

ON

BOWEL MANAGEMENT

Continence Advisory Service NHS Grampian

January 2006 Date of review January 2008

NHS GRAMPIAN RESOURCE PACK ON BOWEL MANAGEMENT CONTENTS

SECTION 1 - INTRODUCTION TO RESOURCE PACK (Pages 1-2)

SECTION 2 - ASSESSMENT (Pages 3-4) (a) Planning a Bowel Programme (Pages 5-15) (b) Guidelines to Completion of Bowel Assessment Form Bowel Assessment Form – Code No. ZOY894 (not included) Bowel Chart – ZOY892 (not included) Three Day Food/Fluid Chart – ZOY893 (not included) Above three forms available from Central Stores

SECTION 3 - MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES (Page 16) (a) Flowchart – Nursing Actions for a Patient with Constipation (Page 17) (b) Flowchart – Nursing Actions for a Patient with Faecal Impaction (Pages 18 – 24) (c) Bowel Policy for Neurogenic Bowel – Maidencraig Rehabilitation Unit, Woodend Hospital

SECTION 4 - PHARMACEUTICAL (Pages 25 – 32) Pharmaceutical Aspects of Bowel Management

SECTION 5 - DIETARY ASPECTS OF BOWEL MANAGEMENT (Pages 33 – 36) Dietary Aspects of Bowel Management

SECTION 6 - PROCEDURES (Pages 37 – 39) (a) Administration of Suppositories (Pages 40 – 43) (b) Administration of Enemas (Pages 44 – 46) (c) Digital Rectal Examination (Pages 47 – 50) (d) Manual Evacuation of Faeces

SECTION 7 - APPENDICES (Page 51) Appendix 1 - Group Members (Pages 52 – 54) Appendix 2 - Anatomy and Physiology of the Normal Bowel (Page 55) Appendix 3 - Definitions in Bowel Management (Pages 56 – 62) Appendices 4 to 9 - Dietary Information (Page 63) Appendix 10 - Fibre Scoring Sheet (Page 64) Appendix 11 - MSQ Chart (Page 65) Appendix 12 - Bristol Stool Chart (Page 66) Appendix 13 - Position Chart (Page 67) Appendix 14 - Guidelines for the Use of Phosphate Enemas (Page 68) Appendix 15 - Sign Guideline 67

SECTION 8 - BIBLIOGRAPHY AND FURTHER READING (Pages 69 – 70)

SECTION 1

INTRODUCTION TO RESOURCE

PACK

PAGES 1 - 2

NHS GRAMPIAN

INTRODUCTION TO RESOURCE PACK

BACKGROUND

Recently there has been increasing professional interest in the neglected area of bowel and anorectal function. It is often not appreciated by health professionals how common bowel dysfunction’s such as constipation and faecal incontinence are and that patients are reluctant to seek help. Control of continence is a basic human need. Any disorder or abnormality will affect the person’s quality of life and could lead to or be an indicator of other underlying conditions. Constipation is a common problem for many people. It can cause discomfort and if not treated can lead to faecal impaction and bowel obstruction. A consistent approach to Bowel Management is pertinent in all clinical areas in NHS Grampian.

BOWEL GUIDELINES

The Bowel Assessment Guidelines have been updated and developed from the previous Grampian Healthcare Guidelines to Good Practice Bowel Management (July 1995). This Resource pack can be used by any health care professional with an interest in this area (although it will be mainly nurses that will be undertaking the assessment). The resource pack is divided into different sections and will act as a reference document.

The AIM of these Guidelines is to outline good practice in bowel management and provide a resource that will be updated according to new research and developments. The assessment forms have been developed following audits in care homes, surgical/medical wards, community bases and community hospitals.

NHS GRAMPIAN ASSESSMENT FORM

The NHS Grampian Assessment bowel assessment, bowel chart and three-day food and fluid form should be adopted as standard practice. This assessment should be undertaken by a registered nurse but non-registered nurses can be allocated appropriate duties relevant to their experience under the guidance of the registered nurse. The Guidelines that are included in the Resource pack will also give practical advice, which will ensure consistency in approach for patient care, based on evidence-based research where possible.

- 1 - BOWEL PROCEDURES

If a patient requires to have any bowel procedures this section provides the information that is required to undertake them safely. The Bowel procedures have been set out by the Royal College of Nursing, Digital Rectal Examination and manual removal of faeces (2004) and the Royal Marsden hospital manual of Clinical Nursing Procedures 5th Edition. These procedures will also be on the Intranet site

TRAINING SESSIONS

Staff should keep themselves up-to-date and attend relevant training sessions (which would be linked to the NHS Grampian learning and development plan) to ensure they are aware of how to assess patients, provide treatment and manage patients who have bowel problems.

INFORMED CONSENT

Patients must give informed consent as per the NHS Grampian Informed Consent Policy before any investigation; treatment or procedure is undertaken.

Any treatment provided or refused should be documented in the patient's notes either in the home, ward or care home setting.

STAFF SHOULD ADHERE TO

 The Nursing and Midwifery Council Code of Professional Code April 2002  Nursing and Midwifery Council Guidelines for Records and Record keeping (2002)  Royal College of Nursing, Digital Rectal Examination and Manual removal of Faeces (2004).

BIBLIOGRAPHY AND FURTHER READING LIST (SECTION 8)

At the rear of the Resource pack is a Bibliography and Further Reading list (Section 8) that can be used for client assessment and background reading

- 2 - SECTION 2 (a) ASSESSMENT

Planning a

Bowel Programme

PAGES 3 - 4

Planning a Bowel Programme

Following assessment and careful planning, a bowel programme should result in achieving bowel continence and adequate evacuation. This should be undertaken as a package of care rather than a single intervention.

Prior to commencing a routine bowel programme it is essential that any constipation or impaction be resolved otherwise it may be difficult to establish a predictable pattern.

Flowcharts for Constipation and Faecal Impaction can be found under Section 3 and may assist with clinical decision making. This is intended as a guide only and clinical judgement still applies.

Included in Section 3 is the Bowel Policy for people with a Neurogenic Bowel as used in Maidencraig Rehabilitation Unit. This is intended as a guide only and clinical judgement still applies.

The following should be considered as part of the programme:  Diet and fluid intake  Current and previous bowel habit  Exercise/Mobility  Medication which may cause constipation or aperients being used  Evacuation techniques  Toileting Facilities/Ability to sit on the toilet  Is gastro-colic reflex being utilized? (See last paragraph of this section)  Is there a package of care in place, will this need to be reviewed as a result of intervention.

If the above aspects have been reviewed and there are still difficulties other interventions may be necessary:

Timed oral aperients may be used in conjunction with rectal medication such as suppositories or micro enemas.

Trial and error is often required to find the best approach for individuals. It is important to be consistent with approach, meal times, sitting on the toilet, privacy, timing of medication etc to allow the programme to work. It is also important not to make too many changes at once.

Where there is known nerve damage, long term interventions may require to be implemented e.g. in conditions such as Multiple Sclerosis and Spinal Cord Injury.

- 3 -

The aims of the programme would be:-

Regular planned bowel movements (At least 3x weekly) Appropriate techniques will be used following assessment Minimise episodes of faecal incontinence

It may be useful to continue charting timing of oral, rectal medicines, consistency of stool, timing of bowel movements and any accidents when establishing the bowel programme. This allows careful adjustments to medication, or timing of interventions. It will also demonstrate the effectiveness of the programme.

Gastro-Colic Reflex

Peristalsis in the gut is normally continuous through out the day but is further stimulated by the taste, smell of food, or eating and drinking. This increase in peristalsis in the gut aids propulsion of stool through the bowel. The best time to take advantage of this as part of a bowel programme is thought to be 20-40 minutes after a meal. Literature suggests it may be stronger after the first meal of the day.

- 4 - SECTION 2 (b) ASSESSMENT

Guidelines on Completion of Bowel Assessment Form

PAGES 5 - 15

GUIDELINES TO COMPLETION OF BOWEL ASSESSMENT FORM SEPTEMBER 2005

The AIM of guidelines is that all patients in NHS Grampian with bowel problems are assessed and treated on an individual basis according to the Charter for Incontinence. This would provide a quality service ensuring effective delivery of care.

INTRODUCTION TO ASSESSMENT

The purpose of the assessment is to help identify the many different causes and contributing factors resulting in bowel problems.

In the majority of cases these symptoms can be improved or cured by identifying and treating the underlying causes. From a full assessment treatment/management of the patients problem can be implemented.

THE PATIENT/CLIENT MUST BE ASSESSED BY A TRAINED NURSE USING THE BOWEL ASSESSMENT FORM AND GUIDELINES

- 5 -

PLEASE TICK ( ) THE APPROPRIATE BOXES AND ADD ANY COMMENTS AS NECESSARY. IF YOU OR THE PATIENT/CARER ARE UNABLE TO ANSWER ANY OF THE QUESTIONS PLEASE INDICATE THIS ON THE ASSESSMENT FORM.

PLEASE SIGN AND DATE EACH PAGE OF THE ASSESSMENT FORM

WHEN THE ASSESSMENT FORM IS COMPLETED A BOWEL MANAGEMENT PLAN SHOULD BE IMPLEMENTED

SECTION ONE - PATIENT DETAILS

Please complete all relevant details paying particular attention to Unit Number/CHI and Postcode

SECTION TWO – FACTORS AFFECTING INDIVIDUALS ABILITY TO COPE

A - Using the MSQ (Mental Status see Appendix 11) questions please record the patients score in the space provided. Each correct answer scores one point

A low score may result in poor compliance with treatment.

B - PLEASE RECORD THE (PATIENT’S) HOME CIRCUMSTANCES

This will give a full picture of the patient’s home circumstances. This information will be important in treatment implementation.

C - COMMUNICATION  SPEECH e.g. Does the patient have any speech difficulties? Does the patient have swallowing difficulties? Does the patient have dentures – do they fit properly?  SIGHT e.g. Can the patient see to access the toilet? Does the patient wear spectacles? Does the patient have problems with their visual fields – When did they last have an optician’s assessment?  HEARING e.g. Is the patient hard of hearing? Is the patient deaf? Does the patient wear a hearing aid?

- 6 - D - MANUAL DEXTERITY e.g.

Can the patient hold their cutlery/cup/glass? Can the patient dress/undress themselves? Can the patient undo zips/buttons/fastenings?

E - MOBILITY e.g.

Is the patient independent? Can the patient get out of the chair/bed unaided? Does the patient use a walking aid/wheelchair? Does the patient require to use a hoist?

F - USING THE TOILET e.g.

Is the patient able to access the toilet/commode unaided? Can the patient get to the toilet in time? Can the patient get on/off the toilet unassisted and clean him or herself? Are the patient’s feet supported whilst on the toilet? (Appendix 13) Would the patient benefit from an O.T./Physiotherapy assessment?

G - OTHER AGENCIES INVOLVED

Do they have a Care Manager, Home Care, Community Psychiatric Nurse Support Worker or Private Agency?

SECTION THREE - PAST MEDICAL HISTORY

This section is made up of a series of boxes to tick in order to detail medical or surgical conditions. These may affect the client’s ability to maintain continence or contribute to constipation. For further information on these conditions details can be obtained from e.g. Library, Internet and liaison with other health professionals i.e. Specialist Nurses, GP, etc.

- 7 -

SECTION FOUR - SEXUAL HEALTH/LIFESTYLE ISSUES

Is the bowel problem having an effect on relationships or lifestyle? Is the person avoiding having a sexual relationship for fear of having an episode of incontinence? Refer to RCN Guidelines – Sexuality and Sexual Health in Nursing Practice.

SECTION FIVE - CURRENT GENERAL HEALTH ISSUES

Please indicate the patient’s current general health status e.g. anxious, coping, tired. Is there a medical condition, which is currently causing problems?

SECTION SIX – OBSTETRIC HISTORY

The following may contribute to nerve or tissue damage to pelvic floor or sphincters:-

Type of delivery e.g. Spontaneous, Forceps, Ventouse, Caesarean Section Episiotomy/Tear/3 degree Tear – was the patient cut or did they tear? Did the patient have any follow-up or treatment? e.g. Physiotherapy Any other comments – e.g. Infections Rapid Delivery Wound Infections/Re-suturing

SECTION SEVEN – MEDICATION

Refer to B.N.F./Mim’s/Intranet for more detailed information. Can current medication be modified to reduce side effects? - discuss with GP or Consultant Computer printouts if available can be attached to Assessment form. Is the patient taking any alternative remedies?

- 8 -

SECTION EIGHT- ALLERGIES

Please document any known allergies/sensitivities or known anaphylactic reaction e.g. latex lanolin peanut allergy (arachis oil enema)

SECTION NINE – DESCRIBE YOUR PRESENT PROBLEMS

What for you is the worst thing about your bowel problem?

Embarrassment Don’t go out Odour

When did the problem start?

Was it related to a specific event? Following surgery Following childbirth Due to medication Due to injury/illness/stressful time in life

Have you had any investigations for this problem?

Any recent or previous bowel investigations such as rectal examination, barium meal, sigmoidoscopy.

- 9 -

Has any medication been tried?

This should include any over the counter medication or alternative therapies. Has it been effective or not? Check if doses were therapeutic.

What helps or aggravates the problem? What makes your problem worse/better?

Any coping mechanisms being used at the moment which are helpful.

Do you use pads or protective clothing?/Are they effective?

Are they used for faecal/urinary incontinence? Is it actual incontinence or fear of being incontinent? What type of pad is used? How often are they changed? Is the pad always soiled when changed? Is there any leakage onto their clothes/bed etc.? Does patient buy them or are they provided by a Health Professional?

Has your bowel pattern changed recently?

If there are significant changes such as a change in normal pattern, rectal bleeding or mucus, +ve FOB, abdominal bloating or discomfort inform GP (Sign Guideline No. 67) - Appendix 15 Could there be other identifiable causes for this: Change in toilet facilities e.g. bedpan/commode Change in diet Change in home circumstances Change in medication

- 10 -

SECTION TEN – PRESENTING BOWEL SYMPTOMS

(Patients with difficulties in the following areas may require further specialist assessment or advice.)

How often do your bowels move?

Is there frequency or constipation? Anything between 3 x daily or 3 x weekly is considered normal.

What is the consistency of your stool?

Use of the Bristol Stool Form Scale Chart (Appendix 12) will identify stool consistency and will ensure consistent reporting of bowel habit. Patients find it easier to look at a chart than trying to describe their stool. Ideally this should be between 3 or 4. 1 > 2 are hard dry stool so could indicate constipation. 5 > 7 are loose and for some patients bulking the stool may lessen risk of incontinence. Loose stool may be indicative of e.g. inflammatory bowel disease, tumour or overflow impaction, or due to rectal prolapse, fistulas or after pelvic radiotherapy.

Do you get a desire to open your bowels?

Is the patient aware of the pressure to pass stool? This may be absent or reduced in neurological damage/disease or in chronic constipation. Ignoring the urge to defecate may lead to faecal loading and impaction. In conditions such as dementia the desire to defecate may be absent but the patient may have automatic emptying at the same time each day i.e. after breakfast, so initiating toileting at this time could reduce the risk of incontinence.

Are you able to delay? /How long for?

If there is external sphincter weakness ability to delay defecation may be considerably reduced. Patient may not have enough voluntary squeeze to stop stool from leaving rectum. This can be worse if stool is loose or if Irritable Bowel Syndrome or Inflammatory Bowel Disease is present. Is there urgency? Is it because they have frequent episodes of incontinence or because they have had some episodes and are fearful of it happening again?

- 11 -

Do you lose control of stool or flatus? Identify if incontinence of stool or flatus is a feature. How often does this happen? Can they tell the difference between flatus or needing a bowel movement? May be as a result of e.g. Neurological damage, Obstetric trauma, Congenital conditions such as imperforate anus, following haemorroidectomy. If inflammatory disease is present, high pressures in the bowel and diarrhoea can make maintenance of continence impossible.

What quantity/consistency? Is it soiling of underwear or do they lose an entire stool? Does the consistency vary?

Do you feel you empty your bowels completely/strain or use manual assistance? Evacuation difficulties may be as a result of e.g. weakened sphincters or obstructive defecation. Does passive soiling occur after a bowel movement – Internal sphincter may not close anal canal and stool will leak out. Incomplete emptying may be as a result of e.g. a rectocele following childbirth or due to excessive straining. Some female patients will describe inserting a finger into their vagina to aid expulsion of stool, this expels faeces trapped in rectocele.

Do you have pain or bloating? Is this associated with opening their bowels? If it is with an urge to defecate and is relieved by opening bowels, it may be due to Irritable Bowel Syndrome or Inflammatory Bowel Disease Pain as stool is passed is likely to be due to haemorrhoids or fissure.

Do you pass blood or mucus? If blood or mucus is a feature this should be reported to medical staff in case the cause is Inflammatory Bowel Disease, malignancy, or caused by haemorrhoids, fissures etc. Fresh blood is more likely to be haemorrhoids/fissures; darker blood could be malignancy. Excessive mucus may be caused by e.g. villious adenoma or Inflammatory Bowel Disease.

- 12 -

SECTION ELEVEN – INFORMATION FROM BOWEL AND DIETARY FIBRE SCORING SHEET

Information from these charts should be recorded in Section 11 and 13 on the Bowel Assessment Form.

Is the patient on Gastrostomy feeding? If so refer to dietician for further assessment. Is there enough fibre in diet? This can be calculated by using the fibre-scoring sheet – Appendix 10 Is eating pattern regular throughout the day e.g. eating three meals a day? The patient’s functional ability to feed must be considered as this may lead to inadequate fibre or fluid intake, which can exacerbate constipation. Is the intake of fibre spread evenly throughout the day or is it consumed at one meal? Fluid intake should be between 1500-1800mls.

SECTION TWELVE- EXAMINATION AND INVESTIGATION

See RCN document on Digital Rectal Examination and Manual Removal of Faeces Remember to gain consent from the patient before undertaking any examination or procedure – nurse must be trained and competent before undertaking any procedure or examination. Provide the reason as to why it is necessary. Patient should be offered opportunity to have a chaperone present during examination.

12B – If stool specimen is sent, document the reason why

SECTION THIRTEEN – PROBLEMS IDENTIFIED FROM ASSESSMENT

Please record information on main problems identified from assessment e.g. - Poor Oral Intake - Assisted Evacuation - Constipation/Diarrhoea - Irritable Bowel Syndrome - Faecal Incontinence - Post-delivery Laceration etc.

- 13 - SECTION FOURTEEN – PLAN OF ACTION

Fluid intake/dietary advice – refer back to Section 11

MEDICATION REVIEW

It is important that the patient’s medication is reviewed regularly to determine if they still need to be on that drug/dose etc. Refer to BNF/MIMS as some medication may cause side-effects that may contribute to constipation. The Community Pharmacist/Hospital Pharmacist will also provide advice/information. Information on positioning – refer to Appendix 13

REFERRAL TO OTHER SPECIALISTS

Following assessment of the patient’s needs and for on-going management, referral to other agencies may be necessary e.g. Dietician, following Consultant assessment - Physiotherapist, Speech Therapist. (In the community this would be done through the GP.)

STRESS/EMOTIONAL MANAGEMENT

 If a patient has incontinence it is important to determine how this has affected their lifestyle. It may be necessary to help patients cope with any aspects of stress or emotion that may be affecting them. Some patients report e.g. feeling restricted and plan journeys around toilet facilities.  Methods of helping may be the use of relaxation tapes, counselling, good communication, explanation of treatment. Referral to GP, Continence Adviser, Stoma Nurse, Colorectal Nurse may also be required.  The Continence Foundation (Tel. No. 0207 831 9831) may also help.  Ensure patients are provided with correct products for managing faecal incontinence and are aware of how to receive them e.g. home delivery service from the companies.  Information on environment – refer to Section 2  Aperient advice – refer to Pharmaceutical aspects of bowel management – refer to Section 4  Bowel Programme/Gastro Colic Reflex – refer to planning a bowel programme – refer to Section 2

-14 -

SECTION FIFTEEN - MANAGEMENT PLAN

Please record the information of selected product, size, and daily amount, code numbers. If patient has been referred to other agencies write date in box

COMMODE

Available from Central Stores or to buy

PADS

Refer to Bowel Assessment Form and Chart for correct type and quantity of pad to be issued N.B. Washable pants are not suitable for patients who have faecal incontinence

ANAL PLUGS

These are available from Coloplast on Prescription in two sizes. These patients must be assessed to determine which size is most appropriate and given the appropriate literature.

FAECAL COLLECTOR

This is available from Hollister on Prescription. Samples are available from the Continence Advisors.

STRETCH FIT PANTS

To be worn with Pad size 6, 7 and 8 but patient should be encouraged to wear their own close fitting underwear. 3 pairs issued every 8 weeks.

REFERRAL TO PHYSIOTHERAPIST

Referral via GP for pelvic floor exercises or advice on perineal support etc. Ensure before referral the patient gives consent to ensure compliance with treatment.

- 15 - SECTION 3 (a) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES

Flowchart Nursing Actions for a Patient with Constipation

PAGE 16

NURSING ACTIONS FOR A PATIENT WITH CONSTIPATION

Patient with Constipation

Assess diet and lifestyle for predisposing factors (Use bowel diary to establish patterns)

Introduce changes if required. Provide health education i.e. diet/fluids/exercise

Yes Effective? No

Assess Stool Hard Consistency Soft

Select Oral Select Oral Laxative Laxative (faecal softener) (faecal stimulator )

Continue Yes Effective?

No

Re-assess stool consistency And review regimes accordingly

- 16 -

SECTION 3 (b) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES

Flowchart Nursing Actions for a Patient with Faecal Impaction

PAGE 17

NURSING ACTIONS FOR A PATIENT WITH FAECAL IMPACTION

Patient with Faecal Impaction

Discomfort? i.e. Yes Immediate action No required

Assess Stool Assess Stool HARD Consistency SOFT HARD Consistency SOFT

Administer stool Administer stool Select Oral Select Oral softening stimulating Laxative (faecal Laxative (faecal suppository/enema suppository/enema softener) stimulant)

Effective? Yes Effective?

No No

Select Oral Select Oral Laxative Laxative (faecal (faecal softener) stimulant)

Effective? Yes Effective? Yes Re-assess stool No Effective? consistency and review regimes No Yes

Manual Evacuation

1. Assess for predisposing factors 2. Address diet and lifestyle changes 3. Follow constipation pathway if required

- 17 - SECTION 3 (c) MANAGEMENT OF PATIENTS WITH IDENTIFIED BOWEL DIFFICULTIES

Bowel Policy for People with Neurogenic Bowel as Implemented in Maidencraig Rehabilitation Unit Woodend Hospital

PAGE 18 - 24

Upper and Lower Motor Neuron Bowels – Explanations

A Neurogenic Bowel can be defined in two ways – Upper Motor Neuron Bowel and Lower Motor Neuron Bowel depending on which part of the nervous system is affected by injury or disease.

Upper Motor Neuron Bowel An upper motor neuron bowel problem occurs in injury or disease in the brain or spinal cord above T12 level e.g. after Head Injury, in Multiple Sclerosis, Parkinson’s Disease or Spinal Injury.

On examination anal sphincter tone is maintained and there may be some sensation and voluntary contraction of anal sphincter. The bowel reflexes are all preserved, therefore the bowel contracts and should empty when stimulated.

Often patients in this group can be managed with alternate day bowel movements but this also depends on their previous bowel pattern.

Even though the bowel contracts and should empty when stimulated, often other impairments and disabilities (e.g. immobility, poor fluid intake, drugs for bladder dysfunction) make people prone to constipation. Cognitive impairments with reduced awareness or understanding can also result in faecal incontinence and as well as the bowel management guidelines, behavioural strategies can also be tried.

Lower Motor Neuron Bowel A lower motor neuron bowel problem occurs due to damage to the lower spinal cord (T12 or below) or from damage or disease of the peripheral nerves. Diseases which may affect the lower cord are Multiple Sclerosis, after injury, Disc disease, infection or tumours. Diseases that can affect the peripheral nerves are Diabetes or injury during abdominal operations.

On examination the anal sphincter is flaccid with little resting tone or active contraction. Although there is some intrinsic peristalsis, it is not usually effective in propelling bowel contents distally. Constipation, impaction, overflow and incontinence often result.

Most patients will require at least daily bowel care in order to keep the rectum empty to avoid incontinence later in the day. Some patients will not respond to stimulant suppositories and may require enemas or manual evacuation to completely empty the rectum. Rigorous management is required in order to prevent constipation.

- 18 - Faecal Incontinence – Management Guidelines For Upper Motor Neuron Bowel Disorders

Bowel Policy – Maidencraig Rehab Unit 2002

- 19 -

Faecal Incontinence – Management Guidelines For Lower Motor Neuron Bowel Disorders

Bowel Policy – Maidencraig Rehab Unit 2002

- 20 -

Faecal Incontinence Management Guidelines Explanation Sheet – (to be used in conjunction with flowchart)

Management options differ slightly for Upper Motor Neuron Bowel than for Lower Motor Neuron Bowel problems Education and Support

Considerations: Bowel symptoms can be distressing and embarrassing for patients. Empathy and support is essential. Give adequate time and privacy for assessment and discussing management. Education for the patient is also important to ensure an understanding of the bowel symptoms, the possible complications and the role of diet, fluids, medications and bowel care.

Advice and Support

Skin Care Odour Control Emotional Support Pads Clothing Storage of soiled clothes Change/clean clothes Set Goals of Management

Considerations: Depends on assessment and diagnosis of bowel problem. Aim to continue premorbid bowel pattern if possible e.g. daily/alternate day. Patient’s wishes important. Patient’s ongoing care package/placement are important to consider early. Upper Motor Neuron Bowel can often manage with alternate day bowel opening. Lower Motor Neuron Bowel almost always will require daily emptying.

Bowel Health Measures

Optimise diet and fluids:

Aim for regular This will usually be in the morning before/after breakfast but routine - will depend on premorbid experience, patient preference as well as the care package. Use gastrocolic / …

- 21 -

Use gastrocolic Peristalsis, the wave movement that propels bowel contents reflex where through the digestive tract, occurs all day, but is further possible - stimulated by the smell/taste of food and by eating – particularly food with a hot drink. The bowel routine can take advantage of this reflex at breakfast with a hot drink/ warm food bolus.

Consider When possible if the patient has adequate sitting balance, positioning on they should get up onto the toilet or commode for bowel toilet, bed/ care. commode - Otherwise, ensuring a comfortable position in bed – this is usually on the left, foetal position, exerting some abdominal pressure.

Is faeces the The Bristol Stool Chart is now recognised as a standard for right consistency? describing stool consistency and is a useful tool. Ideal results are 3, 4 or 5. The stool consistency is influenced by fluid intake and dietary fibre as well as by some medications which, by relaxing the bowel, can lead to excessive re- absorption of water from the stool leading to hard, constip- ated stools e.g. codeine and other opiods, as well as Oxybutinin, inflammatory bowel disease or other bowel pathology, as well as overuse of laxatives or loose stool due to overflow incontinence.

Impaction? If bowel management gives no results over 3-4 treatments/ days, consider impaction. Impaction is a mass of com- pressed faeces in the rectum/sigmoid colon. This is not always due to hard stool. Initial management involves re- hydration and stimulation of the bowel using fluids, fibre and if necessary, Movicol.

Is faeces in the i.e. Is the faeces in or near the rectum ready for expulsion? right place? This is influenced by a regular routine and making use of the gastrocolic reflex. If required, stimulant laxatives will assist in the propulsion of bowel contents into the rectum.

Is there a Is there a reliable trigger to stimulate rectal emptying? - This right trigger? is mainly for Upper Motor Neuron bowels although some Lower Motor Neuron bowels may still have some weak reflex activity to utilise triggers. Triggers may be abdominal pressure/massage, digital rectal stimulation or pharmacological.

- 22 - Is expulsion at the right time? / … Is expulsion at Because sensation is usually impaired, patients need a the right time? predictable time for bowel opening. This results from having a regular routine that fits in with their individual daily schedule or care package. If bowels are additionally, regularly moving between scheduled times – either stimulant laxatives can be reduced or bowel care frequency may need increased e.g. to daily instead of alternate day. If bowel care results are taking a long time or are moving later in the day, the timing of stimulant laxatives could be changed to earlier in the day, to allow longer to work before the morning bowel routine.

Is the result i.e. Does the rectum empty fully (need check rectal exam- right? ination after bowels move). This can be helped by using the gastrocolic reflex, increasing oral or rectal stimulant – in some patients the frequency of bowel care may need to be increased.

Liaise with Necessary again prior to discharge to update them on Community Staff progress, explain bowel routine and reasons for it, and to ensure bowel routine is manageable.

- 23 -

Constipation – Management Guidelines

Bowel Policy – Maidencraig Rehab Unit 2002

- 24 - SECTION 4

PHARMACEUTICAL ASPECTS OF BOWEL MANAGEMENT

PAGES 25 – 32

Pharmaceutical Aspects of Bowel Management

Laxatives are important adjuncts to the management of constipation, but they are not innocuous and should only be given when other measures are inadequate. Laxative abuse may lead to hypokalaemia and an atonic non-functioning colon. It is important to be sure that the patient is constipated before prescribing laxatives and that the constipation is not secondary to an underlying undiagnosed complaint. Ideally a full bowel assessment should be completed before laxatives are prescribed.

Constipation can be defined as, the passage of hard stools less frequently than the patient’s own normal pattern. This may be difficult to define in practice as the perception of “normal” bowel habit varies from person to person. What one patient may regard as constipation another may regard as normal bowel activity and misconceptions about bowel habits can lead to excessive laxative use. Many elderly people incorrectly assume that they are constipated if they do not have a daily bowel movement. Non-pharmacological methods to address bowel management problems should always be the first step. Drug treatment of constipation should only be considered where it cannot be addressed by:

 Increasing the fibre intake of the normal diet.  Increasing fluid intake.  Increasing the mobility of the patient.  Selecting dietary products/fruit juices with a laxative effect as appropriate.  Reviewing patient’s current medication to alleviate constipation caused as a side effect of medication for another condition.

In general laxatives should only be used:

 Where straining may exacerbate conditions such as angina, cerebral and/or cardiovascular disease.  To reduce the risk of rectal bleeding & straining e.g. hemorrhoids, anal fissures.  Where bowel motility has been reduced by drugs such as opiates or anticholinergics. (Where possible contributing drug therapy should be discontinued, including over-the-counter medicines).  In elderly patients who may have weak abdominal and perineal muscles.  Where dietary interventions have persistently failed.  To clear the bowel before surgery or a diagnostic procedure, or to expel parasites after anthelmintic treatment.  Immobilised patients threatened with constipation.  In-patients with motor neurone problems, either resulting from an accident or through disease.

Ideally laxatives should be prescribed for short-term use only i.e. the lowest effective dose for the shortest possible time. Over-dosage of any preparation is accompanied by looseness, abdominal pain and increased frequency of bowel action. An acute episode of constipation needs to be treated and it may be necessary to consider maintenance therapy for some patients. Prolonged treatment is not usually required, except occasionally in the elderly or some patients with neurological disease or injury. The patient’s medication (including over-the-counter medicines) should be reviewed for potentially constipating drugs and where possible stopped or changed. The use of laxatives in children should be discouraged unless absolutely necessary (refer to “Tough going” Childhood Idiopathic Constipation Management Pathway).

- 25 - General Points

Each patient should be assessed individually and their need for laxatives determined by their bowel function, stool type and their ability to make the necessary changes to their lifestyle e.g.: fluid & fibre intake and exercise. The choice of laxative should relate to the individual patient’s needs and relative risk. Laxative choice should also follow the recommendations contained in the Grampian Nursing Formulary, Symptomatic Relief Policy and the Grampian Joint Formulary. The latter be accessed on the Grampian intranet: http://intranet/ccc/files/Chapter%201fd.pdf. The latest edition of the BNF should always be used to determine current availability, cautions, contra- indications and doses of laxatives.

Special indications

Palliative Care

Where bowel management issues are a consequence of opioid drug use for palliative care refer to the Grampian Palliative Care guidelines on the Grampian Intranet: http://cgi.grampian.scot.nhs.uk/palliative_care/constipation.asp

Pregnancy and breastfeeding

Constipation in pregnancy should preferably be managed by increased dietary fibre, fluid intake and exercise wherever possible. Where pharmacological therapy is required, bulking agents are safer, however, other laxatives may be appropriate in specific individuals. Caution should be exercised in using stimulant laxatives near to term or if pregnancy is unstable.

Constipation in breastfeeding mothers should be treated as for normal patients. However, it is important that co-danthramer is not used in these patients.

Management of impaction or overflow

Evacuation may be necessary when the rectum is full and there is impaction or overflow. Use a step-wise approach until the bowel is evacuated using a minimum number of steps.

Step 1: Micro-enema sodium citrate microenema Or Bisacodyl suppositories 10mg* in the morning

Step 2: If stool is hard Fletchers phosphate enema

If stool is soft Bisacodyl suppositories 10mg* in the morning

Step 3: Arachis oil enema Check for peanut allergy. Warm before use. *adult dose

- 26 -

MAIN LAXATIVE GROUPS – PHARMACOLOGY, DOSAGE AND USE

BULK FORMING DRUGS

Bulk forming drugs relieve constipation by increasing faecal mass, which stimulates peristalsis. The full effect may take some days to develop and so they are of limited use when rapid relief is desired and are therefore best for long term use. They are of particular value in ambulatory patients with small hard stools, but should not be required unless fibre cannot be increased in the diet. They are useful in the management of patients with colostomy, ileostomy, haemorrhoids, anal fissure, chronic diarrhoea associated with diverticular disease, irritable bowel syndrome and ulcerative colitis. Adequate fluid intake must be maintained to avoid intestinal obstruction (approximately 1 glass of fluid per average dose). Bulk forming drugs are the only laxatives acceptable for long-term use and they may be useful for weaning patients off long term use of stimulant laxatives. They should not normally be used in the elderly with atonic bowels as obstruction may ensue and should only be used with great caution in non-ambulatory patients. Patients with slow-transit constipation and those with a functional outlet obstruction may have their symptoms aggravated by the use of bulk forming drugs as the patient will have to move and expel more stool which may magnify their symptoms. Bulk forming laxatives may be appropriate for long- term use only in-patients with normal gut motility and otherwise uncomplicated constipation where good fluid intake can be assured.

a) Ispaghula Husk

The normal adult dose is one sachet in water, twice daily, preferably after meals, but an evening dose should not be taken immediately before going to bed. Ispaghula Husk is indicated for treating mild or moderate chronic constipation. (Note: - in the elderly one sachet daily may be sufficient along with adequate fluid intake)

STIMULANT LAXATIVES

They act directly on the myenteric plexus and stimulate colonic peristalsis, but their mechanisms of action may be diverse and more complex. They increase intestinal motility and often cause abdominal cramp. They should not be used in intestinal obstruction and prolonged use can precipitate the onset of atonic non-functioning colon and hypokalaemia. They are potent laxatives and the agents most often implicated in the cathartic bowel syndrome i.e. poorly functioning bowel.

Stimulant laxatives may be used when rapid relief of constipation is desired, but are recommended for short-term use only. Improved mobility and the provision of time and privacy for going to the toilet may be all that is required. They should not be used for faecal impaction, which should be first cleared manually or with the use of enemas. Patients with neurological constipation and those taking opiates may require the continuous use of stimulant laxatives.

- 27 - a) Senna

This is an anthraquinone. It increases the patient’s sensitivity to the stimuli, which normally promote defaecation. The correct dose is the smallest required to produce a comfortable, soft, formed motion. It varies between individuals but the laxative effect takes between 8 - 12 hours. The usual adult dose is 2 tablets at bedtime (up to 4 on medical advice). If no bowel action has occurred after 3 days progressively increased dosage, a medical examination should be considered. Once regularity has been achieved, dosage should be reduced and can usually be stopped. Senna is thus indicated for the short-term treatment of acute constipation. Senna is also available as a syrup (5mL syrup = 1 tablet). Senna is included in the NHS Grampian symptomatic relief policy. b) Bisacodyl

Bisacodyl is a diphenylmethane used for the treatment of constipation and for bowel evacuation in oral doses of 5-10mg at night. The night before radiological procedures and surgery, 10-20mg . A 10mg dose is used in adults when given by suppository. It is usually effective within 10 to 12 hours following oral administration and within 20 to 60 minutes following rectal administration. Rectal administration may be associated with local irritation. b) Sodium Picosulphate

This is given by mouth as a solution once daily in a dose of 5 -10mg at night for adults. It is effective within 6 – 12 hours. It is also available, in combination with magnesium citrate, as Picolax® sachets for bowel evacuation prior to abdominal radiological procedures, endoscopy and surgery. It should be used with caution in-patients with active inflammatory bowel disease. c) Docusate Sodium

This acts as a stimulant and softening agent, effective within 1 - 2 days. The usual adult dose is up to 500mg daily in divided doses. This can be used in doses up to 600mg in palliative care but this dose is outside the licence for the product. Initial doses should be large and gradually reduced. Adverse effects rarely occur. It is useful in-patients, when given orally, with hemorrhoids who are constipated, for the elderly and to treat opioid - induced constipation. Docusate is usually considered to be comparatively ineffective on its own and is usually used in combination with a stimulant laxative. (Rectal preparations of Docusate should not be used if there are hemorrhoids or anal fissures)

Docusate sodium is available as 100mg capsules or as an adult oral solution containing 50mg/5mL. d) Danthron

Danthron is an anthraquinone laxative that now has limited indications because rodent studies indicate potential carcinogenic risk. It is now only indicated for constipation in terminally ill patients of all ages. Danthron acts within 6 - 12 hours and may colour the urine red. Prolonged contact with the skin (as in incontinent patients) should be avoided as irritation and excoriation may occur. Danthron is available combined with a stool softener as Co-Danthrusate capsules (danthron 50mg,docusate sodium 60mg). The usual dose is 1 - 3 capsules at bedtime.

- 28 - Co-danthramer or co-danthramer strong (Danthron with poloxamer ’188’(a wetting agent)) is available as capsules or suspension. The usual dose is 1-2 capsules or 5 -10mL at night. (NB: 5mL for the strong suspension)

e) Glycerol (Glycerin) suppositories act as a rectal stimulant due to the mildly irritant action of glycerol, an osmotic agent with lubricating properties. It is absorbed when given orally and is therefore only effective when given by suppository. Glycerol suppositories are available in 4g size for adult use. They should be moistened with water before use. Glycerol suppositories are included in both the symptomatic relief policy and the Patient Group Direction for the Grampian Formulary of Nursing Care Products.

FAECAL SOFTENERS

Faecal softeners have a detergent action that reduces surface tension and promotes the admixture of water and fat, allowing their penetration into the faeces and thus softening the stool. They may also act directly on the intestine, stimulating the secretion of water and electrolytes. Rectally administered suppositories and enemas lubricate and soften impacted faeces and promote a bowel movement.

Arachis Oil enemas are used to lubricate and soften faeces, which are impacted higher than the rectum. The enemas should be warmed before use. They are expensive and should only be used where other measures have failed. Contra-indicated in patients with peanut allergy.

OSMOTIC LAXATIVES

Osmotic laxatives are poorly absorbed and act by drawing water into the intestine, increasing the bulk and water content of the stool and promoting peristalsis by mechanical distension. Most have a rapid onset of action (except lactulose) and are useful when rapid relief is desired.

a) Lactulose is a semi-synthetic disaccharide, which is not absorbed from the gastro- intestinal tract. It is broken down by colonic bacteria into simple organic acids, which exert a local osmotic effect in the colon resulting in increased faecal bulk and stimulation of peristalsis. It may take up to 48 hours before an effect is obtained. Lactulose should not be used routinely as a laxative. It can be unpalatable, causes abdominal discomfort, flatulence and cramps, has a slow onset of action, requires large doses for effect and is expensive. It should be used with caution in patients with lactose intolerance. Lactulose should be reserved for situations where other laxatives are unsuitable or for patients with hepatic encephalopathy. For hepatic encephalopathy larger than normal doses are used, the pH in the colon is reduced significantly by this acid production and the absorption of ammonium ions and other toxic nitrogenous compounds is decreased, leading to a fall in blood- ammonia concentration. Lactulose is available as a solution containing 3.35g/5mL. For constipation the initial dose is 15mL twice daily, gradually reducing according to patient’s needs.

- 29 - b) Saline Laxatives The osmotically active ions are sulphate, magnesium, phosphate and citrate in order of decreasing potency. They are indicated when rapid relief of constipation is desired. Sodium citrate micro-enemas are available for rectal use in constipation. Sodium citrate microenemas are included in the Patient Group Direction for the Grampian Formulary of Nursing Care Products. In susceptible individual sodium salts may give rise to sodium and water retention.

Phosphate enemas are used in bowel clearance before radiology, endoscopy and surgery. They may also occasionally be required for the treatment of impacted faeces, where the rectum and lower colon contain soft faeces or for in-patients where dehydration is a problem.

MACROGOLS

Macrogols are inert polymers of ethylene glycol which sequester fluid in the bowel. Giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives. Macrogol 3350 or 4000 are high molecular weight polymers that are virtually unabsorbed by the gut. The polymer exerts an osmotic pressure when dissolved in water, thus retaining water in the gut. This fluid load lubricates the faeces stimulating peristalsis and facilitating the easy passage of stools.

Movicol® is a combination of macrogol (polyethylene glycol) 3350 and electrolytes (sodium, potassium, chloride, bicarbonate). The inclusion of electrolytes in Movicol® may help prevent electrolyte depletion sometimes experienced in long term use of laxatives. If patients develop any symptoms indicating shifts of fluid/electrolytes (e.g. oedema, shortness of breath, increasing fatigue, dehydration, cardiac failure) macrogols should be stopped immediately. Abdominal distension, pain and nausea due to the expansion of the contents of the intestinal tract can also occur. Movicol® is available in two sachet sizes Movicol® and Movicol-Half® (13.8g & 6.9g respectively) for reconstitution with 125mL and 62.5mL of water respectively to an oral solution.

Movicol® (Macrogols) is included within the Grampian Joint Formulary for restricted use only. It should be reserved only for the treatment of acute faecal impaction when other therapies have failed to be effective. Usual duration of 3 days in adults. Macrogrols (Movicol®) can also be used in the treatment of chronic severe constipation, with faecal loading, only in patients with neurological disorders (eg: multiple sclerosis, spinal injury) when other therapies have failed to be effective. A course of treatment should not normally exceed two weeks.

The recommended oral dose for chronic constipation is 1-3 Movicol® sachets (or 2-6 of Movicol-Half®) daily in divided doses, reducing according to individual response. A course of Movicol should not normally exceed 2 weeks.

Movicol® is also licensed for faecal impaction in adults, adolescents and the elderly where the dose is 8 sachets dissolved in 1 litre of water and consumed within 6 hours, for a maximum of 3 days.

Movicol® is not licensed for use in children under 12.

- 30 -

All laxatives can be prescribed by nurse prescribers except magnesium sulphate mixture which can only be prescribed by extended nurses prescribers. Nurse prescribers are reminded that they need to prescribe these medicines generically (see BNF for correct names).

Drugs with the Potential to cause constipation

 Antacids containing Aluminium or Calcium e.g. Aludrox

 Anti-diarrhoeals e.g. Loperamide

 Antihistamines e.g. Chlorpheniramine

 Anticholinergics e.g. Benzhexol

 Calcium-channel blockers e.g. Verapamil

 Cough suppressants e.g. Codeine

 Diuretics (if dehydration occurs)

 Opioid analgesics e.g. codeine, dihydrocodeine , morphine

 Tricyclic antidepressants e.g. Amitriptyline

 Phenothiazine anti-psychotics e.g. Chlorpromazine

 Iron preparations

This list is not exhaustive – see the BNF for more information.

- 31 - MAIN LAXATIVE GROUPS – SUMMARY TABLE

Group DRUG & ADULT INDICATION GENERAL DOSE INFORMATION Bulk Ispaghula Husk Valuable in patients producing small hard Patients MUST be able to Forming (Fybogel®, Regulan®) stools where an increase in fibre in the diet maintain a good fluid intake Drugs cannot be achieved. Useful in the in order to avoid intestinal management of patients with colostomies, obstruction. ileostomies, haemorrhoids and anal fissures. Useful in patients who cannot The full effect may take tolerate bran. Suitable for long term use. some days to develop. May worsen problem in immobile patients who have slow transit times. Abdominal distension can occur. Stimulant Senna Short term treatment of acute constipation. Orally takes 8 to 12 hours laxatives Senna may be used long term in patients to act. Bisacodyl with opioid induced constipation. Bisacodyl suppositories act Oral & rectal within 20-60 minutes, tablets within 10-12 hours Dantron (co- Used only for treatment of constipation in Dantron takes 6 to 12 hours danthramer, co- terminally ill patients. to work danthrusate) Docusate sodium Acts both as a weak stimulant and as a Oral preparation takes 1 to softening agent so useful for softening hard 2 days to work. stools. Useful for patients with anal fissures or haemorrhoids and in the elderly. Large doses used in constipation induced by opioids in palliative care. Sodium picosulfate Useful for bowel evacuation before surgery Acts within 6-12 hours. or radiological/endoscopic procedure. Glycerol (Glycerin) Effective for acute constipation. Moisten with water suppositories before use. Faecal Arachis Oil Enema Lubricates and softens impacted faeces to Contra-indicated in peanut Softners cause a bowel movement. Only to be used allergy. Warm before use. when other methods have failed. Osmotic Lactulose Not suitable for acute relief of symptoms. Can take up to 48 hours to laxatives Used for hepatic encephalopathy and work. Caution in lactose situations where other laxatives are intolerant patients. Good unsuitable. Not indicated as first line choice. fluid intake is essential. Phosphate Enemas Useful for bowel clearance before surgery or radiological/ endoscopic procedures. Sodium citrate Suitable where large volume enemas are Indicated when rapid relief (rectal) (eg: Micolette® contra-indicated. of constipation needed. Magnesium Sulphate Used for rapid bowel evacuation. Useful Acts in 2-4 hours. Mixture before radiological procedures. Not for long term use. Macrogrols Reserved for the treatment of acute faecal Usual duration of treatment (Movicol® impaction when other therapies have failed 3 days in adults. Movicol-Half®) to be effective.

May also be used in the treatment of A course of Movicol® chronic severe constipation, with faecal should not normally exceed loading, in patients with neurological 2 weeks. disorders (eg: multiple sclerosis, spinal injury) when other therapies have failed to be effective.

- 32 - SECTION 5

DIETARY ASPECTS OF BOWEL MANAGEMENT

PAGES 33 – 36

DIETARY ASPECTS OF BOWEL MANAGEMENT

Inadequate intake of food, dietary fibre and fluid may all contribute to the development of constipation.

Intake of Food

A poor intake of food results in an inadequate volume of colonic contents and this may lead to constipation. When dietary intake is considered as insufficient try encouraging with small, well presented meals and nourishing snacks between meals (Appendix 4 – Snack Ideas). Suggestions regarding suitable snack foods can be given to carers/relatives who may be able to provide these and encourage intake. If dietary intake food remains consistently poor the Dietician should be contacted.

Dietary Fibre – (Non Starch Polysaccharides)

Non Starch Polysaccharides (NSP) comprise the major proportion of what is commonly called ‘dietary fibre’. These include the parts of cereals, fruit and vegetables, which are not digested and absorbed in the small intestine. Dietary fibre is important in preventing constipation. It increases stool weight and reduces bowel transit time and has the ability to absorb water which results in the formation of a soft more easily passed stool. Wholegrain cereals, pulses and some vegetables and fruit are high in dietary fibre and are recommended in particular because they are also valuable sources of several other nutrients. High fibre diets have also been used effectively to improve blood glucose control and may help to reduce blood cholesterol. Dietary fibre intake needs to be increased gradually in an attempt to avoid problems such as flatulence and abdominal discomfort. Carers/relatives of the patients can be given suggestions of suitable high fibre snack foods to bring in (Appendix 5 – High Fibre Snacks).

Most people enjoy foods which are high in dietary fibre but those with ill fitting dentures or those who do not wear their dentures may have difficulty chewing several of the foods rich in fibre and therefore may avoid them. Those requiring the consistency of their diet altered due to dysphagia may also be avoiding high fibre foods. However, there are high fibre foods of suitable consistency available (Appendix 6 – High Fibre Foods suitable for those with Chewing/Swallowing Difficulties).

A high fibre intake results in a feeling of fullness. Care should, therefore, be taken with the frail or chronically sick with small appetites to ensure the amount of fibre rich foods in the diet does not reduce their intake of foods providing other important nutrients.

- 33 - The use of unprocessed bran/natural bran is not advised as a way of increasing fibre intake. In order to increase the quantity of fibre taken in the diet, it is more favoured to eat a variety of foods, which are naturally high in fibre. Unprocessed bran is tasteless and unpalatable and if added in large quantities to a previously low fibre diet it can result in stomach pains, diarrhoea and flatulence. It may also reduce the absorption of some minerals e.g. calcium and zinc. It should only be used under medical/dietetic supervision.

In order for patients to achieve higher fibre intakes, certain measures can be taken:-

 If porridge and wholegrain cereals are liked, patients should be encouraged to choose them.

 Stewed fruits (prunes/apple) or grapefruit segments can be offered at breakfast.

 An increased intake of wholemeal toast, if liked, should be encouraged – it can be offered at breakfast and it makes an ideal mid-morning and evening snack.

 If wholemeal bread is particularly disliked offer a white bread that has been fortified with fibre or contains multigrains.

 Offer wholemeal bread or wholemeal rolls along with soup.

 Encourage fruit daily – fresh, tinned, stewed or dried.

 Encourage vegetables daily – hot or in salad.

(Appendix 7 – High Fibre Foods Available from the Catering Department and Appendix 8 – Fibre Content of Everyday Foods)

Fluid

An inadequate fluid intake is often forgotten as a cause of constipation. If fluid intake is poor dietary fibre cannot expand (absorb enough water) and soften sufficiently to pass through the digestive tract. Faeces can become hard and compacted.

An adequate fluid intake is essential for health. Aim for a fluid intake of 8-10 cups (1.5 – 2 litres) per day.

- 34 - The 8-10 cups of fluid can be taken as water, tea, coffee, milky drinks, fruit juices or squashes. To achieve the desired intake, fluids should be offered both with and between meals (Appendix 9 – Fluids).

Some individuals may have a fading sense of thirst and they will require prompting to consume some fluids at regular intervals even if they are not thirsty. Fear of incontinence may also lead to an insufficient quantity of fluids being consumed. For those concerned about nocturnal incontinence, sufficient fluids should continue to be encouraged throughout the day.

Ways to achieve adequate fluid intakes of 8-10 cups per day:-

 Regular fluid rounds

 Offering drinks the patient likes

 Assist fluid intake through use of feeder cups or straws if required

 For individuals who are able to take drinks independently the cup/glass should be placed within easy reach.

 Encourage carers/relatives to offer drinks to the individual.

 Additional information and leaflets available from Dietetics Department – 01224 227831

- 35 -

DIETARY ASPECTS OF BOWEL MANAGEMENT SUMMARY

An adequate intake of food, dietary fibre and fluid is important to help prevent and also to treat constipation.

 Intake of food: If dietary intake is poor try encouraging small frequent meals. If intake does not improve contact the Dietician.

 Dietary fibre has an important role in the prevention of constipation. Encourage porridge, wholegrain cereals, pulses, wholemeal bread, fruit and vegetables. It is important to increase intake of dietary fibre gradually to avoid abdominal discomfort. The use of unprocessed bran is not advised.

 Fluid: An inadequate intake of fluid can cause constipation. Aim for a fluid intake of 8 – 10 cups (1.5 – 2 litres) per day.

 Appendices: Appendix 4 – Snack Ideas Appendix 5 – High Fibre Snacks Appendix 6 – High Fibre Foods Suitable for those with chewing / swallowing difficulties Appendix 7 – High fibre foods available from the Catering Department Appendix 8 – Fibre Content of Everyday Foods Appendix 9 - Fluids

- 36 -

SECTION 6 (a) PROCEDURES

Administration of Suppositories

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

PAGES 37 – 39

ADMINISTRATION OF SUPPOSITORIES

Refer to Pharmaceutical Section for details of suppositories – Pages 25-32

DEFINITION

A semi-solid pellet introduced into the anal canal

INDICATIONS

1. To evacuate the lower bowel/rectum before certain types of surgery 2. To empty the bowel to relieve acute constipation or when other treatments for constipation have failed 3. To empty the bowel before endoscopic examination 4. To soothe and treat haemorrhoids 5. To administer certain systemic medicine

CONTRA-INDICATIONS

1. Chronic constipation which would require repetitive use 2. Paralytic ileus 3. Colonic obstruction 4. Following gastrointestinal or gynaecological operations, unless specified by a Doctor

REQUIREMENTS

 Prescription and drug recording sheet  Prescribed suppository  Non-sterile disposable gloves as per Glove Guidelines Policy  Disposable apron  Paper tissue  Lubricating jelly/water for glycerine suppository  Scissors if required  Disposal bag as per Clinical Waste Guidelines  Bed protection

NB – Check for latex, lanolin, peanut allergy

- 37 -

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

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

RECTAL MEDICATION

Rectal medication avoids liver metabolism and can have a greater and faster effect than oral medication

- 39 - SECTION 6 (b) PROCEDURES

Administration of Enemas

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

PAGES 40 – 43

ADMINISTRATION OF ENEMAS

Refer to Pharmaceutical Section for details of enemas – Pages 25-32

DEFINITION

An enema is the introduction into the rectum or lower colon of fluid for the purpose of producing a bowel action or instilling medication.

INDICATIONS

1. To evacuate the bowel 2. To prepare the lower bowel prior to surgery or X-ray examination 3. To introduce medication and fluids into the body for absorption 4. To soothe and treat bowel mucosa 5. To decrease body temperature 6. To stop local haemorrhage 7. To reduce hyperkalaemia (calcium resonium) 8. To reduce portal systemic encephalopathy(phosphate enema)

CONTRAINDICATIONS

1. Paralytic ileus 2. Colonic obstruction 3. Where the administration of tap water or soap and water enemas may cause circulatory overload, water intoxication, mucosal damage and necrosis, hyperkalaemia and cardiac arrhythmias. 4. When the administration of large amounts of fluid may cause perforation and haemorrhage 5. Following gastrointestinal or gynaecological surgery, where suture lines may be ruptured (unless medical consent has been given) 6. The use of micro-enemas and hypertonic saline enemas in patients with inflammatory or ulcerative conditions of the large colon

TYPES OF ENEMAS 1. EVACUANT Is a solution introduced into the rectum or lower colon with the intention of it being expelled, along with faecal matter and flatus, within a few minutes.

2. RETENTION Is a solution introduced into the rectum or lower colon with the intention of being retained for a specified length of time

- 40 -

REQUIREMENTS

 Prescription and Drug Recording Sheet  Prescribed enema  Non sterile gloves as per Glove Guidelines  Disposable apron  Paper Tissue  Lubricating jelly  Jug  Disposal bag as per Clinical Waste Guidelines  Bed protection NB – Check for Latex, Lanolin. Peanut Allergy

PROCEDURE RATIONALE Explain and discuss procedure to Ensure patient understands patient procedure and gives consent Allow patient to empty bladder if A full bladder may cause discomfort necessary during the procedure Ensure patient privacy Provide patient comfort and dignity Ensure that a bedpan, commode or Incase the patient feels the need to toilet is readily available expel the enema before the procedure is complete Warm the enema to the required Heat is an effective stimulant of the temperature by immersing in a jug of nerve plexi in the intestinal mucosa. An hot water enema heated to body temperature or just above will not damage the intestinal mucosa. To minimise shock and prevent bowel spasms Assist the patient to remove clothing This allows ease of passage into the from the waist down and lie the rectum by following the natural patient in the left lateral position with anatomy of the colon. In this knees flexed ensuring they are position, gravity will aid the flow of covered at all times. the solution onto the colon. Flexing the knees ensures a more comfortable passage of the enema nozzle or rectal tube Place bed protection under the To prevent risk of cross-infection. patients hips and buttocks Reduce potential of soiled linen

Wash and dry hands thoroughly Prevent risk of cross-infection Apply apron and put on gloves Prevent risk of cross-infection

- 41 -

PROCEDURE RATIONALE Place some lubricating jelly on a To prevent trauma to the anal and swab/tissue. Remove cap from rectal mucosa by reducing surface enema and lubricate the nozzle of the friction enema or the rectal tube Expel excessive air from enema tube. To prevent distension of colon and Separate buttocks and introduce the minimise spasm of the intestinal wall. nozzle or tube slowly into the anal canal (to a depth of 10-12.5 cm, if long tube used) while separating the buttocks RETENTION ENEMA – Introduce To avoid increasing peristalsis and to the fluid slowly by rolling the pack reduce pressure on rectal walls. from the bottom to the top to prevent Elevating the foot of the bed aids in backflow, until the pack is empty or retention of the enema by force of the solution is completely finished. gravity Slowly withdraw the nozzle. Leave the patient in bed with the foot of the Avoid reflex emptying of the rectum bed elevated (if possible) for as long To enhance the evacuant effect as prescribed before evacuating the bowel EVACUANT ENEMA – Introduce the Avoid pressure on rectal walls and fluid slowly by rolling the pack from the encourage retention of enema bottom to the top to prevent backflow Avoid reflex emptying of the rectum until the pack is empty or the solution is completely finished. Slowly withdraw the rube or nozzle, request patient to retain enema according to manufacturers instructions Dry the patient’s perineal area with Promote patient comfort and prevent tissue and place in disposal bag excoriation

Ensure the patient is near the To enhance patient comfort and bedpan, commode or toilet and has prevent excoriation adequate toilet paper Remove gloves, apron and dispose of Prevent risk of cross-infection equipment as per clinical waste guidelines Wash and dry hands thoroughly Prevent risk of cross-infection

- 42 -

PROCEDURE RATIONALE Record details of procedure in Provide a legal record and monitor patients notes patients bowel function Type of enema Expiry date Amount of enema instilled Result –(colour, consistency, content and amount of faeces produced). Related to Bristol stool chart

NOTES

STEROID ENEMA Should be given after defecation, preferably at bedtime

COMPLICATIONS OF PHOSPHATE ENEMA

 Trauma to anal/rectal mucosa caused by the enema nozzle  Topical activity in the local tissue caused by the phosphate  Some people have a greater risk of localised and systemic complications and are therefore more at risk when other complications occur  They should not be used in patient’s who are elderly, debilitated or have advanced malignancy.  If there is bleeding after a phosphate enema a surgical opinion should be sought  Avoid in patient’s who have colitis, procitis, inflammatory bowel conditions, inflamed haemorrhoids, skin tags acute, gastrointestinal conditions, anal or rectal surgical wounds, trauma, recent radiotherapy to lower pelvic area

- 43 - SECTION 6 (c) PROCEDURES

Digital Rectal Examination

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

PAGES 44 – 46

DIGITAL RECTAL EXAMINATION

Refer to Royal College of Nursing Digital Rectal Examination and Manual Removal of Faeces (2004) A nursing assessment should be undertaken before this procedure is performed.

THIS SHOULD NOT BE PERFORMED ON A CHILD

DEFINITION

Insertion of a finger into a patient’s rectum to perform an examination

INDICATIONS

1. To assess anal tone and the ability to initiate a voluntary contraction and to what degree 2. Anal/rectal sensation 3. To assess if faecal matter is present, amount and consistency 4. The need and outcome of using digital stimulation to trigger defecation by stimulating the recto-anal reflex 5. The need for manual removal of faeces and evaluating bowel emptiness 6. To assess the need for and effects of rectal medication and/or to evaluate its outcome in patients who are unable to communicate or who have diminished anal/rectal sensation 7. The outcome of rectal/colonic washout/irrigation if appropriate

PRECAUTIONS

1. Active inflammation of the bowel 2. Recent radiotherapy to the pelvic area 3. Rectal/anal pain 4. Rectal surgery or trauma to the anal/rectal area 5. Patients with tissue fragility and obvious rectal bleeding 6. Patients with a history of abuse 7. Spinal patients with known autonomic dysreflexia 8. Patients with known allergies e.g. latex/soap/phosphate and peanut (present in arachis oil enema)

- 44 - OBSERVATIONS WHILE UNDERTAKING PROCEDURE

1. Rectal prolapse 2. Haemorrhoids, position, grade, prolapse 3. Anal skin tags 4. Wounds, dressings, discharge 5. Anal lesions 6. Gaping anus 7. Skin conditions, broken areas, pressure sores of all grades 8. Bleeding and colour 9. Faecal matter 10. Infestation 11. Foreign bodies

REQUIREMENTS

 Disposable apron  Non-sterile disposable gloves as per Glove Guidelines  Bed protection  Paper tissue  Lubricating jelly  Disposable bag as per Clinical Waste Guidelines

PROCEDURE RATIONALE Explain and discuss procedure to Ensure patient understands procedure patient and gives consent. Document that consent has been given Allow the patient to empty bladder if A full bladder may cause discomfort necessary during procedure Ensure patient privacy Provide patient comfort and dignity Assist the patient to remove clothing To expose the anus and allow for from the waist down and lie them in insertion of finger for examination the left lateral position with knees flexed. Place bed protection under the Prevent risk of cross-infection and patient’s hips and buttocks reduce potential of soiled linen Wash and dry hands thoroughly Prevent risk of cross-infection Apply apron and put on disposable Prevent risk of cross-infection gloves

- 45 -

PROCEDURE RATIONALE Examine the anal area as in the list above Apply lubricating gel to the gloved To facilitate easier insertion and index finger minimise patient discomfort Inform the patient that you are going To ensure the patient is relaxed to perform the procedure Insert one gloved finger slowly into the To minimise discomfort patient’s rectum and undertake examination for presence of faecal matter, amount and consistency (using the Bristol Stool Chart) To ensure nurse only examines within N.B. This may also be required to criteria. assess the need for or outcome of rectal medication, and for assessment of size, consistency of prostate gland (if trained for this)

Slowly withdraw finger from patient’s To minimise patient discomfort rectum when finished N.B. At this point rectal medication can be administered Dry the patient’s peri-anal area with Prevent skin irritation or soreness tissue and place is disposal bag Leave patient comfortable and minimise risk of cross-infection Make patient comfortable and offer the Examination may stimulate the patient toilet, commode, bedpan if required to defecate Remove apron and gloves and dispose Prevent risk of cross-infection of equipment as per Clinical Waste Guidelines Wash and dry hands thoroughly Prevent risk of cross-infection Record results of examination in Provide a legal record and ensure patient’s notes and communicate with correct care is provided patient/carer/doctor as necessary  Record observations  Findings  Action taken  What information was given to patient written/verbal

- 46 - SECTION 6 (d) PROCEDURES

Manual Evacuation of Faeces

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

PAGES 47 – 50

MANUAL EVACUATION OF FAECES

Refer to Royal College of Nursing – Digital Rectal Examination and Manual Removal of Faeces (2004) A nursing assessment should be undertaken including a DIGITAL RECTAL EXAMINATION before this procedure is undertaken

THIS SHOULD ONLY BE PERFORMED IN THE FOLLOWING SITUATIONS

 It has been identified as an acceptable bowel management method  Faecal impaction/loading  Incomplete defecation  Inability to defecate  All other bowel emptying techniques have failed  Neurogenic bowel dysfunction  In patients with spinal injury

EXCLUSIONS

 There is lack of consent from the patient  The patient’s Doctor has given specific instructions that these procedures are not to take place  The patient has recently undergone rectal/anal surgery or trauma  The patient gains sexual satisfaction from these procedures and the nurse involved find them embarrassing. In this instance consultation with a Doctor is advised.

CAUTION WHEN PERFORMING THIS PROCEDURE IN THE FOLLOWING

 Acute inflammation of the bowel, including Crohns Disease, Ulcerative Colitis and Diverticulitis  Recent radiotherapy to the pelvic area  Rectal/anal pain  Rectal surgery/trauma to the anal/rectal area  Tissue fragility due to age, radiation, loss of muscle tone in neurological diseases or malnourishment  Obvious rectal bleeding  If patient has known history of abuse  In spinal injured patients because of autonomic dysreflexia  If patient has known history of allergies e.g. latex, soap, phosphate and peanut (present in an arachis oil enema)

- 47 -

OBSERVATIONS AND RISK FACTORS

 Pulse at rest during procedure  Pulse during procedure  Blood pressure in spinal injuries prior to, during and at the end of procedure. A baseline blood pressure is advised for comparison  Signs and symptoms of autonomic dysreflexia – headache, flushing, sweating, hypertension  Distress, pain, discomfort  Bleeding  Collapse  Stool consistency/amount

REQUIREMENTS

 Disposable apron  1-2 pairs of Gloves as per Glove Guidelines  Lubricating jelly/Anaesthetic gel  Bed protection  Paper tissue  Bedpan/commode

1. A nurse should NOT undertake the manual removal of faeces from a child as it is viewed as being traumatic and disturbing. 2. Manual removal of faeces is viewed as a last resort and should only be used if all other treatments have been tried. 3. If the manual removal of faeces is an established aspect of care, prior examination by a Doctor is not required.

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

- 49 -

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

- 50 -

SECTION 7

APPENDICES

PAGES 51 - 68 CONTACTS APPENDIX 1

NAME TITLE TELEPHONE E-MAIL ADDRESS BASE

Caroline Hind Pharmacist Extn 56088 [email protected] Pharmacy Department Woodend Hospital Eday Road Aberdeen, AB15 6XS

Effie Jamieson Community Rehabilitation Nurse Extn 56884 [email protected] Horizons Rehabilitation Centre 2 Eday Walk Aberdeen, AB15 6LN

Isobel MacDonald Senior Dietitian Extn 56248 [email protected] Dept of Nutrition and Dietetics Woodend Hospital Eday Road Aberdeen, AB15 6XS

Susan May Development Nurse for the Extn 56235 [email protected] Staff Home Promotion of Continence Woodend Hospital Eday Road Aberdeen, AB15 6XS

Wilma Nicolson Community Continence Advisor Extn 72748 [email protected] Continence Advisory Service Inverurie Hospital Upperboat Road Inverurie, AB51 3UL

Wendy Robertson Pharmacist Extn 56636 [email protected] Pharmacy Department Woodend Hospital Eday Road Aberdeen, AB15 6XS 01343 567423 Sheila Shearer Continence Advisor Extn 67423 [email protected] Continence Service Spynie Hospital Elgin, IV30 5PW Aberdeen Maternity Hospital Sandra Whyte Senior 1 Physiotherapist Extn 59342 [email protected] Foresterhill Site Aberdeen, AB25 2ZL

APPENDIX 2

ANATOMY AND PHYSIOLOGY OF THE NORMAL BOWEL

The main functions of the bowel are

 Storage of unabsorbed food residue  Absorption  Secretion of mucus  Elimination of waste

For the purposes bowel management we will focus on the LARGE BOWEL

A – Mouth B – Oesophagus C – Stomach D – Small Bowel E – Large Bowel F – Rectum

The large bowel is about 5 feet long and extends from the ILEO-CAECAL VALVE to the ANUS It consists of the ASCENDING, TRANSVERSE, DECENDING and SIGMOID COLON, the RECTUM and the ANUS.

The muscle in the rectum contains sensory nerves, which are thought to detect the presence of faeces. - 52 - APPENDIX 2

ANAL SPHINCTERS

2 MUSCULAR SPHINCTERS, the INTERNAL and EXTERNAL SPHINCTERS, surround the anal canal.

 The INTERNAL anal sphincter is composed of SMOOTH MUSCLE (involuntary)

 The EXTERNAL sphincter is composed of SKELETAL MUSCLE (voluntary)

 Another important factor in maintaining continence is the role of the pelvic floor muscles, in particular the PUBORECTALIS portion of the LEVATOR ANI MUSCLE, this forms a sling around the rectum and forms an angle known as the ANORECTAL ANGLE.

- 53 -

APPENDIX 2 THE PROCESS OF DEFECATION

Within the colon lies thick bands of muscle, which contract and relax to form peristaltic waves along the bowel. These strong surges propel waste products along the length of the bowel. These surges often occur after a meal and are known as the GASTRO COLIC REFLEX. External influences such as exercise, emotion, medication etc can affect this process. These mass movements propel the faecal mass into the rectum.

Sensory nerve endings are stimulated which triggers the SPINAL REFLEX, the rectum contracts, the internal sphincter relaxes and we experience the desire to defecate

If it is appropriate to defecate the external sphincter relaxes, peristaltic waves increase, the internal sphincter and pelvic floor relaxes the levator ani muscle lifts the rectum and the faeces is expelled through the anus. Evacuation is assisted by an increase in ABDOMINAL PRESSURE and an increase in thoracic pressure (VALSALVA MANOUVRE), this is also known as BRACE AND BULGE.

If defecation is not appropriate the external sphincter contracts inhibiting the defecation reflex, the walls of the sigmoid colon and rectum relax, as the reflex abates the faecal mass is pushed back up into the colon leaving the rectum in the normal state that of empty.

- 54 - APPENDIX 3

DEFINITIONS IN BOWEL MANAGEMENT

Constipation (1) "The state in which an individual experiences or is at risk of experiencing a delay in the passage of food residue resulting in dry, hard stool".

Constipation (2) "A condition in which bowel evacuation occurs infrequently or in which the faeces are hard and small or where passage of faeces causes difficulty or pain". (National agreed definition)

Faecal Incontinence "A state in which an individual experiences a change in normal bowel habits characterized by involuntary passage of stool".

Diarrhoea Presence of loose, watery stool.

Faecal Impaction Mass of compressed faeces in rectum and/or sigmoid colon.

- Faecal loading - Not always caused by hard stool

(Ref. – "Rehabilitation Nursing Practice" 1998 – Chin, Finocchiaro, Rosebrough P. 348 – 364, Chapter 19)

Incomplete Emptying Reflex and voluntary defecation process only partially empties rectum. May result in sensation of fullness or further defecation.

Urgency Reduced times from awareness of desire to defecate to actual defecation process.

Frequency Different for individuals but more than three motions daily is considered frequent.

- 55 - APPENDIX 4

Snack Ideas

Yoghurts/Fromage Frais

Tubs of Desserts e.g. Custard, Trifle, Rice Pudding

Fruit based puddings e.g. Fruit crumble, Bread & Butter pudding, Individual Apple Pies / Jam Tarts.

Ice Cream

Malt Loaf/Fruit Loaf/Sponge Cake

Scones/Pancakes/Muffins

Biscuits e.g. Crackers, Digestives, Oatcakes, Butter Biscuits

Individual Cheese Portions/Spreading Cheese

Pate/Meat Paste

Sandwiches – variety of fillings e.g. Cold Meat, Egg Mayonnaise, Tuna, Cheese

Fresh Fruit

Fruit Salad (ready made)

Tinned Fruit

Bowl of Breakfast Cereal

Milk Based Drinks e.g. Malted Drinks, Hot Chocolate

For those who are Diabetic:- Sugar-free varieties of foods e.g. Yoghurts, Fromage Frais, Breakfast Cereal should be used.

Tinned Fruit should be in natural juice.

Fruit pies/tarts and sweet biscuits should be avoided.

- 56 - APPENDIX 5

High Fibre Snacks

Fresh Fruit Juice – small individual cartons are ideal

Fresh Fruit

Fruit Salad (ready made)

Tinned Fruit

Biscuits e.g. Digestives, Oatcakes, Wholegrain Crackers, Crispbread

Cereal Bars

Scones – Fruit/Wholemeal

Pancakes – Wholemeal

Fruit Loaf

Wholegrain Breakfast Cereals e.g. Bran Flakes, Sultana Bran, Fruit & Fibre

Dried Fruit and Nuts

- 57 - APPENDIX 6

High Fibre Foods Suitable for those with Chewing/Swallowing Difficulties

Wholegrain Breakfast Cereals e.g. Porridge, Weetabix

Stewed Fresh Fruit e.g. Apples, Rhubarb

Pureed Fresh Fruit/Tinned Fruit – This can be added to milk and blended together to make a tasty drink.

Fresh Fruit Juice – small individual cartons are ideal

Soups which contain pulses and vegetables

Baked Beans

Vegetables which have been cooked until soft

- 58 - APPENDIX 7

High Fibre Foods Available from the Catering Department

These following foods are available from the Catering Department:-

Porridge

Wholegrain Breakfast Cereal e.g. Weetabix, Bran Flakes

Grapefruit Segments

Stewed Fruit e.g. Prunes, Apple

Wholemeal Rolls

Wholemeal Bread

Soft Grain Bread

Digestive Biscuits

Oatcakes

Soups which contain pulses and vegetables

Potatoes

Vegetables – hot at meal times or in salad

Baked Beans

Tinned Fruit

Fresh Fruit

NOTE The Catering Department liase with the Dietitians when designing the hospital menu and aim to ensure that all patients receive a nutritionally balanced diet in hospital. - 59 - APPENDIX 8

FIBRE CONTENT OF EVERYDAY FOODS

BREAD: Wholemeal 1 medium slice 2g per serving Brown 1 medium slice 1g per serving White 1 medium slice 0.5g per serving Wholemeal softie 2g per serving

BREAKFAST CEREAL: All bran 1 medium bowl 12g per serving Branflakes 1 medium bowl 5g per serving Cornflakes 1 medium bowl 0.4g per serving Porridge 1 medium bowl 1.5g per serving Shredded Wheat 2 biscuits 4g per serving Weetabix 2 biscuits 4g per serving

ROOT VEGETABLES: Beetroot 4 slices 1g per serving Carrots medium portion 1.5g per portion Potatoes 3 medium boiled 2g per portion Jacket 5g per serving Turnip medium portion 0.5g per serving

LEAF VEGETABLES: Broccoli 2 florets 2g per serving Cabbage medium portion 2g per serving Celery – raw 2 sticks 0.5g per serving Leeks medium portion 1g per serving Lettuce 6 leaves 0.2g per Pepper 2 rings 0.5g per serving Spinach medium portion 2g per serving

- 60 - APPENDIX 8

FIBRE CONTENT OF EVERYDAY FOODS

OTHER VEGETABLES: Cucumber 5 slices Trace Lentils(brown) 1 tablespoon 1g per serving Mushrooms 3 cooked 0.5g per serving Peas 2 tablespoons 3g per serving Sweetcorn 1 tablespoon 0.5g per serving Tomatoes 1 medium 1g per serving Baked beans 1 small can 8g per serving Kidney beans 1 tablespoon 2g per serving

FRUIT: Apple medium with skin 2g per serving Banana medium 1g per serving Figs 1 dried 1.5g each Grapefruit ½ fruit 1g per serving Grapes small bunch 1g per serving Melon 1 slice 1.5g per serving Pear 1 medium 4g per serving Pineapple canned, 1 ring 0.5g per serving Strawberries 6 average 1.0g per serving

NUTS: Peanuts roasted and salted 1.5g per serving (small bag)

BISCUITS: Digestive 0.5g per biscuit Rich Tea 0.1g per biscuit Cream Cracker 0.1g per biscuit Wholewheat cracker 0.5g per biscuit Oatcakes 0.75g per biscuit

- 61 - APPENDIX 9

FLUIDS

Water – preferably with ice added

Tea

Coffee

Refresh – this provides Vitamin C which is an important nutrient

Fresh Fruit Juice – small individual cartons are ideal

Milk

Milk based drinks e.g. Malted Drinks, Drinking Chocolate

Squashes

Fizzy Drinks

Bovril

For those who are Diabetic:-

Sugar-free varieties of juice should be used

- 62 - APPENDIX 10

FIBRE SCORING SHEET

Rate your Diet for Fibre

Pick the foods you eat a home and find your score:

SCORE - 1 2 3 Write your TYPE OF FOOD: score here  BREAD White Brown Variety of breads e.g Wholemeal/ Granary BREAKFAST CEREAL Rarely or Cornflakes Bran Flakes never eat. Rice Weetabix Or eat sugar Crispies Shredded coated cereal Cheerios Wheat e.g. Frosties Special K Muesli Shreddies Porridge POTATOES, PASTA, RICE Rarely or Eat Eat potatoes never eat potatoes, in jackets, white rice brown rice or or pasta pasta most most days days PULSES, BEANS, NUTS Rarely or 1-2 times Three times never eat per week per week or more VEGETABLES – ALL KINDS Less than 1-3 times Daily OTHER THAN PULES, once a week per week POTATOES AND BEANS FRUIT – ALL KINDS Less than 1-3 times Daily once per per week week OATCAKES, WHOLEWHEAT Rarely or 1-3 times Daily CRACKERS, never per week WHOLEMEAL/FRUIT SCONES, CRISPBREADS YOUR TOTAL SCORE GUIDE SCORE -

0 – 12 Increase your fibre

13 – 17 Good

18+ Excellent

- 63 - Name ………………………………………….. APPENDIX 11

Address ………………………………………. MSQ …………………………………………………

Date of Birth …………………………………..

Unit No. ……………………………………… INSTRUCTIONS: Ask questions 1 – 10 in this list and record all errors. Ask question 4A only if the patient does not have a telephone. Record the total number of errors based on 10 questions. Fully date and sign each entry.

DATE DATE DATE DATE DATE 1. What is the date today? (d-m-y)

2. What day of the week is it?

3. What is the name of this place?

4. What is your telephone number?

4a What is your street address? (ask only if no telephone)

5. How old are you?

6. When were you born?

7. Who is the Prime Minister?

8. Who was the previous Prime Minister?

9. What was your mother’s maiden name?

10 Take 3 away from 20 and keep taking 3 from each new number you get, all the way down.

TOTAL ERRORS:

Administered by: ……………………………………………….

0-2 errors intact intellectual function 3-4 errors mild intellectual impairment 5-7 errors moderate intellectual impairment 8-10 errors severe intellectual impairment

- 64 -

APPENDIX 12

APPENDIX 12

- - 65 -

APPENDIX 13

POSITION CHART

Each patient must be assessed individually to ascertain whether the above is appropriate, comfortable and SAFE Feet supported or heels raised Knees above hip joint level, legs apart, lean forward, back straight (neutral spine) and forearms supported on thighs

Perineal Support Placing a hand on the perineum in front of the anus can aid effective defaecation. This can be particularly helpful for patients with a prolapse, perineal descent or pain.

- 66 -

APPENDIX 14

GUIDELINES FOR THE USE OF PHOSPHATE ENEMAS IN THE TREATMENT OF CONSTIPATION

BACKGROUND

Phosphate enemas are extensively prescribed for bowel evacuation associated with constipation and are generally well tolerated. However, they may rarely cause problems, colostomy (temporary or permanent) being the commonest due to localised severe adverse reactions. In rare situations, perforation of the bowel has been fatal. It is likely that there is under-reporting of complications caused by phosphate enemas for a number of reasons – litigation being perhaps the commonest. Administration of a phosphate enema is not without risks and appropriate precautions should be taken. APPENDIX 15 Complications associated with Phosphate Enemas are mainly caused by: 1. Trauma to the anal or rectal mucosa by the enema nozzle. 2. The topical and corrosive activity of phosphate on mucus membrane and local tissue. 3. Individuals who are more at risk of localised and systemic complications as listed below. 4. A combination of all the three above factors.

Phosphate Enemas are therefore best avoided in: 1. The frail elderly 2. Malnourished patients due to tissue fragility 3. Debilitated patients 4. Patients with known inflammatory bowel conditions/diseases 5. Patients with inflamed haemorrhoids or skin tags 6. Patients following anal/recta surgery/trauma 7. Patients with sacral pressure sores who are likely to retain a 100ml enema 8. Patients following radiotherapy directly or indirectly involving the anal/rectal area 9. Acute gatro-intestinal conditions

Key Statements: 1. If anal bleeding develops following administration of a phosphate enema, this should be viewed as a medical emergency and colorectal referral is indicated to arrest localised complications. 2. Phosphate enemas have a limited role and should be used with caution.

Produced by: Ray Addison, Nurse Specialist in Bladder and Bowel Dysfunction; Wendy Ness, Colorectal Nurse Specialist; Ian Swift, Colorectal Consultant; Muti Abulafi, Colorectal Consultant; Simon Badcott, Deputy Chief Pharmacist, Mayday healthcare NHS Trust; Mark Robinson, Pharmacist, Prescribing Manager, Croydon PCGs.

- 67 -

SECTION 8

BIBLIOGRAPHY AND FURTHER

READING

PAGES 69 – 70

BIBLIOGRAPHY AND FURTHER READING

1. Adults with Incapacity (Scotland) Act 2000:- Code of Practice – Scottish Executive

2. ADDISON, R Digital Rectal Examination 1 Nursing Times Supplement 33.1

3. ADDISON, R Digital Rectal Examination 2 Nursing Times Supplement 33.2

4. ADDISON, R (2000) How to Administer Enemas and Suppositories Nursing Times Plus 96 (6) February

5. ADDISON, R. and SMITH, M (2000) Digital Rectal Examination and Manual Removal of Faeces – Guidance for Nurses Royal College of Nursing 2000

6. BRITISH MEDICAL ASSOCIATION AND ROYAL PHARMACEUTICAL SOCIETY OF GREAT BRITAIN (March 2005) British National Formulary (BNF) 41

7. BUTLER, M. (1998) Laxatives and Rectal Preparations Nursing Times 94 (3)

8. CHELVANAYAGAM, S. and NORTON, C. (1998) Causes and Assessment of Faecal Incontinence Journal of Community Nursing 4 (1)

9. CHIARELLI, P. and MARKWELL, S. Let’s Get Things Moving Neen Healthcare Chapter 3 Page 25

10. CHIN, P.A. and FINOCCHIARO, D and ROSEBROUGH, A (1998) Rehabilitation Nursing Practice pp.350-363

11. FOWLER, C.J.(1999) Neurology of Bladder, Bowel and Sexual Dysfunction Butterworth Heinemann pp. 185-207

12. GOVEN ET AL – ROYAL COLLEGE OF NURSING (1993) Nursing Standard Vol 14 (4) 9 August

13. GREATER GLASGOW PRIMARY CARE NHS TRUST AND SOUTH GLASGOW UNIVERSITY HOSPITALS NHS TRUST (2001) Guidelines for Bowel Management, Procedure for Bowel Management

14. KYLE, G. and OLIVER, H. and PRYNN, P. The Procedure for the Digital Removal of Faeces Norgine Ltd

15. LAYCOCK, J. (2002) Information from Study Day at Culgaith Clinic

16. MALLET, J. and DOUGHERTY, L. (2003) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Fifth Edition) Blackwell Science

- 69 -

17. MANAGEMENT OF AUTONOMIC DYSREFLEXIA BOOKLET (1999) – The Queen Elizabeth National Spinal Injuries Unit for Scotland, Glasgow

18. MANAGEMENT OF THE NEUROPATHIC BOWEL BOOKLET (2004) – The Queen Elizabeth National Spinal Injuries Unit for Scotland, Glasgow

19. MARKWELL, S. (1995) Physiotherapy Management of Obstructed Defaecation Australian Physiotherapy 41 (4) pp. 279-283

20. NHS GRAMPIAN – INFORMED CONSENT POLICY

21. NORTH HAMPSHIRE BOWEL CARE PATHWAY – Produced with the aid of an educational grant from Norgine Ltd

22. NORTON, C. (20040 Bowel Continence Nursing Beaconfield

23. Nursing and Midwifery Council Code of Professional Conduct – 2002

24. Nursing and Midwifery Council Guidelines for Records and Record Keeping – 1998

25. POWELL, M. Constipation Checklist, Symptoms and Suggestions Incontact Page 1

26. POWELL, M. and RIGBY, D. (2000) Management of Bowel Dysfunction: Evacuation Difficulties Nursing Standard 14 (47) August pp. 47-51

27. Prescribing Nurse Bulletin (1999) – National Prescribing Centre 6 (1) pp. 21.24

28. RCN GUIDANCE DOCUMENT (2000) Sexuality and Sexual Health in Nursing Practice

29. RCN GUIDANCE DOCUMENT (2004) Digital Rectal Examination and Manual Removal of Faeces

30. RICKETT & COLEMAN (1999) Towards a Laxative Policy – Guidance for Primary and Secondary Healthcare Wells Healthcare Communications

31. SIGN GUIDELINE NO 16 – Colorectal Cancer

32. WITHELL, B. (2000) A Protocol for Treating Acute Constipation in the Community Setting British Journal of Community Nursing 5 (3) pp.110-119

- 70 -