Bowel Care for Patients with a Spinal Cord Lesion

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2. Clinical Management

2.1 Staff & equipment

Staff

All staff should have received training in the techniques and be deemed competent before undertaking the manual techniques^6,7. This training can take place on the ward, or in the community, whilst caring for patients with a competent registered nurse or by achieving theoretical and practical competencies in a classroom setting^6,. The competent practitioners are responsible for ensuring that their staff achieve competencies prior to undertaking these techniques. Competencies will consist of practical skills and knowledge base (Appendix 1).

Equipment

Disposable gloves
Plastic apron
Incontinence pad
Lubricant – water soluble lubricant or local anaesthetic gel (e.g. Instillagel)
Cleaning wipes
Receptacle for waste/small clinical waste bag (yellow)
Cleaning foam/soap and water
Suppository/ies as required
Commercially prepared enema as required

2.2 Method/procedure

The clinician should carry out a thorough bowel assessment with the patient to determine an individual bowel regime ⁸. This should be carried out within one week of admission, repeated when the patient enters the rehabilitation stage (Appendices 2, 3), and at follow-up if bowel problems occur (Appendix 4). The time of day at which bowel care is carried out should reflect the patient’s preference and future goals for bowel management in the community ⁵.

Consent

The following procedures (2.2.1, 2.2.2, 2.2.3, 2.2.4, 2.2.5) all require patient consent. To give legal consent the patient must

have the mental ability to consent ⁹
be given sufficient information to make an informed choice ⁹
give consent freely ⁹

The clinician must document consent has been given in the patients’ notes ¹⁰.

2.2.1 Digital Rectal Examination

Definition: Examination of the rectum by using one finger ¹¹
Indications
- Assess anal tone/reflex activity ⁷
- Assess anal sensation ⁷
- Assess presence and consistency of stool ⁷
- To administer rectal medication ⁷
- Assess need for suppositories ⁷
- Prior to digital stimulation and/or manual evacuation ⁷
- Placement of a rectal manometer line before undertaking video-urodynamics ⁷
- Placement of a probe for electroejaculation ⁷
- Assess presence of haemorrhoids, skin tags, anal lesions, rectal prolapse, discharge, bleeding ^{8, 19}
Procedure:

No.	ACTION	RATIONALE
1	Explain the procedure to the patient	To obtain patient consent and co-operation
2	Create privacy	This will help the patient to relax. To maintain privacy and dignity
3	The patient is positioned in the left lateral position with knees flexed, or left sided pelvis twist, as appropriate to their level of injury	To expose the anus and allow easy insertion of a finger for examination
4	Wash hands and put on disposable apron and gloves (double glove)	To minimize cross infection and protect hands for examination purposes
5	Place protective covering (incontinence pad) under the patient’s bottom	To prevent contamination and reduce patient’s embarrassment
6	Examine the perianal area	To observe for skin damage, haemorrhoids etc.
7	Lubricate your gloved index finger N.B. clinician’ nails must be kept short	To facilitate easier insertion and minimize patient discomfort. Reduce mucosal trauma
8	Warn patient when you are ready to insert your finger and ask them to relax (separate patient’s buttocks gently)	To ensure patient is ready and relaxed To prevent natal cleft splits, and easy identification of orifice
9	Check for ano-rectal sensation. If this is present, insert local anaesthetic gel into the rectum and wait for 5 minutes before proceeding	To minimise patient discomfort
10	Insert one gloved finger slowly into the patient’s rectum and undertake examination as per indications (2.2.1. b)	To ensure clinician only examines within specified criteria. To safeguard patient and nurse
11	Slowly withdraw finger from patient’s rectum when finished. At this point rectal medication can be given if appropriate	To minimize patient discomfort Reduce inconvenience to patient and save time
12	Remove top glove and clean patient’s peri-anal area with proprietary foam or soap and water	Reduce risk of cross infection. To leave patient comfortable
13	Remove gloves, apron, incontinence pad and dispose of in clinical waste bag, wash hands	To minimise cross infection
14	Make patient comfortable and offer further bowel care if appropriate	Examination may stimulate the patient to defaecate
15	Wash hands	To minimize cross infection
16	Record findings in nursing/medical documentation and communicate findings with the patient/carer and their doctor if appropriate	To ensure correct care and continuity of care. To avoid duplication of care. To pass care on to other clinicians as required. To ensure the patient understands the results of the examination and associated care.