Nursing standard



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Impacted faeces
FIGURE 1
Bladder
Pubic bone
Urethra
Vagina
Rectum
Uterus
Obstructed urinary outflow
Faecal mass
Normal
Impacted
Left lateral positioning of the patient
FIGURE 2
Insert the gloved lubricated index finger into
the rectum
FIGURE 3
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38 june 1 :: vol 30 no 40 :: 2016
NURSING STANDARD
Art & science

clinical skills
discontinue the procedure. Take the patient’s blood pressure and compare with the baseline blood pressure recording. Sit the patient up if possible, administer prescribed medication for autonomic dysreflexia and explain your actions to the patient. It maybe necessary to refer the patient to a local spinal cord injury centre. Dispose of any equipment and waste, adhering to local policy and procedures. Wash and dry the patient’s buttocks and anal area using hand-hot water, wipes and a towel. Remove gloves and apron and dispose of as per local policy. Wash and dry your hands and offer the patient the opportunity to do the same. Document the procedure in the patient’s notes.
Evidence base
Practitioners should adopt a structured approach to the assessment of patients with bowel dysfunction, in accordance with evidence-based guidance (National Institute for Health and Care Excellence Bowel care is an important aspect of holistic patient care. Performing digital removal of faeces can be embarrassing and uncomfortable for the patient, and not without risk (Association for Continence Advice 2011, Royal College of Nursing (RCN) 2012,
Ness 2013). Practitioners should ensure they respect the patient’s privacy and dignity, and demonstrate compassion and sensitivity (NHS Commissioning Board and Department of Health In some individuals, such as those with neurological conditions, defecation is not possible without intervention. Defecation is essential for the elimination of waste (Waugh and Grant 2014). Assistance with defecation may include the use of oral medication, for example, laxatives to make the stool softer enabling faeces to move around the colon. Mechanical approaches include transanal irrigation, digital rectal stimulation or digital removal of faeces (Wiesel and Bell 2004, RCN Practitioners are accountable for their actions or omissions (Nursing and Midwifery Council 2015) and the practitioner undertaking digital removal of faeces should be skilled and competent to do so
(RCN 2012). Practitioners must act in the patient’s best interests and adhere to policy and guidelines.
Practitioners need to perform a risk assessment of the patient before and during digital removal of faeces. The practitioner should check blood pressure inpatients with a spinal cord injury who are at risk of autonomic dysreflexia, before and at the end of the procedure. A baseline blood pressure is used to provide a benchmark value for comparison (RCN 2012). Ness (2013) suggested that for those with spinal cord injury where digital removal of faeces is routine, and they have been able to demonstrate tolerance to the procedure, routine recording of blood pressure is not required.
During digital removal of faeces, the patient should be observed for signs of distress, pain, discomfort, bleeding and collapse, and the consistency of stool should be noted (RCN 2012). The Rome III diagnostic criteria (Mostafa 2008) can be used to identify and classify functional constipation. The Bristol Stool Chart (Lewis and
Heaton 1997) can be used to identify the type of stool passed.
Autonomic dysreflexia is a sudden, abnormal and exaggerated autonomic response to an unpleasant stimulus, such as a full rectum, constipation or digital stimulation of the rectum that occurs during bowel evacuation (Kyle et al 2005, RCN 2012,
Ness 2013). The condition occurs in people with spinal injuries at Tor above. In an acute episode, the patient presents with marked hypertension and headache. Since autonomic dysreflexia may occur in response to digital interventions such as digital removal of faeces, the patient should be observed for symptoms such as flushing, sweating, chills, nasal congestion, blurred vision and headache (Coggrave
2008, Ness 2013). If autonomic dysreflexia occurs during digital removal, the procedure should be stopped, medical assistance sought and treatment instigated promptly. Effective bowel care is a vital component of holistic patient care and failure to provide such care could be fatal for some patients
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