Clinical protocol

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criteria You need to be aware of Contraindications The Registered Nurses should consider the following points prior to undertaking manual removal of faeces (acute, especially if the patient is not known to them. The following is not a comprehensive list a) Reason for manual removal of faeces (acute, note that manual removal of faeces should not be the first choice treatment inpatients with acute faecal impaction. Absolute contraindications (manual removal of faeces should not be used) a) Severe/acute inflammatory bowel disease. b) Rectal or colonic surgical anastomosis in the last 6 months. c) Severe cognitive impairment (unless carer available to supervise/administer) Additional Supervision and monitoring. Some patients may require additional supervision or monitoring at least until it is clear that manual removal of faeces is not causing any problems. This will depend on the judgement of the assessing professional. a) Spinal cord injury at Tor above, monitor for autonomic dysreflexia. b) Anorectal conditions that could cause pain or bleeding during the procedure (e.g. third degree haemorrhoids, anal fissure. Relative contraindications. (Only use after careful discussion with relevant medical practitioner. a) Anal fissure. b) Large haemorrhoids that bleed easily. c) Past pelvic radiotherapy. d) Anal surgery within the last 6 months. Procedure for performing Manual Removal of Faeces in an acute intervention in an adult patient.
1. Ensure all equipment is available before proceeding. This should include disposable gloves, plastic apron, water-soluble lubricant, tissues, treatment sheet, a clinical waste bag, bedpan/commode.
2. Explain the procedure to the patient and ensuring their comfort, privacy and dignity.
3. Gain informed consent and offer chaperone as per Trust policy.
4. Allow the patient to empty their bladder first.
5. Check for allergies.
6. Ideally this technique should require two nurses. One nurse to perform the intervention and the other to monitor the patient, including pulse and blood pressure

this is most important for patients at risk of autonomic dysreflexia.
7. Wash and dry hands thoroughly.
8. Take the patient’s pulse and blood pressure at rest. During the procedure the pulse and blood pressure should be monitored. If the pulse drops and/or the blood pressure rises, the procedure must be stopped. Treat any reaction according to the patient’s care plan (i.e. autonomic dysreflexia care, or as necessary.

Kent Community Health NHS Foundation Trust Protocol for manual removal of faeces (acute) In adults over the age of 18 years V Page of July 2016 9. It is desirable to have the patient in the left lateral position with knees flexed to expose the anus. Protect the patient and ensure the patient is safe and covered to maintain dignity. (Some patients may require an alternative position.
10. Put on disposable gloves.
11. Digital rectal examination of the rectum should be performed in advance of performing manual removal of faeces. (See additional SOP for digital rectal examination.
12. Warn the patient you are ready to insert your finger and ask them to relax.
13. Lubricate gloved finger with lubricant gel. (Please ensure fingernails are kept short, as this can cause extra trauma to the rectal mucosa).
14. Insert gloved finger into the patient’s rectum slowly, the finger should be slightly crooked away from the bowel wall, and a) In Scybala-type stool (hard, smaller lumps, remove a lump at a time until no more faecal matter can be felt. b) Ina solid mass, push finger into the middle of the faecal mass and split it, remove small sections until no more faecal matter can be felt. DO NOT attempt to hook and drag faeces as this can damage the bowel wall. c) If the faecal matter is more than cm in diameter and cannot be broken up, then the procedure should not be continued and medical advice sought. d) If the faeces are hard and dry, consider inserting two glycerine suppositories 30 minutes before commencing the procedure. e) If faeces are too soft to remove effectively, consider leaving the patient for another 24 hours to enable further re-absorption of water content and review fibre content of diet or prescribe appropriate bulking agent.
15. Stop the procedure if the patient starts to complain of feeling unwell, having pain or bleeding, or if patient asks you to discontinue. Stop the procedure also in spinal cord patients who are having an autonomic dysreflexic attack (flushing, high blood pressure, flushing above the level of spinal lesion. Administer their prescribed medication and they may improve if they sit upright. Seek medical attention if required.
16. When all faecal matter has been removed, wash and dry the patient’s buttocks and anal area and dispose of clinical waste according to local policy.
17. Ensure a toilet, commode or bedpan is available.
18. Record findings in nursing documentation and communicate these findings with patient, carer and doctor where appropriate

Clinical protocol
Executive summary
Governance arrangements
Related policies/procedures
Document tracking sheet
Contents page
Ethnicity and diversity
Roles and responsibilities
Training and awareness
Monitoring compliance and effectiveness of this policy
Monitoring matrix:
Equality analysis
Glossary and abbreviations
Appendix 2 bristol stool form scale
Knowledge and
Appendix 3 care and management of autonomic dysreflexia
Common causes of autonomic dysreflexia.
Signs and symptoms
Specialist advice

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